OMB No.
Expiration Date:
Attachment 9
Public reporting burden of this collection of information is estimated to average 42 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 an 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 (0920-XXXX)
Registry of Unexplained Fatiguing Illnesses and CFS
Participant's ID Number I___I___I___I___I___I___I___I___I
ZIP Code I___I___I___I___I___I
Interview Date:_____________________ Start Time: I__I__I : I__I__I |
1A. Hello, my name is [INTERVIEWER NAME]. (May I please speak to /Am I speaking to) (NAME/PARENT NAME)?
BOX A
AGE to be calculated on DOB; or if DOB is missing, on YOB preloads. IF R IS ON LINE AND AN ADULT, GO TO INTRODUCTION A. IF ADOLESCENT R’s PARENT IS ON THE LINE, GO TO INTRODUCTION B. IF R COMES TO PHONE, REPEAT Q1A. IF R IS NOT AVAILABLE, SET CALLBACK. IF NO SUCH RESPONDENT, SKIP TO CLOSING 1. IF RESPONDENT HAS MOVED, GO TO CLOSING 2.
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INTRODUCTION A:
I am calling on behalf of Abt Associates Incorporated for the Centers for Disease Control and Prevention, or CDC. We are calling people about a research study on fatiguing illnesses. You received information from your medical provider in Bibb County Georgia about a registry of unexplained fatiguing illnesses and chronic fatigue syndrome. Recently, you let us know you are interested in taking part in the registry. This registry is a research study that will help identify people with fatiguing illnesses and track them as their illness changes. I would like to interview you to see if you qualify for the registry. Your answers may help provide information about the nature of these illnesses.
Before we begin, I need to be sure that you have the following information. This interview will take about 25 minutes of your time. Because we are also studying causes of illness, I will ask you about your health and life experiences, including traumatic events that may have happened to you. Your name and your answers to our questions will be kept private to the extent permitted by law. Only staff that has been allowed by the CDC to do this research will know your personal information.
CDC is allowed by a law called the Public Health Service Act to do a lot of public health activities, including this research study. This law allows us to ask about many things, including your health. Still, completing this interview is your choice. You may choose not to answer any question for any reason and you can stop at any time. Whether you complete this interview or not will in no way affect any health benefits that you expect to get. To evaluate my performance, my supervisor may record and listen as I ask the questions. We may contact you again about participating in further research.
If you have any questions about your rights in this study, I can give you the number for the CDC Director for Science. If you have any other questions about this research study, you can call Dr. Elizabeth Maloney at the CDC. I can give you her number as well.
INTERVIEWER: DO YOU VERIFY THAT YOU HAVE READ THE INFORMED CONSENT IN ITS ENTIRETY TO THE PARTICIPANT?
YES 1 GO TO BOX B
NO 2 GO BACK TO BEGINNING OF INTRODUCTION
INTRODUCTION B
I am calling on behalf of Abt Associates Incorporated for the Centers for Disease Control and Prevention, or CDC. We are calling people about a research study on fatiguing illnesses. You received information from (CHILD’s) medical provider in Bibb County Georgia about a registry of fatiguing illnesses and chronic fatigue syndrome. Recently, you let us know you are interested in having your child take part in the registry. This registry is a research study that will help identify people with fatiguing illnesses and track them as their illness changes. I would like to interview you about (CHILD) to see if (he/she) qualifies for the registry. Your answers about your child may help provide information about the nature of these illnesses.
Before we begin, I need to be sure that you have the following information. This interview will take about 25 minutes. I will ask you about your child’s past and current health and family demographic information. Your name, your child’s name, and your answers to our questions will be kept private to the extent permitted by law. Only staff that has been allowed by the CDC to do this research will know your and your child’s personal information.
CDC is allowed by a law called the Public Health Service Act to do a lot of public health activities, including this research study. This law allows us to ask about many things, including your child’s health. Still, completing this interview about your child is your choice. You may choose not to answer any question for any reason. You can stop at any time. Whether you complete this interview or not will in no way affect any health benefits that you or your child expects to get. To evaluate my performance, my supervisor may record and listen as I ask the questions. We may contact you again about taking part in further research.
If you have any questions about your rights or your child’s rights in this study, I can give you the number for the CDC Director for Science. If you have any other questions about this research study, you can call Dr. Elizabeth Maloney at the CDC. I can give you her number as well.
INTERVIEWER: DO YOU VERIFY THAT YOU HAVE READ THE INFORMED CONSENT IN ITS ENTIRETY TO THE PARTICIPANT?
YES 1 GO TO BOX B
NO 2 GO BACK TO BEGINNING OF INTRODUCTION
box B
If sex is not missing go to Q2 If sex is missing go to q2a.
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2. Based on the contact information you provided, my records show that (you are/your child is) (female/male). Is that correct?
YES 1 SKIP TO Q3
NO 2
DON’T KNOW 8 SKIP TO Q3
REFUSED 7 SKIP TO Q3
2A. (Are you/Is your child) male or female?
MALE 1
FEMALE 2
3. Do you consider (yourself/your child) to be Latino, Hispanic, or of Spanish origin or descent?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
BOX C
IF RACE IS MISSING, GO TO Q4A.
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4. My records show that (you are/your child is) (RACE). Is that correct?
YES 1 SKIP TO BOX D
NO 2
DON’T KNOW 8 SKIP TO BOX D
REFUSED 7 SKIP TO BOX D
4A. What race do you consider (yourself/your child) to be? Please note that you may choose more than one option. (CODE ALL THAT ARE MENTIONED.)
White 1
Black or African-American 2
Asian 3
American Indian or Alaskan Native 4
Native Hawaiian or Other Pacific Islander 5
OTHER (SPECIFY) 95
DON’T KNOW 98
REFUSED 97
BOX D
IF DOB IS COMPLETE, GO TO Q5. IF DOB IS INCOMPLETE, GO TO Q5A.
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According to our records, (your/your child’s) birth date is [RESPONDENT’S DATE OF BIRTH]. Is this correct?
YES 1 GO TO BOX E
NO 2
DON'T KNOW 8 SKIP TO Q5 B
REFUSED 7 SKIP TO Q5 B
5A. What is (your/your child’s) date of birth?
