Download:
pdf |
pdfPrimary Health Care Patient Surveys
Cognitive Interview Report —Round 1 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
Draft: November 19, 2008
Final: December 22, 2008
Table of Contents
I
Background and Introduction .......................................................................................................... 1
II
Recruitment ...................................................................................................................................... 2
A. Grantee Recruitment.................................................................................................................. 2
B. Participant Recruitment ............................................................................................................. 2
III
Procedures ........................................................................................................................................ 4
IV
General Results and Recommendations........................................................................................... 6
V
Question-by-Question Results and Recommendations .................................................................... 6
Appendices
A
Recruitment Cover Letter .................................................................................................. Append-1
B
Recruitment Flyer .............................................................................................................. Append-2
C
Patient Screening Form ...................................................................................................... Append-3
D
Informed Consent Forms ................................................................................................... Append-5
List of Tables
1
Cohort A Selection........................................................................................................................... 3
2
Cohort B Selection ........................................................................................................................... 3
3
Cohort C Selection ........................................................................................................................... 3
4
Cohort A Module Distribution ......................................................................................................... 5
5
Cohort B Module Distribution ......................................................................................................... 5
6
Cohort C Module Distribution ......................................................................................................... 5
i
I.
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.
1
RTI International is a trade name of Research Triangle Institute.
1
This report summarizes the results of the first round of in-person cognitive testing of
questions included on the PHCPS questionnaire. The report is organized into the following
sections: (II) Recruitment, (III) Procedures, (IV) General Results and Recommendations, and
(V) Question-by-Question Results and Recommendations.
II.
Recruitment
A. Grantee Recruitment
Three grantees in North Carolina were selected for inclusion in the cognitive test. They were
selected because they served patients through one or more of the above-mentioned grant
programs and because of their close proximity to the RTI offices. The selected grantees were
Lincoln Community Health Center in Durham, Goshen Medical Center in Faison, and Wake
Health Systems in Raleigh.
Recruitment began with a letter to each grantee being sent via Federal Express. The letter
explained the study and sought the grantees’ participation (Appendix A). The letter was
followed by telephone calls to secure participation.
Two of the three grantees (Lincoln Community Health Center and Goshen Medical Center)
promptly agreed to participate. Several attempts were made to recruit Wake Health Systems, but
the grantee staff seemed extremely busy, and recruitment was unsuccessful.
B. Participant Recruitment
RTI sent participant recruitment flyers and handouts to the person identified as our point-ofcontact at each facility (Appendix B). The point-of-contact was instructed to hang the flyers in
the lobby and waiting areas and to place the handouts near the admission desk and other highly
visible locations.
Recruitment progressed at an unexpectedly slow rate. Therefore, two RTI project staff visited
each location, talked with the point-of-contact and other staff about the study, ensured that flyers
and handouts were placed in prominent locations, and conducted on-site recruitment and
screenings. These efforts proved quite successful, and we began receiving many calls from
individuals interested in participating in the cognitive interviews.
Individuals who expressed interest in participating in the study—either through on-site
recruitment efforts or by calling RTI—were screened for eligibility (Appendix C). RTI staff
developed a list of over 80 eligible clients.
From the list of eligible respondents, RTI staff scheduled interviews with 27 clients separated
into three cohorts. Tables 1 through 3 show the distribution of clients within each cohort by key
data collection factors.
2
Table 1 – Cohort A Selection
Interview
ID
A1
A2
A3
A4
A5
A6
A7
A8
A9
Site
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Gender
M
F
M
F
F
F
F
F
M
Age
41
31
14
45
61
56
51
15
5
Health
Insurance
YES
NO
YES
NO
YES
NO
YES
YES
NO
Migrant/
Seasonal
Farm Worker
NO
NO
NO
YES
NO
NO
NO
NO
NO
Homeless
During the
Past 12 Months
YES
YES
NO
YES
NO
NO
NO
NO
NO
Currently
Living in
Public
Housing
NO
NO
YES
NO
YES
NO
NO
NO
NO
Health
insurance
NO
YES
NO
YES
NO
NO
YES
NO
YES
Migrant/
Seasonal
Farm Worker
NO
NO
YES
NO
NO
NO
NO
NO
NO
Homeless
During the
Past 12 Months
YES
YES
NO
NO
YES
NO
NO
NO
NO
Currently
Living in
Public
Housing
NO
NO
NO
NO
NO
NO
NO
NO
NO
Health
Insurance
YES
YES
YES
YES
NO
YES
YES
YES
YES
Migrant/
Seasonal
Farm Worker
NO
NO
NO
NO
NO
NO
NO
NO
NO
Homeless
During the
Past 12 Months
YES
YES
NO
NO
NO
NO
NO
NO
NO
Currently
Living in
Public
Housing
NO
NO
NO
YES
NO
YES
NO
NO
NO
Table 2 – Cohort B Selection
Interview
ID
B1
B2
B3
B4
B5
B6
B7
B8
B9
Site
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Gender
M
F
M
M
F
F
F
F
F
Age
40
40
29
13
24
63
28
50
3
Table 3 – Cohort C Selection
Interview
ID
C1
C2
C3
C4
C5
C6
C7
C8
C9
Site
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Goshen
Lincoln
Lincoln
Gender
M
F
F
M
F
F
F
M
M
Age
41
35
6
55
54
31
24
14
4
The distribution of clients by key factors was generally diverse. However, a few exceptions
are noted:
A slightly larger number of females than males were interviewed (17 females and 10
males).
3
All but one of the participants were clients of Lincoln Community Health Center. Lincoln
Community Health Center seemed to have a larger number of clients than Goshen
Medical Center during the time of our recruitment efforts.
Only two migrant farm laborers were identified and interviewed. This round of the
cognitive interviews was conducted in English, and it was difficult to find
migrant/seasonal farm workers who spoke English.
Only two clients over the age of 60 were identified and interviewed.
III. Procedures
Selected respondents were called and invited to take part in a one-on-one interview with an
RTI staff member. The majority of interviews took place in an office at Lincoln Community
Health Center. A handful of interviews were conducted at other locations, such as the
respondent’s home, local libraries, and RTI’s central office.
The cognitive interviews were conducted from October 28 through November 7, 2008. The
interviews were conducted by Tim Flanigan (the Instrumentation Task Leader) and three
additional survey methodologists. The interviews ranged from approximately 45 to 90 minutes,
and the participants were provided a $50 cash incentive as compensation for their time.
Before starting the interviews, interviewers read each participant an informed consent
document that described the study and outlined the participants’ rights as a research volunteer
(Appendix D). Participants were required to sign the form and were given a copy to take home.
Adolescent participants were required to sign an adolescent assent form along with the consent
form signed by a parent or guardian. 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.
The interviewers used both scripted and spontaneous concurrent probing techniques to assess
the clarity and effectiveness of the proposed questions. Scripted probes were developed prior to
patient recruitment and were designed to provide standardization of probing by all interviewers
for particular questions that appeared problematic. Spontaneous probes were developed during
the interview by the interviewer.
Three questionnaires were developed with specific modules to test. Each cohort of
respondents received one of the three questionnaires to be tested. Tables 4 through 6 show the
distribution of modules, by patient.
4
Table 4 – Cohort A Module Distribution
Patient ID
A1
A2
A3
A4
A5
A6
A7
A8
A9
A
B
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
C
D
E
F
G
•
•
•
•
•
•
•
•
•
H
Modules Received
I
J
K L
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
M
N
•
•
•
•
•
O
P
•
•
•
•
•
•
•
•
•
•
•
•
O
P
Q
R
•
•
•
•
•
•
•
•
•
•
•
Table 5 – Cohort B Module Distribution
Patient ID
B1
B2
B3
B4
B5
B6
B7
B8
B9
A
B
•
•
•
•
•
•
•
•
•
C
D
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
E
F
G
H
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Modules Received
I
J
K L
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
M
N
Q
•
•
•
•
•
•
•
•
•
•
•
•
•
•
R
•
•
•
•
Table 6 – Cohort C Module Distribution
Patient ID
C1
C2
C3
C4
C5
C6
C7
C8
C9
A
B
C
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
D
•
•
•
•
•
•
•
• •
E
F
•
•
•
•
•
•
•
•
•
•
G
H
Modules Received
I
J
K L
•
•
•
•
•
•
•
•
•
•
5
M
N
O
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
P
•
•
•
•
Q
R
•
•
•
•
•
•
•
IV. General Results and Recommendations
There were generally very few problems. Global issues and potential resolutions are as
follows:
Time frames in questions are inconsistent (e.g., some questions ask about the past 12
months, some about the past 3 months, and some about the past month). This issue did
not seem to be too problematic and can be resolved with some minor revisions.
Specifically, we will emphasize (via bold or underlined text) time frames when they
change often within a module. This will help ensure that respondents understand the time
frame to which we are referring. Interviewers will also be provided with a calendar that
they can show to respondents to help them focus on the proper time frames.
Several modules were administered to adolescents who could not answer the questions
(e.g., questions about insurance and household income are very difficult for an adolescent
to answer). RTI will review these items with BPHC to make decisions on how best to
address this issue.
There were some formatting issues regarding the consistency of uppercase/mixed-case
text. Interviewers are instructed to read all text that is lowercase, but not text that is
uppercase. This type of issue usually occurred in lists that required show cards. These
items are noted in the question-by-question findings, and the correction was made.
Some long and repetitious response sets and complicated question stems could benefit
from additional show cards (e.g., CONF3a in Module E, HEA11 in Module G, and INC3
in Module Q). The question-by-question findings describe various questions where a
show card is recommended.
There were also some isolated questions where respondents did not understand certain
terminology. These items are identified in the question-by-question findings. RTI will
work with BPHC to address these issues.
Small errors in skip logic were identified and corrected within the question-by-question
findings. However, any logic problems that require a decision are identified in the
findings.
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.
6
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
Findings: YES = 5 NO = 22
Recommendations: None
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
Findings: R1 = 4 R2 = 1
Recommendations: None
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
5
White
Black or African American
American Indian or Alaska Native
Asian
Other (SPECIFY:_____________)
F3
DON’T KNOW
F4
REFUSED
Findings: R1 = 2 R2 = 20 R3=1 R5= Tex Mex, Hispanic (2), Native American
A-1
Recommendations: Consider removing specify and just allow an “other” category.
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
Findings: R1 = 10 R2=17
Recommendations: None
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
Findings: R1=5 R3=9 R4=2
Recommendations: None
CONCHK1 IF AGE < 2, CONTINUE; ELSE GO TO CON3
CON2. 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
Findings: R1=6 R2=2 R3=6
Recommendations: None
CON3. How tall (are you/is name) without shoes?
PROGRAMMERS: ALLOW METRIC
_________ (0-8 feet)
_________ (0-11 inches)
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied greatly
Recommendations: None
CON4. How much (do you/does name) weigh without shoes?
B-1
PROGRAMMERS: ALLOW METRIC
a. ________ POUNDS
F3
F4
DON’T KNOW
REFUSED
Findings: Responses varied greatly
Recommendations: None
CONCHK2 IF AGE GE 18, CONTINUE; ELSE GO TO CONCHK4
CON5. Do you consider yourself obese, overweight, underweight, or just about right? IF
FEMALE AGED 18 TO 59 ADD: If you are currently pregnant, 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
Findings: Responses varied. Although no one considered themselves “obese”
Recommendations: None
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
Findings: Responses varied. No problems found.
Recommendations: None
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
Findings: Responses varied. Respondents were probed about what was meant by most
successful attempt. In general, respondents thought of the occasion where they lost the most
weight or stuck to it the longest.
Recommendations:
None
CON6b. How did you try to lose weight?
CODE ALL THAT APPLY.
1
2
3
4
5
6
7
8
F3
F4
CHANGED WHAT I ATE OR HOW MUCH I ATE OR WHEN I ATE
EXERCISED
JOINED A WEIGHT LOSS PROGRAM
TOOK 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
OTHER
DON’T KNOW
REFUSED
Findings: Most responses were #1 (4) and #2 (3). Two respondents said we should add a
“Drink water” option.
Recommendations: Consider adding a category for “Drank water”. Consider adding “diet” in
front of “pills” as that caused some confusion.
CONCHK4 IF AGE 12 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
Findings: The adolescent respondents said “About the right weight”
Recommendations: None
B-3
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
Findings: Responses varied.
