Attachment 13 - Cognitive Interview Report_2nd round _2_

Cognitive Interview Report_2nd round _2_.pdf

Bureau of Primary Health Care Patient Survey

Attachment 13 - Cognitive Interview Report_2nd round _2_

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Primary Health Care Patient Surveys
Cognitive Interview Report—Round 2 Interviews
Submitted to:
Anne Pope
Health Resources and Services Administration
Bureau of Primary Health Care
Parklawn Building, 5600 Fishers Lane
Rockville, MD 20857

Submitted by:
RTI International
3040 Cornwallis Road
Research Triangle Park, NC 27709-2194

December 19, 2008

Table of Contents
I

Background and Introduction .......................................................................................................... 1

Recruitment ...................................................................................................................................... 2

III

Procedures ........................................................................................................................................ 2

General Results and Recommendations........................................................................................... 3

Question-by-Question Results and Recommendations .................................................................... 4

List of Tables
1

Cohort A Selection........................................................................................................................... 2

Timing Estimates, by Module .......................................................................................................... 3

Background and Introduction

The Primary Health Care Patient Surveys (PHCPS), sponsored by the Health Resources and
Services Administration (HRSA), aim to collect nationally representative data on patients who
use health centers funded under Section 330 of the Public Health Service Act. Results from the
Patient Surveys will guide and support the Bureau of Primary Health Care (BPHC) in its mission
to improve the health of the nation’s underserved communities and vulnerable populations by
assuring access to comprehensive, culturally competent, quality primary health care service. The
Patient Surveys will collect data from the clients of health centers funded through four BPHC
grant programs: the Community Health Center Program (CHC), the Migrant Health Center
Program (MHC), the Health Care for the Homeless Program (HCH), and the Public Housing
Primary Care Program (PHPC).
To this end, the BPHC funded two contracts:



The Community Health Center Patient Survey (CHC) contract will collect and analyze
data from clients of the CHC program. This program serves low-income individuals.
The Health Center Special Populations Patient Survey (Special Populations) contract will
collect and analyze data from clients of the MHC, HCH, and PHPC. Respectively, these
three programs serve migrant and seasonal farm workers, homeless individuals, and
residents of public housing.

Because some of the Section 330–funded health center grantees receive grants through more
than one of the aforementioned grant programs, extensive coordination between the two
contracts will create efficiencies that will allow for larger sample sizes and ensure consistency
between the two studies. Therefore, the sample design for the CHC and Special Populations
studies reflects the decision by BPHC to coordinate these two studies using a harmonized
sampling and data collection approach.
In the PHCPS, the primary analytic units are patients who receive services from the funded
grantees. The primary analytic units are clustered within the health center sites within a grantee.
Because most of the grantees operate more than one site, the sites are clustered within the
grantees. RTI International1 will use a three-stage sample design in which the grantees are
selected as the primary sampling units (PSUs), sites are selected within selected grantees, and
patients are selected within selected sites. Because of the high costs involved with recruiting a
grantee and hiring a field interviewer (FI) to perform the data collection, we will select an
independent patient sample from each funding program for grantees receiving multiple funding
programs. The sample design allows us to obtain more patient interviews with fewer data
collection costs due to the high costs of recruiting grantees.
Development of the questionnaire began in October 2007 with a review of the 2002
User/Visit Surveys and the National Health Interview Survey (NHIS) in accordance with
BPHC’s desire to make national comparisons. A meeting with the technical advisory panel
(TAP) was held in February 2008. The questionnaire was streamlined and adjusted to meet the
current data needs of the BPHC, and a final version was ready for cognitive testing in early
October 2008.
This report summarizes the results of the second round of in-person cognitive testing of
questions included on the PHCPS questionnaire. The report is organized into the following
1

RTI International is a trade name of Research Triangle Institute.
1

sections: (II) Recruitment, (III) Procedures, (IV) General Results and Recommendations, and
(V) Question-by-Question Results and Recommendations.
II.

Recruitment

The sample was developed from existing contacts made during Round 1 recruiting. In
addition, two RTI project staff visited Goshen Medical Center to conduct on-site screenings of
patients and encourage participation. Goshen was selected because of the small number of
contacts made in Round 1 interviews. Of the patients that were screened at Goshen, four
respondents were selected and interviewed on-site. The remaining five interviews were
conducted with patients of Lincoln Community Health Center.
Table 1 shows the demographic distribution of patients interviewed during Round 2.
Table 1 –Selection
Interview
ID
A1
A2
A3
A4
A5
A6
A7
A8
A9

Site
Goshen
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln

Gender
M
F
F
M
F
F
F
F
F

Age
61
56
74
60
25
48
54
19
11

Health
Insurance
NO
NO
YES
YES
YES
NO
NO
YES
YES

Migrant/
Seasonal Farm
Worker
NO
NO
NO
NO
NO
NO
NO
NO
NO

Homeless During Currently Living
the Past 12
in Public
Months
Housing
YES
NO
YES
NO
NO
YES
NO
NO
NO
YES
NO
NO
NO
YES
NO
NO
NO
NO

The distribution was quite diverse, with a few exceptions:




A larger number of women (78%) were interviewed than men.
No migrant farm laborers were interviewed. This was due, in part, to the difficulty in
finding Hispanic farm laborers that spoke English.
Of the three adolescents that were screened, two were no-shows and the third never
returned our calls for participation.

III. Procedures
Once the sample was established, patients were then called and invited to take part in a oneon-one interview with an RTI staff member. Four interviews were conducted in a private office
at Goshen Medical Center. The remaining interviews were arranged at other locations, such as
the respondent’s home and local libraries.
The cognitive interviews were conducted from December 9, 2008, through December 16,
2008. The nine interviews were conducted by Tim Flanigan (the Instrumentation Task Leader)
and three additional survey methodologists. The interviews ranged from approximately 38 to 80
minutes, and the participants were provided a $50 cash incentive as a token of appreciation for
their time and travel. Mr. Flanigan oversaw the entire operation, including recruitment, set-up,
conduct of interviews, and report writing.
2

Before starting the interviews, participants were required to read and sign an informed
consent document that described the study and outlined the participants’ rights as research
volunteers. A copy of the informed consent form was given to each participant. Proxy
participants signed a consent form explaining that the questions would be asked about their child
and the responses would be provided by the parent.
Respondents received the instrument in its entirety. Following the interview, a few
prescripted debriefing questions were administered, along with additional follow-up questions
that the interviewers may have had to clarify points in the interview. Each interviewer kept
timing of each module, as well. Table 2 shows the timing estimates of each of the modules.
Table 2 – Timing Estimates, by Module
Administration Time (in Minutes), by Module
Interview
ID
A
A1
1
A2
1
A3
1
A4
1
A5
1
A6
1
A7
1
A8
1
A9
1

B
14
11
16
13
13
14
11
11
8

C
0
4
2
6
0
2
4
0
0

D
5
3
4
5
3
4
3
3
3

E
7
3
3
7
4
0
0
0
3

F
0
4
0
0
4
4
7
2
0

G
13
12
13
11
14
13
14
9
9

H
10
4
0
4
8
8
13
9
0

Average

12 3.6

3.6

4.5

4.2

I
3
2
2
3
4
3
3
2
2

J
5
5
8
3
5
5
4
4
2

2.7 4.6

K
3
2
3
2
4
4
5
2
0

L
0
0
0
0
3
1
0
3
0

M
2
2
0
1
2
1
1
1
0

N
1
1
1
0
1
1
1
1
0

O
2
4
4
0
3
3
2
2
4

3.1

2.3

1.4

Q
5
3
3
2
4
6
6
4
2

R
3
5
5
4
4
4
3
3
3

Avg.
Total
77
67
67
62
78
76
80
59
38

1.8 3.9

3.8

P
3
1
2
0
1
2
2
2
1

IV. General Results and Recommendations
Overall, we found that the questionnaire worked quite well. There were a few logic and
wording issues. These are displayed in blue font after the question in the question-by-question
findings section. Global issues included the following:







Module timings conducted determined that Modules B and G are each averaging 12
minutes to administer. Overall, timings ranged from 38 minutes (proxy interview) to 1
hour and 20 minutes in length. The average interview took 67 minutes to complete.
Administering the interview by computer-assisted personal interviewing should bring the
average administration time down to about 60 minutes.
Skip logic is much improved compared with Round 1 interviews.
Lengthy introductions (i.e., work-related injuries in Module M) are difficult to
administer. Consider making these longer introductions into bullets for the interviewer to
read.
The largest area of concern is the lengthy response categories. These do not seem to be a
problem on show cards, but do pose a problem when the interviewer is left to code the
respondents answer. This may lead to interviewer error. Consider shortening these lists
with an “other” category as a catch-all.
Respondents did not have much to add when asked a few debriefing questions at the end
of the survey. They seemed to be generally interested in the survey, with only one
respondents saying it felt “long.” Other debriefing questions asked by the interviewers
3

were to clarify questions within the questionnaire. Those comments were placed within
the questionnaire.
V. Question-by-Question Results and Recommendations
This section provides a question-by-question review of the findings from the cognitive
testing. In addition, recommendations for improving the questions are provided where
appropriate.

MODULE A: INTRODUCTION
The first few questions are for statistical purposes only, to help us analyze the results of the
study.
INT1. Do you consider [yourself/name] to be Hispanic or Latino?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

INTCHK1

IF INT1 = 1, CONTINUE; ELSE GO TO INT2

INT1a. Which group represents [your/name’s] Hispanic origin or ancestry...
CODE ALL THAT APPLY.
1
2
F3
F4

Mexican or Mexican American
Other Latin American, Hispanic, Latino or Spanish Origin
DON’T KNOW
REFUSED

INT2. What race or races do you consider (yourself/name) to be? (Are you/Is he/she)...
CODE ALL THAT APPLY.
1
2
3
4
4
5
F3
F4

White
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
Other
DON’T KNOW
REFUSED

INT3. IF SELF-RESPONDENT: RECORD; IF UNSURE, ASK: What is your gender?
IF PROXY-RESPONDENT, ASK: What is (name’s) gender?
1
2
3
F3
F4

MALE
FEMALE
OTHER (SPECIFY:_____________)
DON’T KNOW
REFUSED

A-1

INT4a. In general, what language [do you/does name] prefer to speak in?
1
2
3
F3
F4

ENGLISH
SPANISH
ANOTHER LANGUAGE
DON’T KNOW
REFUSED

IF INT4a = 1, DK, OR RE GO TO AGE
IF INT4a = 2, GO TO INT4c
IF INT4a = 3 CONTINUE
INT4b. SPECIFY LANGUAGE: ____________________
F3
DON’T KNOW
F4
REFUSED
INT4c. [Are you/ Is name] comfortable conversing in English?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

AGE: What is [your/name’s] current age?
_______AGE IN YEARS
F3
DON’T KNOW
F4
REFUSED
No problems found in this module.

