Form Not Assigned Not Assigned Family Identification

Page 1 of 9

2007 NHIS Questionnaire - Family

Family Identification

Document Version Date: 12-Jul-06

Question ID: FID.100_00.000 Instrument Variable Name: HHCHANGE QuestionnaireFileName: Family

QuestionText: I have recorded that [your name is {fill fullname}, you are /fill ALIAS is] [fill sex], [fill age] years old, born on [fill

birthdate]. [His/Her] national origin is [fill Hispanic origin], and [his/her] race is [fill race]:

Is this information correct?

1 Yes, this information is correct

2 No, correction(s) needed/more corrections needed

UniverseText: All nondeleted family members

SkipInstructions: <1> if no additional PX remain

if SCREENIN = 0 and I_SCRN_STATUS = S [goto EXIT(HHC)]

else [goto FIDCC13]

<2> [goto CWHAT2]

Question ID: FID.110_00.000 Instrument Variable Name: CWHAT2 QuestionnaireFileName: Family

QuestionText: * Change(s) needed for [ALIAS].

* Enter each number that applies. If a wrong choice, type that choice again.

1 Name

2 Age or DOB

3 Sex

4 National origin

5 Race

UniverseText: HHCHANGE = 2 (No, not correct)

SkipInstructions: <1> [goto CHG_NAME_FNAME]

<2> [goto CHG_AGEDOB_1]

<3> [goto CHG_SEX]

<4> [goto CHG_NATOR]

<5> [goto CHG_RACE]

Question ID: FID.245_00.000 Instrument Variable Name: HHCHANGE_1 QuestionnaireFileName: Family

QuestionText: I have recorded that {your name is/ALIAS is} {fill full name}, age is {fill age}, date of birth is {fill birthdate}, {his/her}

national origin is {fill Hispanic origin}, and {his/her} {fill race} is:

Is this information correct?

UniverseText: All nondeleted family members with a change made to their demographic information

SkipInstructions: <1> if no additional PX remain

if SCREENIN = 0 and I_SCRN_STATUS = S, GOTO EXIT(HHC)

else GOTO FIDCC13

<2> GOTO ERR_HHCHANGE_1

Page 2 of 9

2007 NHIS Questionnaire - Family

Family Identification

Document Version Date: 12-Jul-06

Question ID: FID.250_00.000 Instrument Variable Name: MARITAL QuestionnaireFileName: Family

QuestionText: * ASK OR VERIFY

[fill: Are you/Is ALIAS] now married, widowed, divorced, separated, never married, or living with a partner?

1 Married

2 Widowed

3 Divorced

4 Separated

5 Never Married

6 Living with partner

7 Refused

9 Don't know

UniverseText: All persons, 14 and older, who don't have a marital status yet

SkipInstructions: <1> [goto SPFLAG]

<2-5, R, D> [goto FIDCCI3]

<6> if LINTAL[FAMINT] = 1 [goto FIDCCI4]

else [goto COHAB1]

Question ID: FID.250_03.000 Instrument Variable Name: MARVER_FLG QuestionnaireFileName: Family

QuestionText:

1 Yes

2 No

7 Refused

9 Don't know

UniverseText:

SkipInstructions:

Question ID: FID.260_00.000 Instrument Variable Name: SPOUS QuestionnaireFileName: Family

QuestionText: * ASK OR VERIFY

Is [fill: your/ALIAS's] spouse living in the household?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: A potential spouse lives in the unit.

SkipInstructions: <1> If SPOUS2[PX] = null [goto SPOUS2]

else [goto FIDCCI3]

<2,R,D> [goto FIDCCI3]

Page 3 of 9

2007 NHIS Questionnaire - Family

Family Identification

Document Version Date: 12-Jul-06

Question ID: FID.270_00.000 Instrument Variable Name: SPOUS2 QuestionnaireFileName: Family

QuestionText: * Probe as necessary and enter the line number of the spouse.

[Display all possible spouse candidates]

01-25 Person # of spouse

UniverseText: Person has an unidentified spouse in the household.

