Attachment 2 - Survey Instrument - 02-12-09

MODULE A: INTRODUCTION
INT1.
The first few questions are for statistical purposes only, to help us analyze the results of the
study.
Do you consider {FILL: yourself/name} to be Hispanic or Latino?
1=YES
2=NO
[PROGRAMMER: QUESTION FILL WILL BE BASED ON SCREENER DATA ON AGE OF
SAMPLE RESPONDENT. IF RESPONDENT AGE IS < = 12 THEN INTERVIEW IS BY
PROXY. IF BY PROXY, FILL SHOULD BE NAME OF SAMPLE RESPONDENT. SOME
QUESTION FILLS WILL REFELECT GENDER AS WELL]
[INTCHK1

IF INT1 = 1, CONTINUE; ELSE GO TO INT2]

INT1a.
Which group represents {FILL: your/name’s} Hispanic origin or ancestry...
CODE ALL THAT APPLY.
1=Mexican or Mexican American
2=Other Latin American, Hispanic, Latino or Spanish Origin

INT2.
What race or races do you consider {FILL: yourself/name} to be? {FILL: Are you/Is he/she}...
CODE ALL THAT APPLY.
NOTE: CODE “NATIVE AMERICAN” AS “AMERICAN INDIAN”
1=White
2=Black or African American
3=American Indian or Alaska Native
4=Native Hawaiian or Other Pacific Islander
5=Asian
6=Other
INT3.
IF SELF-RESPONDENT: RECORD; IF UNSURE, ASK: What is your gender?
IF PROXY-RESPONDENT, ASK: What is {FILL: name’s} gender?
1=MALE
A-1

2=FEMALE
3=OTHER
INT4a.
In general, what language {FILL: do you/does name} prefer to speak in?
1=ENGLISH
2=SPANISH
3=ANOTHER LANGUAGE
[IF INT4a = 1, DK, OR RE GO TO AGE]
[IF INT4a = 2, GO TO INT4c]
[IF INT4a = 3 CONTINUE]
INT4b.
SPECIFY LANGUAGE:
[INSERT LIST OF LANGUAGES TO SELECT FROM]

INT4c.
{FILL: Are you/ Is name} comfortable conversing in English?
1=YES
2=NO
INTDOB:
What is {FILL: your/name’s} date of birth?
___ ___ DAY
___ __ MONTH
___ ___ ___ ___YEAR

[ALLOW 01-31]
[ALLOW 01-12]
[ALLOW 1900–2009]

[PROGRAMMER: CALCULATE AGE BASED ON RESPONSE FROM DOB. CREATE
NEW VARIABLE = AGE. IF AGE LESS THAN 12 MONTHS, CODE AS 1 YEAR. IF
DOB = DK OR RE CONTINUE, ELSE GOTO MODULE B]
INTAGE:
Can you tell me {FILL: your/name’s} current age?
IF AGE LESS THAN 12 MONTHS – CODE AS 1 YEAR.
___ ___ ___ AGE IN YEARS

[ALLOW 001-109]

A-2

MODULE B: CONDITIONS
CON1. Would you say {your/name’s} health in general is excellent, very good, good, fair, or
poor?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

CON1a. Compared with 12 months ago, that is since {12 MONTH REFERENCE DATE},
would you say {your/name’s} health is now better, worse, or about the same?
1=BETTER
2=WORSE
3=ABOUT THE SAME

[CONCHK2

ASK CON2 IF FEMALE AGE GE 15 CONTINUE ELSE GOTO CON3]

CON2. Have you ever been pregnant?
1=YES
2=NO

[CONCHK2a IF CON2=1 CONTINUE ELSE GOTO CON3; IF FEMALE AGE 15-49
CONTINUE, ELSE GOTO CON3]
CON2a. Are you currently pregnant?
1=YES
2=NO

CON3. How tall {are you/is name} without shoes?
[PROGRAMMERS: ALLOW METRIC]

B-1

_________ FEET
[ALLOW 0-8]
_________ INCHES [ALLOW 00-11]
CON4. {IF CON2a =1 FILL: “How much do you weigh without clothes or shoes before your
pregnancy?” ELSE FILL: “How much {do you/does name} weigh without clothes or shoes?”}
[PROGRAMMERS: ALLOW METRIC]
a. ________ POUNDS [ALLOW ___]

[CONCHK5 IF AGE GE 13, CONTINUE; ELSE GO TO CONCHK4]
CON5. {IF CON2a=1, FILL: “What did you consider yourself to be before you were pregnant,
overweight, underweight, or just about right?” ELSE FILL: “Do you consider yourself now to
be overweight, underweight, or just about right?”}
1=OVERWEIGHT
2=UNDERWEIGHT
3=ABOUT RIGHT

CON6a. {IF CON2=1 FILL: If you were pregnant a year ago, how much did you weigh before
your pregnancy? ELSE FILL: How much did you weigh a year ago?}
[ALLOW METRIC]
____________

[ALLOW ___]

CON6b. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, have you
tried to lose weight?
1=YES
2=NO

[CONCHK6c

IF CON6b = 1, CONTINUE; ELSE GO TO CONCHK4]

B-2

CON6c. How did you try to lose weight?
CODE ALL THAT APPLY.
1=CHANGED WHAT I ATE OR HOW MUCH I ATE OR WHEN I ATE
2=EXERCISED
3=JOINED A WEIGHT LOSS PROGRAM
4=TOOK DIET PILLS PRESCRIBED BY A DOCTOR
5=TOOK OTHER PILLS, MEDICINES, HERBS, OR SUPPLEMENTS NOT NEEDING A
PRESCRIPTION
6=STARTED TO SMOKE OR BEGAN TO SMOKE AGAIN
7=TOOK LAXATIVES OR VOMITED
8=DRANK A LOT OF WATER
9=OTHER

CON7. During the past 12 months, has a doctor or other health professional at {the reference
health center} told you that {you/name} had a problem with {your/his/her} weight?
1=YES
2=NO

[CONCHK8

IF CON7 = 1, CONTINUE; ELSE GO TO CONCHK10c]

CON8. Has anyone at {the reference health center} ever talked to you about things you can do to
manage {your/name’s} weight, such as meal planning, nutrition, or an exercise program?
1=YES
2=NO

[CONCHK8a

IF CON8 = 1, CONTINUE; ELSE GO TO CON9]

CON8a. Has anyone at {the reference health center} ever given you a referral to a nutritionist
because of {your/name’s} weight?
1=YES
2=NO

[CONCHK8b

IF CON8a = 1, CONTINUE; ELSE GO TO CON9]

B-3

CON8b. After you were given the referral, did {you/name} go to see a nutritionist?
1=YES
2=NO

CON9. Has anyone at {the reference health center} ever prescribed medications to help
{you/name} lose weight?
1=YES
2=NO

HIGH BLOOD PRESSURE
[CONCHK10 IF AGE GE 2, THEN CONTINUE; ELSE GO TO CON11 ]
CON10. Now I am going to ask you about certain medical conditions.
Have you ever been told by a doctor or other health professional that {you/name} had
hypertension, also called high blood pressure?
IF NEEDED: Blood pressure is checked by a health care provider using a blood pressure cuff
placed on your upper arm and a stethoscope.
1=YES
2=NO

[CONCHK10a IF CON10 = 1 CONTINUE; ELSE GO TO CON10b ]
CON10a. Were you told on two or more different visits that {you/name} had hypertension, also
called high blood pressure?
1=YES
2=NO

B-4

CON10b. About how long has it been since {you/name} had {your/his/her} blood pressure
checked by a doctor, nurse, or other health professional?
88=BLOOD PRESSURE CHECKED TODAY
99= NEVER
_______ MONTHS [ALLOW ___]
_______ YEARS
[ALLOW ___]

[CONCHK10c

IF CON10a = 1 CONTINUE, ELSE GO TO CON11 ]

CON10c. At that time, were you told that {your/his/her} blood pressure was high, normal, or
low?
1=HIGH
2=NORMAL
3=LOW
4=BORDERLINE
5=NOT TOLD

ASTHMA
CON11. Have you ever been told by a doctor or other health professional that {you/name} had
asthma?
1=YES
2=NO

[CONCHK11a IF CON11 = 1, CONTINUE; ELSE GOTO CON12]
CON11a. {Do you/Does name} still have asthma?
1=YES
2=NO

B-5

CON11b. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} had an episode of asthma or an asthma attack?
1=YES
2=NO

[CONCHK11c IF CON11b = 1, CONTINUE; ELSE GO TO CON12]
CON11c. During the past 12 months, {have you/has name} had to visit an emergency room or
urgent care center because of asthma?
1=YES
2=NO

DIABETES
CON12. {[IF CON2=1 ADD:] Other than during pregnancy,} Have you ever been told by a
doctor or health professional that {you/name} had diabetes or sugar diabetes?
1=YES
2=NO
3=BORDERLINE

[CONCHK12a IF CON12 = 1, CONTINUE; ELSE GO TO CONCHK13 ]
CON12a. How old {were you/was name} when a doctor first told you that {you/he/she)} had
diabetes or sugar diabetes?
________ AGE IN YEARS [ALLOW ___]

B-6

OTHER HEALTH CONDITIONS
[CONCHK13 IF AGE GE 18, CONTINUE; ELSE GOTO CON14 ]
CON13. These next questions are about blood cholesterol.
About how long has it been since you had your blood cholesterol checked by a doctor, nurse, or
other health professional?
1=NEVER
2=LESS THAN 1 YEAR AGO
3=AT LEAST 1 YR, LESS THAN 2 YEARS
4=AT LEAST 2 YRS, LESS THAN 3 YEARS
5=AT LEAST 3 YRS, LESS THAN 4 YEARS
6=AT LEAST 4 YRS, LESS THAN 5 YEARS
7=5 OR MORE YEARS AGO

[CONCHK13a IF CON13 = 1 OR DK OR RF, GO TO CON14; ELSE CONTINUE]

CON13a. Was this at {the reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE

CON13b. Have you ever been told by a doctor or other health professional that your blood
cholesterol level was high?
1=YES
2=NO

CON14a. The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…
congestive heart failure?
1=YES
2=NO

B-7

CON14b. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
coronary heart disease?
1=YES
2=NO

CON14c. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
Angina, also called angina pectoris?
1=YES
2=NO

CON14d. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
a heart attack (also called myocardial infarction)?
1=YES
2=NO

CON14e. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
a stroke?
1=YES
2=NO

B-8

CON14f. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
Emphysema?
1=YES
2=NO

CON14g. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
a thyroid problem?
1=YES
2=NO

CON14h. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
chronic bronchitis?
1=YES
2=NO

CON14i. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
any kind of liver condition?
1=YES
2=NO

B-9

CON14j. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
weak or failing kidneys
1=YES
2=NO

CON14k. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
Tuberculosis (TB)
1=YES
2=NO

[CONCHK14_current IF CON14a THROUGH CON14k ALL ARE NOT EQUAL TO
YES, THEN GO TO CON15]

[CONCHK14g_current IF CON14g = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14g_current. {Do you/Does name} CURRENTLY still have a thyroid problem?
1=YES
2=NO
[CONCHK14h_current IF CON14h = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14h_current. {Do you/Does name} CURRENTLY still have chronic bronchitis?
1=YES
2=NO
[CONCHK14i_current IF CON14i = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14i_current. {Do you/Does name} CURRENTLY still have any kind of liver condition?

B-10

1=YES
2=NO

[CONCHK14k_current IF CON14k = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14k_current. {Do you/Does name} CURRENTLY still have Tuberculosis (TB)?
1=YES
2=NO

[CONCHK14a_AGE IF CON14a = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14a_AGE. How old {were you/was name} when you were first told {you/he/she} had
congestive heart failure?
_________

AGE IN YEARS [ALLOW ____]

[CONCHK14b_AGE IF CON14b = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14b_AGE. How old {were you/was name} when you were first told {you/he/she} had
coronary heart disease?
_________

AGE IN YEARS [ALLOW ____]

[CONCHK14c_AGE IF CON14c = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14c_AGE. How old {were you/was name} when you were first told {you/he/she} had
Angina, also called angina pectoris?
_________

AGE IN YEARS [ALLOW ____]

[CONCHK14d_AGE IF CON14d = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]

B-11

CON14d_AGE. How old {were you/was name} when you were first told {you/he/she} had a
heart attack (also called myocardial infarction)?
_________

AGE IN YEARS [ALLOW ____]

[CONCHK14e_AGE IF CON14e = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14e_AGE. How old {were you/was name} when you were first told {you/he/she} had a
stroke?
_________

AGE IN YEARS [ALLOW ____]

[CONCHK14f_AGE IF CON14f = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14f_AGE. How old {were you/was name} when you were first told {you/he/she} had
Emphysema?
_________

AGE IN YEARS [ALLOW ____]

[CONCHK14g_AGE IF CON14g = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14g_AGE. How old {were you/was name} when you were first told {you/he/she} had a
thyroid problem?
_________

AGE IN YEARS [ALLOW ____]

[CONCHK14h_AGE
IF CON14h = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14h_AGE. How old {were you/was name} when you were first told {you/he/she} had
chronic bronchitis?
_________

AGE IN YEARS [ALLOW ____]

B-12

[CONCHK14i_AGE
IF CON14i = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14i_AGE. How old {were you/was name} when you were first told {you/he/she} had any
kind of liver condition?
_________

AGE IN YEARS [ALLOW ____]

[CONCHK14j_AGE
IF CON14j = 1 (YES) THEN CONTINUE; ELSE MOVE TO
LOGIC PRECEDING THE NEXT QUESTION]
CON14j_AGE. How old {were you/was name} when you were first told {you/he/she} had weak
or failing kidneys?
_________

AGE IN YEARS [ALLOW ____]

[CONCHK15a IF AGE GE 18 GO TO CON16, ELSE CONTINUE]
CON15a. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} had any of the following conditions? Please tell me yes or no for each condition.
Any kind of food or digestive allergy?
1=YES
2=NO

CON15b. (During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} had any of the following conditions? Please tell me yes or no for each condition.)
Frequent or repeated diarrhea or colitis?
1=YES
2=NO

[CONCHK15c IF AGE GE 3, ASK CON15c; ELSE GO TO NEXT QUESTION]
CON15c. (During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} had any of the following conditions? Please tell me yes or no for each condition.)

B-13

Frequent or severe headaches, including migraines?
1=YES
2=NO

CON15d. (During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} had any of the following conditions? Please tell me yes or no for each condition.)
Anemia?
1=YES
2=NO

CON15e. (During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} had any of the following conditions? Please tell me yes or no for each condition.)
Three or more episodes of ear pain or ear infections?
1=YES
2=NO

CON15f. (During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} had any of the following conditions? Please tell me yes or no for each condition.)
Seizures?
1=YES
2=NO

[CONCK15g IF AGE GE 3, ASK CON15g; ELSE GO TO NEXT QUESTION]
CON15g. (During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} had any of the following conditions? Please tell me yes or no for each condition.)
Stuttering or stammering?
1=YES
2=NO

B-14

CON16. During the past 12 months, {have you/ has name} had Pneumonia?
1=YES
2=NO

[CONCHK19 IF AGE GE 2 GO TO CON19; ELSE GO TO CON22 ]
CANCER
CON19. Have you ever been told by a doctor or other health professional that {you/name} had
cancer or a malignancy of any kind?
1=YES
2=NO

[CONCHK20

IF CON19 = 1, CONTINUE; ELSE GO TO CONCHK22]

CON20. What kind of cancer was it?
@BSHOWCARD CON1@B
CODE UP TO 3 KINDS
a
__________
b
__________
c
__________

1=BLADDER
2=BLOOD
3=BONE
4=BRAIN
5=BREAST
6=CERVIX
7=COLON
8=ESOPHAGUS
9=GALLBLADDER
10=KIDNEY
11=LARYNX-WINDPIPE
12=LEUKEMIA
13=LIVER
14=LUNG
15=LYMPHOMA
16=MELANOMA

B-15

17=MOUTH/TONGUE/ LIP
18=OVARY
19=PANCREAS
20=PROSTATE
21=RECTUM
22=SKIN (NON-MELANOMA)
23=SKIN (DON’T KNOW WHAT KIND)
24=SOFT TISSUE (MUSCLE OR FAT)
25=STOMACH
26=TESTIS
27=THROAT - PHARYNX
28=THYROID
29=UTERUS
30=OTHER

CON21a. For EACH cancer indicated, please also specify {your/name’s} age at the time the
cancer was first diagnosed.
{name of first cancer listed in CON20}:
_______ AGE IN YEARS [ALLOW ____]

[CONCK 21b IF MORE THAN ONE CANCER LISTED IN RESPONSE TO CON20,
ASK CON21b, ELSE GOT TO CONCHK22]
CON21b. (For EACH cancer indicated, please also specify {your/name’s} age at the time the
cancer was first diagnosed.)
{name of second cancer listed in CON20}:
_______ AGE IN YEARS [ALLOW ____]

[CONCK21c IF MORE THAN TWO CANCERS LISTED IN RESPONSE TO CON20,
ASK CON21c, ELSE GOT TO CONCHK22]
CON21c. (For EACH cancer indicated, please also specify {your/name’s} age at the time the
cancer was first diagnosed.)
{name of third cancer listed in CON20}:
_______ AGE IN YEARS [ALLOW ____]

B-16

CHOLESTEROL
[CONCHK22 IF CON13b=1, CONTINUE; ELSE GO TO CON25 ]
CON22. Earlier you mentioned that you were told by a doctor or other health professional that
your blood cholesterol level was high.