A-2

MODULE B: CONDITIONS
CON1. Would you say (your/name’s) health in general is excellent, very good, good, fair, or
poor?
1
2
3
4
5
F3
F4

EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON’T KNOW
REFUSED

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
2
3
F3
F4

BETTER
WORSE
ABOUT THE SAME
DON’T KNOW
REFUSED

CON2. IF FEMALE AGE 15-49 CONTINUE ELSE GOTO CON3
Have you ever been pregnant?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CON2a. IF CON2=1 CONTINUE ELSE GOTO CON3
Are you currently pregnant?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CON3. How tall (are you/is name) without shoes?
PROGRAMMERS: ALLOW METRIC
_________ (0-8 feet)
_________ (0-11 inches)
F3
DON’T KNOW
F4
REFUSED

B-1

CON4. How much (do you/does name) weigh without shoes?
PROGRAMMERS: ALLOW METRIC
a. ________ POUNDS
F3
F4

DON’T KNOW
REFUSED

CONCHK2

IF AGE GE 16, CONTINUE; ELSE GO TO CONCHK4

CON5. Do you consider yourself obese, overweight, underweight, or just about right?
IF CON2a=1 ADD: What did you consider yourself to be before you were pregnant?
1
2
3
4
F3
F4

OBESE
OVERWEIGHT
UNDERWEIGHT
ABOUT RIGHT
DON’T KNOW
REFUSED

CON6. During the past 12 months, that is since (12 MONTH REFERENCE DATE), have you
tried to lose weight?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK3 IF CON6 = 1, CONTINUE; ELSE GO TO CONCHK4
CON6a. During the past 12 months, how much weight did you lose in your most successful
attempt to lose weight?
______ POUNDS
F3
DON’T KNOW
F4
REFUSED

B-2

CON6b. How did you try to lose weight?
CODE ALL THAT APPLY.
1
2
3
4
5
6
7
8
9
F3
F4

CHANGED WHAT I ATE OR HOW MUCH I ATE OR WHEN I ATE
EXERCISED
JOINED A WEIGHT LOSS PROGRAM
TOOK DIET PILLS PRESCRIBED BY A DOCTOR
TOOK OTHER PILLS, MEDICINES, HERBS, OR SUPPLEMENTS NOT
NEEDING A PRESCRIPTION
STARTED TO SMOKE OR BEGAN TO SMOKE AGAIN
TOOK LAXATIVES OR VOMITED
DRANK A LOT OF WATER
OTHER
DON’T KNOW
REFUSED

Round 2:
Response 1 = 4
Response 2 = 3
Response 8 = 1

CONCHK4 IF AGE 13 TO 15, CONTINUE; ELSE GO TO CON7
CON6c. .Do you consider yourself to be fat or overweight, too thin, or about the right weight?
1
2
3
F3
F4

FAT OR OVERWEIGHT
TOO THIN
ABOUT THE RIGHT WEIGHT
DON’T KNOW
REFUSED

CON6d. During the last 12 months, that is since (12 MONTH REFERENCE DATE), how often
have you tried to lose weight? Would you say….
1
2
3
F3
F4

never
sometimes
a lot
DON’T KNOW
REFUSED

CONCHK4A IF CON6d=1, THEN GO TO CON7; ELSE CONTINUE

B-3

CON6e. How did you try to lose weight? Please tell for the following…
1
2
3
4
5
6
F3
F4

Went on a diet
Starved (not eaten) for a day or more
Cut back on what you ate
Skipped meals
Exercised
Ate less sweets or fatty foods
DON’T KNOW
REFUSED

FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK5 IF CON7 = 1, CONTINUE; ELSE GO TO CONCHK8
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK6 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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK7 IF CON8a = 1, CONTINUE; ELSE GO TO CON9

B-4

CON8b. After you were given the referral, did (you/name) go to see a nutritionist?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CON9. Has anyone at [the reference health center] ever prescribed medications to help
(you/name) lose weight?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

HIGH BLOOD PRESSURE
CONCHK8 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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK9 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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

B-5

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?
_______ MONTHS
_______ YEARS
99
NEVER
F3
DON’T KNOW
F4
REFUSED
Five of the nine respondents said “today”. Consider adding a response “BLOOD PRESSURE
CHECKED TODAY” or providing instruction to interviewer “CODE 1 MONTH IF BLOOD
PRESSURE CHECKED TODAY”
CONCHK10 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
2
3
4.
5.
F3
F4

HIGH
NORMAL
LOW
BORDERLINE
NOT TOLD
DON’T KNOW
REFUSED

ASTHMA
CON11.Have you ever been told by a doctor or other health professional that (you/name) had
asthma?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK11 IF CON11 = 1, CONTINUE; ELSE GOTO CON12
CON11a. (Do you/Does name) still have asthma?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

B-6

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK12 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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

DIABETES
CON12. [IF CON2=1 ADD:] Other than during pregnancy, [ELSE] Have you ever been told by
a doctor or health professional that (you/name) had diabetes or sugar diabetes?
1
2.
3.
F3
F4

YES
NO
BORDERLINE
DON’T KNOW
REFUSED

CONCHK13 IF CON12 = 1, CONTINUE; ELSE GOTO CONCHK14
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
F3
DON’T KNOW
F4
REFUSED

B-7

OTHER HEALTH CONDITIONS
CONCHK14 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
2
3
4
5
6
7
F3
F4

NEVER
LESS THAN 1 YEAR AGO
AT LEAST 1 YR, LESS THAN 2 YEARS
AT LEAST 2 YRS, LESS THAN 3 YEARS
AT LEAST 3 YRS, LESS THAN 4 YEARS
AT LEAST 4 YRS, LESS THAN 5 YEARS
5 OR MORE YEARS AGO
DON’T KNOW
REFUSED

CONCHK15 IF CON13 = 1 OR F3 OR F4, GO TO CON14; ELSE CONTINUE

CON13a. Was this at [the reference health center] or some other place?
1
2
F3
F4

REFERENCE HEALTH CENTER
SOME OTHER PLACE
DON’T KNOW
REFUSED

CON13b. Have you ever been told by a doctor or other health professional that your blood
cholesterol level was high?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

B-8

CON14. 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.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

Congestive heart failure
Coronary heart disease
Angina, also called angina pectoris
a heart attack (also called myocardial infarction)
a stroke
Emphysema
a thyroid problem
chronic bronchitis
Any kind of liver condition
Weak or failing kidneys
Tuberculosis (TB)

FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
FOR EACH YES RESPONSE IN CON14g, h, i, and k, ASK CON14_CURRENT; ELSE
GOTO CON15
Skip logic problem found and corrected

CON14_current. (Do you/Does name) CURRENTLY still have…
g.
h.
i.
k.

a thyroid problem
chronic bronchitis
any kind of liver condition
Tuberculosis (TB)

FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED

CON14_AGE.
FOR EACH YES RESPONSE IN CON14a THROUGH j, CONTINUE; ELSE GOTO
CON15.

B-9

How old (were you/was name) when you were first told (you/he/she) had...
a._age
b_age.
c_age.
d_age.
e_age.
f_age.
g_age.
h_age.
i_age.
j_age.

Congestive heart failure
Coronary heart disease
Angina, also called angina pectoris
a heart attack (also called myocardial infarction)
a stroke
Emphysema
a thyroid problem
Chronic bronchitis
Any kind of liver condition
Weak or failing kidneys

FOR EACH:
_________
AGE IN YEARS
F3
DON’T KNOW
F4
REFUSED
A couple of respondents gave responses of 15-20 years ago and over 10 years ago for this
question. We had them estimate their age but it was only a crude estimate.
One respondent said “I had bronchitis but not chronic bronchitis”
CON15. 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.
a.
b.
c.
d.
e.
f.
g.

Any kind of food or digestive allergy?
Frequent or repeated diarrhea or colitis?
[IF AGE GE 3] Frequent or severe headaches, including migraines?
Anemia?
Three or more episodes of ear pain or ear infections?
Seizures?
[IF AGE GE 3] Stuttering or stammering?

FOR EACH QUESTION:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
One respondent said “acid reflux?” for Con15a.
One respondent did not know what we meant by “anemia”

B-10

CON16. POTENTIAL DROP: During the past 12 months, (have you/ has name) had any of the
following medical conditions? Please tell me yes or no for each condition.
a.
b.
c.

Pneumonia
Skin disease, skin infection, skin sores, skin ulcers
Lice, scabies, similar infestations

FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
One respondent asked “skin rash- does that count?”

JOINT PROBLEMS
CONCHK16 IF AGE GE 18, CONTINUE; ELSE GOTO CONCHK20
CON17. The next questions refer to your joints. Please do NOT include the back or neck.
During the past 30 days, have you had any symptoms of pain, aching, or stiffness in or around a
joint?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK17 IF CON17 = 1, CONTINUE; ELSE GO TO CON17c
CON17a. Did your joint symptoms FIRST begin more than 3 months ago?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CON17b. Have you EVER seen a doctor or other health professional for these joint symptoms?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

B-11

CON17c. Have you EVER been told by a doctor or other health professional that you have some
form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia (fy-bro-my-AL-jee-uh)?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK18 IF CON17a = 1 OR CON17c=1, CONTINUE; ELSE GO TO CON18
CON17d. Are you now limited in any way in any of your usual activities because of arthritis or
joint symptoms?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

PAIN
CON18. The following questions are about pain you may have experienced in the past three
months. Please refer to pain that lasted a whole day or more. Do not report aches and pains that
are fleeting or minor.
During the past three months, did you have neck pain?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CON18a. During the past three months, did you have low back pain?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK19 IF CON18a = 1, CONTINUE; ELSE GO TO CON18c
CON18b. Did this pain spread down either leg to areas below the knees?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

B-12

CON18c. During the past three months, did you have…
1.
2.
3.

facial ache or pain in the jaw muscles or the joint in front of the ear?
severe headache or migraine?
pelvic pain

FOR EACH QUESTION:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
CONCHK20 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.
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK21 IF CON19 = 1, CONTINUE; ELSE GO TO CONCHK22
CON20. What kind of cancer was it?
[SHOWCARD CON1]

B-13

CODE UP TO 3 KINDS
a
__________
b
__________
c
__________
F3
DON’T KNOW
F4
REFUSED
1
2
3
4
5
6
7
8
9
10
11
12

BLADDER
BLOOD
BONE
BRAIN
BREAST
CERVIX
COLON
ESOPHAGUS
GALLBLADDER
KIDNEY
LARYNX-WINDPIPE
LEUKEMIA

13
14
15
16
17
18
19
20
21
22

LIVER
LUNG
LYMPHOMA
MELANOMA
MOUTH/TONGUE/
LIP
OVARY
PANCREAS
PROSTATE
RECTUM
SKIN (NONMELANOMA)

23
24
25
26
27
28
29
30

SKIN (DON’T KNOW
WHAT KIND)
SOFT TISSUE
(MUSCLE OR FAT)
STOMACH
TESTIS
THROAT - PHARYNX
THYROID
UTERUS
OTHER

CON21. For EACH cancer indicated, please also specify (your/name’s) age at the time the
cancer was first diagnosed.
REPEAT FOR EACH CANCER LISTED IN CON20
_______ AGE IN YEARS
F3
F4

DON’T KNOW
REFUSED

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.
To lower (your/his/her) blood cholesterol, (have you/has name) ever been told by a doctor or
other health professional…
a.
b.
c.
d.

to eat fewer high fat or high cholesterol foods?
to control your weight or lose weight?
to increase your physical activity or exercise?
to take prescribed medicine?

B-14

FOR EACH QUESTION:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
A respondent said “I control my weight not lose weight”. This double-barreled response may
lead to confusion among some respondents. Consider breaking into two different response
categories. We can always collapse them during analysis.

CONCHK23 FOR EACH ITEM CODED AS "1" in CON22, CONTINUE; ELSE GO TO
CONCHK24
CON23. Are you now following this advice to...
a.
b.
c.
d.

to eat fewer high fat or high cholesterol foods?
to control your weight or lose weight?
to increase your physical activity or exercise?
to take prescribed medicine?

FOR EACH QUESTION:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
CONCHK24 IF CON22A-D=1 CONTINUE; ELSE GOTO CON25
CON24. Did you ever receive this advice from someone at [the reference health center]?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

HEARING
The next few questions are about (your/ name’s) hearing and vision.

