RANDS 11 Questionnaire-12.10.2024

[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research

0920-0222 Attachment 1 - RANDS 11 Questionnaire

[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research - RANDS 11

OMB: 0920-0222

Document [docx]
Download: docx | pdf

Attachment 1: 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 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, 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 or CIPSEA (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 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 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 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’ 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: Non-probability Sample Demographics



[FORCE RESPONSE: “Please enter in your age. We require this information for your responses to be counted.”]

#[SHOW IF PANEL_TYPE>=20]

[NUMBOX]

AGE2.

What is your current age?


[0-100] years


[IF AGE2<18, TERMINATE AND SET QUAL=2]


[COMPUTE S_AGE=AGE2]



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

[RECORD TIME ON SCREEN]

#[SP]

SEX_BIRTH_OPT.

[CAWI] What sex were you assigned at birth on your original birth certificate?

[SPACE]


RESPONSE OPTIONS:

  1. Male

  2. Female

[COMPUTE S_SEX=SEX]




[FORCE RESPONSE]

#[SHOW IF PANEL_TYPE>=20]

[NUMBOX]

ZIP.

What is your zipcode?


__[00000-99999,777777,999998,999999]__

[ZIP validation check: must contain 5-digits, only numbers, leading 0s okay]



[FORCE RESPONSE]

#[SHOW IF PANEL_TYPE>=20]

[DROPDOWN]

STATE2.

What state do you live in?


[DROPDOWN LIST OF STATES]


[COMPUTE S_STATE=STATE2]



[FORCE RESPONSE]

#[SHOW IF PANEL_TYPE>=20]

#[SP]

RACE_OPT.

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 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 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

  1. 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 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 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 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 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 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]



[COPY OF ADEV SID 3328]

#[SP]

SEXID_OPT.

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


CAWI RESPONSE OPTIONS:

  1. Lesbian or gay

  2. Straight; that is, not lesbian or gay

  3. Bisexual

  4. Something else

  1. I don’t know


CATI RESPONSE OPTIONS:

  1. Lesbian or gay

  2. Straight; that is, not lesbian or gay

  3. Bisexual

  4. Something else

  1. You don’t know



[COPY OF ADEV SID 3328]

#[SHOW IF SEXID = 4]

[SP]

PROBE_SEXID_OPT.

What do you mean by “something else”?


RESPONSE OPTIONS:

  1. [CAWI: I am; CATI: You are] not straight, but identify with another label such as queer, pansexual, or omnisexual

  2. [CAWI: I am; CATI: You are] asexual or on the asexual spectrum (including, but not limited to, demisexual and greysexual)

  3. [CAWI: I; CATI: You] have not figured out or [CAWI: am; CATI: are] in the process of figuring out [CAWI: my; CATI: your]sexuality

  4. [CAWI: I; CATI: You] do not use labels to identify [CAWI: myself; CATI: yourself]

  5. Something else, please explain [TEXTBOX]


#[SHOW IF PANEL_TYPE>=20]

[FORCE RESPONSE]

[SP]

HHSIZE1.

Tell us a little about your household. <u>Including yourself</u>, how many persons currently live in your household at least 50 percent of the time? Please include any children as well as adults.


RESPONSE OPTIONS:

    1. One person, I live by myself

    2. Two persons

    3. Three persons

    4. Four persons

    5. Five persons

    6. Six or more persons


[COMPUTE S_HHSIZE1=HHSIZE1]



#[SHOW IF HHSIZE1>1]

[FORCE RESPONSE]

[NUMBOXES]

Please tell us how many persons currently living in your household, including yourself, are…


HH01S. ___ 0-1 years old

HH25S. ___ 2-5 years old

HH612S. ___ 6-12 years old

HH1317S. ___ 13-17 years old

HH18OVS. ___ 18 years old or older

HHtotal. ____ Total household members



HHtotal SHOULD SHOW AUTO-SUM OF HH01S-H18OVS

DO NOT ALLOW R TO CONTINUE IN SURVEY IF HHtotal<HHSIZE1


COMPUTE HH01=HH01S .

COMPUTE HH25=HH25S .

COMPUTE HH612=HH612S .

COMPUTE HH1317=HH1317S .

COMPUTE HH18OV=HH18OVS .


COMPUTE HHMINORS=sum(HH01, HH25, HH612, HH1317)



#[SHOW IF PANEL_TYPE>=20]

[DISPLAY]

HHINCINTRO.