CON22a. To lower {your/his/her} blood cholesterol, {have you/has name} ever been told by a
doctor or other health professional…
to eat fewer high fat or high cholesterol foods?
1=YES
2=NO

CON22b. To lower {your/his/her} blood cholesterol, {have you/has name} ever been told by a
doctor or other health professional…
to control your weight or lose weight?
1=YES
2=NO

CON22c. To lower {your/his/her} blood cholesterol, {have you/has name} ever been told by a
doctor or other health professional…
to increase your physical activity or exercise?
1=YES
2=NO

CON22d. To lower {your/his/her} blood cholesterol, {have you/has name} ever been told by a
doctor or other health professional…
to take prescribed medicine?

B-17

1=YES
2=NO

[CONCHK23a IF CON22a=1 (YES), CONTINUE; ELSE GO TO THE LOGIC
PRECEDING THE NEXT QUESTION]
CON23a. Are you now following this advice to...
eat fewer high fat or high cholesterol foods?
1=YES
2=NO

[CONCHK23b IF CON22b=1 (YES), CONTINUE; ELSE GO TO THE LOGIC
PRECEDING THE NEXT QUESTION]
CON23b. Are you now following this advice to...
control your weight or lose weight?
1=YES
2=NO

[CONCHK23c IF CON22c=1 (YES), CONTINUE; ELSE GO TO THE LOGIC
PRECEDING THE NEXT QUESTION]
CON23c. Are you now following this advice to...
increase your physical activity or exercise?
1=YES
2=NO

[CONCHK23d IF CON22d=1 (YES), CONTINUE; ELSE GO TO THE LOGIC
PRECEDING THE NEXT QUESTION]
CON23d. Are you now following this advice to...

B-18

take prescribed medicine?
1=YES
2=NO

[CONCHK24 IF CON22A-D=1 CONTINUE; ELSE GOTO CON25 ]
CON24. Did you ever receive this advice from someone at {the reference health center}?
1=YES
2=NO

HEARING
The next few questions are about {your/name’s} hearing and vision.
CON25. {Have you/Has name} ever worn a hearing aid?
1=YES
2=NO

CON25a. @UWithout@U the use of hearing aids or other listening devices, is {your/name’s}
hearing excellent, good, a little trouble hearing, moderate trouble hearing, a lot of trouble
hearing, or {are you/is name} deaf?
1=EXCELLENT
2=GOOD
3=A LITTLE TROUBLE HEARING
4=MODERATE TROUBLE HEARING
5=A LOT OF TROUBLE HEARING
6=DEAF

VISION

B-19

CON 26. {Do you/ Does name} have any trouble seeing, even when wearing glasses or contact
lenses?
[IF AGE UNDER 2: ] {Does name} have any trouble seeing?
1=YES
2=NO

[CONCHK26a IF CON26 = 1, CONTINUE; ELSE GO TO CONCHK27 ]
CON26a. {Are you/Is name} blind or unable to see at all?
1=YES
2=NO

[CONCHK27 IF AGE GE 10 CONTINUE; ELSE GO TO MODULE C ]
CON27. Because of a physical, mental, or emotional problem, {do you/does name} need help of
other persons with @Upersonal care needs@U such as eating, bathing, dressing, or getting
around inside your home?
1=YES
2=NO

[CONCHK27a-f IF CON27=1 CONTINUE ELSE GOTO CONCHK28 ]
CON27a. {Do you/ Does name} need help with…
bathing or showering?
1=YES
2=NO

CON27b. {Do you/ Does name} need help with…
dressing?
1=YES

B-20

2=NO

CON27c. {Do you/ Does name} need help with…
eating?
1=YES
2=NO

CON27d. {Do you/ Does name} need help with…
getting in or out of bed or chairs?
1=YES
2=NO

CON27e. {Do you/ Does name} need help with…
using the toilet, including getting to the toilet?
1=YES
2=NO

CON27f. {Do you/ Does name} need help with…
getting around inside the home?
1=YES
2=NO

[CONCHK28 IF AGE GE 18, CONTINUE; ELSE GO TO MODULE C ]
CON28. Because of a physical, mental, or emotional problem, do you need the help of other
persons in handling routine needs, such as everyday household chores, doing necessary business,
shopping, or getting around for other purposes?

B-21

1=YES
2=NO

[CONCHK29 IF AGE 18 TO 69, CONTINUE; ELSE GO TO MODULE C ]
CON29. Does a physical, mental, or emotional problem now keep you from working at a job or
business?
1=YES
2=NO

[CONCHK30

IF CON29=1 GO TO MODULE C, ELSE CONTINUE]

CON30. Are you limited in the kind or amount of work you can do because of a physical, mental
or emotional problem?
1=YES
2=NO

B-22

MODULE C: ACCESS TO CARE
The next set of questions ask about availability of various types of health services. When
answering the next few questions, do not include dental care, prescription medicines, counseling
or mental health treatment..
MED1. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a
doctor believe {you/name} needed any medical care, tests, or treatment?
1=YES
2=NO

[MEDCHK2 IF MED1=1, THEN CONTINUE; ELSE GO TO MODULE D ]
MED2. In the last 12 months, {were you/was name} unable to get medical care, tests, or
treatments you or a doctor believed necessary?
1=YES
2=NO

[MEDCHK2a IF MED2=1, THEN CONTINUE; ELSE GO TO MED5 ]
MED2a. Please describe the main reason {you were/name was} unable to get medical care, tests,
or treatments you or a doctor believed necessary?
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER

C-1

MED2b. How much of a problem was it that {you/name} did not get medical care, tests, or
treatments you or a doctor believed necessary? Would you say...
1=A big problem
2=A small problem
3=Not a problem

MED3. What kind of care was it that {you/name} needed but did not get?
_____________ [ALLOW 40]

MED4. The last time {you/name} did not get the medical care, tests, or treatments {you/he/she}
needed, did a doctor tell you that {you/he/she} needed it?
1=YES
2=NO

MED5. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, were
{you/name} delayed in getting medical care tests, or treatments you or a doctor believed
necessary?
1=YES
2=NO

[MEDCHK5a

IF MED5=1, THEN CONTINUE; ELSE GO TO MODULE D ]

C-2

MED5a Which of these best describes the main reason {you were/name was} delayed in getting
medical care, tests, or treatments you or a doctor believed necessary?
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER

MED5b. How much of a problem was it that {you were/name was} delayed in getting medical
care, tests, or treatments you or a doctor believed necessary? Would you say it was a...
1=Big problem
2=Small problem
3=Not a problem

MED6. What kind of medical care, tests, or treatment was it that {you were/name was} delayed
in getting?
_____________[ALLOW 40]

MED7. At that time, did a doctor tell you that {you/name} needed that medical care, tests, or
treatment?
1=YES
2=NO

C-3

MODULE D:

ROUTINE CARE

Next, I’m going to ask you about health services that {you/name} received in the past 12
months, that is since {12 MONTH REFERENCE DATE}.
ROU1. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} seen or talked to any of the following health care providers about {your
own/his/her} health? Please tell me yes or no for each of the following…

ROU1a. (During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} seen or talked to any of the following health care providers about {your
own/his/her} health? Please tell me yes or no for each of the following…)
An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses)?
1=YES
2=NO

ROU1b. (During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} seen or talked to any of the following health care providers about {your
own/his/her} health? Please tell me yes or no for each of the following…)
A foot doctor?
1=YES
2=NO

ROU1c. (During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} seen or talked to any of the following health care providers about {your
own/his/her} health? Please tell me yes or no for each of the following…)
A chiropractor?
1=YES
2=NO

ROU1d. (During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} seen or talked to any of the following health care providers about {your
own/his/her} health? Please tell me yes or no for each of the following…)

D-1

A medical doctor who specializes in a particular medical disease or problem (other than
obstetrician, gynecologist, psychiatrist, or ophthalmologist)
1=YES
2=NO

ROU2. During the past 12 months, how many times {have you/has name} gone to a hospital
emergency room about {your own/his/her} health? This includes emergency room visits that
resulted in a hospital admission.
________ TIMES [ALLOW 000-365]

ROU3. (Were you/Was name} ever hospitalized @Uovernight@u in the past 12 months? Do not
include an overnight stay in the emergency room.
1=YES
2=NO

[ROUCHK4

IF ROU3 = 1 CONTINUE ELSE GOTO ROU5 ]

ROU4. Altogether, how many nights {were you/was name} in the hospital during the past 12
months?
_______ NIGHTS [ALLOW 000-365]

ROU5. During the past 12 months, {have you/has name} had a flu shot? A flu shot is usually
given in the fall and protects against influenza for the flu season.
READ IF NECESSARY: A flu shot is injected in the arm. Do not include an influenza vaccine
sprayed in the nose
1=YES
2=NO

D-2

ROU6: During the past 12 months, {have you/has name} had a flu vaccine sprayed in
{your/his/her} nose by a doctor or other health professional? {IF AGE GE 18 ADD: A health
professional may have let you spray it.} This vaccine is usually given in the fall and protects
against influenza for the flu season.
READ IF NECESSARY: This influenza vaccine is called FluMist {trademark}.
1=YES
2=NO

[ROUCHK7 IF ROU6=1 OR POU5=1, THEN CONTINUE; ELSE GO TO ROUCHK8]
ROU7. Did {you/name} get the flu shot or vaccine sprayed in the nose at {the reference health
center}?
1=YES
2=NO

[ROUCHK8 IF AGE GE 65, CONTINUE; ELSE GO TO ROU10 ]
ROU8. Have you ever had a pneumonia shot? This shot is usually given only once or twice in a
person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.
1=YES
2=NO

[ROUCHK9 IF ROU8 =1, CONTINUE; ELSE GO TO ROU10 ]
ROU9. Did you get the pneumonia vaccination at {the reference health center}?
1=YES
2=NO
[GO TO ROU10 ]

ROU9a. [IF AGE = 4 MONTH – 6 YEARS CONTINUE, ELSE GO TO ROU10 ]
Did {name} receive any shots in the last 12 months?
1=YES

D-3

2=NO

[ROUCHK9b IF ROU9a =1, CONTINUE; ELSE GO TO ROU10]
ROU9b. How many of the shots {name} received in the past 12 months were provided by
{reference health center}? Would you say all, some, or none?
1=ALL
2=SOME
3=NONE

[ROUCHK9c IF ROU9b =2 OR 3, CONTINUE; ELSE GO TO ROU9d]
ROU9c. Were you referred to the other place where {name} got the shots by {reference health
center}?
1=YES
2=NO

ROU9d. Are you the person who took {name} for most of {his/her} shots? Most means at least
half of the shots.
1=YES
2=NO

[ROUCHK9e

IF ROU9d =1, CONTINUE; ELSE GO TO ROU10]

ROU9e. In your opinion, has {name} received all of the recommended shots for {his/her} age?
1=YES
2=NO

[ROUCHK9f IF ROU9d =2, CONTINUE; ELSE GO TO ROU10]
ROU9f. What is the main reason {name} has not had all the shots that he/she is supposed to have
at his/her age?

D-4

@BNEED SHOWCARD@B
1=DID NOT THINK IT WAS IMPORTANT
2=AFRAID OF THE SIDE EFFECTS OF THE IMMUNIZATION
3=CHILD WAS SICK AND COULD NOT HAVE IMMUNIZATIONS AT THAT TIME
4=I DON’T TRUST THE SHOTS/ I DON’T BELIEVE IN SHOTS
5=COULDN’T AFFORD CARE
6=PROBLEMS GETTING TO DOCTOR'S OFFICE
7=DIFFERENT LANGUAGE
8=COULDN’T GET TIME OFF WORK
9=DIDN’T KNOW WHERE TO GO TO GET CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER

ROU10. [IF AGE GE 18, CONTINUE; ELSE GO TO ROUCHK12]
These next questions are about general physicals or routine check-ups.
About how long has it been since your last general physical exam or routine check-up by a
medical doctor or other health professional? Do not include a visit about a specific problem.
1=NEVER
2=LESS THAN 1 YEAR AGO
3=AT LEAST 1 YR, LESS THAN 2 YEARS
4=AT LEAST 2 YRS, LESS THAN 3 YEARS
5=AT LEAST 3 YRS, LESS THAN 4 YEARS
6=AT LEAST 4 YRS, LESS THAN 5 YEARS
7=5 OR MORE YEARS AGO

[ROUCHK11 IF ROU10= 2 OR 3, CONTINUE; ELSE IF ROU10=DK OR RF, GO TO
ROUCHK12; ELSE GO TO ROU11a ]
ROU11. Did you get this check-up at {the reference health center}?
1=YES
2=NO

[ROUCHK11a

GO TO ROUCHK12]

D-5

ROU11a. What is the main reason you have not had a general physical exam or routine check-up
in the past 2 years?
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER

[ROUCHK12

IF AGE <18, THEN CONTINUE; ELSE, GO TO ROU14 ]

ROU12. These next questions are about well-child check-ups, that is a general check-up,
performed when {you were/name was} not sick or injured. About how long has it been since
{you/he/she} received a well-child or general check-up?
1=NEVER
2=LESS THAN 1 YEAR AGO
3=AT LEAST 1 YR, LESS THAN 2 YEARS
4=AT LEAST 2 YRS, LESS THAN 3 YEARS
5=AT LEAST 3 YRS, LESS THAN 4 YEARS
6=AT LEAST 4 YRS, LESS THAN 5 YEARS
7=5 OR MORE YEARS AGO

[ROUCHK13

IF ROU12=2 OR 3, CONTINUE;
ELSE IF ROU12=DK OR RF, GO TO ROU14
ELSE GO TO ROU13a ]

ROU13. Did {you/he/she} get this check-up at {the reference health center}?
1=YES
2=NO

D-6

[ROUCHK13a GO TO ROU14[
ROU13a. What is the main reason {you/name} has not had a general physical exam or routine
check-up in the past 2 years?
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER

LEAD SCREENING
ROU14. [IF AGE 9 MONTHS - 5 YEARS CONTINUE, ELSE GO TO MODULE E]
Has {name} ever had a blood test to check the amount of lead in {his/her} blood?
1=YES
2=NO

[ROUCHK15

IF ROU14=1, CONTINUE; ELSE GO TO ROU17]

ROU15. How old was {name} the last time this test was done?
______AGE [ALLOW ____]

ROU16. Was that done at the {reference health center}?
1=YES
2=NO

D-7

ROU17. Has anyone ever talked to you about things that might cause {name} to be exposed to
lead, such as living in or visiting a house or apartment built before 1978?
1=YES
2=NO

D-8

MODULE E: CONDITIONS – FOLLOWUP
HIGH BLOOD PRESSURE
[CONFCHK1 I_INTRO

CON10a=1, THEN CONTINUE; ELSE GO TO CONFCHK4]

Earlier you mentioned that {you/name} had been told that {you/he/she} had high blood pressure.
I’d like to ask a few more questions about that.

[CONFCHK1

IF CON2=1 CONTINUE; ELSE GO TO CONF1a]

CONF1. Did you only have high blood pressure during pregnancy?
1=YES
2=NO

[CONFCHK1a IF CONF1=1, GO TO CONCHK4; ELSE CONTINUE]
CONF1a. Because of {your/name’s} high blood pressure, has a doctor or other health
professional EVER advised {you/him/her} to…..
CONF1a_a … go on a diet or change {your/his/her} eating habits to help lower {your/his/her}
blood pressure?
1=YES
2=NO

CONF1a_b (Because of {your/name’s} high blood pressure, has a doctor or other health
professional EVER advised {you/him/her} to…)
cut down on salt or sodium in {your/his/her} diet?
1=YES
2=NO

CONF1a_c (Because of {your/name’s} high blood pressure, has a doctor or other health
professional EVER advised {you/him/her} to…)
exercise?