B-15

CON25. (Have you/Has name) ever worn a hearing aid?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CON25a. Without 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
2
3
4
5
6
F3
F4

EXCELLENT
GOOD
A LITTLE TROUBLE HEARING
MODERATE TROUBLE HEARING
A LOT OF TROUBLE HEARING
DEAF
DON’T KNOW
REFUSED

VISION
CON 26. (Do you/ Does name) have any trouble seeing, even when wearing glasses or contact
lenses?
IF UNDER 2: (Does name) have any trouble seeing?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK25 IF CON26 = 1, CONTINUE; ELSE GO TO CONCHK26
CON26a. (Are you/Is name) blind or unable to see at all?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK26 IF AGE GE 10 CONTINUE; ELSE GO TO MODULE C

B-16

CON27. Because of a physical, mental, or emotional problem, (do you/does name) need the help
of other persons with personal care needs such as eating, bathing, dressing, or getting around
inside your home?
FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
One respondent said “yes – due to an accident”
IF CON27=1 CONTINUE ELSE GOTO CONCHK27
CON27a. (Do you/ Does name) need the help of…
a.
bathing or showering?
b.
dressing?
c.
eating?
d.
getting in or out of bed or chairs?
e.
using the toilet, including getting to the toilet?
f.
getting around inside the home?
FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
CONCHK27 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?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK28 IF AGE 18 TO 69, CONTINUE; ELSE GO TO MODULE C

B-17

CON29. Does a physical, mental, or emotional problem now keep you from working at a job or
business?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK29 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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

B-18

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 and prescription medicines.
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

MEDCHK1 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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

MEDCHK2 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?
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
F3
F4

COULD NOT AFFORD CARE
INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
PROBLEMS GETTING TO DOCTOR’S OFFICE
DIFFERENT LANGUAGE
COULDN’T GET TIME OFF WORK
DIDN’T KNOW WHERE TO GO TO GET CARE
WAS REFUSED SERVICES
COULDN’T GET CHILD CARE
DIDN’T HAVE TIME OR TOOK TO LONG
OTHER SPECIFY:_____________
DON’T KNOW
REFUSED

C-1

Responses:
Insurance did not cover surgery
No insurance
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
2
3
F3
F4

A big problem
A small problem
Not a problem
DON’T KNOW
REFUSED

MED3. What kind of care was it that (you/name) needed but did not get?
_____________ (Allow 40)
F3
DON’T KNOW
F4
REFUSED
Responses:
Ulcers of the stomach in 9/2008
Therapy
X-ray in wrist and ankle after car accident
Right medication and getting to a podiatrist
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
F3
DON’T KNOW
F4
REFUSED
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

Two respondents had already said they did not get the services and the following questions and
then answered YES to this with the same explanation. Consider skip logic for situations where
they say they did not get the services so they won’t repeat their responses.
MEDCHK3 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?
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
F3
F4

Responses:
Insurance did not cover surgery
Lack of insurance
#4
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
2
3
F3
F4

Big problem
Small problem
Not a problem
DON’T KNOW
REFUSED

MED6. What kind of medical care, tests, or treatment was it that (you were/name was) delayed
in getting?
_____________(Allow 40)
F3
DON’T KNOW
F4
REFUSED
Responses:
X-rays on hips

C-3

MED7. At that time, did a doctor tell you that (you/name) needed that medical care, tests, or
treatment?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

C-4

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…
a.
b.
c.
d.
e.

A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or
clinical social worker
An optometrist, ophthalmologist, or eye doctor (someone who prescribes
eyeglasses)?
A foot doctor?
A chiropractor?
A medical doctor who specializes in a particular medical disease or problem (other than
obstetrician, gynecologist, psychiatrist, or ophthalmologist)

FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
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.
________ (0-365) TIMES
F3
DON’T KNOW
F4
REFUSED
ROU3. (Were you/Was name) ever hospitalized overnight in the past 12 months? Do not include
an overnight stay in the emergency room.
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

IF ROU3 = 1 CONTINUE ELSE GOTO ROU5

D-1

ROU4. Altogether, how many nights (were you/was name) in the hospital during the past 12
months?
________ (0-365) NIGHTS
F3
DON’T KNOW
F4
REFUSED
ROU5. IF AGE = 6 MONTH – 6 YEARS GOTO ROU9a, ELSE CONTINUE
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

ROUCHK2 IF ROU6=1, THEN CONTINUE; ELSE GO TO ROUCHK3
ROU7. Did (you/name) get the flu shot or vaccine sprayed in the nose at (the reference health
center)?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

ROUCHK3 IF AGE GE 65, CONTINUE; ELSE GO TO ROU10

D-2

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

ROUCHK4 IF ROU8 =1, CONTINUE; ELSE GO TO ROU10
ROU9. Did you get the pneumonia vaccination at (the reference health center)?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

GOTO ROU10
ROU9a. Did {name} receive any flu shots in the last 12 months?
Read if necessary: A flu shot is injected in the arm. Do not include an influenza vaccine sprayed
in the nose
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
3
F3
F4

ALL
SOME
NONE
DON’T KNOW
REFUSED

IF ROU9b =2 OR 3, CONTINUE; ELSE GO TO ROU9d

D-3

ROU9c. Were you referred to the other place where (name) got the shots by [reference health
center]?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

ROU9d. Are you the person who took (name) for most of {his/her} shots? Most means at least
half of the shots.
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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?
1
2
3
4
5
6
7
8
9
10
11
F3
F4

DID NOT THINK IT WAS IMPORTANT
AFRAID OF THE SIDE EFFECTS OF THE IMMUNIZATION
CHILD WAS SICK AND COULD NOT HAVE IMMUNIZATIONS AT THAT TIME
I DON’T TRUST THE SHOTS/ I DON’T BELIEVE IN SHOTS
COULDN’T AFFORD CARE
PROBLEMS GETTING TO DOCTOR'S OFFICE
DIFFERENT LANGUAGE
COULDN’T GET TIME OFF WORK
DIDN’T KNOW WHERE TO GO TO GET CARE
DIDN’T HAVE TIME OR TOOK TOO LONG
OTHER
DON’T KNOW
REFUSED

ROU10. IF AGE GE 18, CONTINUE; ELSE GO TO ROUCHK8

D-4

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
2
3
4
5
6
7
F3
F4

ROUCHK6 IF ROU10= 2 OR 3, CONTINUE;
ELSE IF ROU10=F3 OR F4, GO TO ROUCHK8
ELSE GO TO ROU11a
ROU11. Did you get this check-up at (the reference health center)?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

ROUCHK7

GO TO ROUCHK8

ROU11a. What is the main reason you have not had a general physical exam or routine check-up
in the past 2 years?
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
F3
F4

D-5

Responses:
#1
ROUCHK8 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
2
3
4
5
6
7
F3
F4

ROUCHK9 IF ROU12=2 OR 3, CONTINUE;
ELSE IF ROU12=F3 OR F4, GO TO ROU14
ELSE GO TO ROU13a
ROU13. Did (you/he/she) get this check-up at (the reference health center)?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

ROUCHK10 GO TO ROU14

D-6

ROU13a. What is the main reason (you/name) has not had a general physical exam or routine
check-up in the past 2 years?
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
F3
F4

LEAD SCREENING
ROU14. IF AGE LE 5 CONTINUE, ELSE GO TO MODULE E
(Have you /Has name) ever had a blood test to check the amount of lead in (your/his/her) blood?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

ROUCHK11 IF ROU14=1, CONTINUE; ELSE GO TO ROU17
ROU15. How old (were you/was name) the last time this test was done?
______AGE
F3
DON’T KNOW
F4
REFUSED
ROU16. Was that done at the [reference health center]?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

D-7

ROU17. Has anyone ever talked to you about things that might cause (you/name) to be exposed
to lead, such as living in or visiting a house or apartment built before 1978?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

D-8

MODULE E: CONDITIONS – FOLLOWUP
HIGH BLOOD PRESSURE
CONFCHK1 IF CON10a=1, THEN CONTINUE; ELSE GO TO CONFCHK7
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.
CONFCHK1a IF CON2=1 CONTINUE; ELSE GO TO CONF1a
CONF1. Did you only have high blood pressure during pregnancy?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONFCHK2 IF CONF1=1, GO TO CONCHK7; ELSE CONTINUE
CONF1a. Because of (your/name’s) high blood pressure, has a doctor or other health
professional EVER advised (you/him/her) to…..
a.
b.
c.
d.

go on a diet or change (your/his/her) eating habits to help lower (your/his/her) blood
pressure?
cut down on salt or sodium in (your/his/her) diet?
exercise?
[IF AGE GE 21 ASK:] cut down on alcohol use?

FOR EACH QUESTION:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
CONFCHK3 FOR EACH ITEM CODED AS "1" in CONF1a, CONTINUE; ELSE GO TO
CONF2
CONF1b (Are you/Is Name) now following this advice?
e.
f.
g.
h.

go on a diet or change (your/his/her) eating habits to help lower (your/his/her) blood
pressure?
cut down on salt or sodium in (your/his/her) diet?
exercise?
[IF AGE GE 21, ASK:] cut down on alcohol use?

E-1

FOR EACH QUESTION:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
One respondent said “sometimes”. Would you consider this as another response category?
CONFCHK4 IF CONF1a, b, c, or d =1 CONTINUE; ELSE GO TO CONF2
CONF1i.Did (you/name) ever receive the advice to [FILL WHERE CONF1a, b, c, or d =1 cut
down on salt or sodium, exercise, cut down on alcohol use] from someone at [the reference
health center]?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONF2. Was any medication ever prescribed by a doctor for (your/name’s) high blood pressure?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONFCHK5 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?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONFCHK6 IF CONF2a=2 CONTINUE, ELSE GO TO CONF3
CONF2b. Did a doctor advise (you/name) to stop taking the medicine?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

E-2

CONF3. (Do you/Does name) regularly check (your/his/her) own blood pressure?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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?
CONF3a.
CONF3b.
CONF3c.
CONF3d.

A telephone call to (your/his/her) house
An appointment with nurse
A visit to (your/his/her) home
A referral to a specialist

FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
One respondent who was homeless said “I am homeless” to CONF3a and CONF3c – consider
logic here for respondents who are homeless. This would require asking a question up front or in
the screener to determine if they are currently homeless.
CONFCHK7 IF CON11a=1 or CON11b=1, CONTINUE; ELSE GO TO CONFCHK11
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONF4b. (Have you\Has name) ever used a PRESCRIPTION inhaler?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

E-3

CONFCHK9 IF CONF4b=1, CONTINUE; ELSE GO TO CONF4d
CONF4c. Now I'm going to ask you about two different kinds of asthma 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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONCHK10 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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONF4f. (Have you/Has name) ever taken a course or class on how to manage asthma
(yourself/himself/herself)?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

E-4

CONF4. Has a doctor or other health professional ever taught (you/name) how to….
g.
h.
i.

recognize early signs or symptoms of an asthma episode?
respond to episodes of asthma?
monitor peak flow for daily therapy?

FOR EACH QUESTION:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
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?
1
2
3
F3
F4

YES
NO
WAS TOLD NO CHANGES NEEDED
DON’T KNOW
REFUSED

CONF4k. 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?
CONF4k1.
CONF4k2.
CONF4k3.
CONF4k4.

A telephone call to (your/his/her) house
An appointment with nurse
A visit to (your/his/her) home
A referral to a specialist

FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED

CONFCHK11 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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

E-5

CONFCHK12

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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.
0
Never
______ TIMES
F3
DON’T KNOW
F4
REFUSED

1
2
3
4
F3
F4

TIME PERIOD:
DAY
WEEK
MONTH
YEAR
DON’T KNOW
REFUSED

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?
0
Never
______ TIMES
F3
DON’T KNOW
F4
REFUSED

E-6

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
2
3
4
5
6
F3
F4

NO TEST IN PAST 12 MONTHS
ALWAYS
MOST OF THE TIME
SOME OF THE TIME
RARELY
NEVER
DON’T KNOW
REFUSED

CONF5e. 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?
CONF5e1.
CONF5e2.
CONF5e3.
CONF5e4.

Telephone call to (your/his/her) house
Appointment with nurse
Visit to (your/his/her) home
Referral to a specialist

FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
CONFCHK13

IF CON10a=1 OR CON11=1 OR CON12=1, THEN CONTINUE;
ELSE GO TO MODULE F

CONF6. In the past two years, (have you/has name) been in the hospital or visited an emergency
room because of [FILL- high blood pressure/asthma/diabetes]?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

Problem: Several respondents had more than one of the conditions in the fill. What should be
done then? During administration, we had to ask (example: high blood pressure –or- diabetes)
for each question. This needs to be fixed.