___ ___/___ ___ /___ ___ ___ ___ GO TO BOX E
MONTH DAY YEAR
DON’T KNOW 98 GO TO Q5B
REFUSED 97 GO TO Q5B
5B. How old (are you/is your child)?
I___I___I
ENTER AGE:________ GO TO BOX E
DON’T KNOW 98 GO TO Q5C
REFUSED 97 GO TO Q5C
5C. (Are you age 18-59?/Is your child age 12-17?)
YES 1
NO 2 FILL OUT PROBLEM SHEET DON’T KNOW 8 FILL OUT PROBLEM SHEET
REFUSED 7 FILL OUT PROBLEM SHEET
BOX E
IF RESPONDENT IS ADOLESCENT AND AGE IS NOT >11 AND <18, FILL OUT PROBLEM SHEET AND GO TO CLOSING IF RESPONDENT IS ADULT AND AGE NOT 18-59, FILL OUT PROBLEM SHEET AND GO TO CLOSING 1 OTHERWISE, GO TO Q6 INTRO
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CLOSING 1 My information may be incorrect. I need to go back to my records to confirm I have contacted the correct person. If I need to contact you again, when would be the best time to reach you?
Thank you for your time.
CLOSING 2 I am trying to reach [SUBJECT] about a research study that (he/she) is interested in. May I please have (his/her) telephone number?
FATIGUE STATUS
The next question is about fatigue.
6. (Have you/Has your child) suffered from severe fatigue, extreme tiredness, or exhaustion within the last month?
YES 1
NO 2 GO TO Q18
DON'T KNOW 8 GO TO Q18
REFUSED 7 GO TO Q18
7. (Have you/Has your child) suffered from this severe fatigue, extreme tiredness, or exhaustion for one month or longer?
YES 1
NO 2 GO TO Q18
DON'T KNOW 8 GO TO Q18
REFUSED 7 GO TO Q18
8. In what year did this fatigue, tiredness, or exhaustion begin?
IF RESPONDENT CANNOT REMEMBER THE YEAR, PROBE: If you cannot remember the specific year, please estimate to the best of your ability.
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW 8 SKIP TO Q8B
REFUSED 7 SKIP TO Q8B
8A. And now I need to know the month this fatigue began.
IF RESPONDENT CANNOT REMEMBER THE MONTH, PROBE: If you cannot remember the specific month, please estimate to the best of your ability.
ENTER MONTH: __ __ IF Q8 = 2007 OR 2008, GO TO BOX F; OTHERWISE GO TO Q9
DON’T KNOW 98 IF Q8 = 2007 OR 2008, GO TO Q8B. OTHERWISE SKIP TO Q9
REFUSED 97 IF Q8 = 2007 OR 2008, GO TO Q8B. OTHERWISE SKIP TO Q9.
8B. How long ago did this fatigue, tiredness, or exhaustion begin?
ENTER NUMBER FOR WEEKS, MONTHS OR YEARS________
SELECT TIME PERIOD ________
WEEK(S) 1 SKIP TO BOX F
MONTH(S) 2 SKIP TO BOX F
YEAR(S) 3 SKIP TO BOX F
DON’T KNOW -1 GO TO Q8C
REFUSED -2 GO TO Q8C
8C. (Have you/Has your child) had this fatigue for six months or longer?
YES 1 SKIP TO Q9
NO 2 GO TO BOX F
DON’T KNOW 8 GO TO BOX F
REFUSED 7 GO TO BOX F
BOX F: Calculate Fatigue Duration For Subjects With Recent Onset
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BOX G: Check if Callback is appropriate
If (TODAY’S DATE) + CALLBACKMO > preset (END DATE), then go to CLOSING3. Else go to CLOSING4.
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CLOSING3: Thank you for this information. To qualify for the registry, you need to be fatigued for 6 months or longer. Based on what I recorded, you haven’t been fatigued for 6 months. Unfortunately, our study will end before we would be able to call you back to check on your fatigue. I do want to thank you for your time. If this study is extended, we will certainly call you back.
CLOSING4: Thank you for this information. To qualify for the registry, you need to be fatigued for 6 months or longer. Based on what I recorded, you haven’t been fatigued for 6 months yet. I would like to call you back in (CALLBACKMO) (month/months) to see if you are still fatigued. If you are still fatigued at that point, then we will continue the interview. Let’s set up a time when we can call you back…
9. (When you are/When your child is) fatigued, tired, or exhausted does rest make this fatigue, tiredness, or exhaustion a lot better? Would you say…
PROBE Can you count on rest to make (your/your child’s) fatigue, tiredness, or exhaustion a lot better...
All of the time 1
Most of the time 2
Some of the time 3
A little of the time 4
Hardly ever 5
DON’T KNOW 8
REFUSED 7
10. How often (do you/does your child) suffer from this fatigue, tiredness, or exhaustion? Would you say…
most of the time 1
sometimes 2
rarely 3
DON’T KNOW 8
REFUSED 7
11. Has this severe fatigue, extreme tiredness, or exhaustion substantially limited (your/your child’s) ability to do (your/his/her) usual job or occupation?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
NOT APPLICABLE 6
12. Has this severe fatigue, extreme tiredness, or exhaustion substantially limited (your/your child’s) ability to do (your/his/her) usual educational activities?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
NOT APPLICABLE 6
13. Has this severe fatigue, extreme tiredness, or exhaustion substantially limited (your/your child’s) social activities?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
14. Has this severe fatigue, extreme tiredness, or exhaustion substantially limited (your/your child’s) leisure or recreational activities?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
15. When this fatigue, tiredness, or exhaustion began, would you say that it came on all of a sudden, or slowly over time?
ALL OF A SUDDEN 1
SLOWLY OVER TIME 2
DON’T KNOW 8
REFUSED 7
16. (Have you/Has your child) ever gone to a doctor because of (your/your child’s) fatigue?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
17. Has a doctor ever diagnosed (you/your child) with the illness called chronic fatigue syndrome?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
HEALTH PERCEPTIONS
18. IF RESPONDENT IS ADOLESCENT, SKIP TO Q25; OTHERWISE, ASK: I’d like to ask you some general questions about your health.
Would you say that in general your health is excellent, very good, good, fair, or poor?