E-1

1=YES
2=NO

[CONFCHK1a_d IF AGE GE 21 ASK CONF1a_d; ELSE GO TO LOGIC PRECEDING
THE NEXT QUESTION]
CONF1a_d (Because of {your/name’s} high blood pressure, has a doctor or other health
professional EVER advised {you/him/her} to…)
cut down on alcohol use?
1=YES
2=NO

[CONFCHK1b FOR EACH ITEM CODED AS "1" in CONF1a, CONTINUE; ELSE GO
TO CONF2 ]
[CONFCHK1b_a IF CONF1a_a EQUALS 1 (YES) THEN CONTINUE, ELSE GO TO
THE LOGIC PRECEDING THE NEXT QUESTION]
CONF1b_a {Are you/Is Name} now following this advice (to go on a diet or change
{your/his/her} eating habits to help lower {your/his/her} blood pressure)?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO

[CONFCHK1b_b IF CONF1a_b EQUALS 1 (YES) THEN CONTINUE, ELSE GO TO
THE LOGIC PRECEDING THE NEXT QUESTION]
CONF1b_b {Are you/Is Name} now following this advice (cut down on salt or sodium in
{your/his/her} diet)?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”

E-2

1=YES
2=NO

[CONFCHK1b_c IF CONF1a_c EQUALS 1 (YES) THEN CONTINUE, ELSE GO TO
THE LOGIC PRECEDING THE NEXT QUESTION]
CONF1b_c {Are you/Is Name} now following this advice (to exercise)?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO

[CONFCHK1b_d IF AGE GE 21 AND IF CONF1a_d EQUALS 1 (YES) THEN
CONTINUE, ELSE GO TO THE LOGIC PRECEDING THE NEXT QUESTION]
CONF1b_d {Are you/Is Name} now following this advice (to cut down on alcohol use)?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO

[CONFCHK1i IF CONF1a, b, c, or d =1 CONTINUE; ELSE GO TO CONF2 ]

[CONFCHK1i_a IF CONF1a_a EQUALS 1 (YES) THEN CONTINUE, ELSE GO TO
THE LOGIC PRECEDING THE NEXT QUESTION]
CONF1i_a. Did {you/name} ever receive the advice to go on a diet or change {your/his/her}
eating habits to help lower {your/his/her} blood pressure from someone at {the reference health
center}?
1=YES
2=NO

E-3

[CONFCHK1i_b IF CONF1a_b EQUALS 1 (YES) THEN CONTINUE, ELSE GO TO
THE LOGIC PRECEDING THE NEXT QUESTION]
CONF1i_b. Did {you/name} ever receive the advice to cut down on salt or sodium in
{your/his/her} diet from someone at {the reference health center}?
1=YES
2=NO

[CONFCHK1i_c IF CONF1a_c EQUALS 1 (YES) THEN CONTINUE, ELSE GO TO
THE LOGIC PRECEDING THE NEXT QUESTION]
CONF1i_c. Did {you/name} ever receive the advice to exercise from someone at {the reference
health center}?
1=YES
2=NO

[CONFCHK1i_d IF CONF1a_d EQUALS 1 (YES) THEN CONTINUE, ELSE GO TO
THE LOGIC PRECEDING THE NEXT QUESTION]
CONF1i_d. Did {you/name} ever receive the advice to cut down on alcohol use from someone
at {the reference health center}?
1=YES
2=NO

CONF2. Was any medication ever prescribed by a doctor for {your/name’s} high blood
pressure?
1=YES
2=NO

[CONFCHK2a IF CONF2= 1, CONTINUE; ELSE GOT TO CONF3 ]
CONF2a. {Are you/Is Name} now taking any medicine prescribed by a doctor for {your/his/her}
high blood pressure?

E-4

1=YES
2=NO

[CONFCHK2b IF CONF2a=2 CONTINUE, ELSE GO TO CONF3]
CONF2b. Did a doctor advise {you/name} to stop taking the medicine?
1=YES
2=NO

CONF3. {Do you/Does name} regularly check {your/his/her} own blood pressure?
1=YES
2=NO

CONF3a. During the last 6 months, have you received any of the following to teach
{you/him/her} how to take care of {your/his/her} high blood pressure?
A telephone call
1=YES
2=NO

CONF3b. (During the last 6 months, have you received any of the following to teach
{you/him/her} how to take care of {your/his/her} high blood pressure?)
An appointment with nurse
1=YES
2=NO

CONF3c. (During the last 6 months, have you received any of the following to teach
{you/him/her} how to take care of {your/his/her} high blood pressure?)
A visit, that is someone came to see you
1=YES
2=NO

E-5

CONF3d. (During the last 6 months, have you received any of the following to teach
{you/him/her} how to take care of {your/his/her} high blood pressure?)
A referral to a specialist
1=YES
2=NO

CONF3e. In the past two years, {have you/has name} been in the hospital or visited an
emergency room because of high blood pressure?
1=YES
2=NO

CONF3f. Has any doctor or nurse (you see/name sees) for {your/his/her} high blood pressure
given {you/him/her} a plan to manage {your/his/her} own care at home?
1=YES
2=NO

[CONFCHK3g IF CONF3f=1, CONTINUE; ELSE GO TO CONF3h ]
CONF3g. Was this plan given to {you/name} by a doctor or nurse at {the reference health
center}?
1=YES
2=NO

CONF3h. How confident {are you/is name} that {you/he/she} can control and manage
{your/his/her} high blood pressure. {Are you/Is he/she}...
1=Very confident
2=Somewhat confident
3=Not too confident
4=Not at all confident

E-6

[CONFCHK4 IF CON11a=1 or CON11b=1, CONTINUE; ELSE GO TO CONFCHK5 ]
CONF4. Earlier, you indicated that {you/name} had been told by a doctor or other health
professional that {you/he/she} had asthma. I’d like to ask you a few more questions about that.
1=CONTINUE
CONF4a. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have
you/has name} stayed overnight in a hospital because of asthma?
1=YES
2=NO

CONF4b. {Have you\Has name} ever used a PRESCRIPTION inhaler?
1=YES
2=NO

[CONFCHK4c IF CONF4b=1, CONTINUE; ELSE GO TO CONF4d ]
CONF4c. Now I'm going to ask you about two different kinds of @Uasthma@U medicine. One
is for quick relief. The other does not give quick relief but protects the lungs and prevents
symptoms over the long term.
During the past 3 months, {have you/has name} used the kind of prescription inhaler that {you
breathe/he/she breathes} in through {your/his/her} mouth, which gives quick relief from asthma
symptoms?
1=YES
2=NO

CONF4d. {Have you/Has name} ever taken the preventive kind of asthma medicine used every
day to protect {your/his/her} lungs and keep {you/him/her} from having attacks? Include both
oral medicine and inhalers. This is different from inhalers used for quick relief.
1=YES
2=NO

E-7

[CONCHK4e IF CONF4d=1, CONTINUE; ELSE GO TO CONF4f ]
CONF4e. {Are you/Is name} now taking this medication (that protects {your/his/her} lungs)
daily or almost daily?
1=YES
2=NO

CONF4f. {Have you/Has name} @Uever@U taken a course or class on how to manage asthma
{yourself/himself/herself}?
1=YES
2=NO

CONF4g. Has a doctor or other health professional @Uever@U taught {you/name} how to….
recognize early signs or symptoms of an asthma episode?
1=YES
2=NO

CONF4h. Has a doctor or other health professional @Uever@U taught {you/name} how to….
respond to episodes of asthma?
1=YES
2=NO

CONF4i. Has a doctor or other health professional @Uever@U taught {you/name} how to….
monitor peak flow for daily therapy?
1=YES
2=NO

CONF4j. Has a doctor or other health professional ever advised {you/name} to change things in
{your/his/her} home, school, or work to improve {your/his/her} asthma?

E-8

1=YES
2=NO
3=WAS TOLD NO CHANGES NEEDED

CONF4k1. During the last 6 months, {have you/has name} received any of the following to
teach {you/him/her} how to take care of your asthma?
A telephone call
1=YES
2=NO

CONF4k2. (During the last 6 months, {have you/has name} received any of the following to
teach {you/him/her} how to take care of your asthma?)
An appointment with nurse
1=YES
2=NO
CONF4k3. (During the last 6 months, {have you/has name} received any of the following to
teach {you/him/her} how to take care of your asthma?)
A visit, that is someone came to see you
1=YES
2=NO

CONF4k4. (During the last 6 months, {have you/has name} received any of the following to
teach {you/him/her} how to take care of your asthma?)
A referral to a specialist
1=YES
2=NO

E-9

CONF4k5. Has any doctor or nurse {you see/name sees} for {your/his/her} asthma given
{you/him/her} a plan to manage {your/his/her} own care at home?
1=YES
2=NO

[CONFCHK4k6

IF CONF4k5=1, CONTINUE; ELSE GO TO CONFCHK5

]

CONF4k6. Was this plan given to {you/name} by a doctor or nurse at {the reference health
center}?
1=YES
2=NO

CONF4k7. How confident {are you/is name} that {you/he/she} can control and manage
{your/his/her} asthma. {Are you/Is he/she}...
1=Very confident
2=Somewhat confident
3=Not too confident
4=Not at all confident

[CONFCHK5 IF CON12=1, CONTINUE; ELSE GO TO CONFCHK13

]

CONF5. Earlier, you indicated that {you/name} had diabetes. I’d like to ask you a few more
questions about that. {Are you/Is name} now taking insulin?
1=YES
2=NO

[CONFCHK5a IF CONF5=1, CONTINUE; ELSE GOT O CONF5b ]
CONF5a. {Are you/Is name} now taking diabetic pills to lower {your/his/her} blood sugar?
These are sometimes called oral agents or oral hypoglycemic agents.
1=YES
2=NO

E-10

CONF5b. How often {do you check your/does name check his/her} blood for glucose or sugar?
Include times when checked by a family member or friend, but do not include times when
checked by a doctor or other health professional. Do not include urine tests.
NEVER=0
______ TIMES [ALLOW ___]

TIME PERIOD:
1=DAY
2=WEEK
3=MONTH
4=YEAR

CONF5c. Glycosylated (GLY-CO-SYL-AT-ED) hemoglobin or the “A one C” test measures the
average level of blood sugar over the past 3 months, and usually ranges between 5 and 14.
During the past 12 months, how many times has a doctor or other health professional checked
{you/name} for glycosylated hemoglobin or A one C?
NEVER=0
______ TIMES [ALLOW ___]

CONF5d. Based on all {your/his/her} blood sugar tests during the past 12 months, how often
would {you/name} say {your/his/her} blood sugar level was too high? Would {you/name} say
always, most of the time, some of the time, rarely, or never?
1=NO TEST IN PAST 12 MONTHS
2=ALWAYS
3=MOST OF THE TIME
4=SOME OF THE TIME
5=RARELY
6=NEVER

CONF5e1. During the last 6 months, {have you/ has name} received any of the following to
teach {you/him/her} how to take care of {your/his/her} diabetes?

E-11

A telephone call?
1=YES
2=NO

CONF5e2. (During the last 6 months, {have you/ has name} received any of the following to
teach {you/him/her} how to take care of {your/his/her} diabetes?)
An appointment with nurse?
1=YES
2=NO

CONF5e3. (During the last 6 months, {have you/ has name} received any of the following to
teach {you/him/her} how to take care of {your/his/her} diabetes?)
A visit, that is someone came to see you?
1=YES
2=NO

CONF5e4. (During the last 6 months, {have you/ has name} received any of the following to
teach {you/him/her} how to take care of {your/his/her} diabetes?)
A referral to a specialist?

1=YES
2=NO

CONF5e5. In the past two years, {have you/has name} been in the hospital or visited an
emergency room because of diabetes?
1=YES
2=NO

E-12

CONF5e6. Has any doctor or nurse {you see/name sees} for {your/his/her} diabetes given
{you/him/her} a plan to manage {your/his/her} own care at home?
1=YES
2=NO

[CONFCHK5e7 IF CONF5e6 = 1 CONTINUE, ELSE GO TO MODULE F]
CONF5e7. Was this plan given to {you/name} by a doctor or nurse at {the reference health
center}?
1=YES
2=NO

CONF5e8. How confident {are you/is name} that {you/he/she} can control and manage
{your/his/her} diabetes? {Are you/Is he/she}...
1=Very confident
2=Somewhat confident
3=Not too confident
4=Not at all confident

E-13

MODULE F: CANCER SCREENING
[CANCHK1 IF <18, GO TO MODULE G;
ELSE IF AGE GE 18 AND FEMALE, GO TO CAN1;
ELSE IF AGE GE 18 AND MALE, GO TO CANCHK4]
PAP SMEARS
CAN1. Next, I’m going to ask you about any cancer screening procedures that you may have
had. Have you ever had a Pap smear or Pap test?
READ IF NECESSARY:
A Pap smear or Pap test is a routine test for women in which the doctor examines the cervix,
takes a cell sample from the cervix with a small stick or brush, and sends it to the lab.
1=YES
2=NO

[CANCHK1a IF CAN1= 1, CONTINUE; ELSE GO TO CAN2 ]
CAN1a. When did you have your most recent Pap smear or Pap test?
1=A YEAR AGO OR LESS
2=MORE THAN 1 YEAR BUT NOT MORE THAN 2 YEARS
3=MORE THAN 2 YEARS BUT NOT MORE THAN 3 YEARS
4=MORE THAN 3 YEARS BUT NOT MORE THAN 4 YEARS
5=MORE THAN 4 YEARS BUT NOT MORE THAN 5 YEARS
6=OVER 5 YEARS AGO

CAN1b. What was the main reason you had this Pap smear or Pap test - was it part of a routine
exam, because of a problem, or some other reason?
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=OTHER REASON

[CANCHK1c

IF CAN1a=1, 2, 3, THEN CONTINUE; ELSE GO TO CAN2]

F-1

CAN1c. As a result of @Uany@U of the Pap smear or Pap tests you had done in the past three
years, were you told that you should have follow-up tests or treatment?
1=YES
2=NO

[CANCHK1d IF CAN1c = 1, CONTINUE; ELSE GO TO CANCHK3]
CAN1d. Were the follow-up tests or treatment done?
1=YES
2=NO

[CANCHK1e IF CAN1d = 1, CONTINUE; IF CAN1d=2, GO TO CAN1f;
ELSE GO TO CANCHK3]
CAN1e. Did {the reference health center} arrange for the follow-up tests or treatment?
1=YES
2=NO
[CANCHK1e_POST GO TO CANCHK3]

CAN1f. Which of these best describes the main reason you did not get the follow-up tests or
treatment?
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER

[CANCHK1f_POST GO TO CANCHK3]

F-2

CAN2. What is the most important reason you have {[IF CAN1= 2 (No), THEN FILL:] “never
had a Pap smear or Pap test” [IF CAN1a=4, 5, OR 6, THEN FILL:] “not had a Pap smear or
[bm1]
Pap test in the LAST 3 years”}?
1=NO REASON/NEVER THOUGHT ABOUT IT
2=DIDN'T NEED/DIDN'T KNOW I NEEDED THIS TYPE OF TEST
3=TOO EXPENSIVE/NO INSURANCE/COST
4=TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
5=HAD HYSTERECTOMY OR PARTIAL HYSTERECTOMY
6=OTHER

CAN2a. In the past 3 years, has anyone at {the reference health center} suggested that you have
a Pap smear or Pap test?
1=YES
2=NO

MAMMOGRAMS
[CANCHK3 IF AGE GE 30, THEN CONTINUE; ELSE GO TO CANCHK4 ]

CAN3. Have you ever had a mammogram?
IF NECESSARY: A MAMMOGRAM IS AN X-RAY TAKEN ONLY OF THE BREAST BY A
MACHINE THAT PRESSES AGAINST THE BREAST.
1=YES
2=NO

[CANCHK3a IF CAN3 = 1, CONTINUE; ELSE GO TO CAN3g ]
CAN3a. When did you have your most recent mammogram?
1=A YEAR AGO OR LESS
2=MORE THAN 1 YEAR BUT NOT MORE THAN 2 YEARS
3=MORE THAN 2 YEARS BUT NOT MORE THAN 3 YEARS
4=MORE THAN 3 YEARS BUT NOT MORE THAN 5 YEARS
5=OVER 5 YEARS AGO

F-3

CAN3b. What was the main reason you had this mammogram - was it part of a routine exam,
because of a problem, or some other reason?
MARK ONLY ONE.
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=SOME OTHER REASON

[CANCHK3c IF CAN3a = 1, 2, OR 3, THEN CONTINUE; ELSE GO TO CAN3g ]
CAN3c. As a result of any mammograms you had done in the past 3 years, were you told that
you should have @Ufollow-up@U tests or treatment?
1=YES
2=NO

[CANCHK3d IF CAN3c = 1, CONTINUE;
IF CAN3c = 2, GO TO CANCHK4;
IF CAN3c =DK OR RF GO TO CANCHK4 ]
CAN3d. Were the @Ufollow-up@U tests or treatment done?
1=YES
2=NO

[CANCHK3e IF CAN3d = 2, THEN GO TO CAN3f; ELSE CONTINUE ]
CAN3e. Did {the reference health center} arrange for the @Ufollow-up@U tests or treatments?
1=YES
2=NO

[CANCHK3e_POST GO TO CANCHK4]

F-4

CAN3f. Which of these best describes the main reason you did not get the @Ufollow-up@U
tests or treatment?
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER
[CANCHK3f_POST GO TO CANCHK4 ]

CAN3g. What is the main reason why you have {[IF CAN3=2 (NO), THEN FILL:] “never had
a mammogram” [IF CAN3a=4 or CAN3A=5, THEN FILL:] [bm2]“not had a mammogram in
the past few years”}?
1=NO REASON/ NEVER THOUGHT ABOUT IT/ DIDN’T KNOW I SHOULD
2=NOT NEEDED/ HAVEN’T HAD ANY PROBLEMS
3=TOO UNPLEASANT OR EMBARRASSING
4=COST TOO MUCH/NO INSURANCE
5=BREASTS MISSING
6=OTHER

CAN3h. In the past 3 years, has anyone at {the reference health center} suggested that you have
a mammogram?
1=YES
2=NO

COLONOSCOPY/ SIGMOIDOSCOPY EXAM
[CANCHK4 IF AGE GE 50, THEN CONTINUE; ELSE GO TO CANCHK5]

F-5

CAN4. Have you EVER HAD a sigmoidoscopy (sigmoid-OS-copy), colonoscopy (colon-OScopy), or proctoscopy (proc-TOS-copy). These are exams in which a health care professional
inserts a tube into the rectum to look for signs of cancer or other problems.
READ IF NECESSARY: A proctoscopy is an older exam that used a rigid tube.
1=YES
2=NO

[CANCHK4a IF CAN4 = 1, CONTINUE; ELSE GO TO CAN4h ]
CAN4a. When did you have your most recent exam?
1=A YEAR AGO OR LESS
2=MORE THAN 1 YEAR BUT NOT MORE THAN 2 YEARS
3=MORE THAN 2 YEARS BUT NOT MORE THAN 3 YEARS
4=MORE THAN 3 YEARS BUT NOT MORE THAN 5 YEARS
5=MORE THAN 5 YEARS BUT NOT MORE THAN 10 YEARS
6=OVER 10 YEARS AGO