Recommendations: None
CONCHK4A IF CON6d=1, THEN GO TO CON7; ELSE CONTINUE
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
Findings: Responses varied. Diet was most prevalent response
Recommendations: None
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
Findings: No problems found. We probed the respondents about the difficulty in recalling the
past 12 months and they said it was not difficult to think back.
B-4
Recommendations:
None
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
Findings: 4 respondents said “YES”. No problems found.
Recommendations: None
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
Findings: Only 2 respondents said “YES”
Recommendations: None
CONCHK7 IF CON8a = 1, CONTINUE; ELSE GO TO CON9
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
Findings: Both respondents said “YES”
Recommendations: None
B-5
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
Findings: Responses varied. No problems found.
Recommendations: None
HIGH BLOOD PRESSURE
CONCHK8 IF AGE GE 2, THEN CONTINUE; ELSE GO TO CON11
Findings: This section need FILLs for Proxy interviews.
Recommendations: Add proxy fills
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?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: Most respondents said “No”. Everyone understood what was meant by high blood
pressure
Recommendations: None
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-6
Findings: We probed to see how difficult it was for respondents to remember whether they had
been told on two or more visits. There didn’t seem to be any confusion and respondents said they
could remember.
Recommendations: None
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
Findings: 9 respondents said that it was within the last 6 months. One respondent wasn’t sure of
the procedure (blood pressure check)
Recommendations: Consider an interviewer note with a description of the procedure.
CONCHK10 IF CON10a = 1 CONTINUE, ELSE GO TO CON11
CON10c. At that time, were you told that your blood pressure was high, normal, or low?
1
2
3
4.
5.
F3
F4
HIGH
NORMAL
LOW
BORDERLINE
NOT TOLD
DON’T KNOW
REFUSED
Findings: 8respondents said that it was normal. No problems found.
Recommendations: None
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
B-7
Findings: 3 of 16 respondents said “YES”.
Recommendations: None
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
Findings 2 of 3 respondents said “YES”.
Recommendations: None
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
Findings: No problems found
Recommendations: None
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
Findings: No problems found
Recommendations: None
DIABETES
CON12. [IF FEMALE AND AGE 15-59, 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?
B-8
1
2.
3.
F3
F4
YES
NO
BORDERLINE
DON’T KNOW
REFUSED
Findings: 2 of 16said “YES”
Recommendations: None
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
________ AGE IN MONTHS
F3
DON’T KNOW
F4
REFUSED
Findings: Bother respondents had to guess at their age when first told as it was not recent.
Recommendations: None
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
Findings: 3 respondents did not know what blood cholesterol was.
Recommendations: Consider explaining blood cholesterol or the procedure so that it is clear to
the respondent.
B-9
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
Findings: 6 respondent indicated that they had it done at the center.
Recommendations: None
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
Findings: No problems found.
Recommendations: None
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
B-10
Findings: One respondent wasn’t sure about a “heart murmur” and where this would be
classified. Another respondent did not know what Angina was.
Recommendations: None
FOR EACH YES RESPONSE IN CON14g, h, i, and k, ASK CON14_CURRENT; ELSE
GOTO CON14_age
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
Findings: No problems found.
Recommendations: None
CON14_age.
FOR EACH YES RESPONSE IN CON14a THROUGH j, CONTINUE; ELSE GOTO
CON15.
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
_________ AGE IN MONTHS
F3
DON’T KNOW
B-11
F4
REFUSED
Findings: We probed how confident respondents were about the age they reported. In most
cases, they guessed at the age. This does not seem very accurate.
Recommendations: Consider dropping this question unless absolutely necessary as data may
be inaccurate.
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?
Frequent or severe headaches, including migraines?
Anemia?
Three or more episodes of ear pain or ear infections?
Seizures?
Stuttering or stammering?
FOR EACH QUESTION:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
Findings: One respondent did not know what “anemia” was.
Recommendations: Consider adding (Excluding during pregnancy,) as two women answered yes
to these and later said it was due to their pregnancy.
CON16. During the past 12 months, (have you/ 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
Findings: Respondents asked about hives and ringworm and whether they should be counted.
Recommendations: Consider adding this list to Con14 as it seems repetitious to continue asking
about conditions. Consider adding hives and ringworm.
B-12
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
Findings: No problems… respondents tended to report knee and shoulder
Recommendations: None
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
Findings: No problems… respondents were confident it began more than 3 months ago.
Recommendations: None
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
Findings: No problems. 6 respondents indicated “YES”
Recommendations: None
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
YES
NO
DON’T KNOW
B-13
F4
REFUSED
Findings: No problems. 3 respondents said “YES”
Recommendations: None
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
Findings: No problems found.
Recommendations: None
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
Findings: One respondent said she does have pain but it was located in the back/spine area.
Recommendations: None
CON18a. During the past three months, did you have low back pain?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No problems found.
Recommendations: None
B-14
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
Findings: No problems found. One respondent did say “ Not below the knee, but upper leg”
Recommendations: None
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
Findings: One respondent said YES during pregnancy.
Recommendations: Consider “Excluding pregnancy” if we don’t want to include pain as a
result of pregnancy. Delete CON18c2 as this was already asked in CON15
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
Findings: One respondent said YES
Recommendations: None
B-15
CONCHK21 IF CON19 = 1, CONTINUE; ELSE GO TO CONCHK22
CON20. What kind of cancer was it?
[SHOWCARD CON1]
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
________ AGE IN MONTHS
F3
F4
DON’T KNOW
REFUSED
Findings: R had breast cancer in her 30’s
Recommendations: None
B-16
CHOLESTEROL
CONCHK22 IF AGE GE 18, CONTINUE; ELSE GO TO CON25
CON22. To lower your blood cholesterol, have you 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?
FOR EACH QUESTION:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
Findings: Both respondents and interviewers were confused by this question. If the respondents
blood pressure was normal then we should skip this series. Question also assumes that the
respondent has “high” blood cholesterol the way it is worded.
Recommendations: Consider a skip here if blood pressure is normal.
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
Findings: Respondents also said that they “diet” and “eat fiber”
Recommendations: Consider additional categories mentioned by respondents.
CONCHK24 IF CON22A-D=1 CONTINUE; ELSE GOTO CON25
B-17
CON24. Did you ever receive this advice from someone at [the reference health center]?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No problems found.
Recommendations: None
HEARING
The next few questions are about your hearing and vision.
CON25. (Have you/Has name) ever worn a hearing aid?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No problems found.
Recommendations: None
CON25a. Which statement best describes (your/name’s) hearing (without a hearing aid): good, a
little trouble, a lot of trouble, deaf?
1
2
3
4
F3
F4
GOOD
A LITTLE TROUBLE
A LOT OF TROUBLE
DEAF
DON’T KNOW
REFUSED
Findings: No problems found.
Recommendations: None
B-18
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
Findings: Several respondents responded using the same response set as Con25a.
Recommendations: Consider using same response set as Con25a
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
Findings: No problems found.
Recommendations: None
CONCHK26 IF AGE GE 10 CONTINUE; ELSE GO TO MODULE C
CON27. These next questions are about limitations. Because of a physical, mental, or emotional
problem, (do you/does name) need the help of other persons with personal care needs such as...
a.
b.
c.
d.
e.
f.
bathing or showering?
dressing?
eating?
getting in or out of bed or chairs?
using the toilet, including getting to the toilet?
getting around inside the home?
FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
B-19
Findings: This series of questions is VERY awkward for most people, especially for a healthy
adolescent. The questions seemed to be focused on the elderly and we received a lot of
comments from respondents about how these do not fit them.
Recommendations: Consider age skip or logic drawn from other questions that give us an
indication of mobility.
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
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
Findings: Same issue as CON27
Recommendations: Same recommendation as CON27
CONCHK28 IF AGE 18 TO 69, CONTINUE; ELSE GO TO MODULE C
CON29. Does a physical, mental, or emotional problem now keep you from working at a job or
business?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No problems found
Recommendations: None
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
Findings: This question is awkward after CON29 (IF YES).
Recommendations: Consider a skip IF CON29=1
B-20
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
Findings: 6 of 15 said “YES”. Two respondents asked if this included “routine care”
Recommendations: Consider clarification on whether routine care should be included.
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
Findings: All 6 said “NO”
Recommendations: None
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
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
C-1
9
10
11
F3
F4
COULDN’T GET CHILD CARE
DIDN’T HAVE TIME OR TOOK TO LONG
OTHER SPECIFY:_____________
DON’T KNOW
REFUSED
Findings: Question not asked as everyone skipped out.
Recommendations: None
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
Findings: Question not asked as everyone skipped out.
Recommendations: None
MED3. What kind of care was it that (you/name) needed but did not get?
_____________ (Allow 40)
F3
DON’T KNOW
F4
REFUSED
Findings: Question not asked as everyone skipped out.
Recommendations: None
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
Findings: Question not asked as everyone skipped out.
Recommendations: None
C-2
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
Findings: Only one person was delayed in getting care. Otherwise, no problems found
Recommendations: None
MEDCHK3 IF MED5=1, THEN CONTINUE; ELSE GO TO MODULE D
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
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
Findings: The one respondent that received this question chose #2. They also chose #4 and #7.
Recommendations: Consider making this and similar questions in the survey a “Select all that
apply”
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
C-3
Findings: The one respondent that received this question chose #3
Recommendations: None
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
Findings: The one respondent that received this question said “eye treatment”
Recommendations: None
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
Findings: The one respondent that received this question said “YES”
Recommendations: None
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, (have you/ has name) seen or talked to any of the following
health care providers about (your/his/her) own health?
a.
b.
A medical doctor who specializes in a particular medical disease or problem
other than obstetrician/gynecologist, psychiatrist, or ophthalmologist)?
A general doctor who treats a variety of illnesses (a doctor in general practice,
family medicine, or internal medicine)?
FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
Findings: 5 of 14 respondents thought this question was complicated or too long. There is a lot
of information here to read and comprehend. One respond said “Would that be like going for a
physical?” when asked ROU1b.
Recommendations: Consider removing the transition statement to make question easier to
understand. Consider adding “…or provides physical exams” following “illnesses” in ROU1b.
ROUCHK1 IF FEMALE AND AGE GE 18, CONTINUE; ELSE GO TO ROU3
ROU2. During the past 12 months, have you seen or talked to a doctor who specializes in
women's health (an obstetrician/ gynecologist)?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No problems found
Recommendations: None
ROU3. Altogether, how many nights (did you/did name) stay in the hospital during the past 12
months?
________ (0-365) NIGHTS
F3
DON’T KNOW
F4
REFUSED
D-1
Findings: Awkward placement of this question, especially after reading ROU2. Another
respondent found this awkward as it assumes that they had spent a night in the hospital.
Recommendations: Consider a different location for this question. Consider adding (if any)
following nights in stem of question.
ROU4. 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
Findings: Responses varies as 8 respondents indicated at least 1 visit. No problems found.
Recommendations: None
ROU5. 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
An optometrist, ophthalmologist, or eye doctor (someone who prescribes
eyeglasses)?
A foot doctor?
A chiropractor?
A physical therapist, speech therapist, respiratory therapist, occupational
therapist, hearing specialist or audiologist?
A nurse practitioner, physician assistant, or mid wife?
FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
Findings: A couple of respondents mentioned confusion with the response (e). When hearing
“midwife” they assumed this is talking of women’s health. One respondent said, “Audiologist?
What is that?”
Recommendations: Consider asking midwife separate or removing this as an example in (e).
D-2
ROU6. During the past 12 months, (have you/has name) had a flu shot or influenza vaccine
sprayed in the nose? READ IF NECESSARY: This vaccination is usually given in the fall and
protects against influenza for about one year.
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: 5 of 14 said YES. No problems found.
Recommendations: None
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
Findings: Two of the five said YES
Recommendations: None
ROUCHK3 IF AGE GE 65, CONTINUE; ELSE GO TO ROU10
0ROU8.
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
Findings: Only one respondent received this shot and another respondent had never heard of it.
Recommendations: None
ROUCHK4 IF ROU8 =1, CONTINUE; ELSE GO TO ROUCHK5
ROU9. Did you get the pneumonia vaccination at (the reference health center)?
1
YES
D-3
2
F3
F4
NO
DON’T KNOW
REFUSED
Findings: The one respondent that received this question said YES
Recommendations: None
ROU10. ROUCHK5
IF AGE GE 18, CONTINUE; ELSE GO TO ROUCHK8
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
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
ROUCHK6 IF ROU10= 2 OR 3, CONTINUE;
ELSE IF ROU10=F3 OR F4, GO TO ROUCHK8
ELSE GO TO ROU11a
Findings: Responses varied but no problems found.