SkipInstructions: Do not allow line number of the subject to be entered. If so [goto ERR_SPOUS2]

<1-25,R,D> [goto FIDCCI3]

Question ID: FID.280_00.000 Instrument Variable Name: COHAB1 QuestionnaireFileName: Family

QuestionText: [fill: Have you/Has ALIAS] ever been married?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: Marital status is "living with a partner."

SkipInstructions: <1> [goto COHAB2]

<2,R,D> if COHAB3[PX] = null [goto COHAB3]

else [goto FIDCCI3]

Question ID: FID.290_00.000 Instrument Variable Name: COHAB2 QuestionnaireFileName: Family

QuestionText: What is [fill: your/ALIAS's] current legal marital status?

1 Married

2 Widowed

3 Divorced

4 Separated

7 Refused

9 Don't know

UniverseText: Person has been married.

SkipInstructions: <1-4,R,D> If COHAB3[PX] = null [goto COHAB3]

else [goto FIDCCI3]

Question ID: FID.300_00.000 Instrument Variable Name: COHAB3 QuestionnaireFileName: Family

QuestionText: * Probe as necessary and enter the line number of the cohabiting partner.

[Display all possible cohabitation candidates]

01-25 Person number

UniverseText: Co-habitating partner has yet to be identified.

SkipInstructions: If line number of the subject is entered [goto ERR_COHAB3]

<1-25,R,D> [goto FIDCCI3]

Page 4 of 9

2007 NHIS Questionnaire - Family

Family Identification

Document Version Date: 12-Jul-06

Question ID: FID.322_00.000 Instrument Variable Name: DEGREE4 QuestionnaireFileName: Family

QuestionText: I noted that [father's fullname] is the father of [child's fullname]. Is [child's fullname] his biological, adoptive, step, foster, or

[fill: son/daughter] in law?

1 Biological

2 Adoptive

3 Step

4 Foster

5 -in-law

7 Refused

9 Don't know

UniverseText: When the reference person is the person in question's parent.

SkipInstructions: <1> if AGEDIFF <12 [goto ERR_DEGREE4]

if ERR_DEGREE4 = 1 [goto FIDCCI4B]

else reset DEGREE4 [goto DEGREE4] endif

else [goto FIDCCI4B]

<2-5,R,D> [goto FIDCCI4B]

Question ID: FID.324_00.000 Instrument Variable Name: DEGREE5 QuestionnaireFileName: Family

QuestionText: I noted that [mother's fullname] is the mother of [child's fullname]. Is [child's fullname] her biological, adoptive, step, foster,

or [fill: son/daughter] in law?

1 Biological

2 Adoptive

3 Step

4 Foster

5 -in-law

7 Refused

9 Don't know

UniverseText: When the reference person is the person in question's parent.

SkipInstructions: <1> if AGEDIFF <12 [goto ERR_DEGREE5]

if yes, continue the interview [goto FIDCCI4B]

else, reset DEGREE5 [goto DEGREE5] endif

else [goto FIDCCI4B]

<2-5,R,D> [goto FIDCCI4B]

Page 5 of 9

2007 NHIS Questionnaire - Family

Family Identification

Document Version Date: 12-Jul-06

Question ID: FID.326_00.000 Instrument Variable Name: MOTHER QuestionnaireFileName: Family

QuestionText: * Ask or verify

Is [fill: your/ALIAS's] mother a household member? (Include biological (natural), adoptive, step, or foster mother or

mother-in-law)

* Enter the line number of the mother or mother-in-law.

If the mother or mother-in-law is not a household member, enter "0".

If the person has no parents present but has a legal guardian, enter "96".

* Choose mother over mother-in-law if both are present.

00 Mother not a household member

01-25 Person number of mother

96 Has legal guardian

97 Refused

99 Don't know

UniverseText: Potential mother in the Family, mother not already identified

SkipInstructions: <01-25> [goto MOTHERCK_A]

<0,R,D> [goto FIDCCI5]

<96> [goto GUARD]

Question ID: FID.330_01.000 Instrument Variable Name: MOTHERCK_A QuestionnaireFileName: Family

QuestionText: [fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster mother or mother-in-law?