The next question is about the <u>total income</u> of YOUR HOUSEHOLD for [CURRENTYEAR-1]. Please include your own income PLUS the income of all members living in your household (including cohabiting partners and armed forces members living at home). Please count income BEFORE TAXES and from all sources (such as wages, salaries, tips, net income from a business, interest, dividends, child support, alimony, and Social Security, public assistance, pensions, or retirement benefits).



[FORCE RESPONSE] Information about your household income is very important. We greatly appreciate your response and will keep your answer confidential.]

#[SHOW IF PANEL_TYPE>=20]

[SP]

INCOME2.

Was your total HOUSEHOLD income in [CURRENTYEAR-1]…


RESPONSE OPTIONS:

    1. Less than $5,000

    2. $5,000 to $9,999

    3. $10,000 to $14,999

    4. $15,000 to $19,999

    5. $20,000 to $24,999

    6. $25,000 to $29,999

    7. $30,000 to $34,999

    8. $35,000 to $39,999

    9. $40,000 to $49,999

    10. $50,000 to $59,999

    11. $60,000 to $74,999

    12. $75,000 to $84,999

    13. $85,000 to $99,999

    14. $100,000 to $124,999

    15. $125,000 to $149,999

    16. $150,000 to $174,999

    17. $175,000 to $199,999

    18. $200,000 or more


[COMPUTE S_INCOME=INCOME2]

IF INCOME2=1-6 S_HHINC4=1

IF INCOME2=7-10 S_HHINC4=2

IF INCOME2=11-13 S_HHINC4=3

IF INCOME2=14-18 S_HHINC4=4


IF INCOME2=1-2 S_HHINC9=1

IF INCOME2=3-4 S_HHINC9=2

IF INCOME2=5-6 S_HHINC9=3

IF INCOME2=7-8 S_HHINC9=4

IF INCOME2=9 S_HHINC9=5

IF INCOME2=10-11 S_HHINC9=6

IF INCOME2=12-13 S_HHINC9=7

IF INCOME2=14-15 S_HHINC9=8

IF INCOME2=16-18 S_HHINC9=9



[FORCE RESPONSE]

#[SHOW IF PANEL_TYPE=>20]

[SP]

ATTENTION.

Below is a list of numbers. Please select the number seven.


RESPONSE OPTIONS:


  1. 1

  2. 3

  3. 5

  4. 7

  5. 9

  6. 11

  7. 12


[IF ATTENTION<>4, TERMINATE AND SET QUAL=2] ED



#[SHOW IF PANEL_TYPE>=20]

[SP] [FORCE RESPONSE]

HOME_TYPE2.

Which best describes the building where you live?


RESPONSE OPTIONS:

  1. A one-family house detached from any other house

  2. A one-family house attached to one or more houses

  3. A building with 2 or more apartments

  4. A mobile home or trailer

  5. Boat, RV, van, etc



#[SHOW IF PANEL_TYPE>=20]

[SP] [FORCE RESPONSE]

HOUSING2.

Share with us a little about where you live. Are your living quarters…


RESPONSE OPTIONS:

  1. Owned or being bought by you or someone in your household

  2. Rented for cash

  3. Occupied without payment of cash rent



#[SHOW IF PANEL_TYPE>=20]

[SP] [FORCE RESPONSE]

Q5PHONE.

What best describes your telephone service for your household?


RESPONSE OPTIONS:

    1. Landline telephone only

    2. Have a landline, but mostly use cellphone

    3. Have cellphone, but mostly use landline

    4. Cellphone only

    5. No telephone service



[FORCE RESPONSE]

#[SHOW IF PANEL_TYPE>=20]

[SP]

MARITAL2.

Are you…


RESPONSE OPTIONS:

  1. Married

  2. Widowed

  3. Divorced

  4. Separated

  5. Never married


[COMPUTE S_MARITAL=MARITAL2]



[FORCE RESPONSE]

#[SHOW IF PANEL_TYPE>=20]

[SP]

EDUC2.

What is the highest level of school you have completed?


RESPONSE OPTIONS:

  1. No formal education

  2. 1st, 2nd, 3rd, or 4th grade

  3. 5th or 6th grade

  4. 7th or 8th grade

  5. 9th grade

  6. 10th grade

  7. 11th grade

  8. 12th grade no diploma

  9. High school graduate – high school diploma or the equivalent (GED)

  10. Some college, no degree

  11. Associate degree

  12. Bachelor’s degree

  13. Master’s degree

  14. Professional or Doctorate degree


[COMPUTE S_EDUC=EDUC2]

IF EDUC2=1-8 COMPUTE S_EDUC5=1

IF EDUC2=9 COMPUTE S_EDUC5=2

IF EDUC2=10-11 COMPUTE S_EDUC5=3

IF EDUC2=12 COMPUTE S_EDUC5=4

IF EDUC2=13-14 COMPUTE S_EDUC5=5



[FORCE RESPONSE]

#[SHOW IF PANEL_TYPE>=20]

[SP]

EMPLOY2.