EXCELLENT 1
VERY GOOD 2
GOOD 3
FAIR 4
POOR 5
DON’T KNOW 8
REFUSED 7
19. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
NUMBER OF DAYS: ___ ____
DON'T KNOW -1
REFUSED -2
20. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
NUMBER OF DAYS: ___ ____
DON'T KNOW -1
REFUSED -2
21. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, school or recreation?
NUMBER OF DAYS: ___ ____
DON'T KNOW -1
REFUSED -2
22. Compared to other adults your age, would you say your health is much better, better, the same, worse, or much worse?
MUCH BETTER 1
BETTER 2
THE SAME 3
WORSE 4
MUCH WORSE 5
DON’T KNOW 8
REFUSED 7
23. How would you rate your overall quality of life at the present time? Would you say excellent, very good, good, fair, or poor?
EXCELLENT 1
VERY GOOD 2
GOOD 3
FAIR 4
POOR 5
DON’T KNOW 8
REFUSED 7
24. In general, how satisfied are you with your life? Would you say very satisfied, satisfied, dissatisfied, or very dissatisfied?
VERY SATISFIED 1
SATISFIED 2
DISSATISFIED 3
VERY DISSATISFIED 4
DON’T KNOW 8
REFUSED 7
25. I am going to ask you about persistent symptoms that (you/your child) may have experienced in the past month. By persistent, we mean that it bothers or bothered (you/your child) a lot of the time.
INTERVIEWER PROBE: Whatever “bother” or “a lot of the time” means to you).
25A. During the past month, (have you/has your child) had persistent <SYMPTOM>?
YES 1
NO 2 GO TO NEXT SYMPTOM
DON’T KNOW 8 GO TO NEXT SYMPTOM
REFUSED 7 GO TO NEXT SYMPTOM
25B. (Have you/Has your child) been bothered by persistent <SYMPTOM> for 1 month or longer?
YES 1
NO 2 GO TO NEXT SYMPTOM
DON’T KNOW 8 GO TO NEXT SYMPTOM
REFUSED 7 GO TO NEXT SYMPTOM
25C. (Have you/Has your child) been bothered by persistent <SYMPTOM> for 6 months or longer?
YES 1
NO 2 GO TO NEXT SYMPTOM
DON’T KNOW 8 GO TO NEXT SYMPTOM
REFUSED 7 GO TO NEXT SYMPTOM
25D. FOR SYMPTOMS 1-9 ONLY: In what year did the <SYMPTOM> begin?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW 8
REFUSED 7
<SYMPTOM>
NOTE: ALTHOUGH NOT ASKED IN THIS SECTION (INCLUDED IN EARLIER SECTION), EXTREME TIREDNESS OR EXHAUSTION IS CONSIDERED SYMPTOM NUMBER 1.
2. unusual fatigue or exhaustion for more than a day, following physical or mental effort
3. unrefreshing sleep
4. forgetfulness or memory problems
5. problems with thinking or concentrating
6. pain in your joints
7. pain in your muscles
8. severe headaches
9. swollen glands in your neck or under your arms
10. sore throat
11. problems falling asleep at night
12. problems staying asleep through the night
13. depression
14. diarrhea
15. nausea
16. stomach or abdominal pain
17. sinus or nasal problems
18. fever
19. shortness of breath
20. your eyes being extremely sensitive to light
BOX H
IF RESPONDENT HAS REPORTED HAVING MORE THAN ONE SYMPTOM (INCLUDING FATIGUE IN Q8A AND Q8B AND Q8C) LASTING SIX MONTHS OR LONGER, GO TO Q26. OTHERWISE, SKIP TO Q27.
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26. Of the symptoms (you have/your child has) reported having for 6 months or more, that is…
<INTERVIEWER READ LIST OF SYMPTOMS REPORTED FOR DURATION OF 6 MONTHS OR LONGER, INCLUDING SEVERE FATIGUE, TIREDNESS, OR EXHAUSTION (Q8)>
Which one bothers (you/your child) the most right now?
RECORD SYMPTOM #: |___|___|
USE STANDARD PROBE IF RESPONDENT HAS TROUBLE PICKING JUST ONE SYMPTOM. REREAD STEM
“If (you/your child) could be cured of just one of these symptoms, which one would it be?
ASSIGNMENT OF SAMPLE TYPE (BASED ON FATIGUE STATUS AND SYMPTOMS ONLY)
IF FATIGUED FOR AT LEAST ONE MONTH OR LONGER (Q7=1) AND HAS HAD AT LEAST ONE UNWELLNESS SYMPTOM OR FATIGUE FOR SIX MONTHS OR LONGER (Q8 AND Q8A AND Q8B AND Q8C INDICATE FATIGUE FOR SIX MONTHS OR LONGER) OR Q25C=1 FOR SYMPTOMS 2, 3, 4, 5, 6, 7, 8, 9, OR 10) THEN RESPONDENT IS CHRONIC UNWELL, FATIGUED (CUF)
ELSE IF RESPONDENT HAS ONE OR MORE UNWELLNESS SYMPTOMS FOR SIX MONTHS OR LONGER (SORE THROAT, SWOLLEN GLANDS, FATIGUE FOLLOWING PHYSICAL/MENTAL EFFORT, PAIN IN JOINTS, PAIN IN MUSCLES, SEVERE HEADACHES, FORGETFULNESS OR MEMORY PROBLEMS, UNREFRESHING SLEEP), THEN RESPONDENT IS CHRONIC UNWELL, NOT FATIGUED (CU)
ELSE IF FATIGUED FOR ONE MONTH OR LONGER (Q7=1) THEN RESPONDENT IS PROLONGED UNWELL, FATIGUED (PUF)
ELSE IF RESPONDENT HAS ONE OR MORE UNWELLNESS SYMPTOMS FOR ONE MONTH OR LONGER, THEN RESPONDENT IS PROLONGED UNWELL, NOT FATIGUED (PU)
ELSE RESPONDENT IS WELL (WL)
27. How tall (are you/is your child)?
|___|___| FEET |___|___| INCHES
DON’T KNOW 8
REFUSED 7
28. Some people may consider the next question to be very sensitive. We are asking it because combinations of weight and height can affect a person’s health. How much (do you/does your child) weigh in pounds? Please be as accurate as possible.