E-7

CONF6a. Has any doctor or nurse (you see/name sees) for (your/his/her) [fill- high blood
pressure/asthma/diabetes] given (you/him/her) a plan to manage (your/his/her) own care at
home?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONFCHK14

IF CONF6a=1, CONTINUE; ELSE GO TO CONF6c

CONF6b. Was this plan given to (you/name) by a doctor or nurse at [the reference health
center]?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CONF6c. How confident (are you/is name) that (you/he/she) can control and manage
(your/his/her) [fill-- high blood pressure/asthma/ diabetes]. (Are you/Is he/she)...
1
2
3
4
F3
F4

Very confident
Somewhat confident
Not too confident
Not at all confident
DON’T KNOW
REFUSED

E-8

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 CONCHK13

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CANCHK2

IF CAN1= 1, CONTINUE; ELSE GO TO CAN2

CAN1a. When did you have your most recent Pap smear or Pap test?
1
2
3
4
5
6
F3
F4

A YEAR AGO OR LESS
MORE THAN 1 YEAR BUT NOT MORE THAN 2 YEARS
MORE THAN 2 YEARS BUT NOT MORE THAN 3 YEARS
MORE THAN 3 YEARS BUT NOT MORE THAN 4 YEARS
MORE THAN 4 YEARS BUT NOT MORE THAN 5 YEARS
OVER 5 YEARS AGO
DON’T KNOW
REFUSED

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
2
3
F3
F4

PART OF A ROUTINE EXAM
BECAUSE OF A PROBLEM
OTHER REASON
DON’T KNOW
REFUSED

CANCHK2A IF CAN1A=1, 2, 3, THEN CONTINUE; ELSE GO TO CAN2

F-1

CAN1c. As a result of any 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.
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CANCHK3

IF CAN1c = 1, CONTINUE; ELSE GO TO CANCHK5

CAN1d. Were the follow-up tests or treatment done?
1.
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CANCHK4

IF CAN1d = 1 CONTINUE, IF CAN1d=2 GOTO CAN1f
ELSE GO TO CANCHK5

CAN1e. Did [the reference health center] arrange for the follow-up tests or treatment?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

GO TO CANCHK5

F-2

CAN1f. Which of these best describes the main reason you did not get the follow-up tests or
treatment?
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
F3
F4

Responses:
Other: Next month will be the test.
GO TO CANCHK5
CAN2. What is the most important reason you have [never had a Pap smear or Pap test/not had a
Pap smear or Pap test in the LAST 3 years]?
1
2
3
4
5
6
F3
F4

NO REASON/NEVER THOUGHT ABOUT IT
DIDN'T NEED/DIDN'T KNOW I NEEDED THIS TYPE OF TEST
TOO EXPENSIVE/NO INSURANCE/COST
TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
HAD HYSTERECTOMY OR PARTIAL HYSTERECTOMY
OTHER
DON’T KNOW
REFUSED

CAN2a. In the past 3 years, has anyone at [the reference health center] suggested that you have a
Pap smear or Pap test?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

F-3

MAMMOGRAMS
CANCHK5

IF AGE GE 40, THEN CONTINUE; ELSE GO TO CANCHK13

Consider lower minimum age for this section
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CANCHK6

IF CAN3 = 1, CONTINUE; ELSE GO TO CAN3g

CAN3a. When did you have your most recent mammogram?
1
2
3
4
5
F3
F4

A YEAR AGO OR LESS
MORE THAN 1 YEAR BUT NOT MORE THAN 2 YEARS
MORE THAN 2 YEARS BUT NOT MORE THAN 3 YEARS
MORE THAN 3 YEARS BUT NOT MORE THAN 5 YEARS
OVER 5 YEARS AGO
DON’T KNOW
REFUSED

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
2
3
F3
F4

PART OF A ROUTINE EXAM
BECAUSE OF A PROBLEM
SOME OTHER REASON
DON’T KNOW
REFUSED

CANCHK8

IF CAN3a = 1, 2, OR 3, THEN CONTINUE; ELSE GO TO CAN3g

F-4

CAN3c. As a result of any mammograms you had done in the past 3 years, were you told that
you should have follow-up tests or treatment?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CANCHK9

IF CAN3c = 1, CONTINUE;
IF CAN3c = 2, GO TO CAN3f;
IF CAN3c =DK OR RE GOTO CANCHK13

CAN3d. Were the follow-up tests or treatment done?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CANCHK10 IF CAN3d = 2, THEN GO TO CAN3f; ELSE CONTINUE
CAN3e. Did [the reference health center] arrange for the follow-up tests or treatments?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

GO TO CANCHK13

F-5

CAN3f. Which of these best describes the main reason you did not get the follow-up tests or
treatment?
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
F3
F4

GO TO CANCHK13
CAN3g. What is the main reason why you have [never had a mammogram/not had a
mammogram in the past few years]?
1
2
3
4
5
6
F3
F4

NO REASON/ NEVER THOUGHT ABOUT IT/ DIDN’T KNOW I SHOULD
NOT NEEDED/ HAVEN’T HAD ANY PROBLEMS
TOO UNPLEASANT OR EMBARRASSING
COST TOO MUCH/NO INSURANCE
BREASTS MISSING
OTHER
DON’T KNOW
REFUSED

CAN3h. In the past 3 years, has anyone at [the reference health center] suggested that you have a
mammogram?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

COLONOSCOPY/ SIGMOIDOSCOPY EXAM
CANCHK13 IF AGE GE 50, THEN CONTINUE; ELSE GO TO CANCHK19

F-6

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CANCHK14 IF CAN4 = 1, CONTINUE; ELSE GO TO CAN4h
CAN4a. When did you have your most recent exam?
1
2
3
4
5
6
F3
F4

A YEAR AGO OR LESS
MORE THAN 1 YEAR BUT NOT MORE THAN 2 YEARS
MORE THAN 2 YEARS BUT NOT MORE THAN 3 YEARS
MORE THAN 3 YEARS BUT NOT MORE THAN 5 YEARS
MORE THAN 5 YEARS BUT NOT MORE THAN 10 YEARS
OVER 10 YEARS AGO
DON’T KNOW
REFUSED

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
2
3
4
F3
F4

SIGMOIDOSCOPY
COLONOSCOPY
PROCTOSCOPY
SOMETHING ELSE
DON’T KNOW
REFUSED

F-7

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
2
3
4
F3
F4

PART OF A ROUTINE EXAM
BECAUSE OF A PROBLEM
HISTORY OF CANCER IN MY FAMILY
OTHER REASON
DON’T KNOW
REFUSED

CAN4d. As a result of this exam, were you told that you should have follow-up tests or
treatment?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CANCHK15 IF CAN4d = 1, CONTINUE; ELSE GO TO CANCHK19
CAN4e. Were the follow-up tests or treatment done?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CANCHK16 IF CAN4e = 2, THEN GO TO CAN4g; ELSE CONTINUE
CAN4f. Did [the reference health center] arrange for the follow-up tests or treatment?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

GO TO CANCHK19

F-8

CAN4g. Which of these best describes the main reason you did not get the follow-up tests or
treatment?
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
F3
F4

GO TO CANCHK19
CAN4h. What is the main reason why you have [never had a colonoscopy, sigmoidoscopy, or
proctoscopy] [not had a more recent colonoscopy, sigmoidoscopy or proctoscopy]?
1
2
3
4
5
6
F3
F4

NO REASON/ NEVER THOUGHT ABOUT IT
DIDN'T NEED/ DIDN'T KNOW I NEEDED THIS TYPE OF TEST
TOO EXPENSIVE/ NO INSURANCE/ COST
TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
HAD DOUBLE-CONTRAST BARIUM ENEMA TEST
OTHER
DON’T KNOW
REFUSED

CAN4i. In the past 3 years, has anyone at [the reference health center] suggested that you should
have a colonoscopy, sigmoidoscopy or proctoscopy?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

BLOOD STOOL OR OCCULT BLOOD TESTS
CANCHK19 IF AGE GE 40, THEN CONTINUE; ELSE GO TO MODULE G

F-9

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 a blood stool test, using a home test kit?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CANCHK20 IF CAN5 = 1, CONTINUE; ELSE GO TO CAN5f
CAN5a. When did you have your most recent blood stool test using a kit at home?
1
2
3
4
5
6
F3
F4

One respondent was confused and gave a time but it was found out that this was a test at a
hospital- not at home. Consider another category for “TEST CONDUCTED AT HOSPITAL”
and also consider underlining “at home” for emphasis.
CANCHK21 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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

CANCHK22 IF CAN5b =1, THEN CONTINUE; ELSE GO TO MODULE G
CAN5c. Were the follow-up tests or treatment done?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

F-10

CANCHK22 IF CAN5c = 2 THEN GO TO CAN 5e; ELSE CONTINUE
CAN5d. Did the [reference health center] arrange for the follow-up tests or treatments?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

GOTO CAN 5f
CAN5e. Which of these best describes the main reason you did not get the follow-up tests or
treatment?
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
F3
F4

COULD NOT AFFORD CARE
INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
PROBLEMS GETTING TO DOCTOR’S OFFICE
DIFFERENT LANGUAGE
COULDN’T GET TIME OFF WORK
DIDN’T KNOW WHERE TO GO TO GET CARE
WAS REFUSED SERVICES
COULDN’T GET CHILD CARE
DIDN’T HAVE TIME OR TOOK TOO LONG
OTHER SPECIFY:_____________
DON’T KNOW
REFUSED

Responses:
#1
CAN5f. In the past 3 years, has anyone at [the reference health center] suggested that you should
have a blood stool test?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

F-11

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
F3
DON’T KNOW
F4
REFUSED
IF HEA1=0, DK, RE THEN GOTO HEA3, ELSE CONTINUE
HEA2. How many of those times did you come to [reference health center]?
_____ TIMES
F3
DON’T KNOW
F4
REFUSED
NOTE: IF RESPONDENT IS UNSURE- ASK THEM TO PROVIDE AN ESTIMATE
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

Skip logic problems is No, DK, RE
HEACHK1 If HEA2a=1, THEN CONTINUE; ELSE GOTO HEACHK2

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

HEACHK2 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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

GOTO HEA3
HEA2d. Which of these best describes the main reason why (you/name) didn't see that doctor?
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
F3
F4

Other = Transportation

G-2

HEA3. How long ago was (your/name’s) first visit to [the reference health center]?
1
2
3
4
5
6
7
F3
F4

LESS THAN 6 MONTHS
AT LEAST 6 MONTHS, BUT NOT MORE THAN 1 YEAR AGO
AT LEAST 1 YEAR, BUT NO MORE THAN 2 YEARS AGO
AT LEAST 2 YEARS, BUT NO MORE THAN 3 YEARS AGO
AT LEAST 3 YEARS, BUT NO MORE THAN 4 YEARS AGO
AT LEAST 4 YEARS, BUT NO MORE THAN 5 YEARS AGO
MORE THAN 5 YEARS AGO
DON’T KNOW
REFUSED

HEA4. How did you find out that (you/name) could come here for services?
CODE ALL THAT APPLY
[SHOWCARD HEA1]
1
2
3
4
5
6
7
8
9
10
F3
F4

FRIEND/FAMILY MEMBER/NEIGHBOR
YOUR MOTHER OR OTHER FAMILY MEMBER TOOK YOU HERE
YOUR FAMILY HAS ALWAYS COME HERE
ADVERTISEMENT IN COMMUNITY
AT A MEETING (AT SCHOOL OR NEIGHBORHOOD ASSOCIATION, FOR
EXAMPLE)
YOU WERE CONTACTED BY SOMEONE WHO WORKS AT THE HEALTH
CENTER
THROUGH YOUR INSURANCE
REFERRED BY SOCIAL SERVICES
REFERRED BY AN EMERGENCY ROOM
SOME OTHER WAY
DON’T KNOW
REFUSED

Responses:
#1=2
#2=2
#3=1
#4=2
#6=2
#10 = By OBGYN doctor
#10 = Referred by another doctor

G-3

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
2
3
F3
F4

YES
THERE IS NO PLACE
MORE THAN ONE PLACE
DON’T KNOW
REFUSED

IF HEA5=2, DK, RE – Need skip
HEA5a. What kind of place (is it/ are those)?
CODE ALL THAT APPLY
[SHOWCARD HEA2]
1
2
3
4
5
6
7
F3
F4

[REFERENCE HEALTH CENTER]
CLINIC OR HEALTH CENTER OFFERING A DISCOUNT TO LOW INCOME OR
UNINSURED PEOPLE
OTHER CLINIC OR HEALTH CENTER
DOCTOR'S OFFICE OR HMO
HOSPITAL EMERGENCY ROOM
HOSPITAL OUTPATIENT DEPARTMENT
SOME OTHER PLACE (SPECIFY)________
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

HEACHK2 IF HEA5b=1, THEN GOTO HEACHK6; ELSE CONTINUE

G-4

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.
[SHOW CARD HEA2]
1
2
3
4
5
6
7
F3
F4

Responses:
Health Department
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)?
1
2
3
4
5.
F3
F4

ENGLISH
THE DOCTOR/HEALTH PROFESSIONAL SPEAKS A LANGUAGE, OTHER THAN
ENGLISH, THAT I CAN UNDERSTAND
I BRING A FRIEND OR FAMILY MEMBER TO TRANSLATE
[THE REFERENCE HEALTH CENTER] HAS A STAFF PERSON WHO
TRANSLATES
OTHER
DON’T KNOW
REFUSED

HEACHK7 IF HEA6=2 or 4, THEN CONTINUE; ELSE GO TO HEA7

G-5

HEA6a. How important was [FILL: having a doctor who speaks in your language/translation
assistance] to your decision (to be/for name to be) a patient of [reference health center]. Would
you say…
1
2
3
4
F3
F4

Very Important
Somewhat Important
Not Very Important
Not at all Important
DON’T KNOW
REFUSED

HEA7. Has anyone at [the reference health center] ever helped (you/name)...
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
F3
DON’T KNOW
F4
REFUSED
This question is hard to administer. Consider repeating the stem for each of the sub-questions.
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
2
3
4
F3
F4

Very Important
Somewhat Important
Not Very Important
Not at all Important
DON’T KNOW
REFUSED

G-6

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
2
3
4
5
6
7
F3
F4

WALKING
DRIVING
BEING DRIVEN BY SOMEONE ELSE
BUS, SUBWAY OR OTHER PUBLIC TRANSPORTATION
TAXI
HEALTH CENTER (OR OTHER AGENCY-PROVIDED) VAN SERVICE
OTHER
DON’T KNOW
REFUSED

Consider adding “…from home”
HEA10. About how long does it usually take you to get (here/there)?
_____ MINUTES
OR
_____ HOURS
F3
DON’T KNOW
F4
REFUSED
One respondent said, “Depends on where I am coming from.” Consider adding “…from your
home”
HEA11.
[SHOWCARD HEA11]
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:
HEA11. EASE OF GETTING CARE:
a.
b.
c.
d.