CAN4b. For a SIGMOIDOSCOPY (sigmoid-OS-copy), a flexible tube is inserted into the
rectum to look for problems. A COLONOSCOPY (colon-OS-copy) 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. A PROCTOSCOPY (proc-TOS-copy) is
an older exam that used a rigid tube.
Was this MOST RECENT exam a sigmoidoscopy, colonoscopy, proctoscopy or something else?
1=SIGMOIDOSCOPY
2=COLONOSCOPY
3=PROCTOSCOPY
4=SOMETHING ELSE

F-6

CAN4c. What was the main reason you had this exam? Was it part of a routine exam, because of
a problem, history of cancer in your family or some other reason?
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=HISTORY OF CANCER IN MY FAMILY
4=OTHER REASON
[bm3]

CAN4d. As a result of this exam, were you told that you should have follow-up tests or
treatment?
1=YES
2=NO

[CANCHK4e IF CAN4d = 1, CONTINUE; ELSE GO TO CANCHK5]
CAN4e. Were the follow-up tests or treatment done?
1=YES
2=NO

[CANCHK4f IF CAN4e = 2, THEN GO TO CAN4g; ELSE CONTINUE]
CAN4f. Did {the reference health center} arrange for the follow-up tests or treatment?
1=YES
2=NO

[CANCHK4f_POST GO TO CANCHK5 ]

F-7

CAN4g. Which of these best describes the main reason you did not get the follow-up tests or
treatment?
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER
[CANCHK4g_POST GO TO CANCHK5]

CAN4h. What is the main reason why you have {[IF CAN4=2 (NO), THEN FILL:] “never had
a colonoscopy, sigmoidoscopy, or proctoscopy” [IF CAN4A= 4 or 5 OR 6, THEN FILL:]
[bm4]“not had a more recent colonoscopy, sigmoidoscopy or proctoscopy”}?
1=NO REASON/ NEVER THOUGHT ABOUT IT
2=DIDN'T NEED/ DIDN'T KNOW I NEEDED THIS TYPE OF TEST
3=TOO EXPENSIVE/ NO INSURANCE/ COST
4=TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
5=HAD DOUBLE-CONTRAST BARIUM ENEMA TEST
6=OTHER

CAN4i. In the past 3 years, has anyone at {the reference health center} suggested that you
should have a colonoscopy, sigmoidoscopy or proctoscopy?
1=YES
2=NO

BLOOD STOOL OR OCCULT BLOOD TESTS
[CANCHK5 IF AGE GE 40, THEN CONTINUE; ELSE GO TO MODULE G ]

F-8

CAN5. The following questions are about the blood stool or occult blood test, a test to determine
whether you have blood in your stool or bowel movement. The blood stool test can be done at
home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it
back to the doctor or lab.
Have you @ever had@U a blood stool test, using a @Uhome@U test kit?
1=YES
2=NO

[CANCHK5a IF CAN5 = 1, CONTINUE; ELSE GO TO CAN5f ]
CAN5a. When did you have your most recent blood stool test using a kit @Uat home@U?
1=A YEAR AGO OR LESS
2=MORE THAN 1 YEAR BUT NOT MORE THAN 2 YEARS
3=MORE THAN 2 YEARS BUT NOT MORE THAN 3 YEARS
4=MORE THAN 3 YEARS BUT NOT MORE THAN 5 YEARS
5=MORE THAN 5 YEARS BUT NOT MORE THAN 10 YEARS
6=OVER 10 YEARS AGO

[CANCHK5b IF CAN5a = 1,2,3 CONTINUE; ELSE GO TO CAN5g ]
CAN5b. As a result of this test, did you need follow-up tests or treatment?
1=YES
2=NO

[CANCHK5c IF CAN5b =1, THEN CONTINUE; ELSE GO TO MODULE G ]
CAN5c. Were the follow-up tests or treatment done?
1=YES
2=NO

[CANCHK5d IF CAN5c = 2 THEN GO TO CAN 5e; ELSE CONTINUE]

F-9

CAN5d. Did the {reference health center} arrange for the follow-up tests or treatments?
1=YES
2=NO
[CANCHK5d_POST GO TO MODULE G]

CAN5e. Which of these best describes the main reason you did not get the follow-up tests or
treatment?
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER

CAN5f. In the past 3 years, has anyone at {the reference health center} suggested that you
should have a blood stool test?
1=YES
2=NO

F-10

MODULE G: HEALTH CENTER SERVICES
Now, I’d like to ask some questions about the services {you/name} have received at {the
reference health center}.
HEA1. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, how many
times have you seen a doctor or other health care professional about {your own/name’s} health
at a doctor’s office, a clinic, or some other place? Do not include times {you/name} were
hospitalized overnight, visits to hospital emergency rooms, home visits, or telephone calls.
NOTE: IF RESPONDENT IS UNSURE- ASK THEM TO PROVIDE AN ESTIMATE
_____ TIMES

[HEACHK2 IF HEA1=0, DK, RF THEN GO TO HEA3, ELSE CONTINUE]
HEA2. How many of those times did you come to {reference health center}?
NOTE: IF RESPONDENT IS UNSURE- ASK THEM TO PROVIDE AN ESTIMATE
_____ TIMES [ALLOW ____]

[IF HEA2=0, DK, RE THEN GOTO HEA3, ELSE CONTINUE]
HEA2a In the past 12 months, did a medical professional at {the reference health center} think
{you/name} should go someplace else to see a different doctor, like a specialist, for a particular
health problem?
1=YES
2=NO

[HEACHK2b If HEA2a=1, THEN CONTINUE; ELSE GOTO HEA3]

G-1

HEA2b. If you received more than one referral in the past 12 months, think of the most recent
one. Did {you/name} see that doctor?
1=YES
2=NO

[HEACHK2c If HEA2b=1, THEN CONTINUE; ELSE GOTO HEA2d]
HEA2c. After {you/name} saw that doctor, did the staff at {reference health center} seem
informed and up-to-date about the care {you/he/she} received from that doctor?
1=YES
2=NO
[HEACHK2c_POST GOTO HEA3]

HEA2d. Which of these best describes the main reason why {you/name} didn't see that doctor?
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER

G-2

HEA3. How long ago was {your/name’s} first visit to {the reference health center}?
1=LESS THAN 6 MONTHS
2=AT LEAST 6 MONTHS, BUT NOT MORE THAN 1 YEAR AGO
3=AT LEAST 1 YEAR, BUT NO MORE THAN 2 YEARS AGO
4=AT LEAST 2 YEARS, BUT NO MORE THAN 3 YEARS AGO
5=AT LEAST 3 YEARS, BUT NO MORE THAN 4 YEARS AGO
6=AT LEAST 4 YEARS, BUT NO MORE THAN 5 YEARS AGO
7=MORE THAN 5 YEARS AGO

[HEACHK4 IF HEA3=1, 2, OR 3 CONTINUE, ELSE GOTO HEA5]
HEA4. How did you find out that {you/name} could come here for services?
CODE ALL THAT APPLY
@BSHOWCARD HEA1@B
1=FRIEND/FAMILY MEMBER/NEIGHBOR TOLD ME
2=FAMILY TOOK YOU HERE
3=ADVERTISEMENT IN COMMUNITY
4=AT A MEETING
5=CONTACTED BY SOMEONE FROM HEALTH CENTER
6=THROUGH YOUR INSURANCE
7=SOCIAL SERVICES
8=A DOCTOR OR THE EMERGENCY ROOM
10=OTHER

HEA5. Is there a place that you usually go to when {you are /name is} sick or you need advice
about {your/ his/her} health?
1=YES
2=THERE IS NO PLACE
3=MORE THAN ONE PLACE

HEA5a. What kind of place {is it/ are those}?
CODE ALL THAT APPLY
@BSHOWCARD HEA2@B

G-3

1={REFERENCE HEALTH CENTER}
2=CLINIC OR HEALTH CENTER OFFERING A DISCOUNT TO LOW INCOME OR
UNINSURED PEOPLE
3=OTHER CLINIC OR HEALTH CENTER
4=DOCTOR'S OFFICE OR HMO
5=HOSPITAL EMERGENCY ROOM
6=HOSPITAL OUTPATIENT DEPARTMENT
7=SOME OTHER PLACE

HEA5b. {Is this/Are these} the same place{s} you usually go when {you need/name needs}
routine or preventive care, such as a physical examination {[IF AGE LE 11, ADD:] or well
child check up?}
1=YES
2=NO

[HEACHK5c IF HEA5b=1, THEN GOTO HEACHK6; ELSE CONTINUE]
HEA5c. What kind of place{s} do you go to when {you need/name needs} routine or preventive
care, such as a physical examination or check up?
CODE ALL THAT APPLY.
@BSHOW CARD HEA2@B
1={REFERENCE HEALTH CENTER}
2=CLINIC OR HEALTH CENTER OFFERING A DISCOUNT TO LOW INCOME OR
UNINSURED PEOPLE
3=OTHER CLINIC OR HEALTH CENTER
4=DOCTOR'S OFFICE OR HMO
5=HOSPITAL EMERGENCY ROOM
6=HOSPITAL OUTPATIENT DEPARTMENT
7=SOME OTHER PLACE

[HEACHK6 IF INT4 =1 GOTO HEA7 ELSE CONTINUE]
HEA6.When {you go/name goes} to {the reference health center}, how do {you/he/she} usually
communicate with the doctor or other health care professional that sees {you/him/her}?

G-4

1=ENGLISH
2=THE DOCTOR/HEALTH PROFESSIONAL SPEAKS A LANGUAGE, OTHER THAN
ENGLISH, THAT I CAN UNDERSTAND
3=I BRING A FRIEND OR FAMILY MEMBER TO TRANSLATE
4={THE REFERENCE HEALTH CENTER} HAS A STAFF PERSON WHO TRANSLATES
5=OTHER

[HEACHK6a IF HEA6=2 or 4, THEN CONTINUE; ELSE GO TO HEA7]
HEA6a. How important was {[IF HEA6=2, THENFILL:] having a doctor who speaks in your
language [IF HEA6=4, THEN FILL:] translation assistance} to your decision {to be/for name
to be} a patient of {reference health center}. Would you say…
1=Very Important
2=Somewhat Important
3=Not Very Important
4=Not at all Important

HEA7. Has anyone at {the reference health center} ever helped {you/name}...
NOTE: REPEAT STEM OF QUESTION AS NECESSARY
a.
b.
c.
d.
e
f

arrange for medical appointments or other medical services at a place other than the
{reference health center}?
apply for any government benefits {you/name} needed such as Medicaid, Food Stamps,
Social Security, obtaining welfare, public benefits, or TANF?
get transportation to medical appointments or provided you with tokens or vouchers to
help you pay for transportation to medical appointments?
with basic needs, such as finding a place to live, finding a job, finding childcare, helping
you obtain food or clothing?
get free medication?
with other kinds of problems?

FOR EACH:
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES

G-5

HEACHK8 FOR EACH ITEM IN HEA7 = 1:
HEA8. How important was that to your decision {to be/for name to be} a patient of {reference
health center}? Would you say…
1=Very Important
2=Somewhat Important
3=Not Very Important
4=Not at all Important

HEA9. IF SELF-RESPONDENT: How {do you/does name} usually get to the health center?
IF PROXY-RESPONDENT: How do you usually get {name} to the health center?
1=WALKING
2=DRIVING
3=BEING DRIVEN BY SOMEONE ELSE
4=BUS, SUBWAY OR OTHER PUBLIC TRANSPORTATION
5=TAXI
6=HEALTH CENTER (OR OTHER AGENCY-PROVIDED) VAN SERVICE
7=OTHER

HEA10. About how long does it usually take you to get {here/there}?
_____ MINUTES [ALLOW ____]
OR
_____ HOURS [ALLOW_____]

HEA11.
@BSHOWCARD HEA11@B
The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.
How well do you think {the reference health center} is doing in the following areas:

HEA11a. EASE OF GETTING CARE:

G-6

Ability to get in to be seen?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA11x. EASE OF GETTING CARE:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA11b. EASE OF GETTING CARE:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

Hours center is open?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA11c. EASE OF GETTING CARE:

G-7

(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

Convenience of center’s location?

1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA11d. EASE OF GETTING CARE:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

Prompt return of calls?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA12a. WAITING:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)

G-8

(How well do you think {the reference health center} is doing in the following areas:)

Time in waiting room?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA12b. WAITING:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

Time in exam room?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA12c. WAITING:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

Waiting for tests to be performed?
1=EXCELLENT

G-9

2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA12d. WAITING:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

Waiting for test results?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA13a. PAYMENT:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

What you pay?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

G-10

HEA13b. PAYMENT:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

Explanation of charges?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA13c. PAYMENT:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

Collection of payment/money?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA14a. FACILITY:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)

G-11

(How well do you think {the reference health center} is doing in the following areas:)

Neat and clean building?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA14b. FACILITY:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

Ease of finding where to go?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA14c. FACILITY:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

Comfort and safety while waiting?
1=EXCELLENT
2=VERY GOOD

G-12

3=GOOD
4=FAIR
5=POOR

HEA14d. FACILITY:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

Privacy?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA15a. CONFIDENTIALITY:
(The next series of questions are about how satisfied you are with the services provided at
{reference health center}. For these questions, please use the following response categories:
Excellent, Very Good, Good, Fair, or Poor.)
(How well do you think {the reference health center} is doing in the following areas:)

Keeping your personal information private?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

G-13

HEA16a. The next questions are about the provider staff at {the reference health center} such as
physicians, dentists, physician assistants and nurse practitioners. How well do you think they are
doing in the following areas:
Listens to you?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA16b. (The next questions are about the provider staff at {the reference health center} such as
physicians, dentists, physician assistants and nurse practitioners. How well do you think they are
doing in the following areas:)
Takes enough time with you?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA16c. (The next questions are about the provider staff at {the reference health center} such as
physicians, dentists, physician assistants and nurse practitioners. How well do you think they are
doing in the following areas:)
Explains what you want to know?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA16d. (The next questions are about the provider staff at {the reference health center} such as
physicians, dentists, physician assistants and nurse practitioners. How well do you think they are
doing in the following areas:)

G-14

Gives you good advice and treatment?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA17a. The next questions are about the nurses and medical assistants at {the reference health
center}. How well do you think they are doing in the following areas:
Friendly and helpful to you?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA17b. (The next questions are about the nurses and medical assistants at {the reference health
center}. How well do you think they are doing in the following areas: )
Answers your questions?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA18a. The next questions are about other staff at {the reference health center}. How well do
you think they are doing in the following areas…
Friendly and helpful to you?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

G-15

HEA18b. (The next questions are about other staff at {the reference health center}. How well do
you think they are doing in the following areas…)

Answers your questions?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA18c. How would you rate the overall quality of the services {you/name} receive at {the
reference health center}?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR

HEA19. What is the likelihood of you referring your friends and relatives to {reference health
center}. Would you say..
1=Very likely
2=Somewhat likely
3=Not very likely
4=Not at all likely

HEA20. What is the main reason {you/name} go to the {reference health center} for
{your/name’s} health care instead of someplace else?
@BSHOWCARD HEA3@B
1=CONVENIENT LOCATION
2=CONVENIENT HOURS
3=YOU CAN AFFORD IT
4={YOU/NAME} CAN BE SEEN WITHOUT AN APPOINTMENT OR GET AN
APPOINTMENT RIGHT AWAY
5=AFTER YOU GET THERE, YOU DON'T HAVE TO WAIT LONG TO BE SEEN

G-16

6=THEY PROVIDE CHILD CARE
7=THEY PROVIDE TRANSPORTATION OR TRANSPORTATION VOUCHERS
8=THEY HAVE SOMEONE WHO SPEAKS YOUR LANGUAGE
9=QUALITY OF CARE
10=IT'S THE ONLY MEDICAL CARE IN THE AREA
11=OTHER

HEA21. Have you ever had a serious problem with the care {you/name} received at the
{reference health center}, the staff, or the way the {reference health center} is run?
1=YES
2=NO

[HEACHK22 IF HEA21=1, THEN CONTINUE; ELSE GO TO MODULE H ]
HEA22. Did you complain to someone or file a written complaint?
1=YES
2=NO

[HEACHK23 IF HEA22=1 THEN CONTINUE; ELSE GO TO MODULE H]
HEA23. Were you satisfied with the way your complaint was handled?
1=YES
2=NO

G-17

MODULE H: SUBSTANCE USE
[SUBCHK0: IF AGE GE 13, THEN CONTINUE; ELSE GO TO MODULE I ]
The next questions are about your use of substances. Your answers to these questions are private
and will not be shared with anyone at the {reference health center}. You also have the right to
refuse any question that you do not want to answer.
SUB1a. Have you smoked at least 100 cigarettes in your entire life?
1=YES
2=NO (GO TO SUB2)

[SUBCHK1b IF DK, GO TO SUB2; IF RF, GO TO SUB2]
SUB1b. Do you now smoke cigarettes every day, some days or not at all?
1=Every day
2=Some days
3=Not at all
[SUBCHK1b_POST IF SUB1B=2, GO TO SUB1d; IF SUB1b=3, GO TO SUB2][bm5]

SUB1c. On the average, how many cigarettes do you now smoke a day?
NOTE: IF RESPONSE IS LESS THAN 1 – ENTER 1
_______CIGARETTES [ALLOW ____]
[SUBCHK1c_POST GO TO SUB1f]

SUB1d. On how many of the past 30 days did you smoke a cigarette?
______ DAYS [ALLOW ____]

SUB1e On average, when you smoked during the past 30 days, about how many cigarettes did
you smoke a day?
______ NUMBER OF CIGARETTES [ALLOW ____]

H-1

SUB1f. During the past @U12 months@U, have you wanted to stop smoking?
1=YES
2=NO

SUB1g. In the past 12 months, did anyone at {the reference health center} talk to you about the
health risks of smoking and ways to quit?
1=YES
2=NO

SUB2.
@BSHOWCARD SUB2@B
Please look at this show card. We are interested in whether you have used any of these for
@Unon-medical reasons.@U Include prescription drugs that you took only if they were not
prescribed for you or you took them only for the experience or feeling they caused.
In your life, which of the following substances have you ever used? Have you used…

SUB2a. (Please look at this show card. We are interested in whether you have used any of these
for @Unon-medical reasons.@U Include prescription drugs that you took only if they were not
prescribed for you or you took them only for the experience or feeling they caused. In your life,
which of the following substances have you ever used? Have you used…)
Alcoholic Beverages?

