2019 BRFSS Questionnaire
2019, BRFSS, Questionnaire
CDC
2019-BRFSS-Questionnaire-508 2019 BRFSS Questionnaire
Table of Contents
OMB Header and Introductory Text ............................................................................................................. 4 Landline Introduction.................................................................................................................................... 5 Cell Phone Introduction .............................................................................................................................. 11 Core Section 1: Health Status ..................................................................................................................... 17 Core Section 2: Healthy Days ...................................................................................................................... 18 Core Section 3: Healthcare Access.............................................................................................................. 20 Core Section 4: Hypertension Awareness................................................................................................... 22 Core Section 5: Cholesterol Awareness ...................................................................................................... 23 Core Section 6: Chronic Health Conditions ................................................................................................. 25 Core Section 7: Arthritis .............................................................................................................................. 28 Core Section 8: Demographics .................................................................................................................... 31 Core Section 9: Tobacco Use....................................................................................................................... 39 Core Section 10: Alcohol Consumption ...................................................................................................... 42 Core Section 11: Exercise (Physical Activity)............................................................................................... 44 Core Section 12: Fruits and Vegetables ...................................................................................................... 46 Core Section 13: Immunization................................................................................................................... 50 Core Section 14: H.I.V./AIDS ....................................................................................................................... 52 Closing Statement/ Transition to Modules ................................................................................................. 55 Optional Modules ....................................................................................................................................... 56 Module 1: Prediabetes................................................................................................................................ 57 Module 2: Diabetes..................................................................................................................................... 58 Module 3: ME/CFS ...................................................................................................................................... 61 Module 4: Hepatitis Treatment .................................................................................................................. 63 Module 5: HPV - Vaccination ...................................................................................................................... 65 Module 6: Place of Flu Vaccination............................................................................................................. 66 Module 7: Shingles Vaccination .................................................................................................................. 67 Module 8: Lung Cancer Screening .............................................................................................................. 68 Module 9: Breast and Cervical Cancer Screening ....................................................................................... 71 Module 10: Prostate Cancer Screening ...................................................................................................... 75 Module 11: Prostate Cancer Decision Making............................................................................................ 78 Module 12: Colorectal Cancer Screening.................................................................................................... 80 Module 13: Cancer Survivorship ................................................................................................................. 83
Module 14: Healthcare Access.................................................................................................................... 89 Module 15: Aspirin for CVD Prevention...................................................................................................... 91 Module 16: Home/ Self-measured Blood Pressure .................................................................................... 92 Module 17: Sodium or Salt-Related Behavior............................................................................................. 94 Module 18: Indoor Tanning ........................................................................................................................ 95 Module 19: Excess Sun Exposure................................................................................................................ 96 Module 20: Cognitive Decline ..................................................................................................................... 99 Module 21: Caregiver................................................................................................................................ 102 Module 22: Adverse Childhood Experiences ............................................................................................ 106 Module 23: Family Planning...................................................................................................................... 110 Module 24: Alcohol Screening & Brief Intervention (ASBI) ...................................................................... 114 Module 25: Marijuana Use ....................................................................................................................... 116 Module 26: Industry and Occupation ....................................................................................................... 118 Module 27: Food Stamps .......................................................................................................................... 119 Module 28: Sex at Birth ............................................................................................................................ 120 Module 29: Sexual Orientation and Gender Identity ............................................................................... 121 Module 30: Random Child Selection......................................................................................................... 125 Module 31: Childhood Asthma Prevalence .............................................................................................. 129 Asthma Call-Back Permission Script.......................................................................................................... 131 Closing Statement ..................................................................................................................................... 134
OMB Header and Introductory Text
Read if necessary
Read
Public reporting burden of this collection of information is estimated to average 27 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 D-74, Atlanta, Georgia 30333; ATTN: PRA (09201061).
HELLO, I am calling for the (health department). My name is (name). We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.
Interviewer instructions (not read) Form Approved OMB No. 0920-1061 Exp. Date 3/31/2021
Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at ivk7@cdc.gov.
Landline Introduction
Question Question text Number
LL01.
Is this [PHONE NUMBER]?
LL02.
Is this a private residence?
Variable names CTELENM1
PVTRESD1
Responses (DO NOT READ UNLESS OTHERWIS E NOTED) 1 Yes 2 No
1 Yes
2 No
SKIP INFO/ CATI Note Go to LL02 TERMINAT E Go to LL04
Go to LL03
Interviewer Note (s)
Thank you very much, but I seem to have dialed the wrong number. It's possible that your number may be called at a later time. Read if necessary: By private residence we mean someplace like a house or apartment. Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year. If no, business phone only: thank you very much but we are only
Column( s) 63
64
LL03. LL04.
3 No, this is a business
Do you live in COLGHOUS 1 Yes college housing?
2 No
Do you currently live in__(state)____ ?
STATERE1
1 Yes 2 No
Go to LL04
TERMINAT E
Go to LL05 TERMINAT E
interviewing
persons on
residential
phones lines at
this time.
NOTE: Business
numbers which
are also used for
personal
communication
are eligible.
Read: Thank you
very much but
we are only
interviewing
persons on
residential
phones at this
time.
Read if
65
necessary: By
college housing
we mean
dormitory,
graduate
student or
visiting faculty
housing, or
other housing
arrangement
provided by a
college or
university.
Read: Thank you
very much, but
we are only
interviewing
persons who
live in private
residences or
college housing
at this time.
66
Thank you very
much but we
are only
interviewing
LL05. LL06.
Is this a cell phone?
Are you 18 years of age or older?
CELPHONE LADULT1
persons who
live in [STATE] at
this time.
1 Yes, it is TERMINAT Read: Thank you 67
a cell
E
very much but
phone
we are only
interviewing by
landline
telephones in
private
residences or
college housing
at this time.
2 Not a cell Go to LL06 Read if
phone
necessary: By
cell phone we
mean a
telephone that
is mobile and
usable outside
your
neighborhood.
Do not read:
Telephone
service over the
internet counts
as landline
service (includes
Vonage, Magic
Jack and other
home-based
phone services).
1 Yes
[CATI
68
NOTE: IF
COLLEGE
HOUSING =
"YES,"
CONTINUE;
OTHERWIS
E GO TO
ADULT
RANDOM
SELECTION
]
2 No
TERMINAT Read: Thank you
E
very much but
we are only
interviewing
LL07. LL08.
LL09. LL10.
Are you male or COLGSEX female?
1 Male 2 Female
persons aged 18
or older at this
time.
ONLY for
69
responden
ts who are
LL and
COLGHOUS
= 1.
7 Don't know/Not sure 9 Refused
I need to randomly select one adult who lives in your household to be interviewed. Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older? Are you male or female?
NUMADULT LANDSEX
1
2-6 or more
1 Male 2 Female
7 Don't know/Not sure 9 Refused
How many of NUMMEN these adults are men?
_ _ Number
TERMINAT E Go to LL09
Go to LL10.
Thank you for your time, your number may be selected for another survey in the future. Read: Are you that adult? If yes: Then you are the person I need to speak with. If no: May I speak with the adult in the household?
GO to Transition Section 1. TERMINAT E
Thank you for your time, your number may be selected for another survey in the future.
70-71
72 73-74
LL11.
LL12
Transitio n to Section 1.
So the number of women in the household is [X]. Is that correct?
NUMWOME N
The person in your household that I need to speak with is [Oldest/Younges t/ Middle//Male /Female]. Are you the [Oldest/Younges t/ Middle//Male /Female] in this household?
RESPSLCT
77 Don't know/ Not sure 99 Refused
1 Male 2 Female
7 Don't know/Not sure 9 Refused
TERMINAT E
I will not ask for your last name, address, or other personal informatio n that can identify you. You do not have to answer any question
Do not read: Confirm the number of adult women or clarify the total number of adults in the household. Read: The persons in your household that I need to speak with is [Oldest/Younges t/ Middle//Male /Female].
75-76 77
Thank you for your time, your number may be selected for another survey in the future.
Do not read: Introductory text may be reread when selected respondent is reached.
Do not read: The sentence "Any information you give me will not be connected to any personal information"
you do not want to, and you can end the interview at any time. Any informatio n you give me will not be connected to any personal informatio n. If you have any questions about the survey, please call (give appropriat e state telephone number).
may be replaced by "Any personal information that you provide will not be used to identify you." If the state coordinator approves the change.
Cell Phone Introduction
Question Question text Number
Variable names
Responses (DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Column(s
Note (s)
)
CP01.
Is this a safe
SAFETIME 1 Yes
time to talk with
2 No
you?
CP02.
Is this [PHONE NUMBER]?
CTELNUM 1 Yes
1
2 No
Go to CP02
78
([set
Thank you
appointmen very much.
t if possible]) We will call
TERMINATE] you back at
a more
convenient
time.
Go to CP03
79
TERMINATE
CP03. CP04. CP05.
Is this a cell phone?
CELLFON5 1 Yes 2 No
Are you 18 years CADULT1 of age or older?
1 Yes 2 No
Are you male or CELLSEX female?
1 Male 2 Female 7 Don't Know/ Not sure
Go to CADULT TERMINATE
80
If "no": thank you very much, but we are only interviewing persons on cell telephones at this time
81
TERMINATE
Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
82
TERMINATE
Thank you for your time, your
CP06. CP07.
9 Refused
Do you live in a private residence?
PVTRESD3 1 Yes
2 No Do you live in CCLGHOU 1 Yes college housing? S
Go to CP08
Go to CP07 Go to CP08
number
may be
selected for
another
survey in
the future.
Read if
83
necessary:
By private
residence
we mean
someplace
like a house
or
apartment
Do not
read:
Private
residence
includes any
home
where the
respondent
spends at
least 30
days
including
vacation
homes, RVs
or other
locations in
which the
respondent
lives for
portions of
the year.
Read if
84
necessary:
By college
housing we
mean
dormitory,
graduate
student or
visiting
faculty
housing, or
CP08. CP09.
Do you currently live in___(state)____ ? In what state do you currently live?
CSTATE1 RSPSTAT1
2 No
TERMINATE
1 Yes 2 No
Go to CP10 Go to CP09
1 Alabama 2 Alaska 4 Arizona 5 Arkansas 6 California 8 Colorado 9 Connecticut 10 Delaware 11 District of Columbia 12 Florida 13 Georgia 15 Hawaii 16 Idaho 17 Illinois 18 Indiana 19 Iowa 20 Kansas 21 Kentucky 22 Louisiana 23 Maine 24 Maryland 25 Massachusett s
other housing arrangemen t provided by a college or university. Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
85
86-87
CP10.
Do you also have LANDLINE a landline
26 Michigan 27 Minnesota 28 Mississippi 29 Missouri 30 Montana 31 Nebraska 32 Nevada 33 New Hampshire 34 New Jersey 35 New Mexico 36 New York 37 North Carolina 38 North Dakota 39 Ohio 40 Oklahoma 41 Oregon 42 Pennsylvania 44 Rhode Island 45 South Carolina 46 South Dakota 47 Tennessee 48 Texas 49 Utah 50 Vermont 51 Virginia 53 Washington 54 West Virginia 55 Wisconsin 56 Wyoming 66 Guam 72 Puerto Rico 78 Virgin Islands 99 Refused 1 Yes 2 No
Read if
88
necessary:
telephone in your home that is used to make and receive calls?
CP11.
Transitio n to section 1.
How many members of your household, including yourself, are 18 years of age or older?