Ability to get in to be seen
Hours center is open
Convenience of center’s location
Prompt return of calls

G-7

HEA12. WAITING:
a.
Time in waiting room
b.
Time in exam room
c.
Waiting for tests to be performed
d.
Waiting for test results
FOR EACH:
1
2
3
4
5
F3
F4

EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON’T KNOW
REFUSED

HEA13. PAYMENT:
a.
b.
c.

What you pay
Explanation of charges
Collection of payment/money

1
2
3
4
5
F3
F4

EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON’T KNOW
REFUSED

HEA14. FACILITY:
a.
b.
c.
d.

Neat and clean building
Ease of finding where to go
Comfort and safety while waiting
Privacy

1
2
3
4
5
F3
F4

EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON’T KNOW
REFUSED

G-8

HEA15. CONFIDENTIALITY:
a.

Keeping your personal information private

1
2
3
4
5
F3
F4

EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON’T KNOW
REFUSED

HEA16. 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:
a.
b.
c.
d.

Listens to you
Takes enough time with you
Explains what you want to know
Gives you good advice and treatment

1
2
3
4
5
F3
F4

EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON’T KNOW
REFUSED

HEA17. 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:
a.
b.

Friendly and helpful to you
answers your questions

1
2
3
4
5
F3
F4

EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON’T KNOW
REFUSED

G-9

HEA18. The next questions are about other staff at [the reference health center]. How well do
you think they are doing in the following areas…
a.
b.

friendly and helpful to you
answers your questions

1
2
3
4
5
F3
F4

EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON’T KNOW
REFUSED

HEA18a. How would you rate the overall quality of the services (you/name) receive at [the
reference health center]?
1
2
3
4
5
F3
F4

EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON’T KNOW
REFUSED

HEA19. What is the likelihood of you referring your friends and relatives to [reference health
center]. Would you say..
1
2
3
4
F3
F4

Very likely
Somewhat likely
Not very likely
Not at all likely
DON’T KNOW
REFUSED

G-10

HEA20. What is the main reason (you/name) go to the [reference health center] for
(your/name’s) health care instead of someplace else?
[SHOWCARD HEA3]
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
F3
F4

THE HEALTH CENTER HAS A CONVENIENT LOCATION.
THE HOURS ARE CONVENIENT - IT IS OPEN WHEN (YOU/NAME) NEED(S) IT.
(YOU DON’T/NAME DOESN’T) HAVE TO WAIT TOO LONG TO SEE
SOMEBODY ONCE (YOU/S/HE) GET(S) HERE.
(YOU KNOW/NAME KNOWS) AND TRUST(S) THE PEOPLE HERE.
(YOU/NAME) CAN GET THE KIND OF CARE (YOU/S/HE) NEED(S) HERE.
(YOU/NAME) CAN AFFORD IT.
THEY ACCEPT MEDICAID.
THEY ACCEPT (YOUR/NAME’S) INSURANCE.
THEY PROVIDE CHILD CARE (E.G. A SUPERVISED PLACE WHERE YOUNG
CHILDREN CAN PLAY WHILE (YOU/NAME) SEE(S) THE DOCTOR).
THEY PROVIDE TRANSPORTATION/BUS VOUCHERS.
THEY SPEAK (YOUR/NAME’S) LANGUAGE OR HAVE A TRANSLATOR.
THEY CARE ABOUT (YOU/NAME) AND YOUR/NAME’S FAMILY.
THERE IS NO OTHER PLACE (YOU/NAME) CAN GET FREE OR LOW COST
MEDICAL CARE.
SECURITY WITHIN THE HEALTH CENTER IS GOOD; LOCATION IS FAIRLY
SAFE (NOT WORSE THAN SURROUNDING AREA).
IT'S THE ONLY CLINIC/ONLY DOCTOR IN THE AREA
(YOU/NAME) CAN BE SEEN WITHOUT AN APPOINTMENT
WHEN (YOU NEED/NAME NEEDS) TO BE SEEN, YOU CAN GET AN
APPOINTMENT RIGHT AWAY
THE QUALITY OF THE CARE IS VERY GOOD
OTHER, SPECIFY: ___________
DON’T KNOW
REFUSED

Responses:
#1=6
#2=1
#6=1
#19=I was pregnant
#19 = I have been going there all my life
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

G-11

HEACHK9 IF HEA21=1, THEN CONTINUE; ELSE GO TO MODULE H
HEA21a. What kind of problem was it?
______________ (Allow 80)
F3
DON’T KNOW
F4
REFUSED
Misdiagnosed – had to go to another doctor at Lincoln
HEA22. Did you complain to someone or file a written complaint?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

HEACHK10 IF HEA22=1 THEN CONTINUE; ELSE GO TO MODULE H
HEA23. Were you satisfied with the way your complaint was handled?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

G-12

MODULE H: SUBSTANCE USE
SUBCHK0 IF AGE GE 12, THEN CONTINUE; ELSE GO TO MODULE I
The next questions are about your use of substances. Your answers to these questions are
confidential and will not be shared with anyone at the [reference health center].
SUB1a. Have you smoked at least 100 cigarettes in your entire life?
1
YES
2
NO (GO TO SUB2)
F3
DON’T KNOW (GO TO SUB2)
F4
REFUSED (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 (GO TO SUB2)
F3
DON’T KNOW (GO TO SUB2)
F4
REFUSED (GO TO SUB2)
SUB1c. On the average, how many cigarettes do you now smoke a day?
_______ CIGARETTES PER DAY
F3
DON’T KNOW
F4
REFUSED
NOTE TO INTERVIEWER: ENTER 1 IF LESS THAN 1

H-1

SUB2.
[SHOWCARD SUB2]
Please look at this show card. We are interested in whether you have used any of these for nonmedical reasons. 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…
a.
b.
c.
d.
e.
f.
g.
h.
i.
F3
F4

Alcoholic Beverages
(BEER, WINE, SPIRITS, ETC.)
Cannabis or Marijuana
(MARIJUANA, POT, GRASS, HASH, ETC.)
Cocaine
(COKE, CRACK, ETC.)
Amphetamine-type Stimulants (SPEED, ECSTASY, CRYSTAL METH, DIET
PILLS, ETC.)
Inhalants
(NITROUS, GLUE, PETROL, PAINT THINNER, ETC.)
Sedatives or Sleeping Pills (VALIUM, SEREPAX, ROHYPNOL, ETC.)
Hallucinogens
(LSD, ACID, MUSHROOMS, PCP, SPECIAL K, ETC.)
Opioids
(HEROIN, MORPHINE, METHADONE, CODEINE,
VICODIN, ETC.)
Any Other
(SPECIFY)_______
DON’T KNOW
REFUSED

FOR EACH:
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

SUBCHK1

IF NONE MENTIONED IN SUB2, GO TO MODULE I;
ELSE CONTINUE

NOTE TO PROGRAMMERS: CODING OF RESPONSE VALUES MUST ALIGN WITH
SCALE

H-2

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
1
2
3
4
F3
F4

Never
Once or twice
Monthly
Weekly
Daily or Almost Daily
DON’T KNOW
REFUSED

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
F3
F4

DON’T KNOW
REFUSED

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
1
2
3
4
F3
F4

Never
Once or twice
Monthly
Weekly
Daily or Almost Daily
DON’T KNOW
REFUSED

H-3

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
F3
DON’T KNOW
F4
REFUSED
SUB2e. How often 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
Would you say…
0
1
2
F3
F4

Never
In the past 3 months
Not in the past 3 months
DON’T KNOW
REFUSED

Consider moving response #1 down to response #3 as this makes more sense when administered.
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…
0
1
2
F3
F4

Never
In the past 3 months
Not in the past 3 months
DON’T KNOW
REFUSED

Consider moving response #1 down to response #3 as this makes more sense when administered.

H-4

SUB3. Have you ever used any drug by injection? (NON-MEDICAL USE ONLY)
Would you say…
0
1
2
F3
F4

Never
In the past 3 months
Not in the past 3 months
DON’T KNOW
REFUSED

Consider moving response #1 down to response #3 as this makes more sense when administered.
SUBCHK2

IF SUB2a NE 0, F3, F4, CONTINUE; ELSE GO TO SUBCHK4

SUB4. On how many of the past 30 days did you smoke a cigarette?
______ DAYS
F3
DON’T KNOW
F4
REFUSED
SUBCHK3

IF SUB4=0, THEN GO TO SUBCHK4; ELSE CONTINUE

SUB4a. On average, when you smoked during the past 30 days, about how many cigarettes did
you smoke a day?
______ NUMBER OF CIGARETTES
F3
DON’T KNOW
F4
REFUSED
SUBCHK4

IF SUB2a NE 0, F3, OR F4, THEN GO TO SUB5a;
ELSE IF SUB1a=3, THEN CONTINUE;
ELSE GO TO SUBCHK6

SUB5. Did you smoke cigarettes in the past 12 months?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

SUBCHK5

IF SUB5=1, THEN CONTINUE; ELSE GO TO SUBCHK6

H-5

SUB5a. During past 12 months, have you wanted to stop smoking?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

SUB6. In past 12 months, did anyone at [the reference health center] talk to you about the health
risks of smoking and ways to quit?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

SUBCHK6

IF SUB2b NE 0, F3, F4, GO TO SUB7a; ELSE
IF SUB1b =3, CONTINUE;
ELSE GO TO SUBCHK9

SUB7. Earlier you indicated that you have used alcohol. Did you drink alcohol in the past 12
months?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

SUBCHK7

IF SUB7=1, CONTINUE; ELSE GO TO SUBCHK9

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
F3
DON’T KNOW
F4
REFUSED
SUB8. In the PAST 12 MONTHS, on how many DAYS did you have 5 or more drinks of any
alcoholic beverage?
______ DAYS
F3
DON’T KNOW
F4
REFUSED

H-6

SUB9. In past 12 months, have you discussed your use of alcohol with your doctor?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

SUBCHK8

IF SUB9=2, CONTINUE; ELSE GO TO SUBCHK9

SUB9a. In past 12 months has your doctor asked you about your use of alcohol?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

DRUG USE
SUBCHK9

IF SUB2c,d,e,f,g,h, i or j NE 0, F3, OR F4, 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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

SUBCHK10 IF SUB10=1, CONTINUE; ELSE GO TO SUBCHK12
SUB10a. In past 12 months, have you discussed your use of drugs with your doctor?
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
SUBCHK11 IF SUB10a=2, THEN CONTINUE; ELSE GO TO SUBCHK12

H-7

SUB10a. In past 12 months has your doctor asked you about your use of drugs?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

INJECTED DRUGS
SUBCHK12 IF SUB3=1 or 2 CONTINUE; ELSE GOTO SUBCHK15
SUB11. Earlier you indicated that you have injected drugs with a needle. Did you inject drugs
with a needle in the past 12 months?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

SUBCHK13 IF SUB11=1, CONTINUE; ELSE GO TO SUBCHK15
SUB11a. How many days have you used drugs that you INJECT WITH A NEEDLE during the
past 12 months.
______ NUMBER OF DAYS
F3
DON’T KNOW
F4
REFUSED

SUBSTANCE USE TREATMENT
SUBCHK15 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, F3, F4, THEN FILL "drugs"; ELSE FILL "alcohol or drugs")?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