Recommendations: None
ROU11. Did you get this check-up at (the reference health center)?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: 6 respondents said YES
Recommendations: None
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?
D-4
[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
Findings: Only one respondent received question and selected #6
Recommendations: None
ROUCHK8 IF AGE <18, THEN CONTINUE; ELSE, GO TO ROU14
ROU12. These next questions are about well-child check-ups. A well-child check-up 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 check-up?
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
ROUCHK9 IF ROU12=1 OR 2, CONTINUE;
ELSE IF ROU12=F3 OR F4, GO TO ROU14
ELSE GO TO ROU13a
Findings: There was a problem with the skip logic which has been corrected. Two adolescents
had some confusion as to what a “well-child check-up” is. This is not terminology they would
use.
Recommendations: Consider adding “or general physical exam” to “well child check up”
D-5
ROU13. Did (you/he/she) get this check-up at (the reference health center)?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: 1 respondent said YES
Recommendations: None
ROUCHK10 GO TO ROU14
ROU13a. What is the main reason (you/name) has not had a general physical exam or routine
check-up in the past 2 years?
[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
Findings: No respondents received this question
Recommendations: None
LEAD SCREENING
ROU14. (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
Findings: Only 2 respondents said YES
D-6
Recommendations:
None
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
Findings: Respondents indicated 3 and 4 years of age. They were very confident about the age.
Recommendations: None
ROU16. Was that done at the [reference health center]?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: Both respondents said YES
Recommendations: None
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
Findings: Both respondents said YES
Recommendations: None
D-7
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 FEMALE AND AGE GE 15, THEN 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
Findings: 2 of 4 respondents said NO
Recommendations: None
CONFCHK2 IF CONF1=1, GO TO CONCHK7; ELSE CONTINUE
CONF1. 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
Findings: Respondents also said they were advised to “not get so angry and stressed”
Recommendations: None
CONFCHK3 FOR EACH ITEM CODED AS "1" in CONF1a, CONTINUE; ELSE GO
TO CONF2
E-1
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?
Findings: Question seems awkward… This can be resolved during programming as each could
immediately follow the one it is linked with.
Recommendations: Consider changing for CAPI
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
Findings: No problems found.
Recommendations: None
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
Findings: No problems found.
Recommendations: None
CONFCHK5 IF CONF2= 1, CONTINUE; ELSE GOT TO CONF3
E-2
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
Findings: 3 of 5 respondents indicated YES. No problems found.
Recommendations: None
CONFCHK6 IF CONF2a=1 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
Findings: Skip logic problem found and corrected.
Recommendations: None
CONF3. (Do you/Does name) regularly check (your/his/her) own blood pressure?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No problems found.
Recommendations: None
CONF3a. When was the last time (you/name) received 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
WITHIN PAST 6 MONTHS
E-3
2
3
4
5
6
F3
F4
MORE THAN 6 MONTHS AGO BUT NO MORE THAN 1 YEAR AGO
MORE THAN 1 YEAR AGO BUT NO MORE THAN 2 YEARS AGO
MORE THAN 2 YEARS AGO BUT NO MORE THAN 5 YEARS AGO
MORE THAN 5 YEARS AGO
NEVER
DON’T KNOW
REFUSED
Findings: Very awkward question to administer. This might help to be a show card for
response categories.
Recommendations: Consider show card of response categories to make the question easier to
understand.
CONFCHK7
IF CON11=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.
CONFCHK8 IF CON11b=1, CONTINUE; ELSE GO TO CONF4b
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
Findings: No problems found.
Recommendations: None
CONF4b. (Have you\Has name) ever used a PRESCRIPTION inhaler?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No problems found.
Recommendations: None
E-4
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
Findings: 3 of 3 respondents indicated YES. No problems found.
Recommendations: None
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
Findings: 2 of the 3 respondents indicated YES. No problems found.
Recommendations: None
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
Findings: No problems found.
Recommendations: None
E-5
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
Findings: No problems found.
Recommendations: None
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
Findings: No problems found. One respondent did ask, “Is this what peak flow is”?
Recommendations: None
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
Findings: No problems found.
Recommendations: None
CONF4k. When was the last time (you/name) received the following to teach (you/him/her) how
to take care of (your/his/her) asthma?
CONF4k1.
CONF4k2.
A telephone call to (your/his/her) house
An appointment with nurse
E-6
CONF4k3.
CONF4k4.
A visit to (your/his/her) home
A referral to a specialist
FOR EACH:
1
WITHIN PAST 6 MONTHS
2
MORE THAN 6 MONTHS AGO BUT NO MORE THAN 1 YEAR AGO
3
MORE THAN 1 YEAR AGO BUT NO MORE THAN 2 YEARS AGO
4
MORE THAN 2 YEARS AGO BUT NO MORE THAN 5 YEARS AGO
5
MORE THAN 5 YEARS AGO
6
NEVER
F3
DON’T KNOW
F4
REFUSED
Findings: Same concerns as CONNF3a
Recommendations: Same recommendations as CONNF3a
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
Findings: Two respondents said NO
Recommendations: None
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
Findings: No problems found.
Recommendations: None
E-7
CONF5b. How often (do you check your/does name check his/her) blood for glucose or sugar?
Include times when G/Q/U 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
Findings: One interviewer did not know how to administer this (G/Q/U)
Recommendations: Need clarification so interviewers will know how to administer.
CONF5c. Glycosylated (GLY-CO-SYL-AT-ED) hemoglobin or the “A one C” test measures the
average level of blood G/Q 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
Findings: One interviewer did not know how to administer this (G/Q). Another respondent was
not familiar with A one C
Recommendations: Need clarification to question so interviewers will know how to
administer.
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
NO TEST IN PAST 12 MONTHS
ALWAYS
MOST OF THE TIME
SOME OF THE TIME
RARELY
NEVER
DON’T KNOW
E-8
F4
REFUSED
Findings: Only respondent said #3
Recommendations: None
CONF5e. When was the last time (you/name) received 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
WITHIN PAST 6 MONTHS
2
MORE THAN 6 MONTHS AGO BUT NO MORE THAN 1 YEAR AGO
3
MORE THAN 1 YEAR AGO BUT NO MORE THAN 2 YEARS AGO
4
MORE THAN 2 YEARS AGO BUT NO MORE THAN 5 YEARS AGO
5
MORE THAN 5 YEARS AGO
6
NEVER
F3
DON’T KNOW
F4
REFUSED
Findings: Same concerns as CONF3a
Recommendations: Same recommendations as CONF3a
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
Findings: 6 of 7 responded NO
Recommendations: None
E-9
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
Findings: 4 of 6 responded YES
Recommendations: None
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], or someplace else?
1
2
F3
F4
REFERENCE HEALTH CENTER
SOMEPLACE ELSE
DON’T KNOW
REFUSED
Findings: One respondent said both 1 and 2.
Recommendations: Consider whether to allow multiple responses or how to deal with multiple
responses.
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
Findings: Responses varied. No problems found.
Recommendations: None.
E-10
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
Findings: 6 of 7 women said YES.. No problems found. Everyone understood definition.
Recommendations: None.
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
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
Findings: Responses varied. Three respondents said greater than 5 years ago and explained
they had a hysterectomy.
Recommendations: Consider adding a response for “NA – HAD A HYSTERECTOMY”
F-1
CAN1b. What was the main reason you had this Pap smear or Pap test?
1
2
3
F3
F4
PART OF A ROUTINE EXAM
BECAUSE OF A PROBLEM
OTHER
DON’T KNOW
REFUSED
Findings: No problems found.
Recommendations: Consider having categories read to respondent as it would make it easier
on the interviewer. Several times we probed their response to get it to fit into one of these
categories.
CANCHK2A IF CAN1A=1, 2, 3, THEN CONTINUE; ELSE GO TO CAN2
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 additional tests or treatment?
1.
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: Only one respondent said YES
Recommendations: None.
CANCHK3
IF CAN1c = 1, CONTINUE; ELSE GO TO CANCHK5
CAN1d. Were the additional tests or treatment done?
1.
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: The one respondent said YES. No problems found.
Recommendations: None.
CANCHK4
IF CAN1d = 2, THEN GO TO CAN1f; ELSE CONTINUE
CAN1e. Did [the reference health center] arrange for the additional tests or treatment?
F-2
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: The one respondent said NO. No problems found.
Recommendations: None.
GO TO CANCHK5
CAN1f. Which of these best describes the main reason you did not get the additional tests or
treatment?
[SHOW CARD MED1]
1
COULD NOT AFFORD CARE
2
INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3
DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4
PROBLEMS GETTING TO DOCTOR’S OFFICE
5
DIFFERENT LANGUAGE
6
COULDN’T GET TIME OFF WORK
7
DIDN’T KNOW WHERE TO GO TO GET CARE
8
WAS REFUSED SERVICES
9
COULDN’T GET CHILD CARE
10
DIDN’T HAVE TIME OR TOOK TO LONG
11
OTHER SPECIFY:_____________
F3
DON’T KNOW
F4
REFUSED
GO TO CANCHK5
Findings: No respondents received this question.
Recommendations: None.
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
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
OTHER
F-3
F3
F4
DON’T KNOW
REFUSED
Findings: No respondents received this question.
Recommendations: None. Consider adding “…OR PARTIAL HYSTERECTOMY” to
category 5.
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
Findings: No respondents received this question.
Recommendations: None.
MAMMOGRAMS
CANCHK5 IF AGE GE 40, THEN CONTINUE; ELSE GO TO CANCHK13
CAN3. Have you ever had a mammogram?
IF NECESSARY: A MAMMOGRAM IS AN X-RAY TAKEN ONLY OF THE BREASTS BY
A MACHINE THAT PRESSES AGAINST THE BREAST.
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: 5 respondents said YES to this question.
Recommendations: None.
CANCHK6
IF CAN3 = 1, CONTINUE; ELSE GO TO CAN3g
CAN3a. When did you have your most recent mammogram?
1
2
3
LESS THAN 1 YEAR AGO
AT LEAST 1 YR, LESS THAN 2 YEARS
AT LEAST 2 YRS, LESS THAN 3 YEARS
F-4
4
5
6
F3
F4
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
Findings: Responses varied. No problems found.
Recommendations: None.
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
Findings: All 5 said YES. No problems found.
Recommendations: Consider reading responses to respondent to make this question easier to
administer.
CANCHK8
IF CAN3a = 1, 2, OR 3, THEN CONTINUE; ELSE GO TO CAN3g
CAN3c. As a result of any mammograms you had done in the past 3 years, were you told that
you should have additional tests or treatment?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: One respondent said “The doctor told me to have a mammogram test every year –
does that count?”
Recommendations: Consider adding “Please don’t consider yearly routine mammograms”
F-5
CANCHK9
IF CAN3b = 1, CONTINUE; ELSE GOTO CANCHK13
CAN3d. Were the additional tests or treatment done?
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
Findings: No respondents received this question.
Recommendations: None.
CANCHK10 IF CAN3d = 2, THEN GO TO CAN3f; ELSE CONTINUE
CAN3e. Did [the reference health center] arrange for the additional tests or treatments?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question.
Recommendations: None.
GO TO CANCHK13
CAN3f. Which of these best describes the main reason you did not get the additional 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 TO LONG
OTHER SPECIFY:_____________
DON’T KNOW
REFUSED
F-6
Findings: No respondents received this question.
Recommendations: None.
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
Findings: No respondents received this question.
Recommendations: None.
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
Findings: No respondents received this question.
Recommendations: None.
COLONOSCOPY/ SIGMOIDOSCOPY EXAM
CANCHK13 IF AGE GE 50, THEN CONTINUE; ELSE GO TO CANCHK19
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
F-7
Findings: Three respondents answered YES
Recommendations: None.
CANCHK14 IF CAN4 = 1, CONTINUE; ELSE GO TO CAN4h
CAN4a. When did you have your most recent exam?
1
2
3
4
5
6
7
F3
F4
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
AT LEAST 5 YEARS, LESS THAN 10 YEARS
10 OR MORE YEARS AGO
DON’T KNOW
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
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
Findings: All 3 respondents said #2
Recommendations: None.
CAN4c. What was the main reason you had this exam? Was it part of a routine exam, because of
a problem, or some other reason?
F-8
1
2
3
F3
F4
PART OF A ROUTINE EXAM
BECAUSE OF A PROBLEM
OTHER REASON
DON’T KNOW
REFUSED
Findings: Two respondents answered #3 – History of colon cancer in the family.