(BEER, WINE, SPIRITS, ETC.)

1=YES
2=NO

H-2

SUB2b. (Please look at this show card. We are interested in whether you have used any of these
for @Unon-medical reasons.@U Include prescription drugs that you took only if they were not
prescribed for you or you took them only for the experience or feeling they caused. In your life,
which of the following substances have you ever used? Have you used…)
Cannabis or Marijuana?

(MARIJUANA, POT, GRASS, HASH, ETC.)

1=YES
2=NO

SUB2c. (Please look at this show card. We are interested in whether you have used any of these
for @Unon-medical reasons.@U Include prescription drugs that you took only if they were not
prescribed for you or you took them only for the experience or feeling they caused. In your life,
which of the following substances have you ever used? Have you used…)
Cocaine?

(COKE, CRACK, ETC.)

1=YES
2=NO

SUB2d. (Please look at this show card. We are interested in whether you have used any of these
for @Unon-medical reasons.@U Include prescription drugs that you took only if they were not
prescribed for you or you took them only for the experience or feeling they caused. In your life,
which of the following substances have you ever used? Have you used…)
Amphetamine-type Stimulants? (SPEED, ECSTASY, CRYSTAL METH, DIET PILLS, ETC.)
1=YES
2=NO

H-3

SUB2e. (Please look at this show card. We are interested in whether you have used any of these
for @Unon-medical reasons.@U Include prescription drugs that you took only if they were not
prescribed for you or you took them only for the experience or feeling they caused. In your life,
which of the following substances have you ever used? Have you used…)
Inhalants?

(NITROUS, GLUE, PETROL, PAINT THINNER, ETC.)

1=YES
2=NO

SUB2f. (Please look at this show card. We are interested in whether you have used any of these
for @Unon-medical reasons.@U Include prescription drugs that you took only if they were not
prescribed for you or you took them only for the experience or feeling they caused. In your life,
which of the following substances have you ever used? Have you used…)

Sedatives or Sleeping Pills? (VALIUM, SEREPAX, ROHYPNOL, ETC.)
1=YES
2=NO

SUB2g. ((Please look at this show card. We are interested in whether you have used any of these
for @Unon-medical reasons.@U Include prescription drugs that you took only if they were not
prescribed for you or you took them only for the experience or feeling they caused. In your life,
which of the following substances have you ever used? Have you used…)
Hallucinogens?

(LSD, ACID, MUSHROOMS, PCP, SPECIAL K, ETC.)

1=YES
2=NO

H-4

SUB2h. ((Please look at this show card. We are interested in whether you have used any of these
for @Unon-medical reasons.@U Include prescription drugs that you took only if they were not
prescribed for you or you took them only for the experience or feeling they caused. In your life,
which of the following substances have you ever used? Have you used…)

Opioids?

(HEROIN, MORPHINE, METHADONE, CODEINE, VICODIN, ETC.)

1=YES
2=NO

SUB2i. (Please look at this show card. We are interested in whether you have used any of these
for @Unon-medical reasons.@U Include prescription drugs that you took only if they were not
prescribed for you or you took them only for the experience or feeling they caused. In your life,
which of the following substances have you ever used? Have you used…)

Any Other?
1=YES
2=NO

[IF SUB2Ii=1, THEN GO TO SUB2i_OTH; ELSE GO TO SUBCHK2a ]
SUB2i_OTH. (SPECIFY)_______ [ALLOW _____]

[SUBCHK2a IF SUB2a-i NE 1 (NO YES ANSWERS), GO TO MODULE I; ELSE
CONTINUE]
[NOTE TO PROGRAMMERS: CODING OF RESPONSE VALUES MUST ALIGN
WITH SCALE]

H-5

SUB2a. In the past three months, how often have you used {FILL RESPONSE SUB1)?
REPEAT QUESTION FOR EACH SUBSTANCE LISTED IN SUB1
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily

SUBCHK2

IF NONE MENTIONED IN SUB2, GO TO SUB2e;
ELSE CONTINUE

SUB2b. During the past three months, how often have you had a strong desire or urge to use
{FILL RESPONSE SUB2)?
REPEAT QUESTION FOR EACH SUBSTANCE LISTED IN SUB2
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily

SUB2c. During the past three months, how often has your use of {FILL RESPONSE SUB2) led
to health, social, legal or financial problems?
REPEAT QUESTION FOR EACH SUBSTANCE LISTED IN SUB2
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily

H-6

SUB2d.
+ During the past three months, how often have you failed to do what was normally expected of
you because of your use of {FILL RESPONSE SUB2)?
REPEAT QUESTION FOR EACH SUBSTANCE LISTED IN SUB2
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily

SUB2e. Has a friend or relative or anyone else ever expressed concern about your use of {FILL
RESPONSE SUB1)?
REPEAT QUESTION FOR EACH SUBSTANCE LISTED IN SUB1
1=In the past 3 months
2=Not in the past 3 months
3=Never

SUB2f. How often have you tried and failed to control, cut down or stop using {FILL
RESPONSE SUB1)?
REPEAT QUESTION FOR EACH SUBSTANCE LISTED IN SUB1
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never

H-7

SUB3. Have you ever used any drug by injection? (NON-MEDICAL USE ONLY)
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never

[SUBCHK7 IF SUB2b NE 0, DK, RF, GO TO SUB7a; ELSE IF SUB1b =3, CONTINUE;
ELSE GO TO SUBCHK10]
SUB7. Earlier you indicated that you have used alcohol. Did you drink alcohol in the past 12
months?
1=YES
2=NO

[SUBCHK7a IF SUB7=1, CONTINUE; ELSE GO TO SUBCHK10]
SUB7a. In the PAST 12 MONTHS, on those days that you drank alcoholic beverages, on the
average, how many drinks did you have?
______ Number of drinks

SUB8. In the PAST 12 MONTHS, on how many DAYS did you have 5 or more drinks of any
alcoholic beverage?
______ DAYS

SUB9. In past 12 months, have you discussed your use of alcohol with your doctor?
1=YES
2=NO

[SUBCHK9a IF SUB9=2, CONTINUE; ELSE GO TO SUBCHK10]
SUB9a. In past 12 months has your doctor asked you about your use of alcohol?

H-8

1=YES
2=NO

DRUG USE
[SUBCHK10 IF SUB2c,d,e,f,g,h, i or j NE 0, DK, OR RE, GOTO SUB10a;
ELSE IF SUB1c, d, e, f, g, h, i, or j = 3, THEN CONTINUE;
ELSE GO TO SUBCHK12]
SUB10. Earlier you indicated that you have used {[FILL FROM SUB2c, d, e, f, g, h, i, j]}. Did
you use any of these drugs in the past 12 month?
1=YES
2=NO

[SUBCHK10a

IF SUB10=1, CONTINUE; ELSE GO TO SUBCHK11]

SUB10a. In past 12 months, have you discussed your use of drugs with your doctor?
1=YES
2=NO

[SUBCHK10b IF SUB10a=2, THEN CONTINUE; ELSE GO TO SUBCHK11 ]
SUB10b. In past 12 months has your doctor asked you about your use of drugs?
1=YES
2=NO

INJECTED DRUGS
[SUBCHK11 IF SUB3=1 or 2 CONTINUE; ELSE GOTO SUBCHK12]
SUB11. Earlier you indicated that you have injected drugs with a needle. Did you inject drugs
with a needle in the past 12 months?

H-9

1=YES
2=NO

[SUBCHK11a IF SUB11=1, CONTINUE; ELSE GO TO SUBCHK12 ]
SUB11a. How many days have you used drugs that you INJECT WITH A NEEDLE during the
past 12 months.
______ NUMBER OF DAYS [ALLOW ___ ]

SUBSTANCE USE TREATMENT
[SUBCHK12 IF SUB1b, c, d, e, f, g, h, i, j=3 OR SUB3=1 OR 2, CONTINUE;
ELSE GO TO MODULE I ]
SUB12. In the past 12 months, did you want or need treatment or counseling for your use of {[IF
SUB1b=3 AND SUB1c, d, e, f, g, h, i, j=0, THEN FILL: “alcohol”]; [IF SUB1b=0 AND
SUB1c, d, e, f, g, h, i, j NE 0, DK, RF, THEN FILL: "drugs"]; [ELSE FILL "alcohol or
drugs"]}?
1=YES
2=NO

SUB12a. In the past 12 months, did you receive treatment or counseling for your use of {[IF
SUB1b=3 AND SUB1c, d, e, f, g, h, i, j=0, THEN FILL: “alcohol”]; [IF SUB1b=0 AND
SUB1c, d, e, f, g, h, i, j NE 0, DK, RF, THEN FILL: "drugs"]; [ELSE FILL "alcohol or
drugs"]}?
1=YES
2=NO

[SUBCHK13 IF SUB12a=1 CONTINUE; ELSE GO TO SUB15]
SUB13. What kind of treatment was it?
SELECT ALL THAT APPLY.

H-10

1=A RESIDENTIAL FACILITY WHERE YOU STAY AT NIGHT
2=AN OUTPATIENT FACILITY WHERE YOU DO NOT STAY AT NIGHT
3=A PRIVATE DOCTOR’S OFFICE
4=A PRISON OR JAIL
5=AA OR NA OR OTHER SELF-HELP GROUP
6=SOME OTHER PLACE

[SUBCHK14 IF SUB13 = DK OR RF, GO TO MODULE I; ELSE CONTINUE ]
SUB14. Did the {reference health center} provide that treatment, pay for that treatment, or refer
you to the place where you got the treatment?
1=PROVIDE TREATMENT
2=PAY FOR TREATMENT
3=REFER TO ANOTHER PLACE
4=NONE

[SUBCHK15 IF SUB12 = 2 GO TO MODULE I, ELSE CONTINUE]
SUB15. During the past 12 months, did you make an effort to get treatment or counseling for
your use of alcohol or drugs?
1=YES
2=NO

SUB16. Did the {reference health center} try to help you get treatment or arrange for treatment?
1=YES
2=NO

SUB17. Which of these statements explain why you did not get the treatment or counseling you
needed for your use of alcohol or drugs?
@BSHOWCARD SUB2@B
1=NO WAY TO PAY FOR IT
2=DID NOT KNOW OF OR COULD NOT GET INTO A TREATMENT PROGRAM

H-11

3=DID NOT HAVE TIME FOR APROGRAM OR A WAY TO GET THERE, OR PROGRAM
NOT CONVENIENT ENOUGH
4=YOU DIDN’T WANT PEOPLE TO FIND OUT THAT YOU HAD A PROBLEM (AT
WORK, IN COMMUNITY, ETC...)
5=YOU DIDN’T REALLY THINK THE TREATMENT WOULD HELP
6=OTHER

H-12

MODULE I: PRESCRIPTION MEDICATION
The next questions are about prescription medication.
PRS1. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a
doctor believe {you/name} needed prescription medicines?
1=YES
2=NO

PRSCHK1

IF PRS1=1, THEN CONTINUE; ELSE GO TO PRS5

PRS2. In the last 12 months, {were you/was name} unable to get prescription medicines you or a
doctor believed necessary?
1=YES
2=NO

PRSCHK2

IF PRS2=1 THEN CONTINUE; ELSE GO TO PRS3

PRS2a. Which of these best describes the main reason {you were/name was} unable to get
prescription medicines you or a doctor believed necessary
@BSHOWCARD MED3@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=PHARMACY DID NOT HAVE IN STOCK
12=OTHER

I-1

PRS2b. How much of a problem was it that {you/name} did not get prescription medicines you
or a doctor believed necessary? Would you say...
1=A big problem
2=A small problem
3=Not a problem

PRS3. In the last 12 months, {were you/was name} delayed in getting prescription medicines
you or a doctor believed necessary?
1=YES
2=NO

PRSCHK3

IF PRS3= 1, THEN CONTINUE; ELSE GO TO PRSCHK4

PRS3a. Which of these best describes the main reason {you were/name was} delayed in getting
prescription medicines you or a doctor believed necessary?
@BSHOWCARD MED3@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=PHARMACY DID NOT HAVE IN STOCK
12=OTHER

I-2

PRS3b. How much of a problem was it that {you were/name was} delayed in getting
prescription medicines you or a doctor believed necessary? Would you say ...
1=A big problem
2=A small problem
3=Not a problem

PRSCHK4

IF PRS2=1 CONTINUE ELSE GOTO PRS5

PRS4. The last time {you/name} did not get prescription medicine {you/he/she} needed, did
{you/he/she} actually have a prescription from a doctor for the medicine?
1=YES
2=NO

PRSCHK5

IF PRS4=1, THEN CONTINUE; ELSE GO TO PRS5

PRS4a. Did you try to get this prescription filled?
1=YES
2=NO

PRS5. {Do you/Does name} take any prescription medication on a regular or on-going basis?
1=YES
2=NO

PRSCHK6

IF PRS5=1, THEN CONTINUE; ELSE GO TO MODULE J

PRS4a. Where do you normally get {your/name’s} prescriptions filled?
1=I get them filled at the {reference health center}
2=I get some of them filled at {the reference health center} and some of them filled elsewhere
3=I get them filled somewhere other than {the reference health center}

I-3

PRS5. About how many different prescription medicines {do you/does name} usually take in a
month?
__________NUMBER/ MEDICINES

PRSCHK7 IF PRS4a =1 OR 2 CONTINUE ELSE GOTO MODULE J
PRS5a. Think about the last time someone at the health center prescribed medication for
{you/name}. Were you satisfied with the way the medication was explained to you, such as
instructions on how to take it and possible side-effects?
1=YES
2=NO
3=NA - HC HAS NOT PRESCRIBED MEDICATION FOR ME

IF PRS5a = 1 OR 2 CONTINUE ELSE GOTO MODULE J
PRS5b. Were you satisfied with the way your questions about the medication were answered?
1=YES
2=NO
3=DIDN’T HAVE ANY QUESTIONS

I-4

MODULE J: DENTAL
DENCHK1 IF AGE GE 2, THEN CONTINUE; ELSE GO TO MODULE K
The next questions are about dental care.
DEN1. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a
dentist believe {you/name} needed any dental care, tests, or treatment?
NOTE: CODE YES IF A DOCTOR BELIEVED DENTAL CARE WAS NECESSARY
1=YES
2=NO

DENCHK2 IF DEN1=1, THEN CONTINUE; ELSE GO TO DEN10
DEN2. In the last 12 months, {were you/was name} unable to get dental care, tests, or treatments
you or a dentist believed necessary?
1=YES
2=NO

DENCHK3 IF DEN2=1, THEN CONTINUE; ELSE GO TO DEN6
DEN3. What kind of dental care, test, or treatment was it that {you/name} needed but did not
get?
________________ (allow 40)

J-1

DEN4. Please describe the main reason {you were/name was} unable to get dental care, tests, or
treatments you or a dentist believed necessary?
@BSHOWCARD MED2@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DENTIST REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DENTIST’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=AFRAID OF GOING TO THE DENTIST/ HAVING DENTAL WORK DONE
12=OTHER

DEN5. How much of a problem was it that {you/name} did not get dental care, tests, or
treatments you or a dentist believed necessary? Would you say...
1=A big problem,
2=A small problem
3=Not a problem

DEN6. In the last 12 months, {were you/was name} delayed in getting dental care tests, or
treatments you or a dentist believed necessary?
1=YES
2=NO

DENCHK4 IF DEN5=1, THEN CONTINUE; ELSE GO TO DEN10
DEN7. What kind of dental care, test, or treatment was it that {you were/name was} delayed in
getting?
________________ (allow 40)

J-2

DEN8. Which of these best describes the main reason {you were/name was} delayed in getting
dental care, tests, or treatments you or a dentist believed necessary?
@BSHOWCARD MED2@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=AFRAID OF GOING TO THE DENTIST/ HAVING DENTAL WORK DONE
12=OTHER

DEN9. How much of a problem was it that {you were/name was} delayed in getting dental care
you or a dentist believed necessary? Would you say...
1=A big problem,
2=A small problem
3=Not a problem

DEN10. About how long has it been since {you/name} last visited a dentist?
Include all types of dentists, such as, orthodontists, oral surgeons, and all other dental specialists,
as well as dental hygienists.
1=6 MONTHS OR LESS
2=MORE THAN 6 MONTHS, BUT NOT MORE THAN 1 YEAR AGO
3=MORE THAN 1 YEAR, BUT NOT MORE THAN 2 YEARS AGO
4=MORE THAN 2 YEARS, BUT NOT MORE THAN 5 YEARS AGO
5=MORE THAN 5 YEARS AGO
7=NEVER HAVE BEEN

DENCHK5 If DEN10=1 or 2, CONTINUE; ELSE GO TO DEN14
DEN11. In the past 12 months, when {you/name} did see a dentist, how many of {your/his/her}
visits were at {the reference health center}? Would you say…

J-3

1=All of the visits
2=Some of the visits
3=None of the visits

DENCHK6 If DEN11=1 or 2, THEN CONTINUE; ELSE GO TO DENCHK6
DEN12. How would you rate the dental services {you/name} received at {the reference health
center}? Would you say…
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor

DENCHK6 If DEN11= 2 OR 3, THEN CONTINUE; ELSE GO TO DEN14
DEN13 Were you referred to the other place where {you/name} got dental services by
{reference health center}?
1=YES
2=NO

DENCHK7 IF AGE LE11 GOTO DEN16a
Now, I have some questions about the condition of {your/name’s} teeth and gums.
DEN14. The following question asks about the number of adult teeth you have lost. Do not count
as "lost" missing wisdom teeth, "baby" teeth, or teeth which were pulled for orthodontia
(straightening the teeth). Have you lost…
1=All of your adult teeth
2=Some of your adult teeth
3=None of your adult teeth

DEN15. IF DEN14=1, GOTO DENT15a ELSE:
IF DEN14=2, CONTINUE ELSE:
IF DEN12=3, DK, RE, GOTO DENCHK8

J-4

How many of your adult teeth have you lost?
__________ TEETH

DEN15a. Are any of your missing teeth replaced by full or partial dentures, false teeth, bridges
or dental plates?
1=YES
2=NO

DENCHK8 DEN14=2 OR 3 CONTINUE ELSE GOTO DEN16b
DEN16a. How would you describe the condition of {your/name’s} teeth? Would you say...
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor

GOTO DEN17
DEN16b Now I have some questions about the condition of {your/name’s} gums and false teeth
or dentures. Would you say the condition of {your/name’s} gums and false teeth or dentures
are…
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor

DEN17. During the past 6 months, {have you/has name} had any of the following problems?
DEN17a.
DEN17b.
DEN17c.