1 Biological mother

2 Adoptive mother

3 Step mother

4 Foster mother

5 Mother-in-law

7 Refused

9 Don't know

UniverseText: Mother is in the immediate family.

SkipInstructions: <1> If AGEDIFF <12 [goto ERR_MOTHERCK_A]

if <1> [goto FIDCCI5]

elseif <2> [goto MOTHER]

elseif <3>, reset MOTHERCK_A [goto MOTHERCK_A]

else [goto FIDCCI5]

<2-5,R,D> [goto FIDCCI5]

Page 6 of 9

2007 NHIS Questionnaire - Family

Family Identification

Document Version Date: 12-Jul-06

Question ID: FID.330_02.000 Instrument Variable Name: MOTHERCK_A QuestionnaireFileName: Family

QuestionText: [fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster mother or mother-in-law?

UniverseText: Mother is in the immediate family.

SkipInstructions: <1> If AGEDIFF <12 [goto ERR_MOTHERCK_A]

if <1> [goto FIDCCI5]

elseif <2> [goto MOTHER]

elseif <3>, reset MOTHERCK_A [goto MOTHERCK_A]

else [goto FIDCCI5]

<2-5,R,D> [goto FIDCCI5]

Question ID: FID.340_00.000 Instrument Variable Name: FATHER QuestionnaireFileName: Family

QuestionText: * Ask or verify

Is [fill: your/ALIAS's] father a household member? (Include biological (natural), adoptive, step, or foster father or father-in-

law).

* Enter the line number of the father or father-in-law.

* If the father is not a household member, enter '0'.

* If the person has no parents present but has a legal guardian, enter '96'.

* Choose father over father-in-law if both are present.

00 Father not in household

01-25 Person # of father

96 Has legal guardian

97 Refused

99 Don't know

UniverseText: Potential Father in Family, not already identified

SkipInstructions: <1-25> [goto FATHERCK_A]

<0,R,D> [goto FIDCCI4]

<96> [goto GUARD]

Page 7 of 9

2007 NHIS Questionnaire - Family

Family Identification

Document Version Date: 12-Jul-06

Question ID: FID.350_01.000 Instrument Variable Name: FATHERCK_A QuestionnaireFileName: Family

QuestionText: [fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster father or father-in-law?

1 Biological father

2 Adoptive father

3 Step father

4 Foster father

5 Father-in-law

7 Refused

9 Don’t know

UniverseText: Father has been identified

SkipInstructions: <1> If AGEDIFF <12 [goto ERR_FATHERCK_A]

if ERRFATHERCK_A = <1> [goto FIDCCI4]

elseif <2> [goto FATHER]

elseif <3> reset FATHERCK_A

[goto FATHERCK_A] endif

else [goto FIDCCI4]

<2-5,R,D> [goto FIDCCI4]

Question ID: FID.350_02.000 Instrument Variable Name: FATHERCK_A QuestionnaireFileName: Family

QuestionText: [fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster father or father-in-law?

UniverseText: Father has been identified

SkipInstructions: <1> If AGEDIFF <12 [goto ERR_FATHERCK_A]

if ERRFATHERCK_A = <1> [goto FIDCCI4]

elseif <2> [goto FATHER]

elseif <3> reset FATHERCK_A

[goto FATHERCK_A] endif

else [goto FIDCCI4]

<2-5,R,D> [goto FIDCCI4]

Question ID: FID.360_01.000 Instrument Variable Name: GUARD QuestionnaireFileName: Family

QuestionText: Who is [fill: your/ALIAS's ] legal guardian?

* Enter the line number of [fill1: your/ALIAS's] guardian.

* If the guardian is not a household member, enter '0'.