Recommendations: Consider adding another response “HISTORY OF CANCER IN MY
FAMILY”
CAN4d. As a result of this exam, were you told that you should have additional tests or
treatment?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: All 3 respondents said NO
Recommendations: None.
CANCHK15 IF CAN4d = 1, CONTINUE; ELSE GO TO CANCHK19
CAN4e. Were the additional tests or treatment done?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question
Recommendations: None.
CANCHK16 IF CAN4e = 2, THEN GO TO CAN4g; ELSE CONTINUE
CAN4f. Did [the reference health center] arrange for the additional tests or treatment?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question
F-9
Recommendations:
None.
GO TO CANCHK19
CAN4g. Which of these best describes the main reason you did not get the additional 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 TO LONG
OTHER SPECIFY:_____________
DON’T KNOW
REFUSED
Findings: No respondents received this question
Recommendations: None.
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
Findings: No respondents received this question
Recommendations: None.
F-10
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
Findings: No respondents received this question
Recommendations: None.
BLOOD STOOL OR OCCULT BLOOD TESTS
CANCHK19 IF AGE GE 40, THEN CONTINUE; ELSE GO TO MODULE G
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
Findings: 7 respondents all said NO to this question.
Recommendations: None.
CANCHK20 IF CAN5 = 1, CONTINUE; ELSE GO TO CAN5g
CAN5a. When did you have your most recent blood stool test using a kit at home?
1
2
3
4
5
6
7
F3
F4
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
AT LEAST YRS, LESS THAN YEARS
10 OR MORE YEARS AGO
DON’T KNOW
REFUSED
F-11
Findings: No respondents received this question
Recommendations: None.
CANCHK21 IF CAN5a = 1,2,3, CONTINUE; ELSE GO TO CAN5g
CAN5b. What was the MAIN reason you had this test?
1
2
3
4
5
F3
F4
PART OF A ROUTINE PHYSICAL EXAM/SCREENING TEST
BECAUSE OF A SPECIFIC PROBLEM
FOLLOW-UP TEST OF AN EARLIER TEST OR SCREENING EXAM
FAMILY HISTORY
OTHER
DON’T KNOW
REFUSED
Findings: No respondents received this question
Recommendations: None.
CAN5c. Was this blood stool test done at home, [the reference health center] or somewhere else?
1
2
3
F3
F4
HOME
THE REFERENCE HEALTH CENTER
SOMEWHERE ELSE
DON’T KNOW
REFUSED
Findings: No respondents received this question
Recommendations: None.
CAN5d. As a result of this test, did you need additional tests or treatment?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question
Recommendations: None.
CANCHK22 IF CAN5d =1, THEN CONTINUE; ELSE GO TO MODULE G
CAN5e. Where were the additional tests or treatment done?
F-12
1
2
3
4
5
6
F3
F4
Did not have additional tests or treatment
The reference health center
Another clinic
A private doctor’s office
A hospital
Other
DON’T KNOW
REFUSED
Findings: No respondents received this question
Recommendations: None.
CANCHK22 IF CAN5e = 3,4,5,6, THEN CONTINUE; ELSE GO TO MODULE G
CAN5f. Did the [reference health center] arrange for the additional tests or treatments?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question
Recommendations: None.
CAN5g. 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
Findings: 1 respondent of 7 said YES to this question. This was because of a problem but then
decided to do a colonoscopy instead.
Recommendations: None.
F-13
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. 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
Findings: All 11 responses varied greatly.
Recommendations: None.
HEA2. 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
Findings: 10 of the respondents selected one or several from the first five categories. Only one
respondent selected #9.
Recommendations: None.
G-1
HEA3. 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
Findings: 8 respondents selected YES.
Recommendations: None.
HEACHK1 IF HEA3=1 OR 3, THEN CONTINUE; ELSE GO TO HEA3c
HEA3a. 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
Findings: Several respondents selected more than one place. Three respondents selected the
health center.
Recommendations: None.
HEA3b. (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
G-2
Findings: This question came across as repetitive – very similar to what was asked in HEA3
Recommendations: None.
HEACHK2 IF HEA3b=1, THEN GOTO HEACHK3; ELSE CONTINUE
HEA3c. 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
[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
DON’T KNOW
REFUSED
Findings: No problems found
Recommendations: None.
HEACHK3 IF HEA3a NE 1 AND HEA3c NE 1, THEN CONTINUE; ELSE GO TO
HEA3e
HEA3d. Earlier you said that the [reference health center] is not the place you usually go when
(you are/name is) sick or need advice. Why is that?
__________ {allow 0-40}
F3
DON’T KNOW
F4
REFUSED
Findings: No respondents received this question
Recommendations: None.
GO TO HEA4
G-3
HEA3e.How long has [the reference health center] been the place you go for (your/name’s)
health care needs?
1
2
3
4
5
6
7
F3
F4
LESS THAN 6 MONTHS
AT LEAST 6 MONTHS, BUT NOT MORE THAN 1 YEAR
AT LEAST 1 YEAR, BUT NO MORE THAN 2 YEARS
AT LEAST 2 YEARS, BUT NO MORE THAN 3 YEARS
AT LEAST 3 YEARS, BUT NO MORE THAN 4 YEARS
AT LEAST 4 YEARS, BUT NO MORE THAN 5 YEARS
MORE THAN 5 YEARS
DON’T KNOW
REFUSED
Findings: 4 of 5 respondents said at least 4 years. One interviewer felt this question was
redundant with HEA1
Recommendations: None. Consider whether this question or HEA1 could be cut since HEA1
is very similar.
HEA4. 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.
_____ TIMES
F3
DON’T KNOW
F4
REFUSED
Findings: This was found to be a long question by 2 respondents. Otherwise, no problems
found. One respondent felt we were still referring to the health center and not any doctor.
Recommendations: Consider possibly shortening the question. Consider skip here for
responses of 0, DK, or RE… they should not get next 2 questions. Consider moving this question
or adding additional text to refocus the respondent on visits to ANY doctor within or outside the
health center.
HEA5. How many of those times did you come to [reference health center]?
_____ TIMES
F3
DON’T KNOW
F4
REFUSED
Findings: No problems found
Recommendations: None.
G-4
HEA6a 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
Findings: No problems found
Recommendations: None.
HEACHK4 If HEA6a=1, THEN CONTINUE; ELSE GOTO HEACHK6
HEA6b. 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
Findings: Two respondents received this question and said YES. No problems found
Recommendations: None.
HEACHK5 If HEA6b=1, THEN CONTINUE; ELSE GOTO HEA6d
HEA6c. 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
Findings: No one received this question.
Recommendations: None.
GOTO HEACHK6
G-5
HEA6d. 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
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
Findings: No one received this question.
Recommendations: None.
HEACHK6 IF ENGLISH IS NOT NATIVE LANGUAGE, THEN CONTINUE; ELSE
GO TO HEA8
HEA7.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
Findings: Two respondents both said ENGLISH
Recommendations: None.
HEACHK7 IF HEA7=2 or 4, THEN CONTINUE; ELSE GO TO HEA8
G-6
HEA7a. 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
Findings: Responses varied from #1 TO #5
Recommendations: None.
HEA8. 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, and so on?
get transportation to medical appointments or provided you with tokens or vouchers to
help you pay for transportation to medical appointments?
obtaining welfare, public benefits, or TANF
with basic needs, such as finding a place to live, finding a job, finding childcare, helping
you obtain food or clothing.
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
Findings: Responses varied. There were a few additional – Asthma meds (helped me get free
meds for 6 months). Another respondent said she was helped to apply for Medicaid at the clinic.
Recommendations: None.
HEACHK8 FOR EACH ITEM IN HEA8 = 1:
HEA9. 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
Very Important
Somewhat Important
Not Very Important
G-7
4
F3
F4
Not at all Important
DON’T KNOW
REFUSED
Findings: All the respondents said it was very or somewhat important
Recommendations: None.
HEA10. IF SELF-RESPONDENT, ASK: How (do you/does name) usually get to the health
center? IF PROXY-RESPONDENT, ASK: 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
Findings: Responses varied but were all of the first 4.
Recommendations: None.
HEA10a. About how long does it usually take you to get there?
_____ MINUTES
OR
_____ HOURS
F3
DON’T KNOW
F4
REFUSED
Findings: No problems found.
Recommendations: None.
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:
Findings: This question is very hard and awkward to administer.
Recommendations: Strongly consider a showcard fro response categories..
HEA11. EASE OF GETTING CARE:
G-8
a.
b.
c.
d.
Ability to get in to be seen
Hours center is open
Convenience of center’s location
Prompt return on calls
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
EXCELLENT
VERY GOOD
GOOD
FAIR
G-9
5
F3
F4
POOR
DON’T KNOW
REFUSED
HEA15. CONFIDENTIALITY:
a.
Keeping my personal information private
1
2
3
4
5
F3
F4
EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON’T KNOW
REFUSED
Recommendations: Consider changing “my” with “your”. “My” was used when this was a
self-administered scale.
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.
are friendly and helpful to you
answers your questions
1
2
3
EXCELLENT
VERY GOOD
GOOD
G-10
4
5
F3
F4
FAIR
POOR
DON’T KNOW
REFUSED
Findings (HEA11 – HEA17): This is a long series to administer. It will be easier as a
showcard. Otherwise, once the respondent understands the series… it move along well.
Recommendations: None.
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.
are 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
Findings: No problems found.
Recommendations: None.
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
Findings: No problems found.
Recommendations: None.
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]
G-11
CODE ALL THAT APPLY
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
Findings: Question asks MAIN reason while it says to code all that apply. We received many
responses to this very long list. It takes a while for respondents to read though and really slows
down the interview.
Recommendations: Consider keeping this as MAIN reason and remove the code all that apply.
Shorten list if possible as this is a lot of reading and slows interview. Another option is to
collapse responses into categories to help shorten list (for example 16 and 17 can be combined).
HEA21. Have you ever had a serious problem with the care (you/name) received at the health
center, the staff, or the way the health center is run?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No problems found.
G-12
Recommendations:
None.
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
Findings: No one received this question.
Recommendations: None.
HEA22. Did you complain to someone or file a written complaint?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No one received this question.
Recommendations: None.
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
Findings: No one received this question.
Recommendations: None.
G-13
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].
[SHOWCARD SUB1]
Please look at this show card. We are interested in whether you have used any of these for nonmedical reasons.
SUB1. In your life, which of the following substances have you ever used? Have you used…
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
F3
F4
Tobacco Products
(CIGARETTES, CHEWING TOBACCO, CIGARS, ETC.)
Alcoholic Beverages (BEER, WINE, SPIRITS, ETC.)
Cannabis
(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
Findings: Respondents felt we should use Marijuana as the category instead of Cannabis. Two
respondents mentioned prescribed drugs they were using. It is clear that we need to be more
specific about illicit use of drugs here.
Recommendations: “:Non-medical use” is not strong enough. We need to be clear that we are
asking about non-prescribed illicit use of these drugs. We might be able to get language from the
NSDUH.
SUBCHK1
IF NONE MENTIONED IN SUB1, GO TO MODULE I;
ELSE CONTINUE
H-1
NOTE TO PROGRAMMERS: CODING OF RESPONSE VALUES MUST ALIGN WITH
SCALE
SUB2. 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
2
3
4
6
F3
F4
Never
Once or twice
Monthly
Weekly
Daily or Almost Daily
DON’T KNOW
REFUSED
SUBCHK2
IF NONE MENTIONED IN SUB2, GO TO SUB2d;
ELSE CONTINUE
Findings: Responses varied greatly. Awkward to administer on paper but will work well on
computer. You get the impression that these respondents are providing a socially-acceptable
response with these questions. This is the reason NSDUH administers these as self-administered.
Recommendations: None.
SUB2a. 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
Findings: No problems found with this question.
Recommendations: None.
H-2
SUB2b. 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
Findings: This question is appropriate for all of the substances except tobacco use. When
administering this to a respondent that uses tobacco, they don’t think in terms of these kind of
problems.
Recommendations: Consider a skip for tobacco use.
SUB2c 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
Findings: No problems found with this question other than this being very awkward for
tobacco users..
Recommendations: Consider a skip for tobacco use.
SUB2d. 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…
H-3
0
1
2
F3
F4
No, never
Yes, in the past 3 months
Yes, but not in the past 3 months
DON’T KNOW
REFUSED
Findings: Response set is awkward
Recommendations: Consider removing No and Yes for easier administration. I.E.