H-8

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, F3, F4, THEN FILL "drugs"; ELSE FILL "alcohol or drugs")?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

SUBCHK16 IF SUB12a=1 CONTINUE; ELSE GO TO SUB15
SUB13. What kind of treatment was it?
SELECT ALL THAT APPLY.
1
2
3
4
5
6
F3
F4

A RESIDENTIAL FACILITY WHERE YOU STAY AT NIGHT
AN OUTPATIENT FACILITY WHERE YOU DO NOT STAY AT NIGHT
A PRIVATE DOCTOR’S OFFICE
A PRISON OR JAIL
AA OR NA OR OTHER SELF-HELP GROUP
SOME OTHER PLACE
DON’T KNOW
REFUSED

SUBCHK17 IF SUB13 = F3 OR F4, 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
2
3
4
F3
F4

PROVIDE TREATMENT
PAY FOR TREATMENT
REFER TO ANOTHER PLACE
NONE
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

H-9

SUB16. Did the [reference health center] try to help you get treatment or arrange for treatment?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

SUB17. Which of these statements explain why you did not get the treatment or counseling you
needed for your use of alcohol or drugs?
[SHOWCARD SUB2]
1
2
3
4
5
6
F3
F4

NO WAY TO PAY FOR IT
DID NOT KNOW OF OR COULD NOT GET INTO A TREATMENT PROGRAM
DID NOT HAVE TIME FOR APROGRAM OR A WAY TO GET THERE, OR
PROGRAM NOT CONVENIENT ENOUGH
YOU DIDN’T WANT PEOPLE TO FIND OUT THAT YOU HAD A PROBLEM (AT
WORK, IN COMMUNITY, ETC...)
YOU DIDN’T REALLY THINK THE TREATMENT WOULD HELP
OTHER
DON’T KNOW
REFUSED

H-10

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
F3
REFUSED
F4
DON’T KNOW
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
2
F3
F4

YES
NO
REFUSED
DON’T KNOW

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
[SHOWCARD MED3]
1
2
3
4
5
6
7
8
9
10
11
12
F3
F4

I-1

Responses:
#1 =1
#12- I had no way to get to the hospital
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
2
3
F3
F4

A big problem
A small problem
Not a problem
REFUSED
DON’T KNOW

PRS3. In the last 12 months, (were you/was name) delayed in getting prescription medicines you
or a doctor believed necessary?
1
2
F3
F4

YES
NO
REFUSED
DON’T KNOW

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?
[SHOWCARD MED3]
1
2
3
4
5
6
7
8
9
10
11
12
F3
F4

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
2
3
F3
F4

A big problem
A small problem
Not a problem
REFUSED
DON’T KNOW

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
2
F3
F4

YES
NO
REFUSED
DON’T KNOW

PRSCHK5

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

PRS4a. Did you try to get this prescription filled?
1
2
F3
F4

YES
NO
REFUSED
DON’T KNOW

PRS5. (Do you/Does name) take any prescription medication on a regular or on-going basis?
1
2
F3
F4

YES
NO
REFUSED
DON’T KNOW

PRSCHK6

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

PRS4a. Where do you normally get (your/name’s) prescriptions filled?
1
2
3
F3
F4

I get them filled at the [reference health center]
I get some of them filled at [the reference health center] and some of them filled
elsewhere
I get them filled somewhere other than [the reference health center]
DON’T KNOW
REFUSED

I-3

PRS5. About how many different prescription medicines (do you/does name) usually take in a
month?
__________NUMBER/ MEDICINES
F3
DON’T KNOW
F4
REFUSED

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
2
3
F3
F4

YES
NO
NA - HC HAS NOT PRESCRIBED MEDICATION FOR ME
DON’T KNOW
REFUSED

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
2
3
F3
F4

YES
NO
DIDN’T HAVE ANY QUESTIONS
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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)
F3
DON’T KNOW
F4
REFUSED
Responses:
Root canal
Tooth abstraction
Cleaning and abstraction

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?
[SHOWCARD MED2]
1
2
3
4
5
6
7
8
9
10
11
12
F3
F4

Responses:
#1
#12 – Transportation
#12 – No Insurance
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
2
3
F3
F4

A big problem,
A small problem
Not a problem
DON’T KNOW
REFUSED

Need skip - GOTO Den10
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

DENCHK4 IF DEN5=1, THEN CONTINUE; ELSE GO TO DEN10

J-2

DEN7. What kind of dental care, test, or treatment was it that (you were/name was) delayed in
getting?
________________ (allow 40)
F3
DON’T KNOW
F4
REFUSED
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?
[SHOWCARD MED2]
1
2
3
4
5
6
7
8
9
10
11
12
F3
F4

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
2
3
F3
F4

A big problem,
A small problem
Not a problem
DON’T KNOW
REFUSED

J-3

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
2
3
4
6
7
F3
F4

6 MONTHS OR LESS
MORE THAN 6 MONTHS, BUT NOT MORE THAN 1 YEAR AGO
MORE THAN 1 YEAR, BUT NOT MORE THAN 2 YEARS AGO
MORE THAN 2 YEARS, BUT NOT MORE THAN 5 YEARS AGO
MORE THAN 5 YEARS AGO
NEVER HAVE BEEN
DON’T KNOW
REFUSED

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…
1
2
3
F3
F4

All of the visits
Some of the visits
None of the visits
DON’T KNOW
REFUSED

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
2
3
4
5
F3
F4

Excellent
Very Good
Good
Fair
Poor
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

J-4

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
2
3
F3
F4

All of your adult teeth
Some of your adult teeth
None of your adult teeth
DON’T KNOW
REFUSED

DEN15. IF DEN14=2 CONTINUE, ELSE GO TO DENCHK8: How many of your adult teeth
have you lost?
__________ TEETH
F3
DON’T KNOW
F4
REFUSED
DEN15a. IF DEN14=1 OR 2 CONTINUE, ELSE GO TO DENCHK8: Are any of your
missing teeth replaced by full or partial dentures, false teeth, bridges or dental plates?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
3
4
5
F3
F4

Excellent
Very Good
Good
Fair
Poor
DON’T KNOW
REFUSED

GOTO DEN17

J-5

DEN16b Now I have some questions about the condition of (your/name’s) gums and false teeth
or dentures. Would you say . . .
1
2
3
4
5
F3
F4

Excellent
Very Good
Good
Fair
Poor
DON’T KNOW
REFUSED

This is missing part of the question… should it be “Would you say the condition of
(your/name’s) gums and false teeth or dentures are…”
DEN17. During the past 6 months, (have you/has name) had any of the following problems?
DEN17a.
DEN17b.
DEN17c.
DEN17e.
DEN17f.
DEN17g.
DEN17h.

A toothache or sensitive teeth
Bleeding gums
Crooked teeth
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
F3
DON’T KNOW
F4
REFUSED
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
F3
DON’T KNOW
F4
REFUSED

J-6

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
F3
DON’T KNOW
F4
REFUSED

J-7

MODULE K: MENTAL HEALTH
MENCHK1 IF AGE GE 18, THEN CONTINUE; ELSE GO TO MENCHK2
MEN1. Now I am going to ask you some questions about feelings you may have experienced
over the past 30 days.
[SHOWCARD MEN1]
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
F3
DON’T KNOW
F4
REFUSED
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
2
3
4
F3
F4

A LOT
SOME
A LITTLE
NOT AT ALL
DON’T KNOW
REFUSED

MEN2a. Have you ever had depression?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

K-1

MEN2b. Have you ever had generalized anxiety?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

Several respondents did not know what was meant by “generalized anxiety” Consider definition.
MEN2c.Have you ever had panic disorder?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
F3
DON’T KNOW
F4
REFUSED
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
F3
DON’T KNOW
F4
REFUSED
MENCHK4 IF AGE =13 TO 17, THEN CONTINUE; ELSE GO TO MEN5
MEN4b. 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 (you/ name) during the past 6 months.
a.
(You/He/She) can’t concentrate or pay attention long?
b.
(You/He/She) lie(s) or cheat(s)?
c.
(You/He/She) (don’t/doesn’t) get along with other kids?
d.
(You/He/She) (have/has) been unhappy, sad, or depressed?
e.
(You/He/She) (do/does) poorly at school work?
f.
(You/He/She) (have/has) trouble sleeping?
FOR EACH:
1
NOT TRUE
2
SOMETIMES TRUE
3
OFTEN TRUE
F3
DON’T KNOW
F4
REFUSED
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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?
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
12
F3
F4

Responses:
#12 – Knew I needed to go but just didn’t
#12 - Transportation
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
2
3
F3
F4

A big problem
A small problem
Not a problem
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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?
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
12
F3
F4

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
2
3
F3
F4

A big problem
A small problem
Not a problem
DON’T KNOW
REFUSED

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, inpatient treatment. Do not include counseling or advice given by a
friend, or spiritual counseling through a church or religious group.)
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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 (Specify)_________________
MEN9. What kind of treatment or counseling was it?
QXQ FOR INDIVIDUAL TREATMENT: This includes counseling with a trained mental health
professional -social worker, psychologist, psychiatrist, psychiatric nurse or other mental health
professional; respondent may not know what qualifications the provider has, however
QXQ FOR GROUP COUNSELING SESSIONS: This includes counseling with a trained mental
health professional -social worker, psychologist, psychiatrist, psychiatric nurse or other mental
health professional; respondent may not know what qualifications the provider has, however)
1.
2.
3.
4.
F3
F4

Individual counseling
Group counseling sessions
Prescription medication
Inpatient treatment in a general hospital or mental health treatment facility
DON’T KNOW
REFUSED

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
2
3
F3
F4

All of the visits
Some of the visits
None of the visits
DON’T KNOW
REFUSED

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
2
3
4
5
F3
F4

Excellent
Very Good
Good
Fair
Poor
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

K-7

MODULE L: PREGNANCY/PRENATAL CARE
PRGCHK0 IF FEMALE AGE 15-49 CONTINUE; ELSE GO TO MODULE M
PRENATAL CARE
PRG1. The next questions are about pregnancy and prenatal care.
Have you been pregnant in the past 3 years?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
3
F3
F4

All of the visits
Some of the visits
None of the visits
DON’T KNOW
REFUSED

One respondent answered “most of the visits”- consider additional category.
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
2
3
4
5
F3
F4

Excellent
Very Good
Good
Fair
Poor
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

PRG6. In the past three years, was there a time that you needed prenatal care but were unable to
get it?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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?
[SHOW CARD MED3]
1
2
3
4
5
6
7
8
9
10
11
F3
F4

Responses:
#4
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?







1
2
F3
F4

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
YES
NO
DON’T KNOW
REFUSED

Need show card for this question – difficult to administer.
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
2
3
F3
F4

All of the services
Some of the services
None of the services
DON’T KNOW
REFUSED

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
2
3
4
5
F3
F4

Excellent
Very Good
Good
Fair
Poor
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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?
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
Refers to a list but there is no list.
PRGCHK9

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

L-4

PRG12. Which of these best describes the main reason you were unable to get that family
planning service?
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
F3
F4

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.
VERY wordy and hard to administer. Consider shortening these into bullets to read.