00 Guardian not a household member

01-25 Person # of guardian

97 Refused

99 Don't know

UniverseText: Child identified as a guard at mother or father or, at the FIDCCI5 procedure, it's determined that the child (AGE<14)

has no mother or father in the family.

SkipInstructions: <0-25,R,D> [goto FIDCCI4]

Page 8 of 9

2007 NHIS Questionnaire - Family

Family Identification

Document Version Date: 12-Jul-06

Question ID: FID.380_00.000 Instrument Variable Name: KNOW2 QuestionnaireFileName: Family

QuestionText: * Verify or ask

Who in the family would you say knows about the health of all the family members?

[Display all family members who not deleted and > 17 or emancipated minors.]

* Mark all that apply, separate with commas.

1 Yes, knows family members' health

2 No, does not know family member's health

7 Refused

9 Don't Know

UniverseText: More than one adult

SkipInstructions: <1-25,R,D>

if SCSEL = 0 [goto FINTRO2]

else [goto KNOWSC2]

Question ID: FID.390_03.000 Instrument Variable Name: FINTRO2 QuestionnaireFileName: Family

QuestionText: * Enter line number(s) of family members listed that are currently present. Enter up to 10 numbers, separate with commas.

[Display all family members who are not deleted and >17 or emancipated minors]

* If any persons listed are not present, say:

We would like to have all adult family members who are at home take part in the interview. Are (READ NAMES) at home

now?

* If yes, ask: Could they join us?

* If nobody is presently available, enter "96" to proceed to a callback screen.

1 Present

2 Not present

UniverseText: All nondeleted persons >17 or emancipated minors

SkipInstructions: <96> [goto FCALLBK1]

if only one PX selected [goto HLTH_BEG]

else [goto FAMRESP]

Question ID: FID.390_04.000 Instrument Variable Name: FAMRESP QuestionnaireFileName: Family

QuestionText: * Ask if necessary: With whom am I speaking?

* Enter the line number of the person you consider to be the main respondent for this family's health questions.

01-25 Person # of Family Respondent

UniverseText: More than 1 adult present.

SkipInstructions: goto HLTH_BEG

Page 9 of 9

2007 NHIS Questionnaire - Family

Family Identification

Document Version Date: 12-Jul-06

Question ID: FID.400_00.000 Instrument Variable Name: FMSSN QuestionnaireFileName: Family

QuestionText: * Read to respondent:

We also need your Social Security Number. The National Center for Health Statistics will use

your Social Security Number to conduct health-related research by linking your survey data with

vital statistics and other records. We may also use it if we need to recontact you or your

family. Except for these purposes, the National Center for Health Statistics will not release your

Social Security Number to anyone, including any government agency. Providing this

information is voluntary and is collected under the authority of the Public Health Service Act.

There will be no effect on your benefits if you do not provide it.

* Read if necessary.

The Public Health Service Act is Title 42, United States Code, Section 242K.

What is your Social Security Number?

* Enter 'N' if no Social Security Number.

001010000-799999999 Number

R Refused

D Don’t know

UniverseText: Only asked of the family respondent if the family respondent is not the sample adult

SkipInstructions: < 001010000-799999999> goto FMSSNREP

<000000000-999999999> goto ERR_FMSSN_2

<R, D> goto ERR_FMSSN_1, if suppressed goto beginning of Sample Child, Sample Adult, or

Back section

<N> goto beginning of Sample Child, Sample Adult, or Recontact

Question ID: FID.405_00.000 Instrument Variable Name: FMSSNREP QuestionnaireFileName: Family

QuestionText: * Enter how Social Security number was reported.

1 From memory

2 From records

UniverseText: SSN was given at FMSSN

SkipInstructions: <1,2> goto FMSSNTEL

Question ID: FID.410_00.000 Instrument Variable Name: FMSSNTEL QuestionnaireFileName: Family

QuestionText: * Select one category below to indicate reporting of Social Security number.

1 In person

2 Telephone

UniverseText: Recorded how SSN was reported

SkipInstructions: <1,2> goto beginning of Sample Child, Sample Adult, or Back section