HHADULT
7 Don't know/ Not sure 9 Refused
_ _ Number 77 Don't know/ Not sure 99 Refused
I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me
If CP07 = yes then number of adults is automaticall y set to 1
By landline telephone, we mean a regular telephone in your home that is used for making or receiving calls. Please include landline phones used for both business and personal use.
89-90
will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).
Core Section 1: Health Status
Question Question Number text
Variable names
C01.01
Would you say that in general your health is--
GENHLTH
Responses (DO NOT READ UNLESS OTHERWISE NOTED) Read: 1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor Do not read: 7 Don't know/Not sure 9 Refused
SKIP
Interviewer Note
INFO/
(s)
CATI Note
Column(s)
101
Core Section 2: Healthy Days
Question Number C02.01
C02.02
C02.03
Question text
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? 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? During the past 30 days, for about how many days did poor physical or
Variable names PHYSHLTH
MENTHLTH
POORHLTH
Responses (DO NOT READ UNLESS OTHERWISE NOTED) _ _ Number of days (0130) 88 None 77 Don't know/not sure 99 Refused
_ _ Number of days (0130) 88 None 77 Don't know/not sure 99 Refused
_ _ Number of days (0130) 88 None
SKIP INFO/ CATI Note
Do not ask this question and skip to next section if C02.01, PHYSHLTH, is
Interviewer Note (s)
Column(s) 102-103 104-105
106-107
mental health keep you from doing your usual activities, such as selfcare, work, or recreation?
77 Don't know/not sure 99 Refused
88 and C02.02, MENTHLTH, is 88
Core Section 3: Healthcare Access
Question Question text Number
C03.01 C03.02
Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Service? Do you have one person you think of as your personal doctor or health care provider?
Variable names HLTHPLN1
PERSDOC2
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes
2 No 7 Don't know/Not Sure 9 Refused
1 Yes, only one 2 More than one 3 No 7 Don't know / Not sure 9 Refused
SKIP INFO/ CATI Note
If using Healthcare Access (HCA) Module go to HCA.01, else continue
C03.03 C03.04
Was there a time in the past 12 months when you needed to see a doctor but could not because of cost? About how long has it been since you last visited a
MEDCOST CHECKUP1
1 Yes 2 No 7 Don't know / Not sure 9 Refused
Read if necessary: 1 Within the past year (anytime less
Interviewer Note (s)
If No, read: Is there more than one, or is there no person who you think of as your personal doctor or health care provider?
Read if necessary: A routine checkup is a general
Column(s) 108
109 110 111
doctor for a routine checkup?
than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 5 years (2 years but less than 5 years ago) 4 5 or more years ago Do not read: 7 Don't know / Not sure 8 Never 9 Refused
physical exam, not an exam for a specific injury, illness, or condition.
Core Section 4: Hypertension Awareness
Question Question text Variable
Number
names
C04.01
Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
BPHIGH4
C04.02
Are you currently taking prescription medicine for your high blood pressure?
BPMEDS
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
1 Yes
2 Yes, but female told only during pregnancy 3 No 4 Told borderline high or prehypertensive 7 Don't know / Not sure 9 Refused
Go to next section
If "Yes" and
112
respondent is
female, ask: "Was
this only when
you were
pregnant?"
By other health professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.
1 Yes
113
2 No
7 Don't know
/ Not sure
9 Refused
Core Section 5: Cholesterol Awareness
Question Question Number text
Variable names
C05.01
Blood cholesterol is a fatty substance found in the blood. About how long has it been since you last had your blood cholesterol checked?
CHOLCHK2
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ Interviewer CATI Note Note (s)
1 Never
2 Within the past year (anytime less than one year ago)
If response = 1, 9.
GOTO Next section.
3 Within the past 2 years (1 year but less than 2 years ago)
4 Within the past 3 years (2 years but less than 3 years ago)
5 Within the past 4 years (3 years but less than 4 years ago)
6 Within the past 5 years (4 years but less than 5 years ago)
8 5 or more years ago
Column(s) 114
C05.02 C05.03
Have you ever been told by a doctor, nurse or other health professional that your blood cholesterol is high?
TOLDHI2
Are you currently taking medicine prescribed by your doctor or other health professional for your blood cholesterol?
CHOLMED2
7 Don't know/ Not sure 9 Refused 1 Yes 2 No 7 Don't know / Not sure 9 Refused
1 Yes 2 No 7 Don't know / Not sure 9 Refused
If response By other health 115 = 2, 7, 9 professional we GOTO next mean nurse section. practitioner, a
physician assistant, or some other licensed health professional.
116
Core Section 6: Chronic Health Conditions
Question Question text Variable
Number
names
C06.01
C06.02 C06.03
Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You're Not Sure. (Ever told) you that you had a heart attack also called a myocardial infarction? (Ever told) (you had) angina or coronary heart disease?
CVDINFR4 CVDCRHD4
(Ever told) (you had) a stroke?
CVDSTRK3
C06.04
(Ever told) (you had) asthma?
ASTHMA3
C06.05
Do you still ASTHNOW have asthma?
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes 2 No 7 Don't know / Not sure 9 Refused
1 Yes 2 No 7 Don't know / Not sure 9 Refused 1 Yes 2 No 7 Don't know / Not sure 9 Refused 1 Yes 2 No 7 Don't know / Not sure 9 Refused 1 Yes 2 No
SKIP INFO/ CATI Note
Go to C06.06
Interviewer Note (s)
Column(s) 117
118 119 120 121
C06.06 C06.07 C06.08 C06.09
C06.10
(Ever told) (you had) skin cancer?
(Ever told) (you had) any other types of cancer?
(Ever told) (you had) chronic obstructive pulmonary disease, C.O.P.D., emphysema or chronic bronchitis? (Ever told) (you had) a depressive disorder (including depression, major depression, dysthymia, or minor depression)? Not including kidney stones, bladder infection or incontinence, were you ever told you have kidney disease?
CHCSCNCR CHCOCNCR CHCCOPD1 ADDEPEV2
CHCKDNY2
7 Don't know / Not sure 9 Refused 1 Yes 2 No 7 Don't know / Not sure 9 Refused 1 Yes 2 No 7 Don't know / Not sure 9 Refused 1 Yes 2 No 7 Don't know / Not sure 9 Refused
1 Yes 2 No 7 Don't know / Not sure 9 Refused
1 Yes 2 No 7 Don't know / Not sure 9 Refused
122 123 124
125
Read if
126
necessary:
Incontinence is
not being able
to control urine
flow.
C06.11 C06.12
(Ever told) (you had) diabetes?
DIABETE3
How old were you when you were told you had diabetes?
DIABAGE2
1 Yes
2 Yes, but female told only during pregnancy 3 No 4 No, prediabetes or borderline diabetes 7 Don't know / Not sure 9 Refused _ _ Code age in years [97 = 97 and older] 98 Don`t know / Not sure 99 Refused
Go to PreDiabetes Optional Module (if used). Otherwise, go to next section.
Go to Diabetes Module if used, otherwise go to next section.
If yes and
127
respondent is
female, ask:
was this only
when you were
pregnant? If
respondent
says pre-
diabetes or
borderline
diabetes, use
response code
4.
128-129
Core Section 7: Arthritis
Question Question text Number
C07.01
(Ever told) (you had) some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?
Variable names
HAVARTH3
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes
2 No 7 Don't know / Not sure 9 Refused
SKIP INFO/ CATI Note
Go to next section
C07.02
Has a doctor ARTHEXER or other health professional
1 Yes 2 No
Interviewer Note Column(s) (s)
Arthritis diagnoses 130 include: rheumatism, polymyalgia rheumatic, osteoarthritis (not osteoporosis), tendonitis, bursitis, bunion, tennis elbow, carpal tunnel syndrome, tarsal tunnel syndrome, joint infection, Reiter's syndrome, ankylosing spondylitis; spondylosis, rotator cuff syndrome, connective tissue disease, scleroderma, polymyositis, Raynaud's syndrome, vasculitis, giant cell arteritis, Henoch-Schonlein purpura, Wegener's granulomatosis, polyarteritis nodosa) If the respondent 131 is unclear about whether this
C07.03 C07.04
ever suggested physical activity or exercise to help your arthritis or joint symptoms? Have you ever taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms? Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?
ARTHEDU LMTJOIN3
7 Don't know / Not sure 9 Refused
1 Yes 2 No 7 Don't know / Not sure 9 Refused
1 Yes 2 No 7 Don't know / Not sure 9 Refused
C07.05
In the next question, we are referring to work for pay. Do arthritis or joint symptoms now affect whether you work, the type of work you do or the amount
ARTHDIS2
1 Yes 2 No 7 Don't know / Not sure 9 Refused
means increase or decrease in physical activity, this means increase.
132
If a respondent 133
question arises
about medication,
then the
interviewer
should reply:
"Please answer
the question
based on how you
are when you are
taking any of the
medications or
treatments you
might use
If respondent
134
gives an answer to
each issue
(whether works,
type of work, or
amount of work),
then if any issue is
"yes" mark the
overall response
as "yes." If a
question arises
about medications
or treatment,
then the
of work you do?
C07.06
Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. During the past 30 days, how bad was your joint pain on average on a scale of 0 to 10 where 0 is no pain and 10 is pain or aching as bad as it can be?
JOINPAI2
__ __ Enter number [0010] 77 Don't know/ Not sure 99 Refused
interviewer should say: "Please answer the question based on your current experience, regardless of whether you are taking any medication or treatment."
135-136
Core Section 8: Demographics
Questi on Numbe r Prolog ue
Question text
Variable names
Responses (DO NOT READ UNLESS OTHERWISE NOTED)
C08.01 C08.02
C08.03
What is your age?
Are you Hispanic, Latino/a, or Spanish origin?
Which one or more of
AGE HISPANC3
_ _ Code age in years 07 Don't know / Not sure 09 Refused If yes, read: Are you...
MRACE1
1 Mexican, Mexican American, Chicano/a 2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino/a, or Spanish origin Do not read: 5 No 7 Don't know / Not sure 9 Refused Please read: 10 White
SKIP INFO/ CATI Note
Interviewe Column( r Note (s) s)
Read if necessary: I will ask you some questions about yourself in the next section. We include these questions so that we can compare health indicators by groups.
137-138
One or more categories may be selected.
139-142
If more than If 40
143-170
one response (Asian) or
the following would you say is your race?
C08.04
Which one of these groups would you say best represents your race?
ORACE3
20 Black or African American 30 American Indian or Alaska Native 40 Asian
41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 88 No additional choices 77 Don't know / Not sure 99 Refused Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan
to C08.03; continue. Otherwise, go to C08.05.
50 (Pacific Islander) is selected read and code subcategor ies underneat h major heading. One or more categories may be selected.
If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategor ies underneat h major heading.
If respondent has selected multiple races in previous and
171-172
C08.05 Are you... MARITAL
C08.06
What is the highest grade or year of school you completed?
EDUCA
C08.07 Do you own RENTHO or rent your M1 home?