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
2
3
F3
F4

YES
NO
HAVE NOT WORKED IN PAST 12 MONTHS
DON’T KNOW
REFUSED

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…
1
while working
2
while traveling between worksites
1. __________ WHILE WORKING
2. __________ WHILE TRAVELING BETWEEN WORKSITES
F3
DON’T KNOW
F4
REFUSED
INJURY LOOP

M-1

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.
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.
[SHOW CARD OCC1]
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
F3
F4

SCRAPE OR ABRASION
BRUISE OR CONTUSION
AMPUTATION OR LOST BODY PART
SPRAIN, STRAIN, TORN LIGAMENT, OR TRAUMATIC RUPTURE
BROKEN, CRUSHED, OR MANGLED BONE
DISLOCATION
CUT, LACERATION, PUNCTURE, OR STAB
BURN, BLISTER OR SCALD
CHEMICAL BURN OR POISONING, EITHER BY INGESTION, BREATHING, OR
SKIN CONTACT
SKIN RASH
NAUSEA OR VOMITING
HEADACHE
HEATSTROKE/OVERHEATING
BURNING OR STINGING
INJURY TO EYE
OTHER INJURY OR ILLNESS
DON’T KNOW
REFUSED

OCC2c. FOR EACH: Did you receive medical care for this injury or illness?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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?
[SHOW CARD OCC2]
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
F3
F4

COULD NOT AFFORD IT
NO INSURANCE
DOCTOR DID NOT ACCEPT MEDICAID/INSURANCE
NOT SERIOUS ENOUGH
WAIT TOO LONG IN CLINIC/OFFICE
DIFFICULTY IN GETTING APPOINTMENT
NO DOCTOR AVAILABLE
DIDN’T KNOW WHERE TO GO
NO WAY TO GET THERE
HOURS NOT CONVENIENT
SPEAK A DIFFERENT LANGUAGE
HEALTH OF ANOTHER FAMILY MEMBER
EMPLOYER WOULDN’T ALLOW IT
AFRAID OF GETTING IN TROUBLE WITH THE LAW
OTHER REASON (SPECIFY) ___________________
DON’T KNOW
REFUSED

GOTO OCC2h
OCC2e. Where did you go for medical care?
1
2
3
6
7
8
F3
F4

THE [REFERENCE HEALTH CENTER]
OTHER CLINIC OR HEALTH CENTER OFFERING A DISCOUNT TO LOW
INCOME OR UNINSURED PEOPLE
DOCTOR'S OFFICE OR HMO
HOSPITAL EMERGENCY ROOM
HOSPITAL OUTPATIENT DEPARTMENT
SOME OTHER PLACE
DON’T KNOW
REFUSED

OCC2f. Who took you there?
1
2
3
4
5
F3
F4

EMPLOYER, SUPERVISOR, OR OTHER EMPLOYEE
FAMILY MEMBER, FRIEND, OR CO-WORKER
AMBULANCE/RESCUE SQUAD
OTHER PERSON
I TOOK MYSELF
DON’T KNOW
REFUSED

M-3

OCC2g. How was the medical care paid for?
ALLOW UP TO 2 RESPONSES
1
2
3
4
5
6
7
8
9
10
11
12
F3
F4

PERSONAL FUNDS
PERSONAL MEDICAL INSURANCE
EMPLOYER PROVIDED MEDICAL INSURANCE
MEDI-CAL/IEHP
MEDICARE/MEDICAID
WORKERS’ COMPENSATION
HEALTHY FAMILIES
STATE DISABILITY INSURANCE
MIA
CHDP
THERE WAS NO CHARGE
OTHER (SPECIFY) _______________________
DON’T KNOW
REFUSED

OCC2h. Has the injury or illness resulted in a continuing disability?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

OCC2i. Did you report this injury or illness to your employer?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

OCC2j. Was a worker’s compensation claim filed as a result of this injury or illness?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

M-4

MODULE N: HIV TESTING

HTGCHK1 IF AGE LE 12, THEN GO TO MODULE O; ELSE
IF AGE 13 TO 17 AND NOT HOMELESS YOUTH, GO TO MODULE O;
ELSE
IF AGE 13-17 AND HOMELESS YOUTH, GO TO HTG1; ELSE
IF AGE GE 18, THEN GO TO HTG1
HTG1. Now I’m going to ask questions about the test for HIV, the virus that causes AIDS.
Except for tests you may have had as part of blood donations, Have you ever been tested for
HIV?
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
HTGCHK2 IF HTG1=1, GO TO HTG4; ELSE CONTINUE
HTG2. I am going to read 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?
1
No reason
2
Don’t consider myself at risk of AIDS
3
Doctor did not recommend it
4
Don’t believe results are accurate
5
Don’t believe anything can be done if I am positive
6
Don’t like needles
7
Don’t trust results to be confidential
8
Afraid of losing job, insurance, housing, friends, family if people knew I was positive
9
I’m tested when I give blood
10
Some other reason (specify) _______________________
F3
DON’T KNOW
F4
REFUSED
Responses:
#10 – Not sexually active.
HTG3. Has anyone at [the reference health center] ever suggested that you have your blood
tested for the AIDS virus infection?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

N-1

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

HTG5. Have you ever been told by a doctor or other health professional that you are HIV
positive or have AIDS?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

HTGCHK3 IF HTG5=1, THEN CONTINUE; ELSE GO TO MODULE O
HTG6a. Are you receiving any medical care now for HIV or AIDS?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

HTG6b. Are you receiving antiretroviral therapy?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

HTG6c. Where do you usually get medical care for HIV or AIDS?
1
2
F3
F4

[THE REFERENCE HEALTH CENTER]
SOMEWHERE ELSE
DON’T KNOW
REFUSED

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
F3
DON’T KNOW
F4
REFUSED

N-2

MODULE O:

LIVING ARRANGEMENTS

Next, I’d like to ask some questions about where (you live/name lives).
LIV1
IF AGE >=18:

IF AGE <=12:
IF AGE = 13-17:

1
2
F3
F4

Do you 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?

YES
NO
DON’T KNOW
REFUSED

Respondent is 19 but said “I stay with my mother”
IF LIV1=1, CONTINUE; ELSE GO TO LIVCHK1
LIV2. How would you describe the kind of place where (you live/name lives) now?
1
2
3
4
5
6
F3
F4

A HOUSE (INCLUDES TRAILERS OR MOBILE HOMES)
AN APARTMENT OR CONDO
A ROOM (OTHER THAN HOTEL)
A TRANSITIONAL SHELTER (INCLUDES TRANSITIONAL HOUSING)
HOTEL OR MOTEL (PLACE WITH SEPARATE ROOMS THAT YOU PAY FOR
YOURSELF)
OTHER
DON’T KNOW
REFUSED

LIVCHK1

IF LIV2=1, 2 OR 3, CONTINUE; ELSE GO TO LIVCHK2

LIV3. Does that place belong to a social service provider, or a public housing authority?
1
SOCIAL SERVICE PROVIDER
2
PUBLIC HOUSING AUTHORITY
3
NEITHER
F3
DON’T KNOW
F4
REFUSED
GOTO LIVCHK2

O-1

LIV4 How would you describe the kind of place where (you/name) slept last night?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
F3
F4

A HOUSE (INCLUDES TRAILERS OR MOBILE HOMES)
AN APARTMENT OR CONDO
A ROOM (OTHER THAN HOTEL)
AN EMERGENCY SHELTER
A TRANSITIONAL SHELTER (INCLUDES TRANSITIONAL HOUSING)
A WELFARE OR VOUCHER HOTEL
A CAR OR OTHER VEHICLE
AN ABANDONED BUILDING
AT A TRANSPORTATION SITE (BUS STATION, AIRPORT, SUBWAY STATION
AT A PLACE OF BUSINESS (ALL NIGHT MOVIE, BAR, LAUNDROMAT, ALL
NIGHT RESTAURANT, FARM BUILDING, STABLES, ETC.)
ANYWHERE OUTSIDE (STREETS, PARKS, CULVERTS, CAMPGROUNDS, OR
CARDBOARD BOXES, ETC)
HOTEL OR MOTEL (PLACE WITH SEPARATE ROOMS THAT YOU PAY FOR
YOURSELF)
DORMITORY HOTEL (PLACE WITHOUT SEPARATE ROOMS THAT YOU PAY
FOR YOURSELF)
A MIGRANT WORKER’S CAMP, DORMITORY OR BARRACKS
OTHER
DON’T KNOW
REFUSED

LIVCHK2

IF LIV2= 1, 2 OR 5 OR LIV4=1, 2 OR 12 CONTINUE;
IF LIV2=3 OR LIV 4=3 GO TO LIV6;
ELSE GOTO LIVCHK3

LIV5 How many rooms there are used for sleeping?
______ ROOMS
F3
DON’T KNOW
F4
REFUSED
LIV6

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

______ NUMBER OF PEOPLE
F3
DON’T KNOW
F4
REFUSED
LIVCHK3

IF LIV 1=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 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
F3
DON’T KNOW
F4
REFUSED
LIV8.
IF AGE >=18:

IF AGE <=12:

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 own
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
F3
DON’T KNOW
F4
REFUSED
IF LIV8 >1 CONTINUE; ELSE GOTO LIV10
LIV9. How old (were you/was name) the first time that happened?
_______ AGE
F3
DON’T KNOW
F4
REFUSED

O-3

LIVCHK4 CURRENTLY WITH OWN PLACE
LIV10.
IF AGE >=18:
IF AGE <=12:
IF AGE =13-17:
1
2
F3
F4

Have you 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?

YES
NO
DON’T KNOW
REFUSED

19 yr old respondent said “I don’t have my own place- it is my mother’s place”
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
F3
DON’T KNOW
F4
REFUSED
IF LIV11=1, CONTINUE; ELSE GOTO LIV14
LIV12. How long did that last?
________ NUMBER
a.
DAYS
b.
WEEKS
c.
MONTHS
d.
YEARS
F3
DON’T KNOW
F4
REFUSED
LIV13. How old (were you/was name) when that happened?
______ AGE
F3
DON’T KNOW
F4
REFUSED
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
F3
DON’T KNOW
F4
REFUSED
LIV15. How old (were you/was name) the first time that happened?
______ AGE
F3
DON’T KNOW
F4
REFUSED
LIVCHK6

IF LIV1=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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
3
4
5
F3
F4

Someone’s home
A shelter
A nursing home or rehabilitation facility
A special program for homeless people to recover
Some other place (SPECIFY:______________)
DON’T KNOW
REFUSED

LIVCHK9

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

LIV6c. How long did you stay?
1
2
3
F3
F4

1-6 DAYS
7-29 DAYS
30 DAYS OR LONGER
DON’T KNOW
REFUSED

LIV6d. Did that program help you get better?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

LIV6e. Did that program help you with getting housing and/or services that you could use after
you were discharged?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51

Nebraska: Kids Connection
Nevada: Nevada Check Up
New Hampshire: Healthy Kids
New Jersey: FamilyCare
New Mexico: New Mexico State Children’s
Health Insurance Program / New MexiKids
New York: Child Health Plus (CHPlus)
North Carolina: North Carolina CHIP Program /
Health Choice for Children
North Dakota: Healthy Steps Program / North
Dakota CHIP
Ohio: Healthy Start
Oklahoma: SoonerCare
Oregon: Oregon SCHIP
Pennsylvania: Pennsylvania CHIP
Rhode Island: RIte Care
South Carolina: Partners for Healthy Children
South Dakota: South Dakota Children’s Health
Insurance Program
Tennessee: CoverKids
Texas: TexCare Partnership / Texas CHIP
Utah: Utah’s Children’s Health Insurance
Program
Vermont: Dr. Dynasaur
Virginia: Family Access to Medical Insurance
Security Plan (FAMIS)
Washington: Washington CHIP
West Virginia: West Virginia’s Children’s Health
Insurance Program (WV CHIP)
Wisconsin: BadgerCare
Wyoming: Wyoming Kid Care
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

INSCHK1

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

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
P-1

care) exclude private plans that only provide extra cash while hospitalized.
CODE ALL THAT APPLY.
1
2
3
4
5
6
7
8
9
10
11
12
F3
F4

PRIVATE HEALTH INSURANCE
MEDICARE
MEDI-GAP
MEDICAID
MILITARY HEALTH CARE/VA
CHAMPUS/TRICARE/CHAMP-VA
INDIAN HEALTH SERVICE
STATE-SPONSORED CHILDREN’S HEALTH INSURANCE PLAN (GIVE STATE’S
S-CHIP NAME – S- CHIP PROGRAM STATE NAMES)
SINGLE SERVICE PLAN (E.G., DENTAL, VISION, PRESCRIPTIONS).
OTHER STATE-SPONSORED HEALTH PLAN
OTHER GOVERNMENT PROGRAM
NONE
DON’T KNOW
REFUSED

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

INS2b. Why (do you/does name) come to [the reference health center] if you have insurance that
most doctors will accept?
__________ (Allow 40)
F3
DON’T KNOW
F4
REFUSED
Responses:
I like the doctors
I haven’t found a good doctor or a good place to go so I don’t know.
I am pregnant
It is closer – more convenient
Location
INSCHK4

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

P-2

INS3. Which of these best describes how this plan was obtained?
1
2
3
4
5
F3
F4

Through employer or union
Policy purchased directly from the insurance company
Through a state or local government or community program
Through an association that has insurance available to association members
Other
DON’T KNOW
REFUSED

INS3a. How many people in your family are covered by that plan?
______ (RANGE 00-20)
F3
DON’T KNOW
F4
REFUSED
INS3b. (Does this plan/Do any of these plans) pay for any of the costs for medicines prescribed
by a doctor?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

INS3c. (Does this plan/Do any of these plans) pay for any of the costs for dental care?
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
GO TO MODULE Q
QUESTIONS FOR INDIVIDUALS WITHOUT HEALTH INSURANCE
INS4. Not including Single Service Plans, about how long has it been since (you/name) last had
health care coverage? A single service plan is one that pays for only one type of service, such as
nursing home care, accidents, or dental care.
1
2
3
4
5
F3
F4

6 months or less
More than 6 months, but not more than 1 yr ago
More than 1 yr, but not more than 3 yrs ago
More than 3 yrs
Never
DON’T KNOW
REFUSED

P-3

Needs skip for #5, DK, and RE responses.
Consider flipping definition before question in INS4.

