Form Not Assigned Not Assigned Adult Identification

Page 1 of 6

2007 NHIS Questionnaire - Sample Adult

Adult Identification

Document Version Date: 12-Jul-06

Question ID: AID.005_00.000 Instrument Variable Name: SADULT QuestionnaireFileName: Sample Adult

QuestionText: * The sample adult person is [fill: Sample Adult name]. The next questions must be answered by this person. Probe as

necessary to determine the availability of [fill: Sample Adult name].

If refused enter CTRL-R

1 Available

2 Not available

3 Physical or mental condition prohibits responding

7 Refused

UniverseText: Sample adult section has not been started or completed

SkipInstructions: <1> [if Sample Adult = demographics.hhc.RELRESP_A]

[goto beginning of adult.asd]

[elseif Sample Adult = demographics.hhc.HHRESP]

[goto beginning of adult.asd]

[else]

[goto AIDVERF_S]

[endif]

<2> [goto callbk.ACALLBK1]

<3> [goto PROX1]

<R> [store <4> in ASTAT]

[if recontact.RCIFLAG <> 1]

[goto recontact.RCI_BEGIN procedure]

[else]

[goto back.OUTCOMEB1 procedure]

[endif]

Question ID: AID.010_00.000 Instrument Variable Name: PROX1 QuestionnaireFileName: Sample Adult

QuestionText: * Proxy interviews can be done for sample adults that have a mental or physical condition that prevents them from

responding for themselves.

Is a family member or caregiver that is knowledgeable about [fill: Sample Adult name]'s health available?

1 Yes

2 No

UniverseText: The Sample adult's physical or mental condition prohibits responding

SkipInstructions: <1> [goto PROX2]

<2> [goto PROX3]

Page 2 of 6

2007 NHIS Questionnaire - Sample Adult

Adult Identification

Document Version Date: 12-Jul-06

Question ID: AID.015_00.000 Instrument Variable Name: PROX2 QuestionnaireFileName: Sample Adult

QuestionText: * Ask if necessary.

What is this person's relationship to [fill: Sample Adult name]?

1 Relative who lives in household

2 Relative who doesn't live in household

3 Other caregiver

4 Other

7 Refused

9 Don't know

UniverseText: Knowledgeable proxy is available

SkipInstructions: <1-4> [goto AIDVERF_S]

Question ID: AID.020_00.000 Instrument Variable Name: PROX3 QuestionnaireFileName: Sample Adult

QuestionText: *Ask if necessary.

Can a callback with someone knowledgeable about [fill: Sample Adult name]'s health be arranged?

1 Yes

2 No

UniverseText: Knowledgeable proxy is not available

SkipInstructions: <1> [goto callbk.ACALLBK1]

<2> [store <3> in ASTAT]

[if recontact.RCIFLAG <> 1]

[goto recontact.RCI_BEGIN procedure]

[else]

[goto back.OUTCOMEB1 procedure]

[endif]

Question ID: AID.030_00.000 Instrument Variable Name: AIDVERF_S QuestionnaireFileName: Sample Adult

QuestionText: * Please verify the following information about the sample adult before proceeding:

I have recorded your sex as [fill: Sex of Sample Adult]. Is this correct?

*If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes

2 No

UniverseText: Sample adult is not the person entered in HHRESP or RELRESP_A Or PROX1 = 'Yes'

SkipInstructions: <1> [goto AIDVERF_A]

<2> [goto AIDSEX]

Page 3 of 6

2007 NHIS Questionnaire - Sample Adult

Adult Identification

Document Version Date: 12-Jul-06

Question ID: AID.040_00.000 Instrument Variable Name: AIDSEX QuestionnaireFileName: Sample Adult

QuestionText: * Ask if appropriate; otherwise, enter your best guess of the person's sex.

Are you Male or Female?

1 Male

2 Female

UniverseText: Respondent said his/her sex is not correct

SkipInstructions: <1,2> [store AIDSEX in SEX]

[goto ERR_AIDSEX]

[reset AIDVERF_S]

[goto AIDVERF_S]

Question ID: AID.045_00.000 Instrument Variable Name: AIDVERF_A QuestionnaireFileName: Sample Adult

QuestionText: * Please verify the following information about the sample adult before proceeding:

I have recorded your age as [fill: Age of Sample Adult] old. Is this correct?

*If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes

2 No

UniverseText: Sample adult said his/her sex is correct

SkipInstructions: <1> [goto AIDVERF_D]

<2> [goto AIDAGE]

Question ID: AID.050_00.000 Instrument Variable Name: AIDAGE QuestionnaireFileName: Sample Adult

QuestionText: How old are you?