_____ POUNDS
DON’T KNOW 8
REFUSED 7
Now I’m going to ask you some questions about when (you were/your child was) born.
28a. Was (you/your child’s) birth premature?
YES………………………………………………….1
NO…………………………………………………...2
28b. How much did (you/your child) weigh when (you/he/she) was born?
_______POUNDS ______OUNCES (IF POUNDS ENTERED IS VALID, SKIP TO 29 INTRO)
DON’T KNOW……………………………………..8 (GO TO 28c)
REFUSED………………………………………….7 (SKIP TO 29 INTRO)
28c. Would you say (you/your child) had a birth weight of:
LESS THAN 3 POUNDS………………………….1
3 POUNDS TO 5 POUNDS 7 OUNCES………..2
5 POUNDS 8 OUNCES OR MORE……………..3
DON’T KNOW……………………………………..8
REFUSED………………………………………….7
I am now going to ask you about (your/your child’s) medical history. I will ask you questions about conditions for which (you have/(he/she) has) been diagnosed. Some of these questions may be perceived as sensitive, so I want to remind you that your responses are completely voluntary. If I ask you a question you don’t want to answer, let me know and I’ll go to the next question.
BOX I
IF RESPONDENT IS FEMALE, ASK Q29, OTHERWISE SKIP TO Q30.
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29. (Have you/Has your child) been pregnant at any time during the past twelve months?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
RECORD UP TO 3 SURGERIES |
30. (Have you/Has your child) had surgery during the past twelve months?
YES 1
NO 2 SKIP TO Q31A1
DON'T KNOW 8 SKIP TO Q31A1
REFUSED 7 SKIP TO Q31A1
30A. What kind of surgery did (you/your child) have?
ENTER SURGERY 1 DISPLAY OPEN-END BOX
REFUSED 7
DON’T KNOW 8
30B. What illness or condition prompted (your/your child’s) surgery?
ENTER ILLNESS/ CONDITION 1 DISPLAY OPEN-END BOX
REFUSED 7
DON’T KNOW 8
30C. When did (you/your child) have this surgery?
DISPLAY PICKLIST FOR MONTH
ENTER MONTH: __ __
DON’T KNOW 98
REFUSED 97
ENTER YEAR (RANGE : 2006-2008): __ __ __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
30D. (Have you/Has your child) had any other surgeries during the past twelve months?
YES 1 GO TO Q30A
NO 2 SKIP TO Q31A1
DON'T KNOW 8 SKIP TO Q31A1
REFUSED 7 SKIP TO Q31A1
31A1. (Have you/Has your child) ever been diagnosed with or treated by a doctor for chronic liver disease, other than cancer?
YES 1
NO 2 SKIP TO Q31A2
DON'T KNOW 8 SKIP TO Q31A2
REFUSED 7 SKIP TO Q31A2
31B1. What type of chronic liver disease was it?
cirrhosis 1
hepatitis B 2
hepatitis C 3
another type (SPECIFY): ________ 4 DISPLAY OPEN-END BOX DON'T KNOW 8
REFUSED 7
31C1. What treatment (were you/was your child) given for (your/your child’s)<DISPLAY Q31B1 RESPONSE OR Q31B1 SPECIFY>?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31A2. (Have you/Has your child) ever been diagnosed with or treated by a doctor for emphysema?
YES 1
NO 2 SKIP TO Q31A3
DON'T KNOW 8 SKIP TO Q31A3
REFUSED 7 SKIP TO Q31A3
31C2. What treatment (were you/was your child) given for your emphysema?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31A3. (Have you/Has your child) ever been diagnosed with or treated by a doctor for an inflammatory bowel disease?
YES 1
NO 2 SKIP TO Q31A4
DON'T KNOW 8 SKIP TO Q31A4
REFUSED 7 SKIP TO Q31A4
31B3. What type of inflammatory bowel disease was it?
crohn’s disease 1
ulcerative colitis 2
another type (SPECIFY): ________ 4 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31C3. What treatment (were you/was your child) given for your <DISPLAY Q31B3 RESPONSE OR Q31B3 SPECIFY>?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31A4. (Have you/Has your child) ever had an organ transplant?
YES 1
NO 2 SKIP TO Q31A5
DON'T KNOW 8 SKIP TO Q31A5
REFUSED 7 SKIP TO Q31A5
31B4. Which organ was it?
ENTER ORGAN 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31A5. (Have you/Has your child) ever been diagnosed with or treated for a heart attack?
YES 1
NO 2 SKIP TO Q31A6
DON'T KNOW 8 SKIP TO Q31A6
REFUSED 7 SKIP TO Q31A6
31C5. What treatment were (you/your child) given for your heart attack?
SPECIFY_________________
31A6. (Have you/Has your child) ever been diagnosed with or treated by a doctor for heart disease, including heart failure?
YES 1
NO 2 SKIP TO Q31A7
DON'T KNOW 8 SKIP TO Q31A7
REFUSED 7 SKIP TO Q31A7
31C6. What treatment (were you/was your child) given for (your/your child’s) heart disease?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31E6a.In what year (were you/was your child) most recently diagnosed with heart disease?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
If Q31E6a YEAR IS > 2004, ASK:
31E6b. In which month?
DISPLAY PICKLIST FOR MONTH
ENTER MONTH: __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
31D6. Has this heart disease limited your ability to walk?
YES 1
NO 2 SKIP TO Q31A7
DON'T KNOW 8 SKIP TO Q31A7
REFUSED 7 SKIP TO Q31A7
31D6.Does (your/ your child’s) <DISPLAY Q31C6 RESPONSE> still limit your ability to walk?
YES 1 SKIP TO Q31A7
NO 2
DON'T KNOW 8 SKIP TO Q31A7
REFUSED 7 SKIP TO Q31A7
31E6a. In what year did (your/your child’s) <DISPLAY Q31C6 RESPONSE> stop limiting (your/your child’s) ability to walk?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
31E6b. If Q31E6a YEAR IS > 2004, ASK: In which month?