54 Other
refuses to
Pacific Islander
select a
Do not read:
single race,
60 Other
code
refused
77 Don't know / Not
sure
99 Refused
Please read:
If using
173
1 Married
Module 28
2 Divorced
insert
3 Widowed
M28.01 prior
4 Separated
to asking this
5 Never married
question
Or
6 A member of an
unmarried couple
Do not read:
9 Refused
Read if necessary:
174
1 Never attended
school or only
attended kindergarten
2 Grades 1 through 8
(Elementary)
3 Grades 9 through 11
(Some high school)
4 Grade 12 or GED
(High school graduate)
5 College 1 year to 3
years (Some college or
technical school)
6 College 4 years or
more (College
graduate)
Do not read:
9 Refused
1 Own
Other
175
2 Rent
arrangeme
3 Other arrangement
nt may
7 Don't know / Not
include
sure
group
9 Refused
home,
staying
with
friends or
family
without
C08.08 C08.09 C08.10
In what county do you currently live? What is the ZIP Code where you currently live? Not including cell phones or numbers used for computers, fax machines or security systems, do you have more than one
CTYCODE 2
ZIPCODE1
NUMHHO L3
_ _ _ANSI County Code 777 Don't know / Not sure 999 Refused _ _ _ _ _ 77777 Do not know 99999 Refused
1 Yes
2 No 7 Don't know / Not sure 9 Refused
paying rent. Home is defined as the place where you live most of the time/the majority of the year. Read if necessary: We ask this question in order to compare health indicators among people with different housing situations.
176-178
179-183
Do not ask
184
this question
if cell
telephone
interview. If
cell interview
go to 8.12
Go to C08.12
C08.11 C08.12
telephone number in your household? How many of these telephone numbers are residential numbers? How many cell phones do you have for personal use?
NUMPHO N3
Enter number (1-5) 6 Six or more 7 Don't know / Not sure 8 None 9 Refused
CPDEMO1 B
Enter number (1-5) 6 Six or more 7 Don't know / Not sure 8 None 9 Refused
C08.13
Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?
VETERAN 3
1 Yes 2 No 7 Don't know / Not sure 9 Refused
C08.14
Are you
EMPLOY1
currently...?
Read: 1 Employed for wages 2 Self-employed 3 Out of work for 1 year or more 4 Out of work for less than 1 year 5 A Homemaker 6 A Student
185
Last question Read if
186
needed for necessary:
partial
Include cell
complete. phones
used for
both
business
and
personal
use.
Read if
187
necessary:
Active duty
does not
include
training for
the
Reserves
or National
Guard, but
DOES
include
activation,
for
example,
for the
Persian
Gulf War.
If more
188
than one,
say "select
the
category
which best
describes
you".
C08.15 C08.16
C08.17
How many children less than 18 years of age live in your household? Is your annual household income from all sources--
About how much do you weigh without shoes?
CHILDREN INCOME2
WEIGHT2
7 Retired Or 8 Unable to work Do not read: 9 Refused _ _ Number of children 88 None 99 Refused
Read if necessary: 04 Less than $25,000 If no, ask 05; if yes, ask 03 ($20,000 to less than $25,000) 03 Less than $20,000 If no, code 04; if yes, ask 02 ($15,000 to less than $20,000) 02 Less than $15,000 If no, code 03; if yes, ask 01 ($10,000 to less than $15,000) 01 Less than $10,000 If no, code 02 05 Less than $35,000 If no, ask 06 ($25,000 to less than $35,000) 06 Less than $50,000 If no, ask 07 ($35,000 to less than $50,000) 07 Less than $75,000 If no, code 08 ($50,000 to less than $75,000) 08 $75,000 or more Do not read: 77 Don't know / Not sure 99 Refused _ _ _ _ Weight (pounds/kilograms) 7777 Don't know / Not sure 9999 Refused
189-190
If respondent refuses at ANY income level, code `99' (Refused)
191-192
If respondent answers in metrics, put 9 in
193-196
C08.18 C08.19 C08.20
About how tall are you without shoes?
HEIGHT3
_ _ / _ _ Height (ft / inches/meters/centim eters) 77/ 77 Don't know / Not sure 99/ 99 Refused
To your knowledge, are you now pregnant?
PREGNAN T
1 Yes 2 No 7 Don't know / Not sure 9 Refused
Some people who are deaf or have serious difficulty hearing use assistive devices to communica te by phone. Are you deaf or do you have serious difficulty hearing?
DEAF
1 Yes 2 No 7 Don't know / Not sure 9 Refused
Skip if Male (M28.01, BIRTHSEX, is coded 1). If M28.01=miss ing and (CP05=1 or LL12=1; or LL09 = 1 or LL07 =1). or C08.01), or AGE, is greater than 49
first column. Round fractions up If respondent answers in metrics, put 9 in first column. Round fractions down
197-200 201 202
C08.21 Are you
BLIND
1 Yes
203
blind or do
2 No
you have
7 Don't know / Not
serious
sure
difficulty
9 Refused
seeing,
even when
wearing
glasses?
C08.22 Because of DECIDE 1 Yes
204
a physical,
2 No
mental, or
7 Don't know / Not
emotional
sure
condition,
9 Refused
do you
have
serious
difficulty
concentrati
ng,
rememberi
ng, or
making
decisions?
C08.23 Do you
DIFFWALK 1 Yes
205
have
2 No
serious
7 Don't know / Not
difficulty
sure
walking or
9 Refused
climbing
stairs?
C08.24 Do you
DIFFDRES 1 Yes
206
have
2 No
difficulty
7 Don't know / Not
dressing or
sure
bathing?
9 Refused
C08.25 Because of DIFFALON 1 Yes
207
a physical,
2 No
mental, or
7 Don't know / Not
emotional
sure
condition,
9 Refused
do you
have
difficulty
doing
errands
alone such
as visiting a
doctor's office or shopping?
Core Section 9: Tobacco Use
Question Question Number text
C09.01
Have you smoked at least 100 cigarettes in your entire life?
C09.02
Do you now smoke cigarettes every day, some days, or not at all?
Variable names SMOKE100
SMOKDAY2
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes
SKIP INFO/ CATI Note
2 No 7 Don't know/Not Sure 9 Refused 1 Every day 2 Some days 3 Not at all
Go to C09.05
Go to C09.04
7 Don't know Go to / Not sure C09.05
Interviewer Note (s)
Column(s)
Do not include: 208 electronic cigarettes (ecigarettes, njoy, bluetip), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs) or marijuana. 5 packs = 100 cigarettes
209
9 Refused
C09.03 During the STOPSMK2 1 Yes
Go to
210
past 12
2 No
C09.05
months,
7 Don't know (skip
have you
/ Not sure C09.04)
stopped
9 Refused
smoking for
C09.04
one day or longer because you were trying to quit smoking? How long has it been since you last smoked a cigarette, even one or two puffs?
LASTSMK2
Read if necessary: 01 Within the past month (less than 1 month ago) 02 Within the past 3 months (1 month but less than 3 months ago) 03 Within the past 6 months (3 months but less than 6 months ago) 04 Within the past year (6 months but less than 1 year ago) 05 Within the past 5 years (1 year but less than 5 years ago) 06 Within the past 10 years (5 years but less than 10 years ago) 07 10 years or more 08 Never smoked regularly
211-212
C09.05
Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?
USENOW3
77 Don't know / Not sure 99 Refused 1 Every day 2 Some days 3 Not at all 7 Don't know / Not sure 9 Refused
Read if
213
necessary: Snus
(Swedish for
snuff) is a moist
smokeless
tobacco, usually
sold in small
pouches that are
placed under the
lip against the
gum.
Core Section 10: Alcohol Consumption
Question Question text Variable Responses
Number
names
(DO NOT
READ
UNLESS
OTHERWISE
NOTED)
C10.01 During the ALCDAY5 1 _ _ Days
past 30 days,
per week
how many
2 _ _ Days in
days per
past 30 days
week or per
month did
you have at
least one
drink of any
alcoholic beverage
888 No drinks in past
such as beer,
30 days
wine, a malt beverage or
777 Don't know / Not
liquor?
sure
999 Refused
C10.02 One drink is AVEDRNK2 _ _ Number
equivalent to
of drinks
a 12-ounce
88 None
beer, a 5-
77 Don't
ounce glass of
know / Not
wine, or a
sure
drink with
99 Refused
one shot of
liquor. During
the past 30
days, on the
days when
you drank,
about how
many drinks
did you drink
on the
average?
C10.03 Considering DRNK3GE5 _ _ Number
all types of
of times
alcoholic
88 None
beverages,
77 Don't
how many
know / Not
times during
sure
SKIP INFO/ CATI Note
Go to next section
CATI X = 5 for men, X = 4 for women
Interviewer Note (s)
INTERVIEWER NOTE: One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor.
Read if necessary: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.
Column(s) 214-216 217-218
219-220
C10.04
the past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion? During the past 30 days, what is the largest number of drinks you had on any occasion?
MAXDRNKS
99 Refused
_ _ Number of drinks 77 Don't know / Not sure 99 Refused
221-222
Core Section 11: Exercise (Physical Activity)
Question Question text Variable
Number
names
C11.01
During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
EXERANY2
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
1 Yes
2 No 7 Don't know/Not Sure 9 Refused
Go to C 11.08
Interviewer Note Column(s) (s)
If respondent
223
does not have a
regular job or is
retired, they may
count the
physical activity
or exercise they
spend the most
time doing in a
regular month.
C11.02
What type of physical activity or exercise did you spend the most time doing during the past month?
EXRACT11
__ __ Specify from Physical Activity Coding List
77 Don't know/ Not Sure 99 Refused
Go to C11.08
See Physical Activity Coding List.
If the respondent's activity is not included in the physical activity coding list, choose the option listed as "other".
224-225
C11.03
How many times per week or per month did you
EXEROFT1
1_ _ Times per week 2_ _ Times per month
226-228
C11.04 C11.05
C11.06 C11.07
take part in this activity during the past month?
777 Don't know / Not sure 999 Refused
And when you took part in this activity, for how many minutes or hours did you usually keep at it?
EXERHMM1
_:_ _ Hour
s and minutes 777 Don't know / Not sure 999 Refused
What other type of physical activity gave you the next most exercise during the past month?
EXRACT21
__ __ Specify from Physical Activity List
88 No other activity 77 Don't know/ Not Sure 99 Refused
Go to C11.08
How many times per week or per month did you take part in this activity during the past month?
EXEROFT2
1_ _ Times per week 2_ _ Times per month 777 Don't know / Not sure 999 Refused
And when you took part in this activity, for how many minutes or hours did you usually keep at it?
EXERHMM2
_:_ _ Hour
s and minutes 777 Don't know / Not sure 999 Refused
229-231
See Physical Activity Coding List.
232-233
If the respondent's activity is not included in the physical activity coding list, choose the option listed as "other".
234-236
237-239
C11.08
During the past month, how many times per week or per month did you do physical activities or exercises to strengthen your muscles?
STRENGTH
1_ _ Times per week 2_ _Times per month 888 Never 777 Don't know / Not sure 999 Refused
Do not count aerobic activities like walking, running, or bicycling. Count activities using your own body weight like yoga, sit-ups or pushups and those using weight machines, free weights, or elastic bands.
240-242
Core Section 12: Fruits and Vegetables
Question Question text Variable
Number
names
C12.01
Now think about the foods you ate or drank during the past month, that is, the past 30 days, including meals and snacks.
FRUIT2
Not including juices, how often did you eat fruit? You can tell me times per day, times per
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
1_ _ Day 2_ _ Week 3_ _ Month 300 Less than once a month 555 Never 777 Don't Know 999 Refused
SKIP INFO/ CATI Note
Interviewer Note Column(s) (s)
If a respondent indicates that they consume a food item every day then enter the number of times per day. If the respondent indicates that they eat a food less than daily, then enter times per week or time per month. Do not enter time per day unless the respondent reports that
243-245
week or times per month.
C12.02
Not including fruit-flavored drinks or fruit juices with added sugar, how often did you drink 100% fruit juice such as apple or orange juice?