Which statement best describes your current employment status?


RESPONSE OPTIONS:

1. Working – as a paid employee

2. Working – self-employed

3. Not working – on temporary layoff from a job

4. Not working – looking for work

5. Not working – retired

6. Not working – disabled

7. Not working – other


[COMPUTE S_EMPLOY=EMPLOY2]



[FORCE RESPONSE]

#[SHOW IF PANEL_TYPE>=20]

[NUMBOX]

AGECONFIRM.

What year were you born?


[NUMBOX: 0-[CURRENTYEAR]]


PN: TERMINATE AND SEND TO TERMSORRY IF ([CURRENTYEAR] – AGECONFIRM) > (AGE2 + 2) OR ([CURRENTYEAR] – AGECONFIRM) < (AGE2 - 2)


#[SHOW IF PANEL_TYPE>=20]

[DISPLAY]

TERMSORRY_OFF. 

Thank you for your time today. Unfortunately, you are not eligible for this study. We appreciate your participation.


SET QUAL=2 AND REDIRECT TO OPT-IN VENDOR


Cint/Lucid redirects:

https://samplicio.us/s/ClientCallBack.aspx?RIS=20&RID=[insert_value]



SECTION: AmeriSpeak Race and Sexual Identity



[FORCE RESPONSE]

#[SHOW IF PANEL_TYPE>=20]

#[SP]

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 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 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

  1. 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 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 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 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 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 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]



[COPY OF ADEV SID 3328]

#[SP]

SEXID.

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


CAWI RESPONSE OPTIONS:

  1. Lesbian or gay

  2. Straight; that is, not lesbian or gay

  3. Bisexual

  4. Something else, please specify: [TEXTBOX]

  1. I don’t know


CATI RESPONSE OPTIONS:

  1. Lesbian or gay

  2. Straight; that is, not lesbian or gay

  3. Bisexual

  4. Something else, please specify: [TEXTBOX]

  1. You don’t know



SECTION: Language and Health


[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

  1. NO


[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:]

  1. English

  2. Spanish

  3. Another language

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. ENGLISH

  2. SPANISH

  3. 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:]

  1. English

  2. Spanish

  3. Another language

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. ENGLISH

  2. SPANISH

  3. 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:]

  1. English

  2. Spanish

  3. Another language

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. ENGLISH

  2. SPANISH

  3. ANOTHER LANGUAGE


#[SP; PROMPT TWICE IF REFUSED]

[COPY FROM ATEST SID 3328]

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



#[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] <i>Select all that apply. </i>

[CATI] SELECT ALL THAT APPLY

RESPONSE OPTIONS:

  1. Your diet and nutrition

  2. Your exercise habits

  3. Your smoking or drinking habits

  4. Your health problems or conditions

  5. Your lack of health problems or conditions

  6. The amount of pain that you have

  7. Your ability to do daily activities without assistance

  8. The amount of sleep you get

  9. Your mental or emotional health

  10. The Coronavirus or COVID-19 pandemic

  11. Something else, please specify: [TEXTBOX]

  12. None of the above [SP]



SECTION: Cognitive Decline



PROGRAMMING: CREATE “TM_START_COG”; CREATE “DATE_START_COG”

CAPTURE TIME IN TM_START_COG

CAPTURE DATE IN DATE_START_COG



#[SHOW IF P_COG=1]

The next few questions ask about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you.


#[SHOW IF P_COG=2]

The next few questions ask about difficulties in thinking or memory that can make a big difference in everyday activities. We want to know how these difficulties may have impacted you.



[SP]

THINKMEMINCR.

During the past 12 months, have you experienced difficulties with thinking or memory that are happening more often or are getting worse?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  1. Don’t know


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  1. DON’T KNOW



[TEXTBOX]

PROBE_THINKMEMINCR.

When answering the previous question, what difficulties were you thinking about?


[LARGE TEXTBOX]



[SP]

#[SHOW IF THINKMEMINCR=1]

THINKMEMWORRY.

Are you worried about these difficulties with thinking or memory?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  1. Don’t know


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  1. DON’T KNOW



[SP]

#[SHOW IF THINKMEMINCR=1]

THINKMEMDISCUSS.