0
1
2
F3
F4
Never
In the past 3 months
Not in the past 3 months
DON’T KNOW
REFUSED
SUB2e. 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
No, never
Yes, in the past 3 months
Yes, but not in the past 3 months
DON’T KNOW
REFUSED
Findings: Response set is awkward
Recommendations: Consider removing No and Yes for easier administration. I.E.
0
1
2
F3
F4
Never
In the past 3 months
Not in the past 3 months
DON’T KNOW
REFUSED
SUB3. Have you ever used any drug by injection? (NON-MEDICAL USE ONLY)
Would you say…
0
1
2
F3
No, never
Yes, in the past 3 months
Yes, but not in the past 3 months
DON’T KNOW
H-4
F4
REFUSED
Findings: Response set is awkward
Recommendations: Consider removing No and Yes for easier administration. I.E.
0
1
2
F3
F4
SUBCHK2
Never
In the past 3 months
Not in the past 3 months
DON’T KNOW
REFUSED
IF SUB2a NE 0, F3, F4, CONTINUE; ELSE GO TO SUBCHK4
SUB4. Earlier you indicated that you have used tobacco products (FILL FROM SUB2a: once or
twice /monthly /weekly /daily or almost daily] in the past three months. On how many of the past
30 days did you smoke a cigarette?
______ DAYS
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
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
Findings: Responses varied. No problems found.
Recommendations: None.
H-5
SUB5. Did you smoke cigarettes in the past 12 months?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No problems found.
Recommendations: None.
SUBCHK5
IF SUB5=1, THEN CONTINUE; ELSE GO TO SUBCHK6
SUB5a. During past 12 months, have you wanted to stop smoking?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
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
Findings: No problems found.
Recommendations: None.
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
YES
NO
DON’T KNOW
H-6
F4
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
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
Findings: 1 of 3 respondents had trouble with this question. It was tough to determine an
average number of drinks. He also had trouble determining if a can of beer = 1 drink.
Recommendations: Consider providing an example that one drink = 1 beer, 1 glass of wine,
etc… NSDUH uses this example effectively.
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
Findings: No problems found.
Recommendations: None.
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
Findings: No problems found.
Recommendations: None.
SUBCHK8
IF SUB9=2, CONTINUE; ELSE GO TO SUBCHK9
SUB9a. In past 12 months has your doctor asked you about your use of alcohol?
H-7
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No problems found.
Recommendations: None.
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
Findings: No problems found.
Recommendations: None.
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
Findings: No problems found.
Recommendations: None.
SUBCHK11 IF SUB10a=2, THEN CONTINUE; ELSE GO TO SUBCHK12
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
H-8
Findings: No problems found.
Recommendations: None.
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
Findings: No respondents received this question.
Recommendations: None.
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
Findings: No respondents received this question.
Recommendations: None.
SUBCHK14 IF SUB11a = 0, GOTO SUBCHK15; ELSE CONTINUE
SUB11b. On how many days in the PAST 12 MONTHS did you use drugs that you INJECT
WITH A NEEDLE?
______ NUMBER OF DAYS
F3
DON’T KNOW
F4
REFUSED
Findings: No respondents received this question.
Recommendations: None.
H-9
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
Findings: 3 respondents said NO to this question.
Recommendations: None.
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
Findings: 3 respondents said NO to this question.
Recommendations: None.
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
Findings: No respondents received this question.
Recommendations: None.
H-10
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
Findings: No respondents received this question.
Recommendations: None.
GO TO MODULE I
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
Findings: No respondents received this question.
Recommendations: None.
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
Findings: No respondents received this question.
Recommendations: None.
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]
H-11
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
Findings: No respondents received this question.
Recommendations: None.
H-12
MODULE I: DENTAL
DENCHK1 IF AGE GE 2, THEN CONTINUE; ELSE GO TO MODULE J
The next questions are about your dental history.
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
Findings: 6 respondents said YES to this question.
Recommendations: None.
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
Findings: 2 of 6 respondents said YES to this question.
Recommendations: None.
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
Findings: Teeth pulled and toothache that lasted 3 weeks.
Recommendations: None.
I-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
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
AFRAID OF GOING TO THE DENTIST/ HAVING DENTAL WORK DONE
OTHER SPECIFY:_____________
DON’T KNOW
REFUSED
Findings: Both respondents said #1 to this question.
Recommendations: None.
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
Findings: Both respondents said #1 to this question.
Recommendations: None.
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
I-2
Findings: This is awkward after the first series for the two respondents that could not get care.
One respondent was delayed in getting care.
Recommendations: Consider a skip for those that answered DEN2-DEN5
DENCHK4 IF DEN5=1, THEN CONTINUE; ELSE GO TO DEN10
DEN7. What kind of dental care, test, or treatment was it that (you were/name was) delayed in
getting?
________________ (allow 40)
F3
DON’T KNOW
F4
REFUSED
Findings: A respondent said she was delayed in getting her teeth pulled because she had other
medical problems going on.
Recommendations: None.
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
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
AFRAID OF GOING TO THE DENTIST/ HAVING DENTAL WORK DONE
OTHER SPECIFY:_____________
DON’T KNOW
REFUSED
Findings: The respondent selected #12 – Due to other health problems.
Recommendations: None.
I-3
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
Findings: Respondent said #2 to this question.
Recommendations: None.
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, BUTNOT MORE THAN 5 YEARS AGO
MORE THAN 5 YEARS AGO
NEVER HAVE BEEN
DON’T KNOW
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
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
Findings: Responses varied. No problems found.
Recommendations: None.
DENCHK6 If DEN11=1 or 2, THEN CONTINUE; ELSE GO TO DENCHK6
I-4
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
Findings: Responses varied but one respondent said that it is sometimes good and sometimes
bad. He couldn’t come up with a clear response.
Recommendations: None.
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
Findings: One respondent said YES. No problems found.
Recommendations: None.
DEN14 In the past 12 months, (have you/has name) received any kind of dental care from a
doctor or other medical professional?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: There was some confusion that this was a duplicative question.
Recommendations: Consider emphasizing “doctor or other medical professional” by
underlining text.
I-5
Now, I have some questions about the condition of (your/name’s) teeth and gums.
Findings: This transition is duplicated in DEN16a and somewhat in Den16b
Recommendations: Consider removing transition.
DENCHK7 IF AGE LE11 GOTO DEN16a
DEN15. Have you lost all of your upper and lower natural, permanent, teeth?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: One respondent said YES. No problems found.
Recommendations: None.
DENCHK8 DEN15=2 CONTINUE ELSE GOTO DEN16b
DEN16a. Now I have some questions about the condition of (your/name’s) teeth and gums. 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
Findings: Responses varied. No problems found.
Recommendations: None.
GOTO DEN17
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
Excellent
Very Good
Good
Fair
Poor
DON’T KNOW
I-6
F4
REFUSED
Findings: No problems found.
Recommendations: None.
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
Findings: Responses varied. No problems found.
Recommendations: None.
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
Findings: Responses varied. No problems found.
Recommendations: None.
I-7
DENCHK8 IF DEN17a-h=1 or DEN18a-f=1, CONTINUE; ELSE GO TO MODULE J
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
Findings: Responses varied. No problems found.
Recommendations: None.
I-8
MODULE J: 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
Findings: 12 respondents said YES. No problems found. One respondent said “for my mouth?”
Recommendations: Consider a better transition statement such as: “The next questions are about
prescription medications for general medical conditions”
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
Findings: All 12 respondents said NO
Recommendations: None.
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
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
J-1
10
11
12
F3
F4
DIDN’T HAVE TIME OR TOOK TO LONG
PHARMACY DID NOT HAVE IN STOCK
OTHER SPECIFY:_____________
DON’T KNOW
REFUSED
Findings: No respondents received this question.
Recommendations: None.
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
Findings: No respondents received this question.
Recommendations: None.
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
Findings: 1 respondent said YES to this question.
Recommendations: None.
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
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
J-2
6
7
8
9
10
11
12
F3
F4
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
PHARMACY DID NOT HAVE IN STOCK
OTHER SPECIFY:_____________
DON’T KNOW
REFUSED
Findings: One respondent selected #7
Recommendations: None.
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
Findings: One respondent selected #1. She said she just moved here and didn’t know where to
go.
Recommendations: None.
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
Findings: One respondent selected NO
Recommendations: None.
PRSCHK5
IF PRS4=1, THEN CONTINUE; ELSE GO TO PRS5
PRS4a. Did you try to get this prescription filled?
1
YES
J-3
2
F3
F4
NO
REFUSED
DON’T KNOW
Findings: No respondents received this question.
Recommendations: None.
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
Findings: 10 respondents said YES to this question.
Recommendations: None.
PRSCHK6
IF PRS5=1, THEN CONTINUE; ELSE GO TO MODULE K
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 then [the reference health center]
DON’T KNOW
REFUSED
Findings: 3 respondents said they get it filled at the health center.
Recommendations: None.
PRS5. About how many different prescription medicines (do you/does name) usually take in a
month?
__________NUMBER/ MEDICINES
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
PRSCHK7 IF PRS4a =1 OR 2 CONTINUE ELSE GOTO MODULE K
J-4
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
Findings: No problems found.
Recommendations: None.
IF PRS5a = 1 OR 2 CONTINUE ELSE GOTO MODULE K
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
Findings: No problems found.
Recommendations: None.
J-5
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
Findings: Responses varied. No problems found.
Recommendations: None.
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
NOT AT ALL
A LITTLE
SOME
A LOT
DON’T KNOW
REFUSED
Findings: 6 respondents selected #1
Recommendations: None.
K-1
MEN2a. Have you ever had depression?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: 4 respondents said YES. No problems found.
Recommendations: None.
MEN2b. Have you ever had generalized anxiety?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: 6 respondents did not know what this means.
Recommendations: Strongly consider a definition of “generalized anxiety”.
MEN2c.Have you ever had panic disorder?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No problems found. We probed all respondents to tell us in their own words what
this meant and they generally understand a “panic disorder”
Recommendations: None.
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?
K-2
FOR EACH:
1
NOT TRUE
2
SOMETIMES TRUE
3
OFTEN TRUE
F3
DON’T KNOW
F4
REFUSED
Findings: No respondents received this question.
Recommendations: None.
MENCHK3 IF AGE =4 TO 11, THEN CONTINUE; ELSE GO TO MENCHK3
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?
FOR EACH:
1
NOT TRUE
2
SOMETIMES TRUE
3
OFTEN TRUE
F3
DON’T KNOW
F4
REFUSED
Findings: One respondent answered Not True to each. No problems found.
Recommendations: None.
MENCHK4 IF AGE =12 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.
Can’t concentrate or pay attention long?
b.
Lies or cheats?
c.
Doesn’t get along with other kids?
d.
Has been unhappy, sad, or depressed?
e.
Does poorly at school work?
f.
Has trouble sleeping?
K-3
FOR EACH:
1
NOT TRUE
2
SOMETIMES TRUE
3
OFTEN TRUE
F3
DON’T KNOW
F4
REFUSED
Findings: One respondent answered Not True to each. No problems found.
Recommendations: None.
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
Findings: All respondents said NO. No problems found.
Recommendations: None.
MENCHK5 IF MEN5 = 1, CONTINUE; ELSE GO TO MENCHK7
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
Findings: No respondents received this question.
Recommendations: None.
MENCHK6 IF MEN6 = 1, CONTINUE; ELSE GO TO MEN7
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
COULD NOT AFFORD CARE
K-4
2
3
4
5
6
7
8
9
10
11
12
F3
F4
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
WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID
NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
OTHER SPECIFY:_____________
DON’T KNOW
REFUSED
Findings: No respondents received this question.
Recommendations: None
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
Findings: No respondents received this question.
Recommendations: None
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
Findings: No respondents answered YES.
Recommendations: None
MENCHK7 IF MEN7=1, CONTINUE; ELSE GO TO MENCHK8
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?
K-5
[SHOW CARD MED1]
1
2
3
4
5
6
7
8
9
10
11
12
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
WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID
NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
OTHER SPECIFY:_____________
DON’T KNOW
REFUSED
Findings: No respondents received this question.
Recommendations: None
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
Findings: No respondents received this question.
Recommendations: None
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
YES
K-6
2
F3
F4
NO
DON’T KNOW
REFUSED
Findings: No respondents said YES to this question.
Recommendations: None. Consider making …” 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.” Optional text.
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)_________________
Findings: No respondents received this question.
Recommendations: None
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
Findings: No respondents received this question.
Recommendations: None
K-7
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
Findings: No respondents received this question.