A toothache or sensitive teeth
Bleeding gums
Crooked teeth

J-5

DEN17e.
DEN17f.
DEN17g.
DEN17h.

Broken or missing teeth
Stained or discolored teeth
Broken or missing fillings
Loose teeth not due to injury
IF AGE LE11: Loose teeth not due to injury or losing baby teeth

FOR EACH:
1=YES
2=NO

DEN18. During the past 6 months, {have you/has name} had any of the following problems that
lasted more than a day?
DEN18a.
DEN18b.
DEN18c.
DEN18d.
DEN18f.

Pain in {your/his/her} jaw joint
Sores in {your/his/her} mouth
Difficulty eating or chewing
Bad breath
Dry mouth

FOR EACH:
1=YES
2=NO

DENCHK8 IF DEN17a-h=1 or DEN18a-f=1, CONTINUE; ELSE GO TO MODULE K
DEN19. Did the problems with {your/name’s} mouth or teeth interfere with any of the
following.
DEN19a.
DEN19b.
DEN19c.
DEN19d.

job or school
sleeping
social activities such as going out or being with other people
usual activities at home

FOR EACH:
1=YES
2=NO

J-6

MODULE K: MENTAL HEALTH
MENCHK1 IF AGE GE 18, THEN CONTINUE; ELSE GO TO MENCHK2
MEN1. The next questions about feelings you may have experienced over the past 30 days. Your
answers to these questions are private and will not be shared with anyone at the {reference health
center}. You also have the right to refuse any question that you do not want to answer.
@BSHOWCARD MEN1@B
Please respond using one of these categories. During the past 30 days, how often did you feel…
a.
b.
c.
d.
e.
f.

so sad that nothing could cheer you up?
nervous?
restless or fidgety?
hopeless?
that everything was an effort?
worthless?

FOR EACH:
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME

MEN2. We just talked about a number of feelings you had during the past 30 days. Altogether,
how much did these feelings interfere with your life or activities; a lot, some, a little, or not at
all?
1=A LOT
2=SOME
3=A LITTLE
4=NOT AT ALL

MEN2a. Have you ever had depression?
1=YES
2=NO

K-1

MEN2b. Have you ever had generalized anxiety?
1=YES
2=NO

MEN2c.Have you ever had panic disorder?
1=YES
2=NO

MENCHK2 IF AGE =2 OR 3, THEN CONTINUE; ELSE GO TO MENCHK3
MEN3. I am going to read a list of items that describe children. For each one, tell me if it has
been not true, sometimes true, or often true of {name} during the past 6 months.
a.
b.
c.
d.
e.
f.

Has been uncooperative?
Has trouble getting to sleep?
Has speech problems?
Has been unhappy, sad, or depressed?
Has temper tantrums or a hot temper?
Has been nervous or high-strung?

FOR EACH:
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE

MENCHK3 IF AGE =4 TO 12, THEN CONTINUE; ELSE GO TO MENCHK4
MEN3a.
I am going to read a list of items that describe children. For each one, tell me if it
has been not true, sometimes true, or often true, of {name} during the past 6 months.
a.
b.
c.
d.
e.
f.

Doesn’t get along with other kids?
Can’t concentrate or pay attention long?
Feels worthless or inferior?
Has been unhappy, sad, or depressed?
Has been nervous or high-strung or tense?
Acts too young for [his/her] age?

K-2

FOR EACH:
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE

MENCHK4 IF AGE =13 TO 17, THEN CONTINUE; ELSE GO TO MEN5
MEN4b. I am going to read a list of items that describe teenagers. For each one, tell me if it has
been not true, sometimes true, or often true, of you during the past 6 months.
a.
You can’t concentrate or pay attention long?
b.
You lie or cheat?
c.
You don’t get along with other kids?
d.
You have been unhappy, sad, or depressed?
e.
You do poorly at school work?
f.
You have trouble sleeping?
FOR EACH:
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE

MEN5. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a
doctor believe {you/name} should receive counseling by a mental health professional?
1=YES
2=NO

MENCHK5 IF MEN5 = 1, CONTINUE; ELSE GO TO MEN7
MEN6. In the last 12 months, {were you/was name} unable to get counseling by a mental health
professional you or a doctor believed necessary?
1=YES
2=NO

MENCHK6 IF MEN6 = 1, CONTINUE; ELSE GO TO MEN7

K-3

MEN6a. Which of these best describes the main reason {you were/name was} unable to get
counseling by a mental health professional you or a doctor believed necessary?
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID
NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
12=OTHER

MEN6b. How much of a problem was it that {you/name} did not get counseling by a mental
health professional you or a doctor believed necessary?
1=A big problem
2=A small problem
3=Not a problem

MEN7.In the last 12 months, were {you/name} delayed in getting counseling by a mental health
professional you or a doctor believed necessary?
1=YES
2=NO

MENCHK7 IF MEN7=1, CONTINUE; ELSE GO TO MENCHK8

K-4

MEN7a. Which of these best describes the main reason {you were/name was} delayed in getting
counseling by a mental health professional you or a doctor believed necessary?
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID
NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
12=OTHER

MEN7b How much of a problem was it that {you were/name was} delayed in getting counseling
by a mental health professional you or a doctor believed necessary?
Would you say…
1=A big problem
2=A small problem
3=Not a problem

TREATMENT QUESTIONS
MENCHK8 IF AGE GE 13, THEN CONTINUE; ELSE GO TO MODULE L
MEN8. In the past 12 months, did you receive any mental health treatment or counseling?
(Please include treatment with prescription medication, group or individual counseling with a
mental health provider such as a social worker, psychologist, psychiatrist, psychiatric nurse or
other mental health professional, inpatient treatment. Do not include counseling or advice given
by a friend, or spiritual counseling through a church or religious group.)
1=YES
2=NO

K-5

MENCHK9 IF MEN8=1, CONTINUE; ELSE GO TO MODULE L
MEN8a. What was this treatment or counseling for? Was it for …
SELECT ALL THAT APPLY
1=Depression
2=Anxiety
3=Panic
4=Stress
5=Personal or family problems/ relationship problems
6=Other
MEN9. What kind of treatment or counseling was it?
SELECT ALL THAT APPLY
1=Individual counseling
2=Group counseling sessions
3=Prescription medication
4=Inpatient treatment in a general hospital or mental health treatment facility

MENCHK10 IF MEN9 = 1-2, THEN CONTINUE; ELSE GO TO MODULE L
MEN9a. How many of your treatment or counseling sessions you received did you get at {the
reference health center}? Would you say…
1=All of the visits
2=Some of the visits
3=None of the visits

MENCHK11 IF MEN9a=1 OR 2, THEN CONTINUE; ELSE GO TO MENCHK12

K-6

MEN9b. How would you rate the treatment or counseling services you received at {the reference
health center}. Would you say….
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor

MENCHK12 IF MEN9a=2 OR 3, THE CONTINUE; ELSE GO TO MODULE L
MEN9c. Were you referred to the other place where you got the treatment or counseling services
by the {reference health center}?
1=YES
2=NO

K-7

MODULE L: PRENATAL CARE/ FAMILY PLANNING
PRGCHK0 IF FEMALE AGE 15-49 CONTINUE; ELSE GO TO MODULE M
PRENATAL CARE
PRG1. IF CON2=2 GOTO PRG8:
IF CON2=2a GOTO PRG2:
ELSE CONTINUE:
The next questions are about pregnancy and prenatal care. Have you been pregnant in the past 3
years?
1=YES
2=NO

PRGCHK1

IF PRG1=1, CONTINUE; ELSE GO TO PRG8

PRG2. Did you receive prenatal care for any pregnancy you had in the last three years?
IF NECESSARY: Prenatal care includes the services and tests that a woman gets during a
pregnancy.
1=YES
2=NO

PRGCHK2

IF PRG2=1, THEN CONTINUE; ELSE GO TO PRG6

PRG3. How many of your prenatal visits did you get at {reference health center}? Would you
say….
1=All of the visits
2=Some of the visits
3=None of the visits

NOTE: IF RESPONSE IS “MOST” – CODE AS “SOME OF THE VISITS”
PRGCHK3

IF PRG3=1-2, THEN CONTINUE; ELSE GO TO PRGCHK4

L-1

PRG4. How would you rate the prenatal care services you received at {the reference health
center}. Would you say….
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor
PRGCHK4 IF PRG3=2 OR 3; THEN CONTINUE; ELSE GO TO PRG6
PRG5. Were you referred to the other place where you got prenatal care by {reference health
center}?
1=YES
2=NO

PRG6. In the past three years, was there a time that you needed prenatal care but were unable to
get it?
1=YES
2=NO

PRGCHK5

IF PRG6=1, CONTINUE ELSE GO TO MODULE PRG8

L-2

PRG7. Which of these best describes the main reason you were unable to get prenatal care?
@BSHOW CARD MED3@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER

FAMILY PLANNING
PRG8. In the past 12 months, that is since {12 MONTH REFERENCE DATE}, have you
received any of the following family planning services?
@BNEED SHOWCARD@B
•
•
•
•
•
•
•

A birth control method or prescription
A check-up or medical test related to using a birth control method
Counseling about birth control
Counseling about getting sterilized
Emergency contraception or the "morning-after pill" or a prescription for
Counseling or information about emergency contraception or the "morning-after pill"
A sterilizing operation

1=YES
2=NO

PRGCHK6

IF PRG8a-PRG8g=1, THEN CONTINUE; ELSE GOTO PRG11

L-3

PRG9. How many of these services did you get at {the reference health center}? Would you
say…
1=All of the services
2=Some of the services
3=None of the services

PRGCHK7

IF PRG9=1 OR 2, THEN CONTINUE; ELSE GO TO PRGCHK8

PRG10a. How would you rate the family planning services you received at {the reference health
center}. Would you say….
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor

PRGCHK8 IF PRG9=2 or 3, THEN CONTINUE; ELSE GO TO PRG11
PRG10b. Were you referred to the other place where you got the family planning services by
{reference health center}?
1=YES
2=NO

PRG11. In the last 12 months, was there a time that you needed any family planning service on
the list but were unable to get it?
@B NEED SHOWCARD@B
•
•
•
•
•
•
•

A birth control method or prescription
A check-up or medical test related to using a birth control method
Counseling about birth control
Counseling about getting sterilized
Emergency contraception or the "morning-after pill" or a prescription for
Counseling or information about emergency contraception or the "morning-after pill"
A sterilizing operation

L-4

1=YES
2=NO

PRGCHK9

IF PRG11=1, THEN CONTINUE; ELSE GO TO MODULE M

PRG12. Which of these best describes the main reason you were unable to get that family
planning service?
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER

L-5

MODULE M: OCCUPATIONAL HEALTH
WORK RELATED INJURIES
OCCCHK0 IF AGE GE 16, THEN CONTINUE; ELSE GO TO MODULE N
Now I am going to ask you about on-the-job injuries or illnesses in the past 12 months. As you
know, little injuries and illnesses occur from time to time when we are working, but sometimes it
is more serious. We are interested in the more serious injuries and illnesses, those which may
have resulted in the following things: you couldn’t work for at least 4 hours; you couldn’t work
normally for at least 4 hours; you had to receive medical attention; or you had to take medicine
prescribed by a doctor in order to be able to continue working. These injuries or illnesses include
those that happen while you were at work and those that occur while traveling to and from the
workplace. Do not include travel from home to work unless your employer provides your living
quarters.
OCC1. During the last 12 months, that is since {12 MONTH REFERENCE DATE}, have you
suffered an injury or illness while doing work or while traveling to and from work?
1=YES
2=NO
3=HAVE NOT WORKED IN PAST 12 MONTHS

OCCCHK1 IF OCC1=1, THEN CONTINUE; ELSE GO TO MODULE N
OCC1a. During the last 12 months, how many injuries or illnesses have you had…
a.
while working?
b.
while traveling between worksites?
______ WHILE WORKING
______ WHILE TRAVELING BETWEEN WORKSITES

INJURY LOOP
OCC2a.
IF OCC1a = TOTAL OF 1 INJURY, ASK: I would like to ask you about this injury or illness.
IF OCC1a = TOTAL OF 2 OR MORE INJURIES, ASK: I would like to ask you about the
TWO most recent injuries or illnesses.
MOST RECENT:
Let’s start by talking about the most recent injury or illness.
NEXT MOST RECENT: Now let’s talk about the time before that when you
experienced a work injury or illness.

M-1

What were you doing when the injury or illness occurred? PROBE AS NEEDED: What caused
the injury or illness?
_________________________ [RECORD UP TO 160 CHARACTERS]
OCC2b. Please look at this card and tell me all the injuries or illnesses that resulted from this
incident? Please select all that apply.
@BSHOW CARD OCC1@B
1=SCRAPE OR ABRASION
2=BRUISE OR CONTUSION
3=AMPUTATION OR LOST BODY PART
4=SPRAIN, STRAIN, TORN LIGAMENT, OR TRAUMATIC RUPTURE
5=BROKEN, CRUSHED, OR MANGLED BONE
6=DISLOCATION
7=CUT, LACERATION, PUNCTURE, OR STAB
8=BURN, BLISTER OR SCALD
9=CHEMICAL BURN OR POISONING, EITHER BY INGESTION, BREATHING, OR
SKIN CONTACT
10=SKIN RASH
11=NAUSEA OR VOMITING
12=HEADACHE
13=HEATSTROKE/OVERHEATING
14=BURNING OR STINGING
15=INJURY TO EYE
16=OTHER INJURY OR ILLNESS

OCC2c. FOR EACH: Did you receive medical care for this injury or illness?
1=YES
2=NO

OCCCHK2 IF OCC2c = 2, THEN CONTINUE; ELSE GO TO OCC2e

M-2

OCC2d. Please look at this card and tell me the main reason you did not receive medical care?
@BSHOW CARD OCC2@B
1=COULD NOT AFFORD IT
2=NO INSURANCE
3=DOCTOR DID NOT ACCEPT MEDICAID/INSURANCE
4=NOT SERIOUS ENOUGH
5=WAIT TOO LONG IN CLINIC/OFFICE
6=DIFFICULTY IN GETTING APPOINTMENT
7=NO DOCTOR AVAILABLE
8=DIDN’T KNOW WHERE TO GO
9=NO WAY TO GET THERE
10=HOURS NOT CONVENIENT
11=SPEAK A DIFFERENT LANGUAGE
12=HEALTH OF ANOTHER FAMILY MEMBER
13=EMPLOYER WOULDN’T ALLOW IT
14=AFRAID OF GETTING IN TROUBLE WITH THE LAW
15=OTHER

GOTO OCC2h
OCC2e. Where did you go for medical care?
1=THE {REFERENCE HEALTH CENTER}
2=OTHER CLINIC OR HEALTH CENTER OFFERING A DISCOUNT TO LOW INCOME
OR UNINSURED PEOPLE
3=DOCTOR'S OFFICE OR HMO
6=HOSPITAL EMERGENCY ROOM
7=HOSPITAL OUTPATIENT DEPARTMENT
8=SOME OTHER PLACE

OCC2f. Who took you there?
1=EMPLOYER, SUPERVISOR, OR OTHER EMPLOYEE
2=FAMILY MEMBER, FRIEND, OR CO-WORKER
3=AMBULANCE/RESCUE SQUAD
4=OTHER PERSON
5=I TOOK MYSELF