DISPLAY PICKLIST FOR MONTH
ENTER MONTH: __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
YES 1
NO 2 SKIP TO Q31A8
DON'T KNOW 8 SKIP TO Q31A8
REFUSED 7 SKIP TO Q31A8
31C7. What treatment (were you/was your child) given for (your/your child’s) rheumatoid arthritis?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31E7a. In what year (were you/was your child) first diagnosed with rheumatoid arthritis?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
YES 1
NO 2 SKIP TO Q31A9
DON'T KNOW 8 SKIP TO Q31A9
REFUSED 7 SKIP TO Q31A9
31C8. What treatment (were you/was your child) given for fluid in (your/your child’s) lungs?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31D8. (Do you/Does your child) still have fluid in (your/your child’s) lungs?
YES 1 SKIP TO Q31A9
NO 2
DON'T KNOW 8 SKIP TO Q31A9
REFUSED 7 SKIP TO Q31A9
31E8a. In what year did (you/your child) no longer have fluid in (your/your child’s) lungs?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
31E8b. If Q31E8a YEAR IS > 2004, ASK: In which month?
DISPLAY PICKLIST FOR MONTH
ENTER MONTH: __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
YES 1
NO 2 SKIP TO Q31A10
DON'T KNOW 8 SKIP TO Q31A10
REFUSED 7 SKIP TO Q31A10
31C9. What treatment (were you/was your child) given for (your/your child’s) multiple sclerosis?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31D9. (Do you/Does your child) still have multiple sclerosis?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
31E9A. In what year (were you/was your child) first diagnosed with multiple sclerosis?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
YES 1
NO 2 SKIP TO Q31A11
DON'T KNOW 8 SKIP TO Q31A11
REFUSED 7 SKIP TO Q31A11
31C10. What treatment (were you/was your child) given for your stroke?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31D10. (Do you/Does your child) still have lingering effects from (your/your child’s) stroke?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
31E10a.In what year was (your/your child’s) most recent stroke?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
31E10b. If Q31E10a YEAR IS > 2004, ASK: In which month?
DISPLAY PICKLIST FOR MONTH
ENTER MONTH: __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
YES 1
NO 2 SKIP TO Q31A13
DON'T KNOW 8 SKIP TO Q31A13
REFUSED 7 SKIP TO Q31A13
31B12a.What type of sleep disorder was it?
narcolepsy 1
sleep apnea 2
another type (SPECIFY): ________ 3 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31C12a What treatment (were you/was your child) given for your <DISPLAY Q31B12a RESPONSE OR Q31B12a SPECIFY>?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31E12aa.In what year (were you/was your child) first diagnosed with <DISPLAY Q31E12a RESPONSE OR Q31E12a SPECIFY>?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
YES 1
NO 2 SKIP TO Q31A13
DON'T KNOW 8 SKIP TO Q31A13
REFUSED 7 SKIP TO Q31A13
31B12b.What type of sleep disorder was it?
narcolepsy 1
sleep apnea 2
another type (SPECIFY): ________ 3 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31C12b.What treatment (were you/was your child) given for your <DISPLAY Q31B12b RESPONSE OR Q31B12b SPECIFY>?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31E12ab.In what year (were you/was your child) first diagnosed with <DISPLAY Q31B12B RESPONSE OR Q31B12B SPECIFY>?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
YES 1
NO 2 SKIP TO Q31A14
DON'T KNOW 8 SKIP TO Q31A14
REFUSED 7 SKIP TO Q31A14
31B13. What type of lupus was it?
systemic 1
discoid 2
another type (SPECIFY): ________ 3 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31C13. What treatment (were you/was your child) given for your lupus?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31E13a.In what year (were you/was your child) first diagnosed with lupus?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
RECORD UP TO 5 CANCERS |
31A14. (Have you/Has your child) ever been diagnosed or treated by a doctor for cancer?
YES 1
NO 2 SKIP TO Q32
DON'T KNOW 8 SKIP TO Q32
REFUSED 7 SKIP TO Q32
31B14. What type of cancer was it?
DO NOT READ LIST.
DISPLAY CANCER PICKLIST:
1=BASAL CELL CANCER
2=BREAST CANCER
3=CERVICAL CANCER
4=COLON CANCER
5=LYMPHOMA
6=LEUKEMIA
7=LUNG CANCER
8=OVARIAN CANCER
9=PROSTATE CANCER
10=SKIN CANCER
11=THYROID CANCER
12=UTERINE CANCER
95 = OTHER (SPECIFIED) DISPLAY OPEN-END BOX
97 = REFUSED
98 = DON'T KNOW
31C14. What treatment (were you/was your child) given for <DISPLAY CANCER>?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
31D14. (Do you/Does your child) still have <DISPLAY CANCER>?
YES 1 SKIP TO Q31A14b
NO 2
DON'T KNOW 8 SKIP TO Q31A14b
REFUSED 7 SKIP TO Q31A14b
31E14. In what year did (your/your child’s) <DISPLAY CANCER> go into remission?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
31E14b. If Q31E14 YEAR IS > 2002, ASK: In which month?
DISPLAY PICKLIST FOR MONTH
ENTER MONTH: __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
31A14b.(Have you/Has your child) ever been diagnosed or treated by a doctor for any other type of cancer?
YES 1 SKIP TO Q31B14
NO 2 SKIP TO Q32A
DON'T KNOW 8 SKIP TO Q32A
REFUSED 7 SKIP TO Q32A
RECORD UP TO 6 OTHER DIAGNOSES |
32A. Are there any other conditions or illnesses that I have not asked about for which (you have/your child has) ever been diagnosed or treated by a doctor?
YES (SPECIFY) 1 DISPLAY OPEN-END BOX
NO 2 GO TO Q33
DON’T KNOW 8 GO TO Q33
REFUSED 7 GO TO Q33
32B. What treatment (were you/was your child) given for <DISPLAY CONDITION>?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON'T KNOW 8
REFUSED 7
32C. Do you currently have <DISPLAY CONDITION>?
YES 1 SKIP TO Q32A
NO 2
DON'T KNOW 8 SKIP TO Q32A REFUSED 7 SKIP TO Q32A
32D. In what year was (your/your child’s) <DISPLAY CONDITION> cured or controlled?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __ SKIP TO Q32A
DON’T KNOW F9 (-1) SKIP TO Q32A
REFUSED F10 (-2) SKIP TO Q32A
EXCLUSIONARY PSYCHIATRIC CONDITIONS
Now I want to ask you some specific questions about conditions (you/your child) may have or have had.