FRUITJU2
1_ _ Day 2_ _ Week 3_ _ Month 300 Less than once a month 555 Never 777 Don't Know 999 Refused
he/she consumed that food item each day during the past month.
Enter quantity in times per day, week, or month. If respondent gives a number without a time frame, ask "was that per day, week, or month?"
Read if respondent asks what to include or says `i don't know': include fresh, frozen or canned fruit. Do not include dried fruits.
Read if respondent asks about examples of fruit-flavored drinks: "do not include fruitflavored drinks with added sugar like cranberry cocktail, Hi-C, lemonade, KoolAid, Gatorade, Tampico, and sunny delight. Include only 100% pure juices or 100% juice blends."
246-248
C12.03
How often did you eat a green leafy or lettuce salad, with or without other vegetables?
FVGREEN1
1_ _ Day 2_ _ Week 3_ _ Month 300 Less than once a month 555 Never 777 Don't Know 999 Refused
C12.04
How often did you eat any kind of fried potatoes, including French fries, home fries, or hash browns?
FRENCHF1
1_ _ Day 2_ _ Week 3_ _ Month 300 Less than once a month 555 Never 777 Don't Know 999 Refused
Enter quantity in times per day, week, or month. If respondent gives a number without a time frame, ask "Was that per day, week, or month?"
Enter quantity in times per day, week, or month. If respondent gives a number without a time frame, ask "Was that per day, week, or month?"
249-251
Read if respondent asks about spinach: "Include spinach salads."
Enter quantity in times per day, week, or month. If respondent gives a number without a time frame, ask "Was that per day, week, or month?"
252-254
Read if respondent asks about potato chips: "Do not include potato chips."
C12.05
How often did you eat any other kind of potatoes, or sweet potatoes, such as baked, boiled, mashed potatoes, or potato salad?
POTATOE1
1_ _ Day 2_ _ Week 3_ _ Month 300 Less than once a month 555 Never 777 Don't Know 999 Refused
C12.06
Not including lettuce salads and potatoes, how often did you eat other vegetables?
VEGETAB2
1_ _ Day 2_ _ Week 3_ _ Month 300 Less than once a month 555 Never 777 Don't Know 999 Refused
Enter quantity in times per day, week, or month. If respondent gives a number without a time frame, ask "Was that per day, week, or month?"
255-257
Read if respondent asks about what types of potatoes to include: "Include all types of potatoes except fried. Include potatoes au gratin, scalloped potatoes."
Enter quantity in times per day, week, or month. If respondent gives a number without a time frame, ask "Was that per day, week, or month?"
258-260
Read if respondent asks about what to include: "Include tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens, and broccoli. Include raw, cooked, canned, or frozen
vegetables. Do not include rice."
Core Section 13: Immunization
Question Question text Variable
Number
names
C13.01 C13.02 C13.03
During the past 12 months, have you had either a flu vaccine that was sprayed in your nose or a flu shot injected into your arm? During what month and year did you receive your most recent flu vaccine that was sprayed in your nose or flu shot injected into your arm? Have you
received a
tetanus shot
in the past 10
years?
FLUSHOT7 FLSHTMY3 TETANUS1
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes
2 No 7 Don't know / Not sure 9 Refused
_ _ / _ _ _ _ Month/ Year 777777 Don't know/ Not sure 999999 Refused
SKIP INFO/ CATI Note
Go to C13.03
Module on Place of Flu Shot Vaccination may be inserted after this question.
Interviewer Note (s)
A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.
Column(s) 261
262-267
1 Yes, received Tdap 2 Yes, received tetanus shot, but not Tdap 3 Yes, received tetanus shot
If yes, ask: Was 268 this Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?
C13.04
but not sure what type 4 No, did not receive any tetanus shot in the past 10 years 7 Don't know/Not sure 9 Refused
Have you ever had a pneumonia shot also known as a pneumococcal vaccine?
PNEUVAC4
1 Yes 2 No 7 Don't know / Not sure 9 Refused
Read if
269
necessary:
There are two
types of
pneumonia
shots:
polysaccharide,
also known as
Pneumovax, and
conjugate, also
known as
Prevnar.
Core Section 14: H.I.V./AIDS
Question Question text Variable
Number
names
C14.01
The next few questions are about the national health problem of H.I.V., the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don't have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.
HIVTST7
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes
2 No 7 Don't know/ not sure 9 Refused
SKIP INFO/ CATI Note
Go to C14.03
Interviewer Note Column(s) (s)
270
Including fluid testing from your mouth, but not including tests you
C14.02 C14.03
may have had for blood donation, have you ever been tested for H.I.V? Not including blood donations, in what month and year was your last H.I.V. test?
I am going to read you a list. When I am done, please tell me if any of the situations apply to you. You do not need to tell me which one.
HIVTSTD3 HIVRISK5
_ _ /_ _ _ _ Code month and year 77/ 7777 Don't know / Not sure 99/ 9999 Refused
If response is before January 1985, code "777777".
1 Yes 2 No
7 Don't know / Not sure 9 Refused
INTERVIEWER NOTE: If the respondent remembers the year but cannot remember the month, code the first two digits 77 and the last four digits for the year.
271-276 277
You have injected any drug other than those prescribed for you in the past year. You have been treated for a sexually transmitted disease or STD in the past year.
You have given or received money or drugs in exchange for sex in the past year. You had anal sex without a condom in the past year. You had four or more sex partners in the past year. Do any of these situations apply to you?
Do any of these situations apply to you?
Closing Statement/ Transition to Modules
Read if necessary
Read
That was my last question. Everyone's answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.
CATI instructions (not read) Read if no optional modules follow, otherwise continue to optional modules.
Optional Modules
Module 1: Prediabetes
Question Number M01.01
M01.02
Question text
Have you had a test for high blood sugar or diabetes within the past three years? Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?
Variable names PDIABTST
PREDIAB1
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes 2 No 7 Don't know/ not sure 9 Refused
1 Yes 2 Yes, during pregnancy 3 No 7 Don't know / Not sure 9 Refused
SKIP INFO/ CATI Note
Skip if Section C06.11, DIABETE3, is coded 1
Skip if Section 06.11, DIABETE3, is coded 1; If C06.11, DIABETE3, is coded 4 automatically code M01.02, PREDIAB1, equal to 1 (yes);
Interviewer Note (s)
If Yes and respondent is female, ask: Was this only when you were pregnant?
Column(s) 278 279
Module 2: Diabetes
Question Question text Variable
Number
names
M02.01 Are you now INSULIN taking insulin?
M02.02
About how often do you check your blood for glucose or sugar?
BLDSUGAR
M02.03
Including times when checked by a family
FEETCHK3
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes 2 No 7 Don't know/ not sure 9 Refused
1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month
4 _ _ Times per year
888 Never
777 Don't know / Not sure 999 Refused
1 _ _ Times per day 2 _ _ Times per week
SKIP
Interviewer
INFO/
Note (s)
CATI Note
To be asked following Core Q6.12; if response to Q6.11 is Yes (code = 1)
Read if necessary: Include times when checked by a family member or friend, but do not include times when checked by a health professional.
Do not read: If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously), fill in `98 times per day.'
Column(s) 280 281-283
284-286
member or friend, about how often do you check your feet for any sores or irritations?
3 _ _ Times per month
4 _ _ Times per year 555 No feet
888 Never
M02.04 M02.05 M02.06
About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes? About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for A-one-C?
About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
DOCTDIAB CHKHEMO3 FEETCHK
777 Don't know / Not sure 999 Refused _ _ Number of times [76 = 76 or more] 88 None 77 Don't know / Not sure 99 Refused
_ _ Number of times [76 = 76 or more] 88 None 98 Never heard of Aone-C test 77 Don't know / Not sure 99 Refused _ _ Number of times [76 = 76 or more] 88 None 77 Don't know / Not sure 99 Refused
If M02.03 = 555 (No feet), go to M02.07
287-288
Read if necessary: A test for A-one-C measures the average level of blood sugar over the past three months.
289-290
291-292
M02.07 When was the EYEEXAM1 Read if
293
last time you
necessary:
had an eye
1 Within the
exam in which
past month
the pupils
(anytime
were dilated,
less than 1
making you
month ago)
temporarily
2 Within the
sensitive to
past year (1
bright light?
month but
less than 12
months ago)
3 Within the
past 2 years
(1 year but
less than 2
years ago)
4 2 or more
years ago
Do not read:
7 Don't
know / Not
sure
8 Never
9 Refused
M02.08 Has a doctor DIABEYE 1 Yes
294
ever told you
2 No
that diabetes
7 Don't
has affected
know/ not
your eyes or
sure
that you had
9 Refused
retinopathy?
M02.09 Have you ever DIABEDU 1 Yes
295
taken a
2 No
course or
7 Don't
class in how
know/ not
to manage
sure
your diabetes
9 Refused
yourself?
Module 3: ME/CFS
Question Question text Number
Variable names
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
M03.01
Have you ever been told by a doctor or other health professional that you had Chronic Fatigue Syndrome (CFS) or (Myalgic Encephalomyelitis) ME?
TOLDCFS
1 Yes 2 No 7 Don't know / Not sure 9 Refused
Go to next section
M03.02
Do you still have Chronic Fatigue Syndrome (CFS) or (Myalgic Encephalomyelitis) ME?
HAVECFS
1 Yes 2 No 7 Don't know/ Not sure 9 Refused
M03.03
Thinking about your CFS or ME, during the past 6 months, how many hours a week on average have you been able to work at a job or business for pay?
WORKCFS
Read if necessary 1 0 or no hours -cannot work at all because of CFS or ME 2 1 - 10 hours a week 3 11- 20 hours a week 4 21- 30 hours a week 5 31 - 40 hours a week
Interviewer Note (s)
My-al-gic En-ceph-a-lomy-eli-tis
My-al-gic En-ceph-a-lomy-eli-tis
Column(s) 296
297 298
Do not read 7 Don't know/ Not sure 9 Refused
Module 4: Hepatitis Treatment
Question Question text Variable
Number
names
M04.01 M04.02
Have you ever been told by a doctor or other health professional that you had Hepatitis C? Were you treated for Hepatitis C in 2015 or after?
TOLDHEPC TRETHEPC
M04.03
Were you treated for Hepatitis C prior to 2015?
PRIRHEPC
M04.04
Do you still
HAVEHEPC
have Hepatitis
C?
M04.05 The next question is
HAVEHEPB
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes 2 No 7 Don't know / Not sure 9 Refused
SKIP INFO/ CATI Note
Go to M04.05
Interviewer Note (s)
Hepatitis C is an infection of the liver from the Hepatitis C virus
Column(s) 299
1 Yes 2 No 7 Don't know/ Not sure 9 Refused
1 Yes 2 No 7 Don't know/ Not sure 9 Refused
1 Yes 2 No 7 Don't know/ Not sure 9 Refused
1 Yes
Most hepatitis C 300
treatments
offered in 2015
or after were
oral medicines
or pills.
Including
Harvoni, Viekira,
Zepatier,
Epclusa and
others.
Most hepatitis C 301
treatments
offered prior to
2015 were shots
and pills given
weekly or more
often over many
months.
You may still
302
have Hepatitis C
and feel
healthy. Your
blood must be
tested again to
tell if you still
have Hepatitis
C.
Hepatitis B is an 303
infection of the
M04.06
about Hepatitis B. Has a doctor, nurse, or other health professional ever told you that you had hepatitis B? Are you currently taking medicine to treat hepatitis B?