Have you or anyone else discussed your difficulties with thinking or memory with a health care provider?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  1. Don’t know


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  1. DON’T KNOW



[MP]

#[SHOW IF THINKMEMDISCUSS=1]

PROBE_THINKMEMDISCUSS.

Which of the following health care providers did you or anyone else discuss your difficulties with thinking or memory with?


RESPONSE OPTIONS:

  1. A physician

  2. A physician assistant, physician associate, or nurse practitioner

  3. A mental health professional

  4. A nurse

  5. Someone else [TEXTBOX]



[SP]

#[SHOW IF THINKMEMINCR=1]

THINKMEMACTIVITY.

During the past 12 months, have your difficulties with thinking or memory interfered with day-to-day activities, such as managing medications, paying bills, or keeping track of appointments?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  1. Don’t know


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  1. DON’T KNOW



[SP]

#[SHOW IF THINKMEMINCR=1]

THINKMEMWORK.

During the past 12 months, have your difficulties with thinking or memory interfered with your ability to work or volunteer?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  1. Don’t know


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  1. DON’T KNOW



[SP]

THINKMEMCOMPARE.

Over the past 12 months, how have your memory and thinking abilities compared with that of your peers (i.e., friends or acquaintances of a similar age)? [CATI: Would you say better than, the same, or worse than?]


CAWI RESPONSE OPTIONS:

  1. Better than

  2. The same

  3. Worse than

  1. Don’t know


CATI RESPONSE OPTIONS:

  1. BETTER THAN

  2. THE SAME

  3. WORSE THAN

  1. DON’T KNOW



[SP]

THINKMEMCONCERN.

During the past 12 months, have you become concerned about your memory loss and thinking?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  1. Don’t know


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  1. DON’T KNOW



PROGRAMMING: CREATE “TM_END_COG”; CREATE “DATE_END_COG”

CAPTURE TIME IN TM_END_COG

CAPTURE DATE IN DATE_END_COG



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]

#[SP]

HICOV. 

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


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[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] <i>Select all that apply. </i>

[CATI] SELECT ALL THAT APPLY


CAWI RESPONSE OPTIONS:

  1. Private health insurance

  2. Medicare

  3. Medigap

  4. Medicaid

  5. Children's Health Insurance Program (CHIP)

  6. Military related health care: TRICARE (CHAMPUS) / VA health care / CHAMP-

VA

  1. Indian Health Service

  2. State-sponsored health plan

  3. Other government program

  4. No coverage of any type [SP]


CATI RESPONSE OPTIONS:

  1. PRIVATE HEALTH INSURANCE

  2. MEDICARE

  3. MEDIGAP

  4. MEDICAID

  5. CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP)

  6. MILITARY RELATED HEALTH CARE: TRICARE (CHAMPUS) / VA HEALTH CARE / CHAMP-

VA

  1. INDIAN HEALTH SERVICE

  2. STATE-SPONSORED HEALTH PLAN

  3. OTHER GOVERNMENT PROGRAM

  4. 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:

  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 3328]

#[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…


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



[COPY FROM ATEST SID 3328]

#[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



[COPY FROM ATEST SID 3328]

#[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



[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 <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…


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:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[COPY FROM ATEST SID 3328]

#[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



[COPY FROM ATEST SID 3328]

[SP]

GESDIB.

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?


RESPONSE OPTIONS:

  1. Yes

  2. No

  3. 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 <u>ever</u> 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 <u>ever</u> 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 <u>ever</u> 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 <u>ever</u> told you that you had diabetes?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[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:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[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:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO


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:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[COPY FROM ATEST SID 3328 RANDS_RTS122_MAIN_CLT]

#[SHOW IF ACCSSINT=1]

[DISPLAY]

HOVER_DISPLAY2.

[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.



[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”: <i>Include Internet and data use through a computer, tablet, smartphone, or other electronic device.</i>

[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:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[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:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[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:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[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:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[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:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[COPY FROM ATEST SID 3328 RANDS_RTS122_MAIN_CLT]

#[SP]

CEVOTELC.