Recommendations: None
MENCHK11 IF MEN9a=1 OR 2, THEN CONTINUE; ELSE GO TO MENCHK12
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
Findings: No respondents received this question.
Recommendations: None
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
Findings: No respondents received this question.
Recommendations: None
K-8
MODULE L: PREGNANCY/PRENATAL CARE
PRGCHK0
IF FEMALE AGE 15-49, CONTINUE; ELSE GO TO MODULE M
PRENATAL CARE
PRG1. Have you been pregnant in the past 3 years?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: 2 respondents said YES.
Recommendations: Consider a transition statement before this question, “The next questions
are about pregnancy and prenatal care.”
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
Findings: Both respondents said YES.
Recommendations: None
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
Findings: Both respondents said SOME.
Recommendations: None
L-1
PRGCHK3
IF PRG3=1-2, THEN CONTINUE; ELSE GO TO PRGCHK4
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
Findings: Respondents said VG and Excellent
Recommendations: None
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
Findings: No problems found
Recommendations: None
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
Findings: Both respondents said NO.
Recommendations: None
L-2
PRGCHK5
IF PRG6=1, CONTINUE ELSE GO TO MODULE PRG8
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
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
Findings: No respondents received this question.
Recommendations: None
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?
a.
b.
c.
d.
e.
f.
g.
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
FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
Findings: Response categories seemed awkward to administer. One respondent said we should
include prenatal vitamins.
L-3
Recommendations:
PRGCHK6
Consider revising categories for easier administration.
IF PRG8a-PRG8g=1, THEN CONTINUE; ELSE GOTO PRG11
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 visits
Some of the visits
None of the visits
DON’T KNOW
REFUSED
Findings: No problems found.
Recommendations: None
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
Findings: No problems found.
Recommendations: None
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
Findings: No respondents received this question.
Recommendations: None
L-4
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
Findings: All respondents said NO. No problems found.
Recommendations: None
PRGCHK9
IF PRG11=1, THEN CONTINUE; ELSE GO TO MODULE M
PRG12. Which of these best describes the main reason you were unable to get that family
planning service?
[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
Findings: No respondents received this question.
Recommendations: None
L-5
MODULE M: OCCUPATIONAL HEALTH
WORK RELATED INJURIES
OCCCHK0 IF AGE GE 12, THEN CONTINUE; ELSE GO TO MODULE N
Now I am going to ask you about on-the-job injuries or illnesses in the past 12 months. As you
know, little injuries and illnesses occur from time to time when we are working, but sometimes it
is more serious. We are interested in the more serious injuries and illnesses, those which may
have resulted in the following things: you couldn’t work for at least 4 hours; you couldn’t work
normally for at least 4 hours; you had to receive medical attention; or you had to take medicine
prescribed by a doctor in order to be able to continue working. These injuries or illnesses include
those that happen while you were at work and those that occur while traveling to and from the
workplace. Do not include travel from home to work unless your employer provides your living
quarters.
OCC1. During the last 12 months, that is since (12 MONTH REFERENCE DATE), have you
suffered an injury or illness while doing work or while traveling to and from work?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: Age of 12 or older seems a little young here. Was awkward for adolescent
interviews. One respondent had not been working since 2005 and another had not worked in past
12 months. We asked all respondents what they thought about the introduction. They said it was
long but easy to understand. Only 1 respondent had been injured. Two respondents were retired.
Recommendations: Consider raising the age to 14 or 16. Consider a category for “HAVE HOT
WORKED IN PAST 12 MONTHS”. Consider breaking up intro into easy to read statements for
the interviewer to emphasize. Consider adding response category “NA – RETIRED”
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
2
while working
while traveling between worksites
1. __________ WHILE WORKING
2. __________ WHILE TRAVELING BETWEEN WORKSITES
F3
DON’T KNOW
F4
REFUSED
Findings: Respondent said 1 while working.
Recommendations: None
M-1
INJURY LOOP
OCC2a.
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]
Findings: This was awkward as it assumes more than one injury. Respondent was injured
pulling a refrigerator up on a dolly..
Recommendations: Include logic for 1 injury and ask “I would like to ask you about this
injury”
OCC2b. Please look at this card and tell me all the diagnoses 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
M-2
Findings: Respondent selected #4
Recommendations: None
OCC2c. FOR EACH: Did you receive medical care for this injury or illness?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: Respondent did not get medical attention.
Recommendations: None
OCCCHK2 IF OCC2c = 2, THEN CONTINUE; ELSE GO TO OCC2e
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
Findings: Respondent selected other… He realized the injury only after he left the job then he
couldn’t afford a doctor to take care of the injury.
Recommendations: None
GOTO MODULE N
M-3
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
Findings: No respondents received this question.
Recommendations: None
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
Findings: No respondents received this question.
Recommendations: None
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
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
M-4
F4
REFUSED
Findings: No respondents received this question.
Recommendations: None
OCC2h. Has the injury or illness resulted in a continuing disability?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question. Respondent should have received this
question
Recommendations: Consider altering skip logic after OCC2d so that they receive this
question.
OCC2i. Did you report this injury or illness to your employer?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question. Respondent should have received this
question
Recommendations: Consider altering skip logic after OCC2d so that they receive this
question.
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
Findings: No respondents received this question. Respondent should have received this
question
Recommendations: Consider altering skip logic after OCC2d so that they receive this
question.
M-5
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
Findings: 2 respondents said NO
Recommendations: None.
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
99
Some other reason (specify) _______________________
F3
DON’T KNOW
F4
REFUSED
Findings: 2 respondents said #2
Recommendations: None.
HTG3. Has anyone at [the reference health center] ever suggested that you have your blood
tested for the AIDS virus infection?
1
2
YES
NO
N-1
F3
F4
DON’T KNOW
REFUSED
Findings: 2 respondents said NO
Recommendations: None.
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
Findings: 5 of 8 respondents said YES
Recommendations: None.
HTG5. Have you ever been told by a doctor or other health professional that you were HIV
positive?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: All 8 respondents said NO
Recommendations: None.
HTG6. Have you ever been told by a doctor or other health professional that you have AIDS?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: All 8 respondents said NO. One respondent though HTG5 and HTG6 were asking
the same thing.
Recommendations: Consider underlining HIV positive and AIDS in these questions for
emphasis
HTGCHK3 IF HTG5 OR HTG6=1, THEN CONTINUE; ELSE GO TO MODULE O
HTG6a. Are you receiving any medical care now for HIV or AIDS?
N-2
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received these questions.
Recommendations: None.
HTG6b. Are you receiving antiretroviral therapy?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received these questions.
Recommendations: None.
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
Findings: No respondents received these questions.
Recommendations: None.
HTGCHK4 IF HTG6c=2, THEN CONTINUE; ELSE GO TO MODULE O
HTG6d. Were you/name referred there by [the reference health center]?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received these questions.
Recommendations: None.
N-3
MODULE O:
LIVING ARRANGEMENTS
Next, I’d like to ask some questions about where (you/name) live.
LIV1 Where were (you/name) living, or sleeping, last night?
IF SLEPT IN DIFFERENT PLACE THAN WHERE “LIVE” - INSTRUCT RESPONDENT TO
RESPOND ABOUT WHERE HE/SHE LIVES.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
A HOUSE (INCLUDES TRAILERS OR MOBILE HOMES)
AN APARTMENT
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
LIVCHK1
IF LIV1=12, 13, OR 14, THEN GO TO LIV1a; ELSE
IF LIV1=1, 2, 3, 4, 5, OR 6, THEN GO TO LIV1b; ELSE
IF LIV1=7, 8, 9, 10, 11, OR 15, THEN GO TO LIV2
Findings: This was somewhat awkward to administer as some respondents would say “at
home”. 13 respondents all chose one of the first 5 categories.
Recommendations: Consider changing question to “What type of place where (you/name)
living, or sleeping, last night?
LIV1a. During the past 30 days, how often did (you/name) sleep there? Would you say…?
1
less than a week a month
2
at least a week, but less than 2-3 weeks a month
3
every night of the month or almost every night of the month
F3
DON’T KNOW
F4
REFUSED
O-1
Findings: No respondents received these questions.
Recommendations: None.
LIVCHK2
IF LIV1a=1 OR 2, THEN GO TO LIV2; ELSE GO TO LIV3
LIV1b. Who does that place belong to?
1
2
3.
4.
5
6
7
F3
F4
I OWN IT
MY PARENT(S) OR GUARDIAN(S) OWN IT
A PRIVATE LANDLORD OR APARTMENT MANAGEMENT
PUBLIC HOUSING AUTHORITY
PROVIDED THROUGH A SOCIAL SERVICE PROVIDER
SPOUSE, PARTNER, OR BOYFRIEND/GIRLFRIEND
SOMEONE ELSE’S PLACE
DON’T KNOW
REFUSED
Findings: Responses varied. Several additional responses came up such as (sister and friend)
Recommendations: Consider adding “relative” and “friend” as responses.
LIVCHK3
IF LIV1b=1, 2, 3, 6, F3, OR F4, THEN GO TO LIV1c; ELSE GO TO LIV1e
LIV1c. Can (you/name) sleep there for the next month (30 days) without being asked to leave?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No problems found.
Recommendations: None.
LIVCHK4
IF LIV1c=1, THEN CONTINUE; ELSE GO TO LIV2
LIV1d. Does social services, Section 8 or some other government program pay part of the rent or
mortgage?
1
2
F3
F4
YES (GO TO LIV3)
NO (GO TO LIV3)
DON’T KNOW (GO TO LIV3)
REFUSED (GO TO LIV3)
Findings: No problems found.
Recommendations: None.
O-2
WITHOUT REGULAR HOUSING
LIV2. When was the last time (you/name) stayed in a place of your own such as a house,
apartment, room, or other housing for 30 or more days?
________ NUMBER
a.
DAYS AGO
b.
WEEKS AGO
c.
MONTHS AGO
d.
YEARS AGO
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied but a few got stuck on “30 days”. They said they might be without
a place to stay here and there but not for 30 days.
Recommendations: None.
LIV2a. How many times in (your/name’s) life (have you/ has he/she) been without regular
housing? That is not living in a house, apartment, room, or other housing for 30 days or more in
the same place?
0
NONE
1
JUST THIS TIME
______NUMBER TIMES
F3
DON’T KNOW
F4
REFUSED
Findings: One respondent was very confused by this question even after repeating it several
times
Recommendations: Consider a revision to this question.
LIV2b. How old (were you/was name) when (you/he/she) first found (your/him/her)self without
regular housing or a regular place to stay?
_______ AGE
F3
DON’T KNOW
F4
REFUSED
Findings: No problems found.
Recommendations: There needs to be a skip here so we don’t continue and ask questions
about regular housing..
O-3
CURRENTLY WITH REGULAR HOUSING
LIV3 At this place where (you/name) currently live(s), how many rooms are used for sleeping?
______ ROOMS
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
.LIV3a How many people, in total, sleep in these rooms?
______ NUMBER OF PEOPLE
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
LIV4. (Have you/Has name) ever been without regular housing or homeless, that is, not living
in your own house, apartment, or room on a regular basis?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
LIVCHK5 IF LIV4=1, THEN CONTINUE; ELSE GO TO LIV5
LIV4a. How many times in (your/name’s) life have (you/he/she) been without regular housing?
______ NUMBER OF TIMES
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
O-4
LIV4b. How old (were you/was name) when (you/he/she) first found (your/himself/herself)
without regular housing or a regular place to stay?
______ AGE
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
LIV4c. How long (were you/was name) without regular housing/homeless? If more than once,
use the most recent one.
________ NUMBER
a.
DAYS AGO
b.
WEEKS AGO
c.
MONTHS AGO
d.
YEARS AGO
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. No problems found.
Recommendations: Remove “AGO” as that does not match the question.
LIV4d. How long ago did (your/name’s) LAST period of homelessness/without regular housing
end?
________ NUMBER
a.
DAYS AGO
b.
WEEKS AGO
c.
MONTHS AGO
d.
YEARS AGO
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
LIV5. The next question is about the food (you/name) eat(s). Which of the following
statements best describes your situation in terms of the food (you/name) eat(s). (Do you/Does
he/she)….
1
get enough of the kinds of foods (you want/you want him/her) to eat
O-5
2
3
4
F3
F4
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
Findings: Responses varied. No problems found.
Recommendations: None.
LIVCHK6
ASK ONLY OF HCH RESPONDENTS; ELSE GOTO MODULE P
The next few questions are about health care (you/name) may or may not have received while
(you were/he/she was) homeless.