MEDSHEPB
2 No 7 Don't know/ Not sure 9 Refused
1 Yes 2 No 7 Don't know/ Not sure 9 Refused
Go to next section
liver from the hepatitis B virus.
304
Module 5: HPV - Vaccination
Questio Question
n
text
Number
Variable names
M05.01
Have you ever had the Human Papilloma virus vaccination or HPV vaccination ?
HPVADVC 3
M05.02
How many HPV shots did you receive?
HPVADSH T
Responses (DO NOT READ UNLESS OTHERWIS E NOTED) 1 Yes
2 No 7 Don't know / Not sure 9 Refused
_ _ Number of shots (12) 3 All shots 77 Don't know / Not sure 99 Refused
SKIP INFO/ CATI Note
To be asked of respondent s between the ages of 18 and 49 years; otherwise, go to next module Go to next module
Interviewer Note (s)
A vaccine to prevent the human papilloma virus or HPV infection is available and is called the cervical cancer or genital warts vaccine, HPV shot, [Fill: if female "GARDASIL or CERVARIX", if male "GARDASIL"]. (Human Papilloma Virus (Human Pap·uh·loh·mu h Virus), Gardasil (Gar·duh· seel), Cervarix (Serv a rix))
Column s 305
306-307
Module 6: Place of Flu Vaccination
Question Question Variable Responses
Number text
names
(DO NOT READ
UNLESS
OTHERWISE
NOTED)
M06.01 At what
IMFVPLA1 Read if
kind of
necessary:
place did
01 A doctor's
you get
office or health
your last flu
maintenance
shot or
organization
vaccine?
(HMO)
02 A health
department
03 Another type
of clinic or
health center (a
community
health center)
04 A senior,
recreation, or
community
center
05 A store
(supermarket,
drug store)
06 A hospital
(inpatient or
outpatient)
07 An
emergency
room
08 Workplace
09 Some other
kind of place
11 A school
Do not read:
10 Received
vaccination in
Canada/Mexico
77 Don't know /
Not sure
99 Refused
SKIP INFO/ CATI Note
Ask if 13.01= 1 This question may be inserted in core after C13.02
Interviewer Note (s)
Read if necessary: How would you describe the place where you went to get your most recent flu vaccine?
Column(s) 308-309
Module 7: Shingles Vaccination
Question Question Number text
Variable names
M07.01
Have you ever had the shingles or zoster vaccine?
SHINGLE2
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
1 Yes
Do not ask Shingles is an 310
2 No
this
illness that
7 Don't know / question results in a rash
Not sure
and go to or blisters on
9 Refused
next
the skin and is
section if usually painful.
age 49. There are two
vaccines now
available for
shingles:
Zostavax, which
requires 1 shot
and Shingrix
which requires 2
shots.
Module 8: Lung Cancer Screening
Question Question Number text
Variable names
M08.01
You've told us that you have smoked in the past or are currently smoking. The next questions are about screening for lung cancer.
LCSFIRST
How old were you when you first started to smoke cigarettes regularly?
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note Column(s) (s)
_ _ _ Age in Years (001 100) 777 Don't know/Not sure 999 Refused
888 Never smoked cigarettes regularly
If C09.01=1 (yes) and C09.02 = 1, 2, or 3 (every day, some days, or not at all) continue, else go to question M08.04.
Go to M08.04
Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all).
311-313
If respondent indicates age inconsistent with previously entered age, verify that this is the correct answer and change the age of the respondent regularly smoking or make a note to correct the age of the respondent.
M08.02 M08.03
How old were you when you last smoked cigarettes regularly?
On average, when you [smoke/ smoked] regularly, about how many cigarettes {do/did} you usually smoke each day?
LCSLAST LCSNUMCG
_ _ _ Age in Years (001 100) 777 Don't know/Not sure 999 Refused _ _ _
Num ber of cigarettes 777 Don't know/Not sure 999 Refused
M08.04
The next question is about CT or CAT scans. During this test, you lie
LCSCTSCN
Read if necessary: 1 Yes, to check for lung cancer
314-316
Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all). Respondents may answer in packs instead of number of cigarettes. Below is a conversion table: 0.5 pack = 10 cigarettes/ 1.75 pack = 35 cigarettes/ 0.75 pack = 15 cigarettes/ 2 packs = 40 cigarettes/ 1 pack = 20 cigarettes/ 2.5 packs= 50 cigarettes/ 1.25 pack = 25 cigarettes/ 3 packs= 60 cigarettes/ 1.5 pack = 30 cigarettes
317-319 320
flat on your back on a table. While you hold your breath, the table moves through a donut shaped x-ray machine while the scan is done. In the last 12 months, did you have a CT or CAT scan?
2 No (did not have a CT scan) 3 Had a CT scan, but for some other reason Do not read: 7 Don't know/not sure 9 Refused
Module 9: Breast and Cervical Cancer Screening
Questio n Number M09.01
M09.02
Question text
(The next questions are about breast and cervical cancer.) Have you ever had a mammogram ?
How long has it been since you had your last mammogram ?
Variable names HADMAM
HOWLON G
Responses (DO NOT READ UNLESS OTHERWIS E NOTED) 1 Yes
2 No 7 Don't know/ not sure 9 Refused Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3
SKIP INFO/ CATI Note
Skip to next module if male ((M28.01, BIRTHSEX, is coded 1). If M28.01=missin g and (CP05=1 or LL12=1; or LL09 = 1 or LL07 =1). Go to M09.03
Interviewer Note (s)
A mammogram is an x-ray of each breast to look for breast cancer.
Column(s ) 321
322
years but
less than 5
years ago)
5 5 or more
years ago
7 Don't
know / Not
sure
9 Refused
M09.03 Have you ever HADPAP2 1 Yes
323
had a Pap test?
2 No
Go to M09.05
7 Don't know / Not sure 9 Refused
M09.04 How long has LASTPAP2 Read if
324
it been since
necessary:
you had your
1 Within
last Pap test?
the past
year
(anytime
less than 12
months
ago)
2 Within
the past 2
years (1
year but
less than 2
years ago)
3 Within
the past 3
years (2
years but
less than 3
years ago)
4 Within
the past 5
years (3
years but
less than 5
years ago)
5 5 or more
years ago
7 Don't know / Not sure 9 Refused
M09.05 M09.06
An H.P.V. test is sometimes given with the Pap test for cervical cancer screening. Have you ever had an H.P.V. test? How long has it been since you had your last H.P.V. test?
HPVTEST HPLSTTST
1 Yes 2 No
Go to M09.07
7 Don't know / Not sure 9 Refused
Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago
Human
325
papillomarviru
s (pap-uh-loh-
muh virus)
326
7 Don't know / Not sure 9 Refused
M09.07
Have you had a hysterectomy ?
HADHYST2
1 Yes 2 No 7 Don't know / Not sure 9 Refused
If response to Read if
327
Core Q8.19 = 1 necessary: A
(is pregnant) do hysterectomy
not ask and go is an operation
to next section. to remove the
uterus
(womb).
Module 10: Prostate Cancer Screening
Question Question text Variable Responses
Number
names
(DO NOT
READ
UNLESS
OTHERWISE
NOTED)
M10.01 Has a doctor, PCPSAAD3 1 Yes
nurse, or
2 No
other health
7 Don't
professional
know/ not
ever talked
sure
with you
9 Refused
about the
advantages of
the Prostate-
Specific
Antigen or
P.S.A. test?
M10.02 M10.03
Has a doctor, nurse, or other health professional ever talked with you about the disadvantages of the P.S.A. test? Has a doctor, nurse, or other health professional ever recommended that you have a P.S.A. test?
PCPSADI1 PCPSARE1
1 Yes 2 No 7 Don't know/ not sure 9 Refused
1 Yes 2 No
7 Don't know / Not sure 9 Refused
SKIP INFO/ CATI Interviewer
Note
Note (s)
If respondent is 39 years of age, or is female, (M28.01, BIRTHSEX, is coded 2). If M28.01=missing and (CP05=2 or LL12=2; or LL09 = 2 or LL07 =2). go to next section.
Read if necessary: A prostatespecific antigen test, also called a P.S.A. test, is a blood test used to check men for prostate cancer.
Column(s) 328
329 330
M10.04 Have you ever PSATEST1 1 Yes
331
had a P.S.A. test?
2 No 7 Don't
Go to next section
know / Not
sure
9 Refused
M10.05 How long has PSATIME Read if
332
it been since
necessary:
you had your
1 Within the
last P.S.A.
past year
test?
(anytime
less than 12
months ago)
2 Within the
past 2 years
(1 year but
less than 2
years ago)
3 Within the
past 3 years
(2 years but
less than 3
years ago)
4 Within the
past 5 years
(3 years but
less than 5
years ago)
5 5 or more
years ago
Do not read:
7 Don't
know / Not
sure
9 Refused
M10.06 What was the PCPSARS1 Read:
333
main reason
1 Part of a
you had this
routine
P.S.A. test
exam
was it ...?
2 Because of
a prostate
problem
3 Because of
a family
history of
prostate
cancer
4 Because
you were
told you had
prostate
cancer
5 Some other reason Do not read: 7 Don't know / Not sure 9 Refused
Module 11: Prostate Cancer Screening Decision Making
Question Question Variable
Number text
names
M11.01
Which one of the following best describes the decision to have the P.S.A. test done?
PCPSADE1
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ Interviewer CATI Note Note (s)
Read: 1 You made the decision alone
If M10.04= 1, continue, otherwise GOTO next module.
If M11.01 = 1, go to next module.
Read: 2 Your doctor, nurse, or health care provider made the decision alone
Go to next module.
Column(s) 334
3 You and one or Continue
more other
with 11.02
persons made the
decision together
4 You don't know Go to next
how the decision module.
was made
Do not read:
9 Refused
M11.02 Who made PCDMDEC1 Read if necessary:
Select one
335
the
1 Doctor/nurse
response. If
decision
/health care
respondent
with you?
provider
offers more
2
than one
Spouse/significant
response ask
other
for primary
3 Other family
person who
member
made
4 Friend/non-
decision.
relative
Do not read: 7 Don't know / Not sure 9 Refused
Module 12: Colorectal Cancer Screening
Question Question text Number
M12.01 M12.02
A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit? How long has it been since you had your last blood stool test using a home kit?
Variable names BLDSTOOL
LSTBLDS3
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes
2 No 7 Don't know/ not sure 9 Refused
SKIP INFO/ CATI Note
Skip if Section 08.02, AGE, is less than 50 Go to M12.03
Interviewer Note (s)
Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago Do not read: 7 Don't know / Not sure 9 Refused
Column(s) 336
337
M12.03 Sigmoidoscopy HADSIGM3 1 Yes
338
and colonoscopy are exams in which a tube is inserted in the rectum to view
2 No
7 Don't know / Not sure 9 Refused
Go to next section
the colon for
signs of cancer
or other health
problems. Have
you ever had
either of these
exams?
M12.04 For a
HADSGCO1 1
339
sigmoidoscopy,
Sigmoidoscopy
a flexible tube is
2 Colonoscopy
inserted into the
7 Don't know /
rectum to look
Not sure
for problems. A
9 Refused
colonoscopy is
similar, but uses
a longer tube,
and you are
usually given
medication
through a
needle in your
arm to make
you sleepy and
told to have
someone else
drive you home
after the test.
Was your most
recent exam a
sigmoidoscopy
or a
colonoscopy?
M12.05 How long has it LASTSIG3 Read if
340
been since you
necessary:
had your last
1 Within the
sigmoidoscopy
past year
or colonoscopy?