000-120 Age in years

997 Refused

999 Don't know

UniverseText: Respondent said his/her age is not correct

SkipInstructions: <0-120, Refused, Don't know>

[if AIDAGE = Refused or AIDAGE = Don't know or AIDAGE = AGE]

[reset AIDVERF_A]

[goto ERR_AIDAGE]

[else]

[store AIDAGE in AGE]

[goto AIDDOB_M]

Page 4 of 6

2007 NHIS Questionnaire - Sample Adult

Adult Identification

Document Version Date: 12-Jul-06

Question ID: AID.055_00.000 Instrument Variable Name: AIDVERF_D QuestionnaireFileName: Sample Adult

QuestionText: * Please verify the following information about the sample adult before proceeding:

I have recorded your birthday as [fill: Birthday of Sample Adult]. Is this correct?

*If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes

2 No

UniverseText: Sample adult said his/her age is correct

SkipInstructions: Do not allow "Don't Know" or "Refused" as an answer.

<1> [if AGE of Sample Adult le <17>]

[goto NO_MORE]

[else]

[goto beginning of adult.asd]

[endif]

<2> [goto AIDDOB_M]

Question ID: AID.060_01.000 Instrument Variable Name: AIDDOB_M QuestionnaireFileName: Sample Adult

QuestionText: 1 of 3

What is your birthday?

*Enter month of birth.

01 January

02 February

03 March

04 April

05 May

06 June

07 July

08 August

09 September

10 October

11 November

12 December

97 Refused

99 Don't know

UniverseText: Respondent said his/her date of birth is not correct or his/her age is not correct

SkipInstructions: <01-12, Refused, Don't know> [goto AIDDOB_D]

Page 5 of 6

2007 NHIS Questionnaire - Sample Adult

Adult Identification

Document Version Date: 12-Jul-06

Question ID: AID.060_02.000 Instrument Variable Name: AIDDOB_D QuestionnaireFileName: Sample Adult

QuestionText: 2 of 3

*Enter day of birth.

01-31 Day of the month

97 Refused

99 Don't know

UniverseText: Respondent said his/her date of birth is not correct or his/her age is not correct

SkipInstructions: <01-31,Refused,Don't know> [goto AIDDOB_Y]

If days not valid, goto ERR_AIDDOB_D

Question ID: AID.060_03.000 Instrument Variable Name: AIDDOB_Y QuestionnaireFileName: Sample Adult

QuestionText: 3 of 3

*Enter year of birth.

1880-2020 Year of Birth

UniverseText: Respondent said his/her date of birth is not correct or his/her age is not correct

SkipInstructions: <1880-2020, Refused, Don't know> if AIDVERF_A = No then reset AIDVERF_A to empty

goto AIDVERF_A

elseif AIDVERF_D = No then reset AIDVERF_D to empty

goto AIDVERF_D

endif

(if year GT current year) or (if year = current year and month GT current month) or (if year = current year and month

= current month and day GT current day)

goto ERR1_AIDDOB_Y

endif

(if birth month = <02> and birth day = <29> and this is not a leap year)

goto ERR2_AIDDOB_Y

endif

(if AIDDOB_M = Ref or DK) or (if AIDDOB_D = Ref or DK) or (if AIDDOB_Y = Ref or DK)

goto ERR3_AIDDOB_Y

else

store AIDDOB_M in DOBM

store AIDDOB_D in DOBD

store AIDDOB_Y in DOBY

if AIDVERF_A = No then reset AIDVERF_A to empty

goto AIDVERF_A

elseif AIDVERF_D = No then reset AIDVERF_D to empty

goto AIDVERF_D

endif

endif

Calculate age from AIDDOB_M, AIDDOB_D, and AIDDOB_Y.

if age from AIDDOB items is ne AGE and age from AIDDOB items is valid

reset AIDVERF_A or AIDVERF_D.

goto ERR4_AIDDOB_Y

endif

Page 6 of 6

2007 NHIS Questionnaire - Sample Adult

Adult Identification

Document Version Date: 12-Jul-06

Question ID: AID.080_00.000 Instrument Variable Name: SASSN QuestionnaireFileName: Sample Adult

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: Sample adults 18+

SkipInstructions: <001010000-799999999> goto SASSNREP

<000000000-99999999> goto ERR_SASSN_2

<R, D> goto ERR_SASSN_1, if suppressed goto beginning of Recontact or

Back section

<N> goto beginning of Recontact or Back section

Question ID: AID.085_00.000 Instrument Variable Name: SASSNREP QuestionnaireFileName: Sample Adult

QuestionText: * Enter how Social Security number was reported.

1 From memory

2 From records

UniverseText: SSN was given at SASSN

SkipInstructions: <1,2> goto SASSNTEL

Question ID: AID.090_00.000 Instrument Variable Name: SASSNTEL QuestionnaireFileName: Sample Adult

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 Recontact or Back section