LIV6. While (you were/name was) homeless, did (you/he/she) ever needed a place to recover
from an illness, injury, or hospitalization?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: 5 respondents all said NO
Recommendations: None.
LIVCHK7
IF LIV6=1, CONTINUE; ELSE GO TO MODULE P
LIV6a. Did you find a place to recover from an illness, injury, or hospitalization?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question.
Recommendations: None.
LIVCHK7 IF LIV6a=1, CONTINUE; ELSE GO TO MODULE P
LIV6b. Where did (you/name) go to recover? Was it…
SELECT ALL THAT APPLY
O-6
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
Findings: No respondents received this question.
Recommendations: None.
LIVCHK8
IF LIV6b=4, CONTINUE; ELSE GO TO GO TO MODULE P
LIV6c. How long did (you/name) stay?
1
2
3
F3
F4
1-6 DAYS
7-29 DAYS
30 DAYS OR LONGER
DON’T KNOW
REFUSED
Findings: No respondents received this question.
Recommendations: None.
LIV6d. Did that program help (you/name) get better?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question.
Recommendations: None.
LIV6e. Did that program help (you/name) with getting housing and/or services that (you/he/she)
could use after (you were/he/she was) discharged?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question.
Recommendations: None.
O-7
MODULE P: HEALTH INSURANCE
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
Findings: This section is particularly difficult for adolescents 13-17. No other problems found.
Recommendations: Consider a skip for adolescents.
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
Findings: 10 of 15 respondents said YES. No problems found.
Recommendations: None.
INSCHK1
IF INS1=1, THEN CONTINUE; ELSE GO TO INS4
P-1
INS2. What kind of health insurance or health care coverage (do you/ does name) have?
INCLUDE those that pay for only one type of service (nursing home care, accidents, or dental
care) exclude private plans that only provide extra cash while hospitalized.
CODE ALL THAT APPLY.
1
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
Findings: Most respondents selected one of the first 4.
Recommendations: None.
INSCHK2
IF INS2 =5, THEN CONTINUE, ELSE GO TO INSCHK3
INS2a. Why (do you/does name) come to [the reference health center] if you have access to the
VA system?
__________ (Allow 40)
F3
DON’T KNOW
F4
REFUSED
Findings: No one received this question.
Recommendations: None.
INSCHK3
IF INS2=1, 2, 3 or 4, CONTINUE; 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
P-2
F4
REFUSED
Findings: Responses varied. No problems with this question.
Recommendations: None.
INSCHK4
IF INS2=1, THEN CONTINUE; ELSE GO TO MODULE Q
INS3. Which of these best describes how this plan was obtained?
1
2
3
4
5
6
7
F3
F4
Employer
Union
Through workplace, but don’t know if employer or union
Through workplace, self-employed or professional association
Purchased directly
State/local government or community program
Other specify __________________
DON’T KNOW
REFUSED
Findings: Responses varied.
Recommendations: Consider better wording for response categories as that caused some
confusion with respondents.
INS3a. How many people in your family are covered by that plan?
______ (RANGE 00-20)
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. No problems with this question. This was very hard for
adolescents to answer.
Recommendations: None.
INS3b.
IF ONLY ONE PERSON COVERED BY THIS PLAN:
Is the annual deductible for medical care for this plan less than $1,100 or $1,100 or more? If
there is a separate deductible for prescription drugs, hospitalization, or out-of-network care, do
not include those deductible amounts here.
IF TWO OR MORE PERSONS IN THE FAMILY ARE COVERED BY THIS PLAN: Is the
family annual deductible for medical care for this plan less than $2,200 or $2,200 or more? If
there is a separate deductible for prescription drugs, hospitalization, or out-of-network care, do
not include those deductible amounts here.
P-3
1
2
F3
F4
LESS THAN [$1,100/$2,200]
[$1,100/$2,200] OR MORE
DON’T KNOW
REFUSED
Findings: All 5 respondents receiving this question answered DK
Recommendations: Consider removing question or revising. This question does not work.
INS3c.(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
Findings: No problems with this question.
Recommendations: None.
INS3d. (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
Findings: No problems with this question.
Recommendations: None.
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
6 months or less
2
More than 6 months, but not more than 1 yr ago
3
More than 1 yr, but not more than 3 yrs ago
4
More than 3 yrs
5
Never
F3
DON’T KNOW
F4
REFUSED
Findings: No problems with this question.
Recommendations: None.
P-4
INS5. Which of these are reasons (you/name) stopped being covered by or (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
Findings: Question wording is very poor. One respondent said they missed open enrollment
when they took a new job.
Recommendations: Revise question so that it is more easily understood.
P-5
MODULE Q: INCOME AND ASSETS
INC1. 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 [your total income/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
Findings: Awkward to administer to adolescents. Respondents said that the introduction was
clear and easy to understand.
Recommendations:
information.
We need an age skip here for 13-17yr olds as they do not know this
INC1a: What is the total number of family member who lived with you during the past 12
months? 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
Findings: 2 respondents did not include themselves in this total.
Recommendations: Consider adding, “Including yourself,” to the beginning of the question.
INCCHK1
IF INC1= F3 OR F4, CONTINUE; ELSE GO TO INC3c
Q-1
INC2. 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
LESS THAN FPL
2
MORE THAN FPL BUT LESS THAN 2 TIMES FPL
3
TWO TIMES FPL OR MORE
F3
F4
DON’T KNOW
REFUSED
Findings: Hard for interviewers to administer as they did not know the poverty level
Recommendations: None.
INC3. 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)______
FOR EACH:
1
YES
2
NO
F3
DON’T KNOW
F4
REFUSED
Findings: Two respondents wanted to know the time frame we were referring to. It would also
help to have a showcard?
Recommendations: Consider a time frame (past 12 months) and add a showcard for easier
administration.
Q-2
Fills for STATE TANF PLANS (in INC4g)
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
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
THE DISTRICT OF COLUMBIA (WASHINGTON, DC)
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
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
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
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)
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)
Q-3
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. In what country (were you/was name) born?
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.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
102.
103.
United States
Puerto Rico
Outlying Area of the
U.S. (American Samoa,
Guam, U.S. Virgin
Islands, Northern
Marianas Other U.S.
Territory)
Canada
Cambodia
China
Colombia
Cuba
Dominican Republic
Ecuador
El Salvador
England
France
Germany
Greece
Guatemala
Guyana
Haiti
Honduras
Hong Kong
Hungary
India
Iran
Ireland/Eire
Italy
Jamaica
Japan
Laos
Mexico
Nicaragua
Peru
Philippines
Poland
Portugal
Russia
Scotland
Korea/South Korea
Taiwan
Thailand
Trinidad & Tobago
Vietnam
Yugoslavia
Austria
Belgium
105.
106.
108.
126.
127.
128.
155.
156.
180.
183.
184.
185.
195.
200.
202.
205.
211.
213.
214.
216.
222.
224.
229.
233.
234.
237.
240.
245.
252.
253.
300.
304.
310.
311.
317.
318.
333.
334.
338.
340.
353.
375.
376.
377.
378.
387.
388.
389.
Czechoslovakia
Denmark
Finland
Holland
Norway
Netherlands
Czech Republic
Slovakia / Slovak
Republic
USSR
Latvia
Lithuania
Armenia
Ukraine
Afghanistan
Bangladesh
Burma
Indonesia
Iraq
Israel
Jordan
Lebanon
Malaysia
Pakistan
Saudi Arabia
Singapore
Syria
Turkey
Asia
Middle East
Palestine
Bermuda
North America
Belize
Costa Rica
Panama
Central America
Bahamas
Barbados
Dominica
Grenada
Caribbean
Argentina
Bolivia
Brazil
Chile
Uruguay
Venezuela
South America
R-1
415.
417.
421.
427.
436.
440.
449.
462.
468.
501.
507.
F3
F4
Egypt
Ethiopia
Ghana
Kenya
Morocco
Nigeria
South Africa
Other Africa
North Africa
Australia
Fiji
DON’T KNOW
REFUSED
Findings: All of the respondents were born in the US except for one born in Mexico.
Recommendations: None.
DMOCHK1 IF DMO1 =1, THEN GO TO DMO5 ELSE CONTINUE
DMO2. In what year did (you/name) come to the United States?
________ YEAR
F3
DON’T KNOW
F4
REFUSED
Findings: Respondent answered 1998
Recommendations: None.
DMO3. Altogether, how many years (have you/has name) lived 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
Findings: Question seemed redundant with DMO2. R answered 10-15 years
Recommendations: None.
DMO4. What language is spoken in (your/name’s) home most of the time?
1
2
3
F3
F4
ENGLISH
SPANISH
ANOTHER LANGUAGE
DON’T KNOW
REFUSED
Findings: Respondent said Spanish
Recommendations: None.
DMO4a. In general, what language do you prefer to speak or communicate in?
1
2
3
ENGLISH
SPANISH
ANOTHER LANGUAGE
R-2
F3
F4
DON’T KNOW
REFUSED
Findings: Respondent said Spanish
Recommendations: None.
DMO5. 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
Findings: Responses varied. Some computation problems
Recommendations: Consider underlining “completed” for emphasis.
DMOCHK3
IF DMO1=1, GO TO DMOCHK4; ELSE CONTINUE
DMO6 During the last year you were in school, were you attending a school in the United
States?
1
YES
R-3
2
F3
F4
NO
DON’T KNOW
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
DMOCHK4 IF AGE 3 TO 21, THEN CONTINUE; ELSE GO TO DMO8
DMO7. (Are you/Is name) either going to school or on vacation from school?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: Response set doesn’t fit question. However, you still get the same response.
Recommendations: You would need to start the question with (Yes or no…)
DMO8. How many times (have you/has name) moved in the past 12 months?
_______ TIMES
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
DMOCHK5 IF DMO8 GE 1, THEN CONTINUE; ELSE GO TO DMOCHK6
DMO8a. How many of these moves were related to work?
_______ TIMES
F3
DON’T KNOW
F4
REFUSED
Findings: This is not a good question for adolescents as they didn’t move for work but the
parents may have. This can also be problematic for proxy interviews. One respondent asked if
this meant “Because of work” or to a new location to “find work”.
Recommendations: Consider a skip for adolescents and proxy or possibly dropping question
all together. Question wording would definitely need to be fixed.
R-4
DMO8b. How many different places have you lived in the past 12 months, that is since (12
MONTH REFERENCE DATE)?
_______ PLACES
F3
DON’T KNOW
F4
REFUSED
Findings: Question is basically the same as DMO8. Also had one respondent answer “one other
place than the one I live now” – Their answer ended up being “1”.
Recommendations: Consider dropping as this is redundant as well as problematic.
MARITAL STATUS
DMOCHK6 IF AGE GE 15, THEN CONTINUE; ELSE GO TO DMOCHK8
DMO9. Are you ……?
1
2
3
4
5
6
F3
F4
Married
Widowed
Divorced
Separated
Never married
Living with a partner
DON’T KNOW
REFUSED
Findings: Responses varied.
Recommendations: Consider removing respond 6 or question DMO9b as they are the same.
DMOCHK7 IF DMO9=1, THEN CONTINUE; ELSE
IF DMO9=2, 3, OR 4, THEN GO TO DMO9b; ELSE
GO TO DMOCHK9
Recommendations:
well.
Consider adding response #5 to skip logic so they will get DMO9b as
MO9a. Is your spouse living with you?
1
2
F3
F4
YES (GOTO DMOCHK9)
NO
DON’T KNOW
REFUSED
Findings: No problems found.
Recommendations: Consider removing respond 6 or question DMO9b as they are the same.
R-5
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
Findings: No problems found other than this being redundant with DMO9
Recommendations: See DMO9
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
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
Findings: No respondents received these questions
Recommendations: None.
R-6
DMO10b. In total, how many years of active duty military service have you had?
______YEARS
______MONTHS
F3
DON’T KNOW
F4
REFUSED
Findings: No respondents received these questions
Recommendations: None.
DMOCHK11 IF DMO10a=1 OR 2, THEN GO TO DMOCHK12; ELSE CONTINUE
DMO10c. Are you eligible for veteran’s benefits?
1
2
F3
F4
YES
NO (GO TO DMOCHK5)
DON’T KNOW
REFUSED
Findings: No respondents received these questions
Recommendations: None.
DMO10d. 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
Findings: No respondents received these questions
Recommendations: None.