M-3

OCC2g. How was the medical care paid for?
ALLOW UP TO 2 RESPONSES
1=PERSONAL FUNDS
2=PERSONAL MEDICAL INSURANCE
3=EMPLOYER PROVIDED MEDICAL INSURANCE
4=MEDI-CAL/IEHP
5=MEDICARE/MEDICAID
6=WORKERS’ COMPENSATION
7=HEALTHY FAMILIES
8=STATE DISABILITY INSURANCE
9=MIA
10=CHDP
11=THERE WAS NO CHARGE
12=OTHER

OCC2h. Has the injury or illness resulted in a continuing disability?
1=YES
2=NO

OCC2i. Did you report this injury or illness to your employer?
1=YES
2=NO

OCC2j. Was a worker’s compensation claim filed as a result of this injury or illness?
1=YES
2=NO

M-4

MODULE N: HIV TESTING

HTGCHK1 IF AGE GE 18 CONTINUE, ELSE GOTO MODULE O
HTG1. The next questions are about the test for HIV, the virus that causes AIDS. Your answers
to these questions are private and will not be shared with anyone at the {reference health center}.
You also have the right to refuse any question that you do not want to answer.
Except for tests you may have had as part of blood donations, have you ever been tested for
HIV?
1=YES
2=NO

HTGCHK2 IF HTG1=1, GO TO HTG4; ELSE CONTINUE
HTG2. I am going to show you a list of reasons why some people have not been tested for HIV,
the virus that causes AIDS. Which one of these would you say is the main reason why you have
not been tested?
@BNEED SHOWCARD@B
1=IT'S UNLIKELY YOU'VE BEEN EXPOSED TO HIV
2=YOU WERE AFRAID TO FIND OUT IF YOU WERE HIV POSITIVE (THAT YOU HAD
HIV)
3=YOU DIDN'T WANT TO THINK ABOUT HIV OR ABOUT BEING HIV POSITIVE
4=YOU WERE WORRIED YOUR NAME WOULD BE REPORTED TO THE
GOVERNMENT IF YOU TESTED POSITIVE
5=YOU DIDN'T KNOW WHERE TO GET TESTED
6=YOU DON'T LIKE NEEDLES
7=YOU WERE AFRAID OF LOSING JOB, INSURANCE, HOUSING, FRIENDS, FAMILY,
IF PEOPLE KNEW YOU WERE POSITIVE FOR AIDS INFECTION
8=I’M TESTED WHEN I GIVE BLOOD
9=NO PARTICULAR REASON
10=SOME OTHER REASON

N-1

HTG3. Has anyone at {the reference health center} ever suggested that you have your blood
tested for the AIDS virus infection?
1=YES
2=NO

HTG4. Has anyone at {the reference health center} ever talked to you about ways to protect
yourself and others from getting the AIDS virus?
1=YES
2=NO

HTG5. Have you ever been told by a doctor or other health professional that you are HIV
positive or have AIDS?
1=YES
2=NO

HTGCHK3 IF HTG5=1, THEN CONTINUE; ELSE GO TO MODULE O
HTG6a. Are you receiving any medical care now for HIV or AIDS?
1=YES
2=NO

HTG6b. Are you receiving antiretroviral therapy?
1=YES
2=NO

HTG6c. Where do you usually get medical care for HIV or AIDS?
1={THE REFERENCE HEALTH CENTER}
2=SOMEWHERE ELSE

N-2

HTGCHK4 IF HTG6c=2, THEN CONTINUE; ELSE GO TO MODULE O
HTG6d. Were you/name referred there by {the reference health center}?
1=YES
2=NO

N-3

MODULE O:

LIVING ARRANGEMENTS

Next, I’d like to ask some questions about where {you live/name lives}.
LIV1a.
IF AGE >=18:
IF AGE <=12:
IF AGE = 13-17:

Do you or your family currently have your own place to live, such as a
house, apartment, or room?
Does {name}s family currently have its own place to live, such as a house,
apartment, or room?
Does your family currently have its own place to live, such as a house,
apartment, or room?

1=YES
2=NO

IF LIV1a=1, CONTINUE; ELSE GO TO LIV3
LIV1b. How would you describe the kind of place where {you live/name lives} now?
1=A HOUSE (INCLUDES TRAILERS OR MOBILE HOMES)
2=AN APARTMENT OR CONDO
3=A ROOM (OTHER THAN HOTEL)
4=A TRANSITIONAL SHELTER (INCLUDES TRANSITIONAL HOUSING)
5=HOTEL OR MOTEL (PLACE WITH SEPARATE ROOMS THAT YOU PAY FOR
YOURSELF)
6=OTHER

LIVCHK1

IF LIV1b=1, 2 OR 3, CONTINUE; ELSE GO TO LIVCHK2

LIV2. Does that place belong to a social service provider, or a public housing authority?
1=SOCIAL SERVICE PROVIDER
2=PUBLIC HOUSING AUTHORITY
3=NEITHER

GOTO LIVCHK2

O-1

LIV3. How would you describe the kind of place where {you/name} slept last night?
1=A HOUSE (INCLUDES TRAILERS OR MOBILE HOMES)
2=AN APARTMENT OR CONDO
3=A ROOM (OTHER THAN HOTEL)
4=AN EMERGENCY SHELTER
5=A TRANSITIONAL SHELTER (INCLUDES TRANSITIONAL HOUSING)
6=HOTEL OR MOTEL (PLACE WITH SEPARATE ROOMS THAT YOU PAY FOR
YOURSELF)
7=OTHER

LIVCHK2

IF LIV1b= 1, 2 OR 5 OR LIV3=1, 2 OR 6 CONTINUE;
IF LIV1b=3 OR LIV3=3 GO TO LIV6;
ELSE GOTO LIVCHK3

LIV5 How many rooms there are used for sleeping?
______ ROOMS

LIV6

How many people, in total, sleep in that room/those rooms?

______ NUMBER OF PEOPLE

LIVCHK3

IF LIV1a=2, CONTINUE;
ELSE GOTO LIVCHK4

O-2

WITHOUT OWN PLACE
LIV7.
IF AGE >=18:
IF AGE <=12:
IF AGE =13-17:

When was the last time you or your family had your own place to live for
30 days or longer, such as a house, apartment or room?
When was the last time {name’s} family had its own place to live for 30
days or longer, such as a house, apartment or room?
When was the last time your family had its own place to live for 30 days
or longer, such as a house, apartment or room?

________ NUMBER
a.
DAYS AGO
b.
WEEKS AGO
c.
MONTHS AGO
d.
YEARS AGO

LIV8.
IF AGE >=18:

IF AGE <=12:
own

IF AGE =13-17:

How MANY times in your life have you NOT had your own place to live,
that is, how many times have you NOT had your own place that you could
stay at for 30 days or longer?
How MANY times in {name’s} life has {name’s} family NOT had its
place to live, that is, not had its own place that it could stay at for 30 days
or longer?
How MANY times in your life has your family NOT had its own place to
live, that is, not had its own place that it could stay at for 30 days or
longer?

1=JUST THIS TIME
______NUMBER TIMES

IF LIV8 >1 CONTINUE; ELSE GOTO LIV10
LIV9. How old {were you/was name} the first time that happened?
_______ AGE

O-3

LIVCHK4

CURRENTLY WITH OWN PLACE

LIV10.
IF AGE >=18:
IF AGE <=12:
IF AGE =13-17:

Have you or your family ever NOT had your own place to live, that is,
NOT had your own place that you could stay at for 30 days or longer?
Has {name}’s family ever NOT had its own place to live, that is, NOT had
its own place that it could stay at for 30 days or longer?
Has your family ever NOT had its own place to live, that is, NOT had its
own place that it could stay at for 30 days or longer?

1=YES
2=NO

IF LIV10=1, THEN CONTINUE; ELSE GO TO LIVCHK6
LIV11. How MANY times in your life have you NOT had your own place to live, that is, how
many times have you NOT had your own place that you could stay at for 30 days or longer?
______ NUMBER OF TIMES

IF LIV11=1, CONTINUE; ELSE GOTO LIV14
LIV12. How long did that last?
________ NUMBER
a.
DAYS
b.
WEEKS
c.
MONTHS
d.
YEARS

LIV13. How old {were you/was name} when that happened?
______ AGE

GOTO LIVCHK6

O-4

LIV14.
IF AGE >=18:
IF AGE <=12:
IF AGE =13-17:

The last time you did not have your own place to live, how long did that
last?
The last time {name’s} family did not have its own place to live, how long
did that last?
The last time your family did not have its own place to live, how long did
that last?

________ NUMBER
a.
DAYS
b.
WEEKS
c.
MONTHS
d.
YEARS

LIV15. How old {were you/was name} the first time that happened?
______ AGE

LIVCHK6

IF LIV1a=2 OR LIV10=1 AND AGE >=18, CONTINUE;
ELSE GOTO MODULE P

LIV16. The next few questions are about health care {you/name} may or may not have received
while you did not have your own place to live.
Did you ever need a place to recover from an illness, injury, or hospitalization during a time that
you did not have your own place to live?
1=YES
2=NO

LIVCHK7

IF LIV16=1, CONTINUE; ELSE GO TO MODULE P

LIV16a. Did you find a place to recover from an illness, injury, or hospitalization?
1=YES
2=NO

LIVCHK8

IF LIV16a=1, CONTINUE; ELSE GO TO MODULE P

O-5

LIV16b. Where did you go to recover? Was it…
SELECT ALL THAT APPLY
1=Someone’s home
2=A shelter
3=A nursing home or rehabilitation facility
4=A special program for homeless people to recover
5=Some other place

LIVCHK9

IF LIV16b=4, CONTINUE; ELSE GO TO GO TO MODULE P

LIV6c. How long did you stay?
1=1-6 DAYS
2=7-29 DAYS
3=30 DAYS OR LONGER

LIV6d. Did that program help you get better?
1=YES
2=NO

LIV6e. Did that program help you with getting housing and/or services that you could use after
you were discharged?
1=YES
2=NO

O-6

MODULE P:

HEALTH INSURANCE

INTERVIEWER NOTE: ADOLESCENTS AGE 13-17 WILL RECEIVE FIRST 2
QUESTIONS OF THIS MODULE.
S-CHIP PROGRAM STATE NAMES
1=Alabama: ALL Kids
2=Alaska: Denali KidCare
3=Arizona: KidsCare
4=Arkansas: ARKids
5=California: Healthy Families Program
6=Colorado: Child Health Plan Plus (CHP+)
7=Connecticut: HUSKY Plan
8=Delaware: Delaware Healthy Children Program (DHCP)
9=Florida: Florida KidCare Program
10=Georgia: PeachCare for Kids
11=Hawaii: Hawaii Quest / Hawaii Title XXI Program
12=Idaho: IdahoHealth / Idaho CHIP
13=Illinois: Illinois All Kids / KidCare
14=Indiana: Indiana CHIP / Hoosier Healthwise
15=Iowa: Healthy and Well Kids in Iowa (hawk-i)
16=Kansas: HealthWave
17=Kentucky: Kentucky CHIP (KCHIP)
18=Louisiana: LaCHIP
19=Maine: MaineCare
20=Maryland: Maryland Children’s Health Program
21=Massachusetts: MassHealth
22=Michigan: MIChild
23=Minnesota: Minnesota’s Children’s Health Insurance
Plan
24=Mississippi: Mississippi CHIP / Mississippi Title XXI
25=Missouri: Managed Care Plus (MC+) For Kids
Program=
26=Montana: Montana’s Children’s Health Insurance Plan
27=Nebraska: Kids Connection
28=Nevada: Nevada Check Up

29=New Hampshire: Healthy Kids
30=New Jersey: FamilyCare
31=New Mexico: New Mexico State Children’s Health
Insurance Program / New MexiKids
32=New York: Child Health Plus (CHPlus)
33=North Carolina: North Carolina CHIP Program / Health
Choice for Children
34=North Dakota: Healthy Steps Program / North Dakota
CHIP
35=Ohio: Healthy Start
36=Oklahoma: SoonerCare
37=Oregon: Oregon SCHIP
38=Pennsylvania: Pennsylvania CHIP
39=Rhode Island: RIte Care
40=South Carolina: Partners for Healthy Children
41=South Dakota: South Dakota Children’s Health
Insurance Program
42=Tennessee: CoverKids
43=Texas: TexCare Partnership / Texas CHIP
44=Utah: Utah’s Children’s Health Insurance Program
45=Vermont: Dr. Dynasaur
46=Virginia: Family Access to Medical Insurance Security
Plan (FAMIS)
47=Washington: Washington CHIP
48=West Virginia: West Virginia’s Children’s Health
Insurance Program (WV CHIP)
49=Wisconsin: BadgerCare
50=Wyoming: Wyoming Kid Care
51=District of Columbia: District of Columbia CHIP / DC
Health Families

INS1. The next questions are about health insurance. Include health insurance obtained through
employment or purchased directly as well as government programs like Medicare and Medicaid
that provide medical care or help pay medical bills. At this time, {are you/is name} covered by
health insurance or some other kind of health care plan?
1=YES
2=NO

INSCHK1

IF INS1=1, THEN CONTINUE; ELSE GO TO INS4

P-1

INS2. What kind of health insurance or health care coverage {do you/ does name} have?
INCLUDE those that pay for only one type of service (nursing home care, accidents, or dental
care) exclude private plans that only provide extra cash while hospitalized.
CODE ALL THAT APPLY.
1=PRIVATE HEALTH INSURANCE
2=MEDICARE
3=MEDI-GAP
4=MEDICAID / (IF CALIFORNIA: MEDICAL)
5=MILITARY HEALTH CARE/VA
6=CHAMPUS/TRICARE/CHAMP-VA
7=INDIAN HEALTH SERVICE
8=STATE-SPONSORED CHILDREN’S HEALTH INSURANCE PLAN (GIVE STATE’S SCHIP NAME – S- CHIP PROGRAM STATE NAMES)
9=SINGLE SERVICE PLAN (E.G., DENTAL, VISION, PRESCRIPTIONS).
10=OTHER STATE-SPONSORED HEALTH PLAN
11=OTHER GOVERNMENT PROGRAM
12=NONE

INSCHK2

IF AGE= 13-17 GOTO MODULE Q
IF INS2=1, 2, 3 or 4, THEN CONTINUE,
IF INS2 = 9 ONLY GOTO INS4
ELSE GO TO INSCHK4

INSCHK4

IF INS2=1, THEN CONTINUE; ELSE GO TO MODULE Q

INS3. Which of these best describes how this plan was obtained?
1=Through employer or union
2=Policy purchased directly from the insurance company
3=Through a state or local government or community program
4=Through an association that has insurance available to association members
5=Other

INS3a. {Does this plan/Do any of these plans} pay for any of the costs for medicines prescribed
by a doctor?
1=YES
2=NO

P-2

INS3b. {Does this plan/Do any of these plans} pay for any of the costs for dental care?
1=YES
2=NO

GO TO MODULE Q
QUESTIONS FOR INDIVIDUALS WITHOUT HEALTH INSURANCE
INS4. A single service plan is one that pays for only one type of service, such as nursing home
care, accidents, or dental care. Not including Single Service Plans, about how long has it been
since {you/name} last had health care coverage?
1=6 months or less
2=More than 6 months, but not more than 1 yr ago
3=More than 1 yr, but not more than 3 yrs ago
4=More than 3 yrs
5=Never

IF INS4=5, DK, OR RE, GOTO MODULE Q, ELSE CONTINUE
INS5. {Which of these are reasons {you/name} stopped being covered? / Which of these are
reasons {you/name} {do/ does} not have health insurance? }
ALLOW UP TO 5 RESPONSES
1=PERSON IN FAMILY WITH HEALTH INSURANCE LOST JOB OR CHANGED
EMPLOYERS
2=GOT DIVORCED OR SEPARATED/DEATH OF SPOUSE OR PARENT
3=BECAME INELIGIBLE BECAUSE OF AGE/LEFT SCHOOL
4=EMPLOYER DOES NOT OFFER COVERAGE/OR NOT ELIGIBLE FOR COVERAGE
5=COST IS TOO HIGH
6=INSURANCE COMPANY REFUSED COVERAGE
7=MEDICAID/MEDICAL PLAN STOPPED AFTER PREGNANCY
8=LOST MEDICAID/MEDICAL PLAN BECAUSE OF NEW JOB OR INCREASE IN
INCOME
9=LOST MEDICAID (OTHER)
10=DROPPED PRIVATE COVERAGE TO MEET THE WAITING PERIOD REQUIREMENT
FOR (S-CHIP NAME - S-CHIP PROGRAM STATE NAMES)
11=OTHER

P-3

P-4

MODULE Q:

INCOME AND ASSETS

INC1a. When [you go/name goes] to {reference health center}, does {reference health center}
reduce the charge for the services provided because of your income level?
1=YES
2=NO

IF AGE 13-17 GOTO INC4; ELSE CONTINUE

INC1b. The next questions are about [your total/your total family] income in [last calendar year
in 4-digit format] before taxes. Income is important in analyzing the health information we
collect. For example, with this information, we can learn whether persons in one income group
use certain types of medical services more or less often than those in another group.
Please be assured that, like all other information you have provided, these answers will be kept
private and will not be shared with anyone at the {reference health center}.
When answering this next question please remember to include your income PLUS the income
of all family members living in your household. Please remember to include all types of income,
including: Income from child support or alimony; rental income; any cash assistance from a
state or county welfare program; income from Worker’s Compensation or unemployment
compensation; any retirement, disability or survivor pension; any interest or investment income.
What is your best estimate of [IF INC1=0: your total income/ELSE: the total income of all
family members] from all sources, before taxes, in [last calendar year in 4 digit format]?
______
999996

(0-999,995) DOLLARS
$999,995+ DOLLARS

INCCHK1

IF INC1b= F3 OR F4, INC1d; ELSE CONTINUE

INC1c. Including you, how many family members did that income support for [last calendar
year in 4 digit format]?
______ FAMILY MEMBERS

GOTO INC3

Q-1

INC1d. Although you were unable to provide your family income for [last calendar year in 4
digit format], can you tell me how many family members were supported by your family income,
including yourself?
______ FAMILY MEMBERS

Poverty Thresholds for 2009 by Size of Family and Number
of Related Children Under 18 Years
Size of Family Unit
One person (unrelated individual)
Two people
Three people
Four people
Five people
Six people
Seven people
Eight people
Source: U.S. Census Bureau

FPL
(weighted
avg)
10,830
14,570
18,310
22,050
25,790
29,530
33,270
37,010

2 times FPL
(weighted
avg)
21,660
29,140
38,620
44,100
51,580
59,060
66,540
74,020

INC2.
PROGRAMMER: USE TABLE AND RESPONSE TO INC1c TO DETERMINE FILLS
FOR FPL AND 2XFPL BELOW:
During [last calendar year in 4-digit format], was your total family income from all sources less
than [FILL FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c], more than
[FILL FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c] but less than [FILL
2X FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c] or [FILL 2X FAMILY
POVERTY LEVEL BASED ON RESPONSE TO INC1c] or more?
PROBE: IF RESPONDENT SAYS DON’T KNOW – AUTOMATICALLY REPEAT
QUESTION AND ASK RESPONDENT TO GIVE US THEIR BEST ESTIMATE.
1=LESS THAN FPL
2=MORE THAN FPL BUT LESS THAN 2 TIMES FPL
3=TWO TIMES FPL OR MORE

Q-2

INC3. During [last calendar year in 4-digit format], did {you/name} or anyone else in
{your/name’s} household receive any of the following forms of public assistance?
a.
b.
c.
d.
e.

food stamps
WIC, the women, infants, and children nutrition program?
aid from the (state TANF plan) program?
section 8 housing
any other assistance from the government?