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


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



PROGRAMMING: CREATE “TM_END_HLTHBHV”; CREATE “DATE_END_HLTHBHV”

CAPTURE TIME IN TM_END_HLTHBHV

CAPTURE DATE IN DATE_END_HLTHBHV



SECTION: Cannabis Use and Experiences




PROGRAMMING: CREATE “TM_START_CANNABIS”; CREATE “DATE_START_ CANNABIS”

CAPTURE TIME IN TM_START_ CANNABIS

CAPTURE DATE IN DATE_START_ CANNABIS



PROGRAMMING: CANNABIS TRIADS


OPTIONS:

Pot or weed

Marijuana gummies

Delta-8 THC gummies

Delta-8 THC distillate

CBD tinctures

CBD lotion or balm


PLEASE RANDOMLY ASSIGN GROUPS OF 3 (20 POSSIBLE COMBINATIONS). EACH RESPONDENT RECEIVES THREE TRIADS AT RANDOM. RESPONDENTS SHOULD NOT RECEIVE THE SAME TRIAD MORE THAN ONCE.



#[SP]

TRIAD_1.

Which one of these is not like the other two? Your best guess is fine.


#[SP]

TRIAD_2.

Which one of these is not like the other two? Your best guess is fine.


#[SP]

TRIAD_3.

Which one of these is not like the other two? Your best guess is fine.


OUTPUT: NCHS SHOULD RECEIVE WHICH TRIAD EACH RESPONDENT WAS ASSIGNED AND THEIR ANSWER.


TRIAD_1_COMPOSITION; TRIAD_1_ANSWER

TRIAD_2_COMPOSITION; TRIAD_2_ANSWER

TRIAD_3_COMPOSITION; TRIAD_3_ANSWER


[DISPLAY]

MARIJUANAINTRO.

The next set of questions asks about marijuana, that is, the kind of cannabis that is intended to get you “high,” including products like delta-8 THC.



#[SHOW IF P_MJ=1]

#[NUMBOX]

MARIJUANA_1.

During the past 30 days, on how many days did you use marijuana?


[INPUT NUMBER] days LIMIT TO 0-30



#[SHOW IF P_MJ=2]

#[SP]

MARIJUANA_2.

During the past 30 days, on how many days did you use marijuana?


RESPONSE OPTIONS:

  1. Every day

  2. Almost every day

  3. Half or more

  4. Less than half

  5. None


[PROGRAMMING]


CREATE DOV_MARIJUANA:

IF MARIJUANA_1=0 | MARIJUANA_2=5 DOV_MARIJUANA=0

ELSE DOV_MARIJUANA=1


[DISPLAY]

MARIJUANADEF.

For the rest of the survey, we will refer to these types of cannabis products as “marijuana.”



[TEXTBOX]

PROBE_MARIJUANA.

What marijuana products were you thinking of when you answered the previous question?


[LARGE TEXTBOX]



#[SP]

PROBE_MEDMAR.

Do you use marijuana for medical purposes?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



#[SHOW IF PROBE_MEDMAR=1]

#[SP]

PROBE_MEDMARINCLUDE.

When you answered [fill: MARIJUANA] days, did you include marijuana used for medical purposes?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



#[SHOW IF PROBE_MEDMAR=1]

#[SP]

PROBE_MEDMARCARD.

Do you have a medical marijuana card?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



#[SHOW IF DOV_MARIJUANA=1]

#[MP]

MJBUY.

In the past 30 days, how did you get the marijuana you use?

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

[CATI] You can say yes or no to each one.

[SPACE]

Did you:


RESPONSE OPTIONS:

  1. buy it from a medical or retail dispensary

  2. buy it from a grocery store, gas station, mall, or other convenience store

  3. buy it from a dealer (in person) or friend

  4. get it for free or share someone else's

  5. grow it yourself at home or have someone grow it for you

  6. have it delivered to you, from the internet, mail order, or delivery service

  7. get it from somewhere else (specify: [TEXTBOX])

  8. I did not obtain marijuana from any source in the past 30 days.



#[SHOW IF MJBUY=1&6]

#[SP]

PROBE_MJBUY.

Do you get marijuana products delivered from the same dispensary you go to in person or from a different business?


CAWI RESPONSE OPTIONS:

  1. Same dispensary

  2. Different business


CATI RESPONSE OPTIONS:

  1. Same dispensary

  2. Different business



#[SHOW IF DOV_MARIJUANA=1]

#[GRID SP]

COUSE.

When you used marijuana in the past 30 days, did you use any of the following substances at the same time or within a few hours? [CATI: You can say yes or no to each one.]