33. (Have you/Has your child) ever received a formal diagnosis of bipolar disorder or schizophrenia by a doctor, psychologist or other health care professional?
YES, BIPOLAR DISORDER 1 GO TO Q33A
YES, SCHIZOPHRENIA 2 SKIP TO Q33B
YES, BOTH 3 GO TO Q33A
NO, NEITHER 4 SKIP TO Q34
DON’T KNOW 8 SKIP TO Q34
REFUSED 7 SKIP TO Q34
33A. What treatment (were you/was your child) given for bipolar disorder?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON’T KNOW 8
REFUSED 7
BOX J
IF Q33=3 (YES, BOTH), GO TO Q33B. OTHERWISE, SKIP TO Q34.
|
33B. What treatment (were you/was your child) given for schizophrenia?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON’T KNOW 8
REFUSED 7
34. In the last five years, (have you/has your child) received a formal diagnosis of anorexia nervosa or bulimia by a doctor, psychologist or other health care professional?
YES, ANOREXIA NERVOSA 1 GO TO Q34A
YES, BULIMIA NERVOSA 2 SKIP TO Q34B
YES, BOTH 3 GO TO Q34A
NO, NEITHER 4 SKIP TO Q35
DON’T KNOW 8 SKIP TO Q35
REFUSED 7 SKIP TO Q35
34A. What treatment (were you/was your child) given for anorexia nervosa?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON’T KNOW 8
REFUSED 7
BOX K
IF Q34=3 (YES, BOTH), GO TO Q34B. OTHERWISE, SKIP TO Q35.
|
34B. What treatment (were you/was your child) given for bulimia nervosa?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON’T KNOW 8
REFUSED 7
35. In the last two years, (have you/has your child) received a formal diagnosis of alcohol abuse or dependence or substance abuse or dependence by a doctor, psychologist or other health care professional?
YES, ALCOHOL ABUSE OR DEPENDENCE 1 GO TO Q35A
YES, DRUG ABUSE OR DEPENDENCE 2 GO TO Q35B
YES, BOTH 3 GO TO Q35A
NO, NEITHER 4 GO TO QQ36
DON’T KNOW 8 GO TO QQ36
REFUSED 7 GO TO QQ36
35A. What treatment (were you/was your child) given for alcohol abuse or dependence?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON’T KNOW 8
REFUSED 7
BOX L
IF Q35=3 (YES, BOTH), GO TO Q35B. OTHERWISE, SKIP TO Q36.
|
35B. What treatment (were you/was your child) given for drug abuse or dependence?
ENTER TREATMENT 1 DISPLAY OPEN-END BOX
DON’T KNOW 8
REFUSED 7
IF R IS AN ADOLESCENT, SKIP TO Q60.
COMORBID PSYCHIATRIC CONDITIONS
36. Have you ever had a period when you were feeling depressed or down most of the day, nearly every day?
YES 1
NO 2 SKIP TO Q37
DON’T KNOW 8 SKIP TO Q37
REFUSED 7 SKIP TO Q37
36A. How long did it last?
ENTER NUMBER FOR DAYS, WEEKS, MONTHS, OR YEARS: ________
DON’T KNOW -1
REFUSED -2
ENTER PERIOD ________
DAY(S) 1
WEEK(S) 2
MONTH(S) 3
YEARS(S) 4
37. Have you ever had a time when you lost interest or pleasure in things you usually enjoyed?
YES 1
NO 2 SKIP TO BOX M
DON’T KNOW 8 SKIP TO BOX M
REFUSED 7 SKIP TO BOX M
38. How long did it last?
ENTER NUMBER FOR DAYS, WEEKS, MONTHS, OR YEARS: ________
DON’T KNOW -1
REFUSED -2
ENTER PERIOD ________
DAY(S) 1
WEEK(S) 2
MONTH(S) 3
YEARS(S) 4
BOX M
IF Q36 (<DEPRESS>) =1 OR Q37 (<LSTPLEA>) =1, GO TO Q39. OTHERWISE, SKIP TO Q43.
|
39. Now I’m going to ask you about the last month. In the last month has there been a period of time when you were feeling depressed or down most of the day, nearly every day?
YES 1
NO 2 SKIP TO Q40
DON’T KNOW 8 SKIP TO Q40
REFUSED 7 SKIP TO Q40
39A. How long did it last?
ENTER NUMBER FOR DAYS, WEEKS, MONTHS, OR YEARS: ________
DON’T KNOW -1
REFUSED -2
ENTER PERIOD ________
DAY(S) 1
WEEK(S) 2
MONTH(S) 3
YEARS(S) 4
40. What about losing interest or pleasure in things you usually enjoyed?
YES 1
NO 2 SKIP TO BOX N
DON’T KNOW 8 SKIP TO BOX N
REFUSED 7 SKIP TO BOX N
41. How long did it last?
ENTER NUMBER FOR DAYS, WEEKS, MONTHS, OR YEARS: ________
DON’T KNOW -1
REFUSED -2
ENTER PERIOD ________
DAY(S) 1
WEEK(S) 2
MONTH(S) 3
YEARS(S) 4
BOX N
IF Q39A GE 2 WEEKS OR Q41 GE 2 WEEKS, GO TO Q42. OTHERWISE, SKIP TO Q43. (DETAILED LOGIC BELOW.)
IF [(DDRLMOP=1 AND DDRLMON GE 14) OR (DDRLMOP=2 AND DDRLMON GE 2) OR DDRLMOP=3 OR DDRLMOP=4] OR [(LPLMOP=1 AND LPLMON GE 14) OR (LPLMOP=2 AND LPLMON GE 2) OR LPLMOP=3 OR LPLMOP=4], THEN GO TO Q42. OTHERWISE, SKIP TO Q43
|
42. Have you ever received a formal diagnosis of depression by a doctor, psychologist or other health care professional?
YES 1
NO 2 SKIP TO Q43
DON’T KNOW 8 SKIP TO Q43
REFUSED 7 SKIP TO Q43
42A. What treatment were you given?