FOR EACH:
1=YES
2=NO

INC4. The next question is about the food {you/name} eat{s}. Which of the following
statements best describes {your/name’s} situation in terms of the food {you/name} eat{s}. {Do
you/Does he/she}….
1=get enough of the kinds of foods {you want/you want him/her} to eat
2=get enough, but not always what {you want/you want him/her}to eat
3=sometimes don’t get enough to eat
4=often don’t get enough to eat

Fills for STATE TANF PLANS (in INC3g)
IN STATES WHERE THERE IS MORE THAN ONE PROGRAM, AN ASTERICK *
DENOTES WHICH MOST RESEMBLES TANF
1=ALABAMA
2=ALASKA
3=ARIZONA
4=ARKANSAS
5=CALIFORNIA
6=COLORADO
7=CONNECTICUT
8=DELAWARE
9=THE DISTRICT OF COLUMBIA (WASHINGTON, DC)
10=FLORIDA
11=GEORGIA
12=HAWAII
13=IDAHO
14=ILLINOIS
15=INDIANA
16=IOWA
17=KANSAS
18=KENTUCKY

Q-3

27=MONTANA
28=NEBRASKA
29=NEVADA
30=NEW HAMPSHIRE
31=NEW JERSEY
32=NEW MEXICO
33=NEW YORK
34=NORTH CAROLINA
35=NORTH DAKOTA
36=OHIO
37=OKLAHOMA
38=OREGON
39=PENNSYLVANIA
40=RHODE ISLAND
41=SOUTH CAROLINA
42=SOUTH DAKOTA
43=TENNESSEE
44=TEXAS

19=LOUISIANA
20=MAINE
21=MARYLAND
22=MASSACHUSETTS
23=MICHIGAN
24=MINNESOTA
25=MISSISSIPPI
26=MISSOURI

45=UTAH
46=VERMONT
47=VIRGINIA
48=WASHINGTON
49=WEST VIRGINIA
50=WISCONSIN
51=WYOMING

IF STATE= 1 THEN TANFFILL = the Family Assistance Program (FA)
IF STATE = 2 THEN TANFFILL = the Alaska Temporary Assistance Program (ATAP)
IF STATE = 3 THEN TANFFILL = Cash Assistance/Temporary Assistance for Needy Families (TANF)
IF STATE = 4 THEN TANFFILL = the Transitional Employment Assistance Program (TEA)
IF STATE = 5 THEN TANFFILL = California Work Opportunity and Responsibility to Kids (CalWORKs)
IF STATE = 6 THEN TANFFILL = Colorado Works
IF STATE = 7 THEN TANFFILL = Jobs First
IF STATE = 8 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 9 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 10 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 11 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 12 THEN TANFFILL = Temporary Assistance for Needy Families (TANF) or Temporary Assistance
to Other Needy Families (TAONF)
IF STATE = 13 THEN TANFFILL = Temporary Assistance for Needy Families (TANFI)
IF STATE = 14 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 15 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 16 THEN TANFFILL = the Family Investment Program (FIP)
IF STATE = 17 THEN TANFFILL = Successful Families Program
IF STATE = 18 THEN TANFFILL = the Kentucky Transitional Assistance Program (K-TAP)
IF STATE = 19 THEN TANFFILL = The Family Independence Temporary Assistance Program (FITAP), Kinship
Care Subsidy Program (KCSP), and the Strategies to Empower People (STEP) Program
IF STATE = 20 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 21 THEN TANFFILL = The Family Investment Program (FIP) or Temporary Cash Assistance (TCA)
IF STATE = 22 THEN TANFFILL = Transitional Aid to Families with Dependent Children (TAFDC)
IF STATE = 23 THEN TANFFILL = the Family Independence Program (FIP)
IF STATE = 24 THEN TANFFILL = the Minnesota Family Investment Program (MFIP)
IF STATE = 25 THEN TANFFILL = Temporary Assistance to Needy Families (TANF)
IF STATE = 26 THEN TANFFILL = Temporary Assistance
IF STATE = 27 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 28 THEN TANFFILL = Employment First
IF STATE = 29 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 30 THEN TANFFILL = the Family Assistance Program (FAP) or the New Hampshire Employment
Program (NHEP)
IF STATE = 31 THEN TANFFILL = Work First New Jersey (WFNJ)
IF STATE = 32 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 33 THEN TANFFILL = Family Assistance (FA)
IF STATE = 34 THEN TANFFILL = Work First
IF STATE = 35 THEN TANFFILL = Temporary Assistance for Needy Families (TANF) or Jobs Opportunities and
Basic Skills (JOBS)
IF STATE = 36 THEN TANFFILL = Ohio Works First (OWF) or Prevention, Retention and Contingency Program
(PRC)
IF STATE = 37 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 38 THEN TANFFILL = JOBS or Job Opportunities and Basic Skills Program or Temporary Assistance
for Needy Families (TANF)
IF STATE = 39 THEN TANFFILL = Pennsylvania Temporary Assistance for Needy Families (Pennsylvania
TANF)
IF STATE = 40 THEN TANFFILL = the Family Independence Program (FIP)

Q-4

IF STATE = 41 THEN TANFFILL = the Family Independence Program
IF STATE = 42 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 43 THEN TANFFILL = Families First
IF STATE = 44 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE =45 THEN TANFFILL = the Family Employment Program (FEP)
IF STATE = 46 THEN TANFFILL = Reach Up
IF STATE = 47 THEN TANFFILL = Temporary Assistance for Needy Families (TANF)
IF STATE = 48 THEN TANFFILL = Work First
IF STATE = 49 THEN TANFFILL = West Virginia Works (WV Works)
IF STATE = 50 THEN TANFFILL = Wisconsin Works (W-2)
IF STATE = 51 THEN TANFFILL = Personal Opportunities with Employment Responsibility (POWER)
ELSE TANFFILL = BLANK

Q-5

MODULE R: DEMOGRAPHICS

The final questions are about {you/name}.
DMO1. {Were you/Was name} born in the United States?
1=YES
2=NO

DMOCHK1 IF DMO1 =1, THEN GO TO DMO4 ELSE CONTINUE
DMO2. In what year did {you/name} come to the United States?
________ YEAR

DMO3. About how long {have you/has name} been in the United States?
_________ YEARS

NOTE: ROUND TO NEARERST YEAR - IF LESS THAN 1 YEAR – RECORD “0”

R-1

DMO4. IF AGE <5 GOTO DMOCHK3 ELSE CONTINUE
What is the HIGHEST grade or year of school {you have/name has} completed?
0=NEVER ATTENDED/KINDERGARTEN
1=1ST GRADE
2=2ND GRADE
3=3RD GRADE
4=4TH GRADE
5=5TH GRADE
6=6TH GRADE
7=7TH GRADE
8=8TH GRADE
9=9TH GRADE
10=10TH GRADE
11=11TH GRADE
12=12TH GRADE, NO DIPLOMA
13=HIGH SCHOOL GRADUATE
14=GED OR EQUIVALENT
15=SOME COLLEGE, NO DEGREE
16=ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR VOCATIONAL
PROGRAM
17=ASSOCIATE DEGREE: ACADEMIC PROGRAM
18=BACHELOR’S DEGREE (EXAMPLE: BA, AB, BS, BBA)
19=MASTER’S DEGREE(EXAMPLE: MA, MS, MENG, MED, MBA)
20=PROFESSIONAL SCHOOL OR DOCTORAL DEGREE (EXAMPLE: MD, DDS, DVM,
JD, PHD, EDD)
21=OTHER

DMOCHK3 IF DMO1=1, GO TO DMOCHK4; ELSE CONTINUE
DMO5. During the last year you were in school, were you attending a school in the United
States?
1=YES
2=NO

DMOCHK4 IF AGE 3 TO 21, THEN CONTINUE; ELSE GO TO DMO7

R-2

DMO6. {Are you/Is name} either going to school or on vacation from school?
1=YES
2=NO

DMO7. How many times {have you/has name} moved in the past 12 months?
1=0
2=1
3=2
4=3
5=4
6=5
7=6-10
8=11-15
9=MORE THAN 15
99=HOMELESS – NOT APPLICABLE

DMOCHK5 IF DMO7 GE 1, THEN CONTINUE;
IF DMO7 = 99 GO TO DMOCHK6
ALL OTHERS GO TO DMOCHK6
DMO8. How many of these moves were related to the work of someone in the family. For
example, moving to a place to do farm work there or to look for work there, and moving back
home after the farming season ended.
1=0
2=1
3=2
4=3
5=4
6=5
7=6-10
8=11-15
9=MORE THAN 15

MARITAL STATUS
DMOCHK6 IF AGE GE 15, THEN CONTINUE; ELSE GO TO DMOCHK8

R-3

DMO9. Are you ……?
1=Married
2=Widowed
3=Divorced
4=Separated
5=Never married

DMOCHK7 IF DMO9=1, THEN CONTINUE; ELSE
IF DMO9=2, 3, 4 OR 5, THEN GO TO DMO9b; ELSE
GO TO DMOCHK9
MO9a. Is your spouse living with you?
1=YES (GOTO DMOCHK9)
2=NO

IF DMOCHK8

IF DMO9a=1, THEN GO TO DMOCHK9; ELSE CONTINUE

DMO9b. Are you living with a partner?
1=YES
2=NO

VETERAN’S STATUS
DMOCHK9 IF AGE GE 18, THEN CONTINUE; ELSE GO TO DMOCHK12
DMO10. Have you ever served on active duty in the U.S. Armed Forces, military Reserves, or
the National Guard?
IF NECESSARY: ACTIVE DUTY DOES NOT INCLUDE TRAINING FOR THE RESERVES
OR NATIONAL GUARD, BUT DOES INCLUDE ACTIVATION, FOR EXAMPLE, FOR
THE PERSIAN GULF WAR.
1=YES
2=NO

R-4

DMOCHK10 IF DMO10=1, THEN CONTINUE; ELSE GO TO DMOCHK12
DMO10a. Which of the following best describes your service in the U.S. military?
1=Currently on active duty
2=Currently in the Reserves or National Guard
3=Retired from military service
4=Medically discharged from military service
5=Discharged from military service

DMOCHK11 IF DMO10a=1 OR 2, THEN GO TO DMOCHK12; ELSE CONTINUE
DMO10b. Are you eligible for veteran’s benefits?
1=YES
2=NO (GO TO DMOCHK5)

DMO10c. In the past 12 months, that is since {12 MONTH REFERENCE DATE}, have you
received health care from VA facilities?
1=YES
2=NO

EMPLOYMENT
DMOCHK12 IF AGE GE 16, THEN CONTINUE; ELSE GO TO DMOCHK17

R-5

DMO11. The next few questions are about employment status. Information on employment is
important in analyzing the health information we collect. For example, with this information, we
can learn whether patients who work full-time use medical services more or less often than those
that don’t work full-time.
Which of the following were you doing last week?
1=Working at a job or business
2=With a job or business but not at work
3=Looking for work
4=Working, but not for pay, at family-owned job or business
5=Not working at a job or business and not looking for work

DMOCHK13 IF DMO11=2 OR 5, THEN CONTINUE; ELSE
IF DMO11=1, THEN GO TO DMO11b; ELSE
IF DMO11=4, THEN GO TO DMO11c; ELSE
GO TO DMO11i

DMO11a. What is the main reason you did not [work last week/have a job or business last
week]?
1=TAKING CARE OF HOUSE OR FAMILY
2=GOING TO SCHOOL
3=RETIRED
4=ON A PLANNED VACATION FROM WORK
5=ON FAMILY OR MATERNITY LEAVE
6=TEMPORARILY UNABLE TO WORK FOR HEALTH REASONS
7=HAVE A JOB/CONTRACT AND OFF-SEASON
8=ON LAYOFF
9=DISABLED
10=OTHER

DMOCHK14 IF DMO11a=4, 5, 6, OR 7, THEN CONTINUE; ELSE GO TO DMO11i

R-6

DMO11b.
IF DMO11=1:
Do you have more than one paying job or business?
ELSE:
When you are working, do you normally have more than one paying job or
business?
1=YES
2=NO

DMO11c.
IF DMO11=1 OR 4: How many hours did you work LAST WEEK at ALL jobs or businesses?
ELSE:
How many hours do you USUALLY work at ALL jobs or businesses?
_______HOURS LAST WEEK

DMOCHK15

IF DMO11c LE 34, RF, OR DK, THEN CONTINUE; ELSE GO TO
DMO11e

DMO11d. Do you USUALLY work 35 hours or more per week in total at ALL jobs or
businesses?
1=YES
2=NO

IF DMO11b=1 CONTINUE ELSE GO TO DMO11f
DMO11e. For the job you work at the most hours, what is the total number of hours you usually
work?
_______HOURS

DMO11f. Do you currently have paid sick leave on this job or business?
1=YES
2=NO

R-7

DMO11g. Now, I have questions about work you did in [last calendar year in 4 digit format].
Did you work for pay at any time in [last calendar year in 4 digit format]?
1=YES
2=NO

DMOCHK15

IF DMO11g=1, THEN CONTINUE; ELSE GO TO DMOCHK16

DMO11h. How many months in [last calendar year in 4 digit format] did you have at least one
job or business?
_______MONTHS

IF DMO11=1 OR 2 AND INS1=2 AND INS5 NE 4 CONTINUE, ELSE GOTO
DMOCHK16
DMO11i. Does your job or business offer health insurance as a benefit to any of its employees?
1=YES
2=NO

DMOCHK16

IF DMO11i=1, THEN CONTINUE; ELSE GO TO DMOCHK17

DMO11j. Does your job or business cover health insurance costs for those employees covered by
this benefit?
1=YES
2=NO

R-8

DMO11k Why aren’t you included in your employer’s health insurance plan?
CODE ALL THAT APPLY.
1=DO NOT NEED OR WANT ANY HEALTH INSURANCE
2=RARELY SICK
3=TOO MUCH HASSLE/PAPERWORK
4=COULD NOT AFFORD/TOO EXPENSIVE
5=DO NOT WORK ENOUGH HOURS IN A WEEK
6=HAVE NOT WORKED THERE LONG ENOUGH
7=DOUBT ELIGIBLE/REJECTED BECAUSE OF HEALTH CONDITION
8=BENEFIT PACKAGE DIDN’T MEET NEEDS
9=OTHER

DMOCHK17 IF MIGRANT AND AGE GE 12, CONTINUE; ELSE GO TO END
DMO12. Have you done farm work in the last 24 months, that is since (24 MONTH
REFERENCE DATE)?
1=YES
2=NO

DMOCHK18 IF DMO12=1, THEN CONTINUE; ELSE GO TO END
DMO12a. Are you currently employed by a:
1=grower/rancher
2=contractor
3=packing service
4=packing house
5=non-farm related employer

DMO12b. Approximately how many years have you done farm work in the U.S.
NOTE: COUNT ANY YEAR IN WHICH 15 DAYS OR MORE WERE WORKED
_______YEARS

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DMO12c. Approximately how many years have you done non-farm work in the U.S.?
NOTE: COUNT ANY YEAR IN WHICH 15 DAYS OR MORE WERE WORKED
_______YEARS

DMO12d. Approximately how many months during the past 12 months have you been in the
U.S.?
_______MONTHS

END. Thank you very much. These are all the questions I have for you today.
1=CONTINUE

R-10