GRID ITEMS:

COUSEA. A tobacco or nicotine product like a cigarette, cigar, blunt, or vape

COUSEB. Alcohol

COUSEC. Prescription medications, including opioids taken as directed by your doctor

COUSED. Prescription opioids not prescribed to you or not used as directed by your doctor

COUSEE. Psychedelics, such as LSD, acid, or mushrooms

COUSEF. Other drugs, including heroin or illicit fentanyl


RESPONSE OPTIONS:

  1. Yes

  2. No



#[SHOW IF DOV_MARIJUANA=1]

#[GRID SP]

REPLACE.

When you used marijuana in the past 30 days, did you use it to cut down on or stop using [CAWI: …?] [CATI: any of the following? You can say yes or no to each one.]


GRID ITEMS:

REPLACEA. A tobacco or nicotine product like a cigarette, cigar, blunt, or vape

REPLACEB. Alcohol

REPLACEC. Prescription medications, including opioids taken as directed by your doctor

REPLACED. Prescription opioids not prescribed to you or not used as directed by your doctor

REPLACEE. Psychedelics, such as LSD, acid, or mushrooms

REPLACEF. Other drugs, including heroin or illicit fentanyl


RESPONSE OPTIONS:

  1. Yes

  2. No



#[SHOW IF DOV_MARIJUANA=1 AND P_DRIVING=1]

#[SP]

DRIVING_HIGH.

During the past 30 days, have you driven a vehicle while high from marijuana use?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



#[SHOW IF DOV_MARIJUANA=1 AND P_DRIVING=2]

#[SP]

DRIVING_IMPAIRED.

During the past 30 days, have you driven a vehicle while impaired from marijuana use?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



#[SHOW IF P_HEALTH=1]

#[SP]

HPASK_1.

In the past 12 months, has a health professional, such as a doctor, nurse, or mental health professional, asked you about your marijuana use?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  3. I haven’t seen a health professional in the past 12 months


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  3. I HAVEN’T SEEN A HEALTH PROFESSIONAL IN THE PAST 12 MONTHS



#[SHOW IF P_HEALTH=2]

#[SP]

HPASK_2.

For the next question, do not include office intake forms completed prior to an appointment. In the past 12 months, has a health professional, such as a doctor, nurse, or mental health professional, asked you about your marijuana use?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  3. I haven’t seen a health professional in the past 12 months


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  3. I HAVEN’T SEEN A HEALTH PROFESSIONAL IN THE PAST 12 MONTHS



#[MP]

HPADVICE.

In the past 12 months, has a health professional, such as a doctor, nurse, or therapist, done any of the following?

[SPACE]

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

[CATI] SELECT ALL THAT APPLY


RESPONSE OPTIONS:

  1. Told you to cut back on or not use marijuana

  2. Recommended medical marijuana or encouraged you to seek out marijuana for treatment purposes

  3. Told you to change the way you use marijuana, for example, from smoking to edibles

  4. Given you other advice about use of marijuana (specify: [TEXTBOX])

  5. They did not provide any advice about marijuana use [SP]

  6. I have not seen a health professional in the past 12 months. [SP]



#[SHOW IF DOV_MARIJUANA=1]

#[SP]

CUTDOWN.

During the past 12 months, were you able to cut down on or stop using marijuana every time you wanted to or tried to?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  3. I did not want or try to cut down on or stop using marijuana

  4. I rarely or never use marijuana


CATI RESPONSE OPTIONS:

  1. I DID NOT WANT OR TRY TO CUT DOWN ON OR STOP USING MARIJUANA

  2. YES

  3. NO

  4. I RARELY OR NEVER USE MARIJUANA




#[MP]

PROBE_CUTDOWN.

During the past 12 months, why did you try to cut down on or stop using marijuana?

[SPACE]

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

[CATI] SELECT ALL THAT APPLY


RESPONSE OPTIONS:

  1. Concern about dependency or addiction

  2. For tolerance levels

  3. For health reasons

  4. Cost

  5. Lack of access to marijuana

  6. Other (specify: [TEXTBOX])



#[SP]

MJLIVESWITH.

Does anyone who currently lives with you use marijuana?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  3. Don’t know


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  3. DON’T KNOW



#[SP]

ADVERTISING.

For the next two questions, please only consider marijuana, that is, the kind of cannabis that is intended to get you “high,” including products like delta-8 THC.


During the past 30 days, how often have you seen or heard an advertisement for marijuana products or stores or seen a marijuana storefront? (Include TV, radio, signs and billboards, newspapers and magazines, pamphlets or flyers, streetside marketing like sign spinners or sandwich boards, online or cell phone advertisements, and dispensary newsletters or rewards programs.)