(anytime less
than 12
months ago)
2 Within the
past 2 years (1
year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 Within the past 10 years (5 years but less than 10 years ago) 6 10 or more years ago Do not read: 7 Don't know / Not sure 9 Refused
Module 13: Cancer Survivorship
Questio Question
n
text
Number
Variable names
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
M13.01
You've told us that you have had cancer. I would like to ask you a few more questions about your cancer.
CNCRDIFF
1 Only one 2 Two 3 Three or more
M13.02
How many different types of cancer have you had?
At what age were you told that you had cancer?
CNCRAGE
7 Don't know / Not sure 9 Refused _ _ Age in Years (97 = 97 and older) 98 Don't know/Not sure 99 Refused
SKIP
Interviewer
INFO/
Note (s)
CATI Note
Column(s )
If C06.06
341
or C06.07
= 1 (Yes)
or M10.06
= 4
(Because
you were
told you
had
prostate
cancer)
continue,
else go to
next
module.
Go to next module
If M13.01= 2 (Two) or 3 (Three or more), ask: At what age were you first diagnosed with cancer? Read if necessary: This question refers to the first time they were told about their first cancer.
342-343
M13.03
What type of cancer was it?
CNCRTYP1
Read if respondent needs prompting for cancer type: 01 Breast cancer Female reproductive (Gynecologic) 02 Cervical cancer (cancer of the cervix) 03 Endometrial cancer (cancer of the uterus) 04 Ovarian cancer (cancer of the ovary) Head/Neck 05 Head and neck cancer 06 Oral cancer 07 Pharyngeal (throat) cancer 08 Thyroid 09 Larynx Gastrointestinal 10 Colon (intestine) cancer 11 Esophageal (esophagus) 12 Liver cancer 13 Pancreatic (pancreas) cancer 14 Rectal (rectum) cancer 15 Stomach Leukemia/Lymphom a (lymph nodes and bone marrow) 16 Hodgkin's Lymphoma (Hodgkin's disease) 17 Leukemia (blood) cancer 18 Non-Hodgkin's Lymphoma Male reproductive 19 Prostate cancer 20 Testicular cancer Skin 21 Melanoma 22 Other skin cancer
If C06.06 = 1 (Yes) and M11.01 = 1 (Only one): ask Was it Melanom a or other skin cancer? then code 21 if Melanom a or 22 if other skin cancer
CATI note: If C16.06 = 4 (Because you were told you had Prostate Cancer) and Q1 = 1 (Only one) then code 19.
If M13.01 = 2 (Two) or 3 (Three or more), ask: With your most recent diagnoses of cancer, what type of cancer was it?
344-345
M13.04 M13.05
Are you currently receiving treatment for cancer?
What type of doctor provides the majority of your health care? Is it a....
CSRVTRT3
CSRVDOC 1
Thoracic 23 Heart 24 Lung Urinary cancer 25 Bladder cancer 26 Renal (kidney) cancer Others 27 Bone 28 Brain 29 Neuroblastoma 30 Other Do not read: 77 Don't know / Not sure 99 Refused Read if necessary: 1 Yes
2 No, I've completed treatment 3 No, I've refused treatment 4 No, I haven't started treatment 7 Don't know / Not sure 9 Refused Read: 01 Cancer Surgeon 02 Family Practitioner 03 General Surgeon 04 Gynecologic Oncologist 05 General Practitioner, Internist 06 Plastic Surgeon, Reconstructive Surgeon 07 Medical Oncologist 08 Radiation Oncologist 09 Urologist 10 Other Do not read:
Go to next module
Go to next module
Read if
346
necessary: By
treatment, we
mean surgery,
radiation
therapy,
chemotherapy
, or
chemotherapy
pills.
If the respondent requests clarification of this question, say: We want to know which type of doctor you see most often for illness or regular health care (Examples: annual exams and/or physicals, treatment of colds, etc.).
347-348
77 Don't know / Not sure 99 Refused
M13.06 M13.07
Did any doctor, nurse, or other health professiona l ever give you a written summary of all the cancer treatments that you received? Have you ever received instructions from a doctor, nurse, or other health professiona l about where you should return or who you should see for routine cancer check-ups after completing your
CSRVSUM
CSRVRTR N
1 Yes 2 No 7 Don't know/ not sure 9 Refused
1 Yes 2 No 7 Don't know/ not sure 9 Refused
Go to M13.09
Read if
necessary: An
oncologist is a
medical
doctor who
manages a
person's care
and treatment
after a cancer
diagnosis.
Read if
349
necessary: By
`other
healthcare
professional',
we mean a
nurse
practitioner, a
physician's
assistant,
social worker,
or some other
licensed
professional.
350
treatment for cancer?
M13.08 M13.09
M13.10 M13.11 M13.12
Were these instructions written down or printed on paper for you? With your most recent diagnosis of cancer, did you have health insurance that paid for all or part of your cancer treatment? Were you ever denied health insurance or life insurance coverage because of your cancer? Did you participate in a clinical trial as part of your cancer treatment? Do you currently have physical pain caused by your cancer
CSRVINST CSRVINSR
CSRVDEIN CSRVCLIN CSRVPAIN
1 Yes 2 No 7 Don't know/ not sure 9 Refused
1 Yes 2 No 7 Don't know/ not sure 9 Refused
1 Yes 2 No 7 Don't know/ not sure 9 Refused
1 Yes 2 No 7 Don't know/ not sure 9 Refused
1 Yes 2 No 7 Don't know/ not sure 9 Refused
351
Read if
352
necessary:
Health
insurance also
includes
Medicare,
Medicaid, or
other types of
state health
programs.
353
354
355 Go to next module
or cancer treatment?
M13.13 Would you CSRVCTL1 Read:
356
say your
1 With medication
pain is
(or treatment)
currently
2 Without
under
medication (or
control...?
treatment)
3 Not under control,
with medication (or
treatment)
4 Not under control,
without medication
(or treatment)
Do not read:
7 Don't know / Not
sure
9 Refused
Module 14: Healthcare Access
Question Question Number text
M14.01
What is the primary source of your health care coverage?
HLTHCVR1
Responses (DO NOT READ UNLESS OTHERWISE NOTED) Read if necessary: 01 A plan purchased through an employer or union (including plans purchased through another person's employer) 02 A plan that you or another family member buys on your own 03 Medicare 04 Medicaid or other state program 05 TRICARE (formerly CHAMPUS), VA, or Military 06 Alaska Native, Indian Health Service, Tribal Health Services Or 07 Some other source
SKIP INFO/ CATI Note
Interviewer Note Column(s) (s)
If the respondent indicates that they purchased health insurance through the Health Insurance Marketplace (name of state Marketplace), ask if it was a private health insurance plan purchased on their own or by a family member (private) or if they received Medicaid (state plan)? If purchased on their own (or by a family member), select 02, if Medicaid select 04.
357-358
08 None (no coverage) Do not read: 77 Don't know/Not sure 99 Refused
Module 15: Aspirin for CVD Prevention
Question Question Number text
Variable names
M15.01
How often do you take an aspirin to prevent or control heart disease, heart attacks or stroke? Would you say....
ASPIRIN
Responses (DO NOT READ UNLESS OTHERWISE NOTED) Read: 1 Daily 2 Some days 3 Used to take it but had to stop due to side effects, or 4 Do not take it Do not read: 7 Don't know / Not sure 9 Refused
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s) 359
Module 16: Home/ Self-measured Blood Pressure
Question Question text Number
Variable names
M16.01
Has your doctor, nurse or other health professional recommended you check your blood pressure outside of the office or at home?
HOMBPCHK
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes 2 No 7 Don't know / Not sure 9 Refused
SKIP INFO/ CATI Note
M16.02 M16.03 M16.04
Do you regularly check your blood pressure outside of your healthcare professional's office or at home? Do you take it mostly at home or on a machine at a pharmacy, grocery or similar location?
How do you share your blood pressure numbers that you collected with your
HOMRGCHK WHEREBP SHAREBP
1 Yes
2 No 7 Don't know / Not sure 9 Refused
1 At home 2 On a machine at a pharmacy, grocery or similar location 3 Do not check it 7 Don't know / Not sure 9 Refused Do not read: 1 Telephone 2 Other methods such as email,
Go to next section
Interviewer Note (s)
Column(s)
By other
360
healthcare
provider
professional we
mean nurse
practitioner, a
physician
assistant, or
some other
licensed health
professional.
361
362
363
health professional? Is it mostly by telephone, other methods such as emails, internet portal or fax, or in person?
internet portal, or fax, or 3 In person Do not read: 4 Do not share information 7 Don't know / Not sure 9 Refused
Module 17: Sodium or Salt-Related Behavior
Question Question text Variable
Number
names
M17.01 M17.02
Are you currently watching or reducing your sodium or salt intake?
WTCHSALT
Has a doctor or other health professional ever advised you to reduce sodium or salt intake?
DRADVISE
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
1 Yes
364
2 No
7 Don't
know/ Not
sure
9 Refused
1 Yes
365
2 No
7 Don't
know/ Not
sure
9 Refused
Module 18: Indoor Tanning
Question Question text Variable
Number
names
M18.01
Not including spray-on tans, during the past 12 months, how many times have you used an indoor tanning device such as a sunlamp, tanning bed, or booth?
INDORTAN
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Number (0365) 777 Don't know/ Not sure 999 Refused
Column(s) 366-368
Module 19: Excess Sun Exposure
Question Question text Variable
Number
names
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
M19.01
During the past 12 months, how many times have you had a sunburn?
NUMBURN3
_ _ _ Number (0365) 777 Don't know/ Not sure 999 Refused
M19.02 M19.03
When you go outside on a warm sunny day for more than one hour, how often do you protect yourself from the sun? Is that....
SUNPRTCT
On weekdays, in the summer, how long are you outside per day between
WKDAYOUT
Read: 1 Always 2 Most of the time 3 Sometimes 4 Rarely 5 Never Do not read: 6 Don't stay outside for more than one hour on warm sunny days 8 Don't go outside at all on warm sunny days 7 Don't know/ Not sure 9 Refused 01 Less than half an hour 02 (More than half an hour) up to 1 hour
Interviewer Note Column(s) (s)
369-371
Protection from 372 the sun may include using sunscreen, wearing a widebrimmed hat, or wearing a longsleeved shirt.
Friday is a weekday. If respondent says never, code 01.
373-374
M19.04
10am and 4pm?
On weekends in the summer, how long are you outside each day between 10am and 4pm?
WKENDOUT
03 (More than 1 hour) up to 2 hours 04 (More than 2 hours) up to 3 hours 05 (More than 3 hours) up to 4 hours 06 (More than 4 hours) up to 5 hours 07 (More than 5) up to 6 hours 77 Don't know/ Not sure 99 Refused 01 Less than half an hour 02 (More than half an hour) up to 1 hour 03 (More than 1 hour) up to 2 hours 04 (More than 2 hours) up to 3 hours 05 (More than 3 hours) up to 4 hours 06 (More than 4 hours) up to 5 hours 07 (More than 5) up to 6 hours 77 Don't know/ Not sure 99 Refused
Friday is a weekday. If respondent says never, code 01.
375-376
Module 20: Cognitive Decline
Question Question text Variable
Number
names
M20.01
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
CIMEMLOS
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes
2 No
7 Don't know/ not sure
9 Refused
SKIP INFO/ CATI Note
If respondent is 45 years of age or older continue, else go to next module.
Go to M20.02 Go to next module
Go to M20.02
Go to next module
Interviewer Note (s)
Column(s) 377
difficulties impact you.