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
2
3
4
5
6
7
8
9
10
11
F3
F4

PERSON IN FAMILY WITH HEALTH INSURANCE LOST JOB OR CHANGED
EMPLOYERS
GOT DIVORCED OR SEPARATED/DEATH OF SPOUSE OR PARENT
BECAME INELIGIBLE BECAUSE OF AGE/LEFT SCHOOL
EMPLOYER DOES NOT OFFER COVERAGE/OR NOT ELIGIBLE FOR
COVERAGE
COST IS TOO HIGH
INSURANCE COMPANY REFUSED COVERAGE
MEDICAID/MEDICAL PLAN STOPPED AFTER PREGNANCY
LOST MEDICAID/MEDICAL PLAN BECAUSE OF NEW JOB OR INCREASE IN
INCOME
LOST MEDICAID (OTHER)
DROPPED PRIVATE COVERAGE TO MEET THE WAITING PERIOD
REQUIREMENT FOR (S-CHIP NAME - S-CHIP PROGRAM STATE NAMES)
OTHER (SPECIFY) _________________
DON’T KNOW
REFUSED

Responses:
#11 – Discharged from residential alcohol treatment facility and lost coverage.

P-4

MODULE Q:

INCOME AND ASSETS

INC1: What is the total number of family members who lived with you in [last calendar year in
4-digit format]? Please only count family members that lived with you AT LEAST 6 of the last
12 months.
______ FAMILY MEMBERS
F3
DON’T KNOW
F4
REFUSED
IF AGE 13-17 GOTO INC4; ELSE CONTINUE
INC1a. 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
strictly confidential.
When answering this next question please remember to include your income PLUS the income
of all family members living in this household.
What is your best estimate of [IF INC1=1: your total income/ELSE: the total income of all
family members] from all sources, before taxes, in [last calendar year in 4 digit format]?
______
(0-999,995) DOLLARS
999996
$999,995+ DOLLARS
F3
DON’T KNOW
F4
REFUSED
Respondent A8, A2, A5, A6 could not answer any of the remaining questions.

INCCHK1

IF INC1= F3 OR F4, CONTINUE; ELSE GO TO INC3c

Q-1

Poverty Thresholds for 2007 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
Nine people or more
Source: U.S. Census Bureau

FPL
(weighted
avg)

2 times FPL
(weighted
avg)

10,590
13,540
16,530
21,203
25,080
28,323
32,233
35,816
42,739

21,180
27,080
33,060
42,406
50,160
56,646
64,466
71,632
85,478

INC2.
INTERVIEWER: REVIEW INC1 FOR SIZE OF FAMILY FOR NEXT QUESTION
During [last calendar year in 4-digit format], was your total family income from all sources less
than [FILL FAMILY POVERTY LEVEL], more than [FILL FAMILY POVERTY LEVEL] but
less than [FILL 2X FAMILY POVERTY LEVEL] or [FILL 2X FAMILY POVERTY LEVEL]
or more?
1
2
3
F3
F4

LESS THAN FPL
MORE THAN FPL BUT LESS THAN 2 TIMES FPL
TWO TIMES FPL OR MORE
DON’T KNOW
REFUSED

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.
f.
g.
h.
i.

food stamps
wic, the women, infants, and children nutrition program?
public assistance payments
general assistance or general relief
transportation assistance, such as gas vouchers, bus passes, or help registering, repairing,
or insuring a car?
child care services or assistance so you could go to work or school or training?
aid from the (state tanf plan) program?
section 8 housing
any other assistance from the government? (specify)______

Q-2

FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
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
2
3
4
F3
F4

get enough of the kinds of foods (you want/you want him/her) to eat
get enough, but not always what (you want/you want him/her) to eat
sometimes don’t get enough to eat
often don’t get enough to eat
DON’T KNOW
REFUSED

Fills for STATE TANF PLANS (in INC3g)
IN STATES WHERE THERE IS MORE THAN ONE PROGRAM, AN ASTERICK *
DENOTES WHICH MOST RESEMBLES TANF
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

ALABAMA
27
ALASKA
28
ARIZONA
29
ARKANSAS
30
CALIFORNIA
COLORADO
32
CONNECTICUT
33
DELAWARE
34
THE DISTRICT OF COLUMBIA (WASHINGTON, DC)
FLORIDA
36
GEORGIA
37
HAWAII
IDAHO
39
ILLINOIS
40
INDIANA
41
IOWA
42
KANSAS
43
KENTUCKY
44
LOUISIANA
45
MAINE
46
MARYLAND
47
MASSACHUSETTS
48
MICHIGAN
49
MINNESOTA
50
MISSISSIPPI
51
MISSOURI

MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
31
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
35
NORTH DAKOTA
OHIO
OKLAHOMA
38
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
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)

Q-3

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)
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-4

MODULE R: DEMOGRAPHICS

The final questions are about (you/name).
DMO1. (Were you/Was name) born in the United States?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

DMOCHK1 IF DMO1 =1, THEN GO TO DMO4 ELSE CONTINUE
DMO2. In what year did (you/name) come to the United States?
________ YEAR
F3
DON’T KNOW
F4
REFUSED
DMO3. About how long (have you/has name) been in the United States?
1
2
3
4
5
F3
F4

LESS THAN 1 YR.
AT LEAST 1 YR., BUT LESS THAN 5 YRS
AT LEAST 5YRS., BUT LESS THAN 10 YRS
AT LEAST 10YRS., BUT LESS THAN 15 YRS
15 YRS. OR MORE
DON’T KNOW
REFUSED

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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
F3
F4

NEVER ATTENDED/KINDERGARTEN
1ST GRADE
2ND GRADE
3RD GRADE
4TH GRADE
5TH GRADE
6TH GRADE
7TH GRADE
8TH GRADE
9TH GRADE
10TH GRADE
11TH GRADE
12TH GRADE, NO DIPLOMA
HIGH SCHOOL GRADUATE
GED OR EQUIVALENT
SOME COLLEGE, NO DEGREE
ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR VOCATIONAL
PROGRAM
ASSOCIATE DEGREE: ACADEMIC PROGRAM
BACHELOR’S DEGREE (EXAMPLE: BA, AB, BS, BBA)
MASTER’S DEGREE(EXAMPLE: MA, MS, MENG, MED, MBA)
PROFESSIONAL SCHOOL OR DOCTORAL DEGREE (EXAMPLE: MD, DDS,
DVM, JD, PHD, EDD)
OTHER (SPECIFY)¬______________
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

DMO7. How many times (have you/has name) moved in the past 12 months?
_______ TIMES
F3
DON’T KNOW
F4
REFUSED
Two respondents said- “I am homeless”
DMOCHK5 IF DMO7 GE 1, THEN CONTINUE; ELSE GO TO DMOCHK6
DMO8. How many of these moves were related to work?
1
1
2
2
3
3
4
4
5
5
6
6-10
7
11-15
8
MORE THAN 15
F3
DON’T KNOW
F4
REFUSED
A response for “0” is needed.
DMO8a. 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.
_______ MOVES
F3
DON’T KNOW
F4
REFUSED
MARITAL STATUS
DMOCHK6 IF AGE GE 15, THEN CONTINUE; ELSE GO TO DMOCHK8

R-3

DMO9. Are you ……?
1
2
3
4
5
F3
F4

Married
Widowed
Divorced
Separated
Never married
DON’T KNOW
REFUSED

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
2
F3
F4

YES (GOTO DMOCHK9)
NO
DON’T KNOW
REFUSED

IF DMOCHK8
IF DMO9a=1, THEN GO TO DMOCHK9; ELSE CONTINUE
DMO9b. Are you living with a partner?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
3
4
5
F3
F4

Currently on active duty
Currently in the Reserves or National Guard
Retired from military service
Medically discharged from military service
Discharged from military service
DON’T KNOW
REFUSED

DMOCHK11 IF DMO10a=1 OR 2, THEN GO TO DMOCHK12; ELSE CONTINUE
DMO10b. Are you eligible for veteran’s benefits?
1
2
F3
F4

YES
NO (GO TO DMOCHK5)
DON’T KNOW
REFUSED

DMO10c. In the past 12 months, that is since (12 MONTH REFERENCE DATE), have you
received health care from VA facilities?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
3
4
5
F3
F4

Working at a job or business
With a job or business but not at work
Looking for work
Working, but not for pay, at family-owned job or business
Not working at a job or business and not looking for work
DON’T KNOW
REFUSED

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
What about DMO11=3?
DMO11a. What is the main reason you did not [work last week/have a job or business last
week]?
1
2
3
4
5
6
7
8
9
10
F3
F4

TAKING CARE OF HOUSE OR FAMILY
GOING TO SCHOOL
RETIRED
ON A PLANNED VACATION FROM WORK
ON FAMILY OR MATERNITY LEAVE
TEMPORARILY UNABLE TO WORK FOR HEALTH REASONS
HAVE A JOB/CONTRACT AND OFF-SEASON
ON LAYOFF
DISABLED
OTHER
DON’T KNOW
REFUSED

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
F3
DON’T KNOW
F4
REFUSED
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
F3
DON’T KNOW
F4
REFUSED
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
F3
DON’T KNOW
F4
REFUSED
DMO11f. Do you currently have paid sick leave on this job or business?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
F3
DON’T KNOW
F4
REFUSED
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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

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
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

R-8

DMO11k Why aren’t you included in your employer’s health insurance plan?
CODE ALL THAT APPLY.
1
2
3
4
5
6
7
8
9
F3
F4

DO NOT NEED OR WANT ANY HEALTH INSURANCE
RARELY SICK
TOO MUCH HASSLE/PAPERWORK
COULD NOT AFFORD/TOO EXPENSIVE
DO NOT WORK ENOUGH HOURS IN A WEEK
HAVE NOT WORKED THERE LONG ENOUGH
DOUBT ELIGIBLE/REJECTED BECAUSE OF HEALTH CONDITION
BENEFIT PACKAGE DIDN’T MEET NEEDS
OTHER (SPECIFY)_____________
DON’T KNOW
REFUSED

DMOCHK17 IF MIGRANT AND AGE GE 12, CONTINUE; ELSE GO TO END
DMO12. Have you done farm work in the last 12 months, that is since (12 MONTH
REFERENCE DATE)?
1
2
F3
F4

YES
NO
DON’T KNOW
REFUSED

DMOCHK18 IF DMO12=1, THEN CONTINUE; ELSE GO TO END
DMO12a. Are you currently employed by a:
1
2
3
4
5
F3
F4

grower/rancher
contractor
packing service
packing house
non-farm related employer
DON’T KNOW
REFUSED

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
F3
DON’T KNOW
F4
REFUSED

R-9

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
F3
DON’T KNOW
F4
REFUSED
DMO12d. Approximately how many months during the past 12 months have you been in the
U.S.?
_______MONTHS
F3
DON’T KNOW
F4
REFUSED
END. Thank you very much. These are all the questions I have for you today.
1

CONTINUE

MODULE Q- END TIME: __________
DEBRIEFING QUESTIONS:
1)

Were there any questions or sections that were confusing? IF YES- EXPLAIN:

They were easy to understand.

Did you feel there were any questions that seem repetitive or long? IF YESEXPLAIN:

Everyone responded no

If I had came to the health center on a day you were there to receive services, would
you have taken the time to complete this interview at that time?

One respondent- after learning that the incentive during the main study would be less said “No I
wouldn’t”
Possibly
Probably
All other were - yes
Would you have had time to complete the survey?

R-10

Possibly
All other were - yes

Do you have any other comments or ways in which we can improve this
questionnaire?

Nope- pretty good survey
Interesting.

R-11

File Type	application/pdf
File Title	Microsoft Word - Cognitive Interview Report_2nd round _2_.doc
Author	acash
File Modified	2009-06-25
File Created	2009-06-25