RESPONSE OPTIONS:

  1. A few of the past 30 days

  2. About half of the past 30 days

  3. Nearly all of the past 30 days

  4. I have not seen or heard marijuana product advertising in the past 30 days



#[SP]

PREVENTION.

During the past 30 days, how often have you seen or heard an advertisement, message, or product label about preventing harmful marijuana use or avoiding marijuana use? (Include TV, radio, signs and billboards, newspapers and magazines, pamphlets or flyers, streetside marketing like sign spinners or sandwich boards, online or cell phone advertisements, and dispensary newsletters or rewards programs.)


RESPONSE OPTIONS:

  1. A few of the past 30 days

  2. About half of the past 30 days

  3. Nearly all of the past 30 days

  4. I have not seen or heard marijuana product advertising in the past 30 days




#[SP]

MJEFFECTS.

In the past 12 months, did you seek help for adverse or negative health effects caused by marijuana?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



#[SHOW IF MJEFFECTS=1]

#[MP]

MJEFFECTSLOCATION.

Where did you seek help for adverse or negative health effects caused by marijuana?

[SPACE]

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

[CATI] SELECT ALL THAT APPLY


RESPONSE OPTIONS:

  1. Emergency department

  2. Poison control center

  3. Doctor or other health professional

  4. Walk-in clinic

  5. Telephone health service/helpline

  6. Addiction support service

  7. Some other place (specify: [TEXTBOX])



[DISPLAY]

CBDINTRO.

The next set of questions ask about CBD products, that is, cannabis products that are not intended to get you “high.” These products are generally derived from hemp. Do not count marijuana products, including products like delta-8 THC, when answering these questions.



#[SHOW IF P_MJ=1]

#[NUMBOX]

CBD_1.

During the past 30 days, on how many days did you use CBD products?


[INPUT NUMBER] days LIMIT TO 0-30



#[SHOW IF P_MJ=2]

#[SP]

CBD_2.

During the past 30 days, on how many days did you use CBD products?


RESPONSE OPTIONS:

  1. Every day of the past 30 days

  2. Almost every day of the past 30 days

  3. Half or more of the past 30 days

  4. Less than half of the past 30 days

  5. None of the past 30 days


[PROGRAMMING]


CREATE DOV_CBD:

IF CBD_1=0 | CBD_2=5 DOV_CBD=0

ELSE DOV_CBD=1


[DISPLAY]

CBDDEF.

For the rest of the survey, we will refer to these types of cannabis products as “CBD products.”



[TEXTBOX]

PROBE_CBD.

What CBD products were you thinking of when you answered the previous question?


[LARGE TEXTBOX]



#[SHOW IF DOV_CBD=1]

#[MP]

CBDUSE.

When you used a CBD product during the past 30 days, how did you use it?

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

[CATI] You can say yes or no to each one.

[SPACE]

Did you:


RESPONSE OPTIONS:

  1. Apply it to the skin (for example, in a lotion, gel, oil, balm, or bath salt)

  2. Smoke it (for example, in a joint, blunt, or cigar)

  3. Eat it or drink it, including drops, sprays, or tinctures (for example, in edibles like brownies or gummies or in capsules, or in tea, cola, or alcohol)

  4. Vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device)

  5. Dab it (for example, using a dabbing rig, knife, or dab pen)

  6. Use it some other way (specify: [TEXTBOX])



#[SHOW IF DOV_CBD=1]

#[MP]

CBDBUY.

In the past 30 days, how did you get the CBD products you use?

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

[CATI] You can say yes or no to each one.

[SPACE]

Did you:


RESPONSE OPTIONS:

  1. buy them from a smoke shop, grocery store, gas station, mall, or other convenience store

  2. buy them from a medical or retail dispensary

  3. buy them from a friend or acquaintance

  4. get them for free or share someone else's

  5. grow them yourself at home or have someone grow them for you

  6. have them delivered to you (from the internet, mail order, or delivery service)

  7. get them from somewhere else (specify: [TEXTBOX])

  8. I did not obtain CBD products from any source in the past 30 days.



#[SHOW IF CBDBUY=1&6, 2&6]

#[SP]

PROBE_CBDBUY.

Do you get CBD products delivered from the same [if CBDBUY=1: business; if CBDBUY=2: dispensary] you go to in person or from a different business?


CAWI RESPONSE OPTIONS:

  1. Same [if CBDBUY=1: business; if CBDBUY=2: dispensary]

  2. Different business


CATI RESPONSE OPTIONS:

  1. Same [if CBDBUY=1: business; if CBDBUY=2: dispensary]

  2. Different business



#[SHOW IF DOV_MARIJUANA=1 OR DOV_CBD=1]

#[SP]

COMPOSITION.