During the
past 12
months, have
you
experienced
confusion or
memory loss
that is
happening
more often or
is getting
worse?
M20.02 During the
CDHOUSE Read:
378
past 12
months, as a
1 Always
result of
2 Usually
confusion or
3 Sometimes
memory loss,
4 Rarely
how often
5 Never
have you given
Do not read:
up day-to-day
7 Don't
household
know/Not
activities or
sure
chores you
9 Refused
used to do,
such as
cooking,
cleaning,
taking
medications,
driving, or
paying bills?
Would you say
it is...
M20.03 As a result of CDASSIST Read:
379
confusion or
1 Always
memory loss,
2 Usually
how often do
3 Sometimes
you need
4 Rarely
Go to
assistance with
5 Never
M20.05
these day-to-
Do not read:
day activities?
7 Don't
Would you say
know/Not
it is...
sure
9 Refused
M20.04 When you
CDHELP Read:
380
need help with
1 Always
these day-to-
2 Usually
day activities,
3 Sometimes
how often are
4 Rarely
you able to get
5 Never
the help that
Do not read:
you need?
7 Don't
Would you say
know/Not
it is...
sure
9 Refused
M20.05 During the
CDSOCIAL Read:
381
past 12
months, how
1 Always
often has
2 Usually
confusion or
3 Sometimes
memory loss
4 Rarely
interfered with
5 Never
your ability to
Do not read:
work,
7 Don't
volunteer, or
know/Not
engage in
sure
social activities
9 Refused
outside the
home? Would
you say it is...
M20.06 Have you or CDDISCUS 1 Yes
382
anyone else
2 No
discussed your
7 Don't
confusion or
know/ not
memory loss
sure
with a health
9 Refused
care
professional?
Module 21: Caregiver
Question Question Number text
Variable names
M21.01 M21.02
During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability? What is his or her relationship to you?
CAREGIV1 CRGVREL3
M21.03
For how long have you provided care for that person?
CRGVLNG1
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes 2 No 7 Don't know/Not sure 8 Caregiving recipient died in past 30 days 9 Refused
01 Mother 02 Father 03 Mother-in-law 04 Father-in-law 05 Child 06 Husband 07 Wife 08 Live-in partner 09 Brother or brother-in-law 10 Sister or sisterin-law 11 Grandmother 12 Grandfather 13 Grandchild 14 Other relative 15 Non-relative/ Family friend 77 Don't know/Not sure 99 Refused Read if necessary: 1 Less than 30 days 2 1 month to less than 6 months
SKIP INFO/ CATI Note
Go to M21.09
Go to next module Go to M21.09
Interviewer Column(s) Note (s)
If caregiving 383 recipient has died in the past 30 days, code 8 and say: I'm so sorry to hear of your loss
If more than one person, say: Please refer to the person to whom you are giving the most care.
384-385
386
M21.04 M21.05
Would you say...
In an average week, how many hours do you provide care or assistance? Would you say...
CRGVHRS1
What is the main health problem, long-term illness, or disability that the person you care for has?
CRGVPRB3
3 6 months to less than 2 years 4 2 years to less than 5 years 5 More than 5 years Do not read: 7 Don't Know/ Not Sure 9 Refused Read if necessary: 1 Up to 8 hours per week 2 9 to 19 hours per week 3 20 to 39 hours per week 4 40 hours or more Do not read: 7 Don't know/Not sure 9 Refused 01 Arthritis/ rheumatism 02 Asthma 03 Cancer 04 Chronic respiratory conditions such as emphysema or COPD 05 Alzheimer's disease, dementia or other cognitive impairment disorder 06 Developmental disabilities such as autism, Down's Syndrome, and spina bifida 07 Diabetes 08 Heart disease, hypertension, stroke 09 Human Immunodeficiency
If M21.05 = 5 (Alzheimer's disease, dementia or other cognitive impairment disorder), go to M21.07. Otherwise, continue
387 388-389
Virus Infection
(H.I.V.)
10 Mental
illnesses, such as
anxiety,
depression, or
schizophrenia
11 Other organ
failure or diseases
such as kidney or
liver problems
12 Substance
abuse or
addiction
disorders
13 Injuries,
including broken
bones
14 Old age/
infirmity/frailty
15 Other
77 Don't
know/Not sure
99 Refused
M21.06 Does the
CRGVALZD 1 Yes
390
person you
2 No
care for also
7 Don't know/
have
Not sure
Alzheimer's
9 Refused
disease,
dementia or
other
cognitive
impairment
disorder?
M21.07 In the past CRGVPER1 1 Yes
391
30 days, did
2 No
you provide
7 Don't know/ not
care for this
sure
person by
9 Refused
managing
personal
care such as
giving
medications,
feeding,
dressing, or
bathing?
M21.08 In the past CRGVHOU1 1 Yes
392
30 days, did
2 No
you provide
7 Don't know/ not
care for this
sure
person by
9 Refused
managing
household
tasks such as
cleaning,
managing
money, or
preparing
meals?
M21.09 In the next 2 CRGVEXPT 1 Yes
If M21.01 =
393
years, do
2 No
1 or 8, go to
you expect
7 Don't know/ not next
to provide
sure
module
care or
9 Refused
assistance to
a friend or
family
member
who has a
health
problem or
disability?
Module 22: Adverse Childhood Experiences
Question Question text Number
Variable names
Prologue M22.01
I'd like to ask you some questions about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life, and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer. All questions refer to the time period before you were 18 years of age. Now, looking back before you were 18 years of age---. 1) Did you live with anyone who was depressed, mentally ill, or suicidal?
ACEDEPRS
Responses (DO NOT READ UNLESS OTHERWISE NOTED)
1 Yes 2 No 7 Don't Know/Not Sure 9 Refused
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
Be aware of the level of stress introduced by questions in this section and be familiar with the crisis plan.
394
M22.02 Did you live with
ACEDRINK 1 Yes
395
anyone who was a
2 No
problem drinker or
7 Don't
alcoholic?
Know/Not
Sure
9 Refused
M22.03 Did you live with
ACEDRUGS 1 Yes
396
anyone who used
2 No
illegal street drugs or
7 Don't
who abused
Know/Not
prescription
Sure
medications?
9 Refused
M22.04 Did you live with
ACEPRISN 1 Yes
397
anyone who served
2 No
time or was sentenced
7 Don't
to serve time in a
Know/Not
prison, jail, or other
Sure
correctional facility?
9 Refused
M22.05 Were your parents
ACEDIVRC 1 Yes
398
separated or
2 No
divorced?
8 Parents
not married
7 Don't
Know/Not
Sure
9 Refused
M22.06 How often did your ACEPUNCH Read:
399
parents or adults in
1 Never
your home ever slap,
2 Once
hit, kick, punch or
3 More than
beat each other up?
once
Was it...
Don't Read:
7 Don't
know/Not
Sure
9 Refused
M22.07 Not including
ACEHURT1 Read:
400
spanking, (before age
1 Never
18), how often did a
2 Once
parent or adult in your
3 More than
home ever hit, beat,
once
kick, or physically hurt
Don't Read:
you in any way? Was
7 Don't
it--
know/Not
Sure
9 Refused
M22.08 How often did a
ACESWEAR Read:
401
parent or adult in your
1 Never
home ever swear at
2 Once
you, insult you, or put
3 More than
you down? Was it...
once
Don't Read:
7 Don't
know/Not
Sure
9 Refused
M22.09 How often did anyone ACETOUCH Read:
402
at least 5 years older
1 Never
than you or an adult,
2 Once
ever touch you
3 More than
sexually? Was it...
once
Don't Read:
7 Don't
know/Not
Sure
9 Refused
M22.10 How often did anyone ACETTHEM Read:
403
at least 5 years older
1 Never
than you or an adult,
2 Once
try to make you touch
3 More than
them sexually? Was
once
it...
Don't Read:
7 Don't
know/Not
Sure
9 Refused
M22.11 How often did anyone ACEHVSEX Read:
404
at least 5 years older
1 Never
than you or an adult,
2 Once
force you to have sex?
3 More than
Was it...
once
Don't Read:
7 Don't
know/Not
Sure
9 Refused
Would you like for me to provide a toll-free number for an organization that can provide information and referral for the issues in the last few questions.
If yes provide number [STATE TO INSERT NUMBER HERE]
Module 23: Family Planning
Questio n Number
M23.01
Question text
The last time you had sex with a man, did you or your partner do anything to keep you from getting pregnant?
Variable names
PFPPRVN3
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes
SKIP INFO/ CATI Note
Interviewer Note (s)
If respondent is female and greater than 49 years of age, has had a hysterectom y (M09.07=1), is pregnant, or if respondent is male go to the next module.
Column(s )
405
M23.02
The last time you had sex with a man, what did you or your partner do to keep you from getting pregnant?
TYPCNTR8
2 No
3 No partner/ not sexually active 4 Same sex partner 7 Don't know / Not sure 9 Refused Read if necessary:
01 Female sterilization (ex. Tubal ligation, Essure, Adiana) 02 Male sterilization (vasectomy) 03 Contraceptive implant (ex. Nexplanon,
Continue Go to M23.03 Go to next section
Go to next module
If respondent reports using more than one method, please code the method that occurs first on the list.
406-407
If respondent reports using "condoms," probe to
Jadelle, Sino Implant, Implanon) 04 IUD, Levonorgestrel (LNG) or other hormonal (ex. Mirena, Skyla, Liletta, Kylena) 05 IUD, Copperbearing (ex. ParaGard) 06 IUD, type unknown 07 Shots (ex. Depo-Provera or DMPA) 08 Birth control pills, any kind 09 Contraceptive patch (ex. Ortho Evra, Xulane) 10 Contraceptive ring (ex. NuvaRing)
determine if "female condoms" or "male condoms."
If respondent reports using an "I.U.D." probe to determine if "levonorgestre l I.U.D." or "copperbearing I.U.D."
If respondent reports "other method," ask respondent to "please specific" and ensure that their response does not fit
M23.03
Some reasons for not doing anything to keep you from getting pregnant the last time you had sex might include wanting a pregnancy , not being able to pay for birth control, or not thinking
NOBCUSE 7
11 Male condoms 12 Diaphragm, cervical cap, sponge 13 Female condoms 14 Not having sex at certain times (rhythm or natural family planning) 15 Withdrawal (or pulling out) 16 Foam, jelly, film, or cream 17 Emergency contraception (morning after pill) 18 Other method Do not read: 77 Don't know/ Not sure 99 Refused Read if necessary:
01 You didn't think you were going to have sex/no regular partner 02 You just didn't think about it 03 Don't care if you get pregnant 04 You want a pregnancy 05 You or your partner don't want to use birth control 06 You or your partner don't like birth
into another category. If response does fit into another category, please mark appropriately.
If respondent reports "other reason," ask respondent to "please specify" and ensure that their response does not fit into another category. If response does fit into another category, please mark appropriately.
408-409
that you can get pregnant. What was your main reason for not using a method to prevent pregnancy the last time you had sex with a man?
control/side effects 07 You couldn't pay for birth control 08 You had a problem getting birth control when you needed it 09 Religious reasons 10 Lapse in use of a method 11 Don't think you or your partner can get pregnant (infertile or too old) 12 You had tubes tied (sterilization) 13 You had a hysterectomy 14 Your partner had a vasectomy (sterilization 15 You are currently breastfeeding 16 You just had a baby/postpartu m 17 You are pregnant now 18 Same sex partner 19 Other reasons Do not read: 77 Don't know/Not sure 99 Refused
Module 24: Alcohol Screening & Brief Intervention (ASBI)
Question Question text Variable
Number
names
M24.01
M24.02 M24.03
You told me earlier that your last routine checkup was [within the past year/within the past 2 years]. At that checkup, were you asked in person or on a form if you drink alcohol?