ENTER TREATMENT 95 DISPLAY OPEN-END BOX
DON’T KNOW 98
REFUSED 97
43. Have you ever had a panic attack, when you suddenly felt frightened or anxious or suddenly developed a lot of symptoms such as accelerated heart rate, sweating, trembling, shaking, chills, hot flushes, shortness of breath or feeling of choking?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
44. Were you ever afraid of going out of the house alone, being in crowds, standing in a line or traveling on buses or trains?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
45. Is there anything that you have been afraid to do or felt uncomfortable doing in front of other people, like speaking, eating or writing?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
46. Are there any other things that you have been especially afraid of, like flying, seeing blood, getting a shot, heights, closed places, or certain kinds of animals or insects?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
47. In the last six months, have you been particularly nervous--that is, worried excessively--and anxious about several things?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
BOX O
IF Q43=1 OR Q44=1 OR Q45=1 OR Q46=1 OR Q47=1, GO TO Q48. OTHERWISE, SKIP TO Q49.
|
48. Have you ever received a formal diagnosis of panic disorder, agoraphobia, social phobia, specific phobia or generalized anxiety disorder by a doctor, psychologist or other health care professional?
YES 1
NO 2 SKIP TO Q49
DON’T KNOW 8 SKIP TO Q49
REFUSED 7 SKIP TO Q49
48A. What treatment were you given?
ENTER TREATMENT 95 DISPLAY OPEN-END BOX
DON’T KNOW 98
REFUSED 97
49. Sometimes things happen to people that are extremely upsetting - things like being in a life threatening situation like a major disaster, very serious accident or fire; being physically assaulted or raped; seeing another person killed or dead, or badly hurt, or hearing about something horrible that has happened to someone you are close to. At any time in your life, have any of these kinds of things happened to you?
YES 1
NO 2 SKIP TO Q50
DON’T KNOW 8 SKIP TO Q50
REFUSED 7 SKIP TO Q50
49A. Sometimes these things keep coming back in nightmares, flashbacks, or thoughts that you can’t get rid of. Has that ever happened to you?
YES 1 SKIP TO Q49C
NO 2
DON’T KNOW 8
REFUSED 7
49B. What about being very upset when you were in a situation that reminded you of one of these terrible things?
YES 1
NO 2 SKIP TO Q50
DON’T KNOW 8 SKIP TO Q50
REFUSED 7 SKIP TO Q50
49C. How long did these problems last?
ENTER NUMBER FOR DAYS, WEEKS, MONTHS, OR YEARS: ________
DON’T KNOW -1
REFUSED -2
ENTER PERIOD ________
DAY(S) 1
WEEK(S) 2
MONTH(S) 3
YEARS(S) 4
49D. Have you ever received a formal diagnosis of posttraumatic stress disorder by a doctor, psychologist or other health care professional?
YES 1
NO 2 SKIP TO Q50
DON’T KNOW 8 SKIP TO Q50
REFUSED 7 SKIP TO Q50
49E. What treatment were you given?
ENTER TREATMENT 95 DISPLAY OPEN-END BOX
DON’T KNOW 98
REFUSED 97
PERCEIVED STRESS
If respondent is a parent responding about a child, skip to #60
Now I’m going to ask you about your feelings and thoughts during the last month. In each case, please indicate how often you felt or thought a certain way.
50. In the last month, how often have you been upset because of something that happened unexpectedly?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
51. In the last month, how often have you felt that you were unable to control the important things in your life?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
52. In the last month, how often have you felt nervous and "stressed"?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
In the last month, how often have you felt confident about your ability to handle your personal problems?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
54. In the last month, how often have you felt that things were going your way?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
55. In the last month, how often have you found that you could not cope with all the things that you had to do?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
56. In the last month, how often have you been able to control irritations in your life?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
57. In the last month, how often have you felt that you were on top of things?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
In the last month, how often have you been angered because of things that were outside of your control?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
SOCIOECONOMIC STATUS DURING CHILDHOOD
IF SUBJECT IS AN ADULT, SKIP TO Q.61. The next questions are about your child’s family background. First, how are you related to (CHILD)?
BIRTH MOTHER 01
BIRTH FATHER 02
ADOPTIVE MOTHER 03
ADOPTIVE FATHER 04
STEPPARENT PARENT 06
FOSTER PARENT 07
OTHER RELATED ADULT 08
OTHER UNRELATED ADULT 09
DON’T KNOW 98
REFUSED 99
For most of (your/ your CHILD’s) childhood, (did your/ has (his/her) family own(ed) their home?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
IF Q60=01, ASK: How much education do you have? OTHERWISE, ASK: How much education (did your/does CHILD’s) birth mother have? Please choose one answer.
Didn't go to high school 1
Some high school 2
High school graduate or GED 3
Some college or technical school 4
4 year college degree graduate or higher 5
DON'T KNOW 8
REFUSED 7
IF Q60=02 ASK: How much education do you have? OTHERWISE, ASK: How much education (did your/does CHILD’s) birth father have? Please choose one answer.
Didn't go to high school 1
Some high school 2
High school graduate or GED 3
Some college or technical school 4
4 year college degree graduate or higher 5
DON'T KNOW 8
REFUSED 7
IF Q.60 =01, ASK: How old were you when CHILD was born? OTHERWISE, ASK: How old was (your/your child’s) mother when (you/your child) were born?
ENTER AGE: ___ ___
DON'T KNOW -1 GO TO Q65
REFUSED -2 GO TO Q65
64A. If you don’t know the exact age, would you say it was between:
15 to 19 1
20 to 30 2
31 to 40 3
or 41 to 50 4
DON'T KNOW 8
REFUSED 7
DEMOGRAPHICS
The next question is about health insurance. (Are you/Is your child) covered by any type of health insurance?
YES 1
NO 2 SKIP TO Q66
DON'T KNOW 8 SKIP TO Q66
REFUSED 7 SKIP TO Q66
65A. What type of health insurance (do you/does your child) have? Please note that you may choose more than one option. Health insurance provided by an employer – either yours or someone else's such as your spouse's, Medicare, Medicaid, or another type of insurance?
HEALTH INSURANCE PROVIDED BY
AN EMPLOYER – EITHER YOURS OR SOMEONE
ELSE’S, SUCH AS YOUR SPOUSE’S 1
MEDICARE 2
MEDICAID 3
ANOTHER TYPE OF INSURANCE
(SPECIFY: ___________) 95
DON'T KNOW 98
REFUSED 97
Are you currently married, not married but living with a partner, separated, divorced, widowed, or have you never been married?