When you use CBD or marijuana products, which of the following best describes the product you use most often? Your best guess is fine.


RESPONSE OPTIONS:

  1. High THC, Low CBD

  2. High THC, High CBD

  3. Low THC, Low CBD

  4. Low THC, High CBD

  5. Other

  6. Not sure

  7. I rarely or never use marijuana or CBD products



PROGRAMMING: CREATE “TM_END_CANNABIS”; CREATE “DATE_END_CANNABIS”

CAPTURE TIME IN TM_END_CANNABIS

CAPTURE DATE IN DATE_END_CANNABIS



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]

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:

  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


[MP]

PROBE_WPH_QOL.

In the previous question, when you rated your quality of life as [FILL], which of the following were you thinking about?


CAWI RESPONSE OPTIONS:

  1. Your financial situation

  2. Your health

  3. Your family situation

  4. Your social life

  5. Your general attitude and outlook towards your life

  6. Politics

  7. Something else, please specify

CATI RESPONSE OPTIONS:

  1. YOUR FINANCIAL SITUATION

  2. YOUR HEALTH

  3. YOUR FAMILY SITUATION

  4. YOUR SOCIAL LIFE

  5. YOUR GENERAL ATTITUDE AND OUTLOOK TOWARDS YOUR LIFE

  6. POLITICS

  7. SOMETHING ELSE, PLEASE SPECIFY


[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:

  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]

PRAPARE16.

In a typical week, [FILL if HHSIZE >1: “and not including people you live with,” how many times do you see or talk to people that you care about and feel close to?


RESPONSE OPTIONS:

  1. Less than once a week

  2. One or two times a week

  3. Three or five times a week

  4. Six or more times a week


#[SP]

SOCCON_TECH.

In a typical week, how many times do you use email, text messages, or social media apps to chat with people that you care about and feel close to? [Examples of social media apps include WhatsApp, Snapchat, Messenger, and Discord.]


RESPONSE OPTIONS:

  1. Less than once a week

  2. One or two times a week

  3. Three or five times a week

  4. Six or more times a week


#[SP]

SOCCON_RELIG

In a typical year, how often do you attend religious services? [Do not include special occasions such as weddings, funerals, or other special events.]


RESPONSE OPTIONS:

  1. Never or less than once a year

  2. 1 to 3 times a year

  3. 4 to 11 times a year

  4. 12 or more times a year


#[SP]

PULSE_SOCIND4.

In a typical year, how often do you attend meetings of clubs or organizations you belong to? [Examples include church groups, unions, fraternal or athletic groups, or school groups.]

RESPONSE OPTIONS:

  1. [IF CAWI: I; IF CATI: You] do not belong to a group

  2. Never or less than once a year

  3. 1 to 3 times a year

  4. 4 to 11 times a year

  5. 12 or more times a year



[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:

  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]

WPH_PHYS.

How would you rate your physical activity, compared with people in your age group?


[CATI] Would you say 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]

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:

  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]

WPH_SLEEP.

How would you rate your sleep?


[CATI] Would you say 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]

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:

  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]

PROBE_WPH_SPIRIT.

Currently, how important is religion in your daily life?


[CATI] Would you say it is very important, somewhat important, or not important?

CAWI RESPONSE OPTIONS:

  1. Very important

  2. Somewhat important

  3. Not important

CATI RESPONSE OPTIONS:

  1. VERY IMPORTANT

  2. SOMEWHAT IMPORTANT

  3. NOT IMPORTANT


[SP]

WPH_HEALTH.

How would you rate your ability to manage your health, focusing on aspects of your health that matter most to you?


[CATI] Would you say 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


[MP]

PROBE_WPH_HEALTH.

When you answered [FILL] to the previous question about your ability to manage your health, which of the following aspects of your life were you thinking about, if any?


RESPONSE OPTIONS:

  1. Ability to stay healthy or recover from illness

  2. Ability to maintain a healthy diet

  3. Ability to maintain an active lifestyle

  4. Whether or not you have a usual health care provider

  5. How easy or difficult it is to see your health care provider

  6. Ability to afford health care and medicine

  7. Some other aspect of your health, please specify



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

CAPTURE TIME IN TM_END_ WPH

CAPTURE DATE IN DATE_END_ WPH



SECTION CLOSE: Burden and Close



[COPY OF ADEV SID 3328]

#[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



[COPY OF ADEV SID 3328]

#[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



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