ASBIALCH
Did the health care provider ask you in person or on a form how much you drink?
ASBIDRNK
Did the healthcare provider specifically ask whether you drank [5 FOR MEN /4 FOR
ASBIBING
Responses (DO NOT READ UNLESS OTHERWISE NOTED) 1 Yes 2 No 7 Don't know/ not sure 9 Refused
1 Yes 2 No 7 Don't know/ not sure 9 Refused
1 Yes 2 No 7 Don't know/ not sure 9 Refused
SKIP INFO/ CATI Note
Interviewer Note (s)
If core q3.4 (CHECKUP), = 1 or 2 (had a checkup within the past 2 years) continue, else go to next module.
Column(s) 410
411 412
WOMEN] or more alcoholic drinks on an occasion?
M24.04 Were you
ASBIADVC 1 Yes
If question
413
offered
2 No
M24.01 =1,
advice about
7 Don't
or M24.02=
what level of
know/ not 1, or M24.03
drinking is
sure
= 1 (yes)
harmful or
9 Refused continue,
risky for your
else go to
health?
next
module.]
M24.05 Healthcare ASBIRDUC 1 Yes
414
providers
2 No
may also
7 Don't
advise
know/ not
patients to
sure
drink less for
9 Refused
various
reasons. At
your last
routine
checkup,
were you
advised to
reduce or
quit your
drinking?
Module 25: Marijuana Use
Question Question Number text
Variable names
M25.01
During the past 30 days, on how many days did you use marijuana or cannabis?
MARIJAN1
M25.02
During the past 30 days, which one of the following ways did you use marijuana the most often? Did you usually...
USEMRJN2
Responses (DO NOT READ UNLESS OTHERWISE NOTED) _ _ 01-30 Number of days 88 None
77 Don't know/not sure
SKIP INFO/ CATI Note
Go to next module
99 Refused Read: 1 Smoke it (for example, in a joint, bong, pipe, or blunt). 2 Eat it (for example, in brownies, cakes, cookies, or candy) 3 Drink it (for example, in tea, cola, or alcohol) 4 Vaporize it (for example, in an ecigarette-like vaporizer or another vaporizing device) 5 Dab it (for example, using waxes or concentrates), or 6 Use it some other way. Do not read:
Interviewer Note (s)
Column(s)
Marijuana and cannabis include both CBD and THC products.
415-416
Select one. If 417 respondent provides more than one say: which way did you use it most often.
7 Don't know/not sure 9 Refused
M25.03 When you RSNMRJN1 Read:
418
used
1 For medical
marijuana or
reasons (like
cannabis
to treat or
during the
decrease
past 30
symptoms of a
days, was it
health
usually:
condition);
2 For non-
medical
reasons (like
to have fun or
fit in), or
3 For both
medical and
non-medical
reasons.
Do not read:
7 Don't
know/Not sure
9 Refused
Module 26: Industry and Occupation
Questio n Number
Question text
Variable names
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewe Column(s r Note (s) )
M26.01
What kind of work do you do? For example, registered nurse, janitor, cashier, auto mechanic.
TYPEWOR K
_______Recor d answer
99 Refused
If C08.14 = 1 (Employed for wages) or 2 (Self-employed) or 4 (Employed for wages or out of work for less than 1 year), continue, else go to next module/section .
If C08.14 = 4 (Out of work for less than 1 year) ask, "What kind of work did you do? For example, registered nurse, janitor, cashier, auto mechanic."
If responden t is unclear, ask: What is your job title?
If responden t has more than one job ask: What is your main job?
419-518
M26.02
What kind of business or industry do you work in? For example, hospital, elementary school, clothing
TYPEINDS
Else go to next module
_______Recor d answer 99 Refused
If Core Q8.14 = 4 (Out of work for less than 1 year) ask, "What kind of business or industry did you work in? For example,
519-618
manufacturing , restaurant
hospital, elementary school, clothing manufacturing, restaurant."
Module 27: Food Stamps
Question Question text Variable
Number
names
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
M27.01
In the past 12 months, have you received food stamps, also called SNAP, the Supplemental Nutrition Assistance Program on an EBT card?
FOODSTMP
1 Yes 2 No 7 Don't Know/Not Sure 9 Refused
Interviewer Note Column(s) (s)
Food Stamps or 619 SNAP (Supplemental Nutrition Assistance Program) is a government program that provides plastic cards, also known as EBT (Electronic Benefit Transfer) cards, that can be used to buy food. In the past, SNAP was called the Food Stamp Program and gave people benefits in paper coupons or food stamps.
Module 28: Sex at Birth
Question Question Number text
M28.01
What was your sex at birth? Was it male or female?
Variable names
BIRTHSEX
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
1 Male 2 Female 7 Don't know/Not sure 9 Refused
SKIP INFO/ CATI Note
Interviewer Column(s) Note (s)
620
Module 29: Sexual Orientation and Gender Identity
Question Question text Variable
Number
names
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
M29.01a The next two SOMALE READ:
Ask if Sex= Read if
621
questions are
1 = Gay
1.
necessary:
about sexual orientation and gender identity.
2 = Straight, that is, not gay 3 = Bisexual 4 = Something else
Read the number of the response to
We ask this question in order to better understand
Which of the
DO NOT READ: allow
the health
following
7 = I don't
respondent and health
best represents how you think of yourself?
know the answer/ The respondent did not understand the question 9 = Refused
to reply with a number.
care needs of people with different sexual orientations.
Please say
the number
before the
text
response.
Respondent
can answer
with either
the number
or the
text/word.
If the
respondent
does not
understand
the question
topic, code 7.
M29.01b Which of the SOFEMALE READ:
Ask if
Read if
622
following
1 = Lesbian or Sex=2.
necessary:
best
Gay
Read the We ask this
represents
2 = Straight, number of question in
how you
that is, not gay the
order to
think of
3 = Bisexual response to better
yourself?
allow
understand
4 = Something else DO NOT READ: 7 = I don't know the answer/ Respondent does not understand the question 9 = Refused
respondent to reply with a number.
the health and health care needs of people with different sexual orientations.
Please say the number before the text response. Respondent can answer with either the number or the text/word.
M29.02
Do you consider yourself to be transgender?
TRNSGNDR
1 Yes, Transgender, male-to-female 2 Yes, Transgender, female to male 3 Yes, Transgender, gender nonconforming 4 No 7 Don't know/not sure 9 Refused
If Yes, read responses 1-3.
If the
respondent
does not
understand
the question
topic, code 7.
Read if
623
necessary:
Some people
describe
themselves
as
transgender
when they
experience a
different
gender
identity from
their sex at
birth. For
example, a
person born
into a male
body, but
who feels
female or
lives as a
woman
would be transgender. Some transgender people change their physical appearance so that it matches their internal gender identity. Some transgender people take hormones and some have surgery. A transgender person may be of any sexual orientation straight, gay, lesbian, or bisexual.
If asked about definition of gender nonconforming: Some people think of themselves as gender nonconforming when they do not identify only as a man or only as a woman.
If yes, ask Do you consider
yourself to be 1. male-tofemale, 2. female-tomale, or 3. gender nonconforming?
Please say the number before the text response. Respondent can answer with either the number or the text/word.
Module 30: Random Child Selection
Question Question Number text
Variable names
Intro text and screening
If C08.15 = 1 and C08.15 does not equal 88 or 99, Interviewer please read: Previously, you indicated there was one child age 17 or younger in your household. I would like to ask you some questions about that child.
If C08.15 is >1 and C08.15 does not equal 88 or 99, Interviewer please read: Previously, you indicated there were [number]
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
If C08.15 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module.
CATI INSTRUCTION: RANDOMLY SELECT ONE OF THE CHILDREN. This is the Xth child. Please substitute Xth child's number in all questions below. INTERVIEWER PLEASE READ: I have some additional questions about one specific child. The child I will be referring to is the Xth [CATI: please fill in correct number] child in your
Column(s)
M30.01
M30.02 M30.03
children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest. The oldest child is the first child and the youngest child is the last. Please include children with the same birth date, including twins, in the order of their birth. What is the
birth month
and year of
the [Xth]
child?
RCSBIRTH
household. All following questions about children will be about the Xth [CATI: please fill in] child.
_ _ /_ _ _ _ Code month and year 77/ 7777 Don't know / Not sure 99/ 9999 Refused
624-629
Is the child a boy or a girl?
Is the child Hispanic, Latino/a, or Spanish origin?
RCSGENDR RCHISLA1
1 Boy 2 Girl 9 Refused
Read if response is yes: 1 Mexican, Mexican
630
If yes, ask: Are 631-634 they...
M30.04
Which one or more of the following would you say is the race of the child?
RCSRACE1
American, Chicano/a 2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino/a, or Spanish origin Do not read: 5 No 7 Don't know / Not sure 9 Refused 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other
[CATI NOTE: IF MORE THAN ONE RESPONSE TO M30.04; CONTINUE. OTHERWISE, GO TO M30.06.]
Select all that apply
If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.
635-662
M30.05 M30.06
Which one of these groups would you say best represents the child's race?
How are you related to the child? Are you a....
RCSBRAC2 RCSRLTN2
77 Don't know / Not sure 99 Refused 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 88 No additional choices 77 Don't know / Not sure 99 Refused Please read: 1 Parent (include biologic, step, or
If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.
663-664
665
adoptive parent) 2 Grandparent 3 Foster parent or guardian 4 Sibling (include biologic, step, and adoptive sibling) 5 Other relative 6 Not related in any way Do not read: 7 Don't know / Not sure 9 Refused
Module 31: Childhood Asthma Prevalence
Question Question text Variable
Number
names
M31.01
The next two questions are about the Xth child.
CASTHDX2
Has a doctor, nurse or other health professional EVER said that
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
1 Yes
SKIP INFO/ Interviewer CATI Note Note (s)
If response to C08.15 = 88 (None) or 99 (Refused), go to next module. Fill in correct [Xth] number.
Column(s) 666
the child has
2 No
Go to next
asthma?
7 Don't
module
know/ not
sure
9 Refused
M31.02 Does the child CASTHNO2 1 Yes
667
still have
2 No
asthma?
7 Don't
know/ not
sure
9 Refused
Asthma Call-Back Permission Script
Question Question Number text
Variable names
Text
We would
like to call
you again
within the
next 2
weeks to
talk in more
detail about
(your/your
child's)
experiences
with
asthma. The
information
will be used
to help
develop and
improve the
asthma
programs in
<STATE>.
The
information
you gave us
today and
any you give
us in the
future will
be kept
confidential.
If you agree
to this, we
will keep
your first
Responses
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
name or initials and phone number on file, separate from the answers collected today. Even if you agree now, you or others may refuse to participate in the future.
CB01.01 Would it be CALLBACK
1 Yes
668
okay if we
2 No
called you
back to ask
additional
asthma-
related
questions at
a later
time?
CB01.02 Which
ADLTCHLD
1 Adult
669
person in
2 Child
the
household
was
selected as
the focus of
the asthma
call-back?
CB01.03 Can I please ____________________
have either Enter first name or
(your/your initials.
child's) first
name or
initials, so
we will
know who
to ask for
when we call back?
Closing Statement
Read
That was my last question. Everyone's answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.
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