MARRIED 1
NOT MARRIED BUT LIVING WITH PARTNER 2
SEPARATED 3
DIVORCED 4
WIDOWED 5
NEVER BEEN MARRIED 6
OTHER 96
DON'T KNOW 98
REFUSED 97
What was the last grade or year of school (you/your child) completed?
No formal schooling 01
First through eighth grade 02
Some high school 03
High school graduate 04
Trade\technical\vocational
after high school 05
Some college 06
Two-year college graduate 07
Four-year college graduate 08
Postgraduate 09
Other (SPECIFY _______________) 10
DON'T KNOW 98
REFUSED 97
Which of the following categories best describes your household's income before taxes in 2006? READ LIST.
$10,000 or less 01
$10,001 to $20,000 02
$20,001 to $30,000 03
$30,001 to $40,000 04
$40,001 to $50,000 05
$50,001 to $60,000 06
$60,001 to $70,000 07
$70,001 or more 08
DON'T KNOW 98
REFUSED 97
CONTACT INFORMATION
According to my records, your telephone number is [NUMBER]. Is that correct?
YES 1 GO TO Q69B
NO 2 GO TO Q69A
DON’T KNOW 8 GO TO Q69B
REFUSED 7 GO TO Q69B
69A. May I please have your correct phone number?
PHONE: ( ) - __________
DON’T KNOW 8
REFUSED 7
69B. Under what name is this phone listed?
LISTED UNDER:
DON’T KNOW 8
REFUSED 7
RESPONDENTS WILL BE ASKED TO CONFIRM CONTACT INFORMATION IF IT HAS BEEN PROVIDED.
IF POSSIBLY ELIGIBLE FOR CLINIC, BUT REQUIRES REVIEW:
“Thank you for this information. We may want to get in touch with you again in the future for further participation in this study. The study will include the completion of medical history interviews, a physical examination and routine laboratory tests and a mental health interview, all at no cost to (you/your child).
I’d like to get some information now that will help us contact you.
IF ELIGIBLE FOR CLINIC:
“Thank you for this information. We would like to get in touch with you again in the future for further participation in this study. The study will include the completion of medical history interviews, a physical examination and routine laboratory tests and mental health interview, all at no cost to (you/your child).
I’d like to get some information now that will help us contact you.
ASK Q70 IF R IS AN ADOLESCENT:
What is your name? [STORE PARENT INFO IN SEPARATE FIELD]
CONFIRM SPELLING.
Title (Ms, Mr. Mrs.):
First Name:
Middle Initial:
Last Name:
Suffix (e.g., Jr., Sr., II):
What is (your/your child’s) name?
CONFIRM SPELLING.
Title (Ms, Mr. Mrs.):
First Name:
Middle Initial:
Last Name:
Suffix (e.g., Jr., Sr., II):
What is your address?
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
IF R IS ADULT, GO TO Q73
72A. Does your child live with you?
YES 1 GO TO Q73
NO 2 GO TO Q72B
DON’T KNOW 8 GO TO Q72B
REFUSED 7 GO TO Q73
72B. What is your child’s address?
STREET ADDRESS: ________________________________
CITY:
STATE: ________________________________
ZIP CODE: ________________________________
What are the last four digits of (your/your child’s) social security number?
|_ _|_ _|_ _|_ _|
IF R IS AN ADOLESCENT, SKIP TO Q75.
What is the name of your employer?
Name of employer:_________________________________________
74A. What is your employer’s address?
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
74B. What is your phone number at work?
(____)_____-__________
EXTENSION: _______
DON’T KNOW 8
REFUSED 7
Is there another number where you can usually be reached?
YES 1
NO 2 GO TO Q76
DON’T KNOW 8 GO TO Q76
REFUSED 7 GO TO Q76
75A. What is that phone number?
(____)_____-__________
EXTENSION: _______
DON’T KNOW 8
REFUSED 7
75B. And where is that? (neighbor, other) ________________
DON’T KNOW 8
REFUSED 7
May I have your email address?
(PROGRAMMER: IF R IS ADULT, DISPLAY RESPONDENT EMAIL FIELD ONLY. IF R IS ADOLESCENT. DISPLAY PARENT EMAIL FIELD ONLY)
Respondent Email:___________________________________________________________
Parent Email:_______________________________________________________________
DON’T KNOW 8
REFUSED 7
In case we have trouble reaching you (about your child), we would like to have the names of two of your close relatives or friends who do not live with you and who would know how to get in touch with you. We will not contact these people for any other reason. IF RESPONDENT HAS NO RELATIVES OR FRIENDS, PROBE: Then who else would be most likely to know how to reach you?
RESPONDENT AGREES 1
RESPONDENT REFUSES 7 SKIP TO Q78
RESPONDENT DOESN’T KNOW ANYONE
TO CONTACT 8 SKIP TO Q78
77A. First Relative/Friend
First Name:
Last Name:
What is <NAME’s> relationship to you?______________________
Street Address:
City:
State: Zip Code:
Phone Number(____)_____-__________
Under what name is this phone listed?_______________________
77B. Second Relative/Friend
First Name:
Last Name:
What is <NAME’s> relationship to you?______________________
Street Address:
City:
State: Zip Code:
Phone Number(____)_____-__________
Under what name is this phone listed?_______________________
You may also be eligible for other studies of fatiguing illness in the future. May we contact you again about these other studies? Telling us now that we may contact you does not obligate you to participate in these studies. You are only giving us permission to contact you and invite you to participate.
May we contact you again for future studies?
YES 1
NO 2
CLOSING: These are all the questions I have. If you have any questions about your rights in this study, you may call the CDC Deputy Director for Science toll-free at 1-800-584-8814. Please be prepared to leave a message and your call will be returned.
If you have any other questions about this research study, or if you think that you have been injured in this study, please call Dr. Elizabeth Maloney at the CDC. Dr. Jones’ number is: 1-404-639-2349 . Please note that this may be a toll call.
END TIME: I__I__I : I__I__I
| File Type | application/msword |
| File Title | Computer-Assisted Telephone Interview, Detailed Questionnaire |
| Author | MartinezE |
| Last Modified By | evm3 |
| File Modified | 2007-11-21 |
| File Created | 2007-05-31 |