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Redesign Questions for Cognitive Testing
ICR 202609-0920-001 · OMB 0920-0214 · Object 172427200.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Redesign Questions for Cognitive Testing |
| Author | python-docx |
| Last Modified By | Writer |
| File Modified | 2026-09-03 |
| File Created | 2026-09-05 |
| Conversion State | complete |
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Attachment 1: NHIS Redesign: Questions for Cognitive Testing NHIS Redesign: Questions for Cognitive Testing Note: NHIS numbering has been preserved. Cognitive testing will proceed through the sections with appropriate skips. Asthma B5. Have you EVER been told by a doctor or other health professional that you had asthma? Yes No [Skip to next section] B6. How long has it been since you last had an asthma attack, flare-up, or episode? Less than 12 months ago At least 1 year ago but less than 2 years ago At least 2 years ago but less than 5 years ago At least 5 years ago but less than 10 years ago 10 years ago or more Never B7. During the past 12 months, have you had to visit an emergency room or urgent care center because of asthma? Yes No B8. During the past 12 months, have you used a preventer inhaler or daily inhaler? Yes No B9. During the past 12 months, have you taken oral corticosteroids to help with your asthma? Yes No Health Insurance and Health Care Costs D1. Are you currently covered by any kind of health insurance or some other kind of health care plan? Yes No D7. Do you have a high-deductible health plan or a HDHP? Yes No --- [Skip to D11] D8. Does this plan cover someone other than yourself? Yes No D9. About how much is this plan’s annual deductible? A deductible is the amount you have to pay for health care before your health insurance or health coverage plan will start paying your medical bills. Less than $1,750 $1,750 to less than $3,500 $3,500 or more D10. There are special accounts or funds that can be used to pay for medical expenses, sometimes referred to as Health Savings Accounts or HSAs, Health Reimbursement Accounts or HRAs, Personal Care accounts, Personal Medical funds, or Choice funds. These are DIFFERENT from Flexible Spending Accounts or FSAs. Does this plan include or allow you to contribute to a health savings account (HSA)? Yes No D11. How often does your health insurance offer benefits or cover services that meet your needs? Always Usually Sometimes Never D12. How often does your health insurance allow you to see the health care providers you need? Always Usually Sometimes Never D13. How often does your health insurance leave you with more out-of-pocket cost than you can comfortably pay without needing to cut back on other basic expenses? Always Usually Sometimes Never F8. Do you currently have any medical or dental bills that are past due or that you are unable to pay? Yes No Primary care E2. Is there a particular place that you usually go to if you are sick or need advice about your health? Yes, there is one place There is more than one place No [If no, skip to next section] E3. What kind of place do you most often go to? A doctor’s office or health center An urgent care center or clinic in a drug store or grocery store A hospital emergency room A VA medical center or VA outpatient clinic Some other place E4. At this place, is there a particular doctor, nurse, or other health professional that you usually see when you get health care? Yes No [If no, skip to next section] E5. Do you usually see this person when you need routine preventive care, such as a checkup or physical exam? Yes No Marijuana H7. Do you currently use marijuana every day, most days, some days, or not at all? Do not include CBD-only products. Every day Most days Some days Not at all [Skip to next section] H8. For what reason or reasons do you use marijuana? Mark (X) yes or no for each item. Yes No H8a. For fun or to get high H8b. Pain relief H8c. Nausea H8d. Anxiety, stress, or other mental health H8e. Help with sleep H8f. Other medical reasons Employment I10. Which of the following best describes your current employment status? Employed full-time Employed part-time Working without pay at a family-owned business Retired [Skip to next section] Not employed but looking for work [Skip to next section] Not employed and not looking for work [Skip to next section] I11. The next questions ask details about your employment. If you have more than one job, describe your main job where you work the most hours. Please be specific in your responses. What kind of work do you do? That is, what is your job title or occupation? For example, registered nurse, 4th-grade teacher, mechanical engineer, cable technician --------------------------- I12. What kind of business or industry is this? That is, what does your company make or do? For example, hospital, elementary school, clothing manufacturing, auto repair ------------------------------- I13. At your workplace, is paid sick leave available to you if you need it? Yes No I14. Is health insurance offered to you through your workplace? Yes No Short-Term Illness X1. Did you have a head cold or chest cold that started during the past 30 days? Yes No [Skip to X2] X1a. Thinking of your most recent head or chest cold, how many days did you spend more than half the day resting in bed or on the couch? _ _ days X2. Did you have a have a stomach or intestinal illness with vomiting or diarrhea that started during the past 30 days? Yes No [Skip to next section] X2a. Thinking of your most recent stomach or intestinal illness, how many days did you spend more than half the day resting in bed or on the couch? _ _ days Program Participation I15. Not including yourself, how many of the people in your household are members of your family? For this survey, family refers to everybody living together who are related by birth, marriage, or adoption, as well as any unrelated children who are cared for by the family, such as foster children. Family also includes any people living together as a couple and their children. If you live alone or live only with unrelated roommates, please answer zero (00). ____ Number of family members in household I16. In 2027, for even one month, did you or any family members receive… Mark (X) yes or no for each item. Yes No I16a. Food stamps or SNAP benefits? I16b. Benefits from the WIC program, that is, the Women, Infants, and Children program? I16c. Free or reduced-price breakfasts or lunches at school? Form Approved OMB No. 0920-0214 Exp. Date 12/31/2026 Public reporting burden of this collection of information is estimated to average 55 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer; 1600 Clifton Road NE, MS H21-8 Atlanta, Georgia 30333; ATTN: PRA (0920-0214)