EMPLOYMENT
DMOCHK12 IF AGE GE 16, THEN CONTINUE; ELSE GO TO DMOCHK17
DMO11. The next few questions are about employment status. Which of the following were you
doing last week?
R-7
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
Findings: One respondent explained that she was working for a volunteer agency
Recommendations: Consider a category for volunteer work.
DMOCHK13 IF DMO11=2 OR 5, THEN CONTINUE; ELSE
IF DMO11=1, THEN GO TO DMO11b; ELSE
IF DMO11=4, THEN GO TO DMO11c; ELSE
GO TO DMO11i
DMO11a. What is the main reason you did not [work last week/have a job or business last
week]?
1
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
Findings: One respondent said #6
Recommendations: None.
DMOCHK14
IF DMO11a=4, 5, 6, OR 7, THEN CONTINUE; ELSE GO TO
DMO11i
DMO11b Do you have more than one paying job or business?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
R-8
Findings: No respondents said YES to this question.
Recommendations: None.
DMO11c. How many hours [did you work LAST WEEK at ALL jobs or businesses/do you
USUALLY work at ALL jobs or businesses]?
_______HOURS LAST WEEK
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
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
Findings: No problems found.
Recommendations: None.
DMO11e. For the job you work at the most hours, what is the total number of hours usually?
_______HOURS
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. Question was awkward to administer.
Recommendations: Consider using “primary” or “main” job rather than “For the job you work
at the most hours”
DMO11f. Is this a permanent, temporary, or seasonal job or business?
1
2
3
F3
F4
PERMANENT
TEMPORARY
SEASONAL
DON’T KNOW
REFUSED
R-9
Findings: Responses varied. No problems found.
Recommendations: None.
DMO11g. Do you have paid sick leave on this job or business?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: One respondent said, “Not during current probationary period but I will soon” –
Interviewer was not sure how to code this.
Recommendations: None.
DMO11h. About how long have you worked at this MAIN job
or business?
a ______DAYS
b ______MONTHS
c ______YEARS
F3
DON’T KNOW
F4
REFUSED
Findings: Responses varied. No problems found.
Recommendations: None.
DMO11i. 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
Findings: Responses varied. Why are we asking this… seems redundant?
Recommendations: Consider deleting.
DMOCHK15
IF DMO11i=1, THEN CONTINUE; ELSE GO TO DMOCHK16
DMO11j. 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
R-10
Findings: Responses varied. Why are we asking this… seems redundant?
Recommendations: Consider deleting.
DMO11k. 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
Findings: Responses varied. Why are we asking this… seems redundant.
Recommendations: Consider deleting.
DMOCHK16
IF DMO11K=1, THEN CONTINUE; ELSE GO TO DMOCHK17
DMO11o. 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
Findings: No problems found.
Recommendations: None.
DMO11p 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
R-11
Findings: No problems found.
Recommendations: None.
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
Findings: Two respondents – one worked in past 12 months and one in past 24 months.
Recommendations: None.
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
Findings: One respondent said #1
Recommendations: None.
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
Findings: No respondents received this question. Appears R was not comfortable answering q’s
Recommendations: None.
R-12
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
Findings: No respondents received this question. Appears R was not comfortable answering q’s
Recommendations: None.
DMO12d. Approximately how many months during the past 12 months have you been in the
U.S.?
_______MONTHS
F3
DON’T KNOW
F4
REFUSED
Findings: No respondents received this question. Appears R was not comfortable answering q’s
Recommendations: None.
DMO13. If you are injured at work or get sick as a result of your work, does your employer
provide health insurance or pay for your health care?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question. Appears R was not comfortable answering q’s
Recommendations: None.
DMO14. If you are injured at work or get sick as a result of your work, do you get any payment
while you are recuperating (i.e., workers’ compensation)?
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question. Appears R was not comfortable answering q’s
Recommendations: None.
R-13
DMO15. If you are injured or get sick off the job, does your employer provide health insurance
or pay for your health care?
NOTE: WHETHER OR NOT THE WORKER TAKES IT OR USES IT
1
2
F3
F4
YES
NO
DON’T KNOW
REFUSED
Findings: No respondents received this question. Appears R was not comfortable answering q’s
Recommendations: None.
DMO16. 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
Findings: No respondents received this question. Appears R was not comfortable answering q’s
Recommendations: None.
END. Thank you very much. These are all the questions I have for you today.
1
CONTINUE
R-14
Appendix A: Recruitment Cover Letter
DATE:
October 20, 2008
TO:
Dr. Evelyn Schmidt, Lincoln Community Health Center
FROM:
Tim Flanigan, RTI International
RE:
Recruitment of patients for survey interviews.
Thank you once again for helping us pre-test our survey instrument. I have attached flyers that can
be posted at the health clinic and hand-outs that can be placed at the check-in desk and any other
location you feel has high visibility. The patient can then contact our office to determine eligibility.
If eligible, we will re-contact the patient to arrange an interview. Let me explain what we would
like, in terms of your help.
1)
2)
3)
4)
5)
We will have 2-3 different medical centers across North Carolina. In total, we are hoping
to complete 27 interviews during round one and 9 in round two. We expect to recruit and
conduct interviews with approximately 10-20 patients from Lincoln Community Health
Center
Arrange for the signs that I have included to be posted where clients would most likely
see them. I sent a total of 20 so that you can replace them as needed. I would think
having a few signs up in highly visible areas would be a great help.
Place handouts in high-visibility areas (check-in desk, payment desk, waiting area, etc..)
If possible, staff could encourage patients informally to take note of this study. I
completely understand if the staff are too busy or wish to remain passive. This just helps
our recruitment whenever possible
Is there is a private or semi-private location at the clinic that we could use to conduct
interviews? We are hoping to cluster interviews and do them all as soon as possible.
Ideally, we would like to complete the interviews prior to November 10, 2008. Please let
me know if there are no private locations as we will need to make arrangements at an
alternate location. We may have patients come to our RTP office or meet them in
another suitable public location if they choose.
That is all we are requesting. We do not want to be a burden to your clinic or staff so we will make
every attempt possible to not disturb the normal flow of clinic patients.
Again, we really appreciate your help with this very important survey.
Append-1
Appendix B: Recruitment Flyer
Patients Needed to Test a Survey Questionnaire - $50
Paid!!
RTI International, a not-for-profit research organization, is seeking patients of this health center to
help test a survey questionnaire being developed by the Bureau of Primary Health Care as part of
the Primary Health Care Patient Surveys (PHCPS).
We are looking for:
Adolescents 13-17 years of age
Parents of children 2-12 years of age
Male and female adults currently without regular housing (ages 18-80)
Male and female adults (English-speaking) farm workers (ages 18-80)
Male and female adults without medical insurance (ages 18-80)
Participants will receive $50 cash for a 1 hour in-person interview. Interviews can be conducted at
the participant’s desired location (e.g., at this health center, home, or other locations such as a
library or community center). All information provided will be kept private and not shared with the
health center.
For more information and to determine eligibility,
Borst TOLL FREE at 1(800) 334-8571 Ext: 26988
or send an email to cborst@rti.org
RTI Survey Interview (Earn $50): Carrie Borst
(800) 334-8571 ext: 26988 cborst@rti.org
RTI Survey Interview (Earn $50): Carrie Borst
(800) 334-8571 ext: 26988 cborst@rti.org
RTI Survey Interview (Earn $50): Carrie Borst
(800) 334-8571 ext: 26988 cborst@rti.org
RTI Survey Interview (Earn $50): Carrie Borst
(800) 334-8571 ext: 26988 cborst@rti.org
RTI Survey Interview (Earn $50): Carrie Borst
(800) 334-8571 ext: 26988 cborst@rti.org
RTI Survey Interview (Earn $50): Carrie Borst
(800) 334-8571 ext: 26988 cborst@rti.org
RTI Survey Interview (Earn $50): Carrie Borst
(800) 334-8571 ext: 26988 cborst@rti.org
RTI Survey Interview (Earn $50): Carrie Borst
(800) 334-8571 ext: 26988 cborst@rti.org
RTI Survey Interview (Earn $50): Carrie Borst
(800) 334-8571 ext: 26988 cborst@rti.org
RTI Survey Interview (Earn $50): Carrie Borst
(800) 334-8571 ext: 26988 cborst@rti.org
RTI Survey Interview (Earn $50): Carrie Borst
(800) 334-8571 ext: 26988 cborst@rti.org
Append-2
please call Carrie
Appendix C: Patient Screening Form
Primary Health Care Patient Surveys
S1.
(Have you/ Has name) received services from a health care professional such as a doctor,
nurse, drug counselor, mental health counselor, or dentist at the Lincoln Community
Health Center in the last 12 months?
YES ............................ 1
NO .............................. 2 (R NOT ELIGIBLE – THANK R AND END)
REFUSED .................. 7 (R NOT ELIGIBLE – THANK R AND END)
DON’T KNOW .......... 9 (R NOT ELIGIBLE – THANK R AND END)
S2.
At this time, (are you/is name) covered by health insurance or some other kind of health care
plan?
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.
YES ............................ 1
IF YES: WHAT KIND?____________________________
NO .............................. 2
DON’T KNOW .......... 9
S3.
Do any of the following apply to you?
Have you worked as a migrant or seasonal farm worker in the past 24 months?
YES ............................ 1
NO .............................. 2
In the past 12 months, has there been a period in which you have been without regular
housing or homeless?
To clarify, that is not living in your own house, apartment, or room on a regular basis and
not in a hospital or jail or prison. For example, living in a shelter, on the
street/campsite/car/etc. or in temporary or transitional housing.
YES ............................ 1
NO .............................. 2
Append-3
Are you currently living in a public housing unit? Do not count Section 8 housing as public
housing.
YES ............................ 1
NO .............................. 2
S4.
What is (your/name’s) age?
____ YEARS
S5.
IF S4 = UNDER 18: Are you currently living with a parent or guardian?
YES ............................... 1
NO ................................. 2
REFUSED ..................... 7
DON’T KNOW ............. 9
ELIGIBILITY: IF RESPONDENT MEETS ANY OF THESE CRITERIA – CONTINUE
WITH COLLECTION OF CONTACT INFORMATION, OTHERWISE THANK THEM
FOR THEIR TIME AND EXPLAIN THAT THEY DO NOT MEET THE
REQUIREMEWNTS OF THE STUDY
S1
ONLY YES RESPONSE ELIGIBLE
S2
YES OR NO RESPONSE IS ELIGIBLE
S3
ANY RESPONSE ELIGIBLE
S4
MUST BE 13 YEARS OF AGE OR OLDER -OR- A PARENT CALLING ON
BEHALF OF A CHILD (2-12 YEARS OF AGE).
S5
CHILDREN 13-17 YEARS OF AGE MUST BE LIVING WITH A PARENT OR
GUARDIAN
NAME: ___________________________________________
GENDER: ( ) MALE
( ) FEMALE
TELEPHONE #:________________
ALT: TELEPHONE #________________
BEST TIME TO CALL: ________________
Append-4
Appendix D: Informed Consent Forms
Informed Consent Form for Adult Pretest Participation Primary Health Care Patient Surveys
About the Surveys
The Primary Health Care Patient Surveys are research studies being conducted by RTI International. The surveys are
sponsored by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA).
They are about people who receive health care at places like this health care center. The surveys will try to find out
what kinds of health problems people come to health centers with and how well the health centers are meeting the
needs of the people who use them. Prior to conducting the surveys we want to find out whether the questions we
plan to ask can be understood. The purpose of this pretest is to test how well the questions work. You are one of 45
people that RTI has selected to participate.
Participation
If you agree to participate, you will be asked some questions about your health and the services that you receive at
this health care center. Some of the questions may be personal, such as questions about drug or alcohol use and your
feelings. There also may be questions about HIV/AIDS. Most of the questions are about less sensitive things like
health care received and whether you have certain health conditions like asthma or diabetes. As much as possible,
try thinking out loud as you answer these questions. I will ask some follow-up questions to find out how you arrive
at your answers. Please let me know if a question doesn’t make sense or makes you feel uncomfortable. Some
people will get a shorter interview, while others will take a bit longer. The interview may last about one hour.
Voluntary Participation
You may choose whether or not you would like to participate. If you choose not to participate it will not affect any
services you may receive at the health center or from any other programs. If you do not want to answer some of the
questions you are asked, that is okay. If you decide not to finish the questions, that is okay too. It is possible that
some questions may make you uncomfortable or feel various emotions. If you need to take a break at any time, just
let me know.
Benefits
There are not any direct benefits to you. However, you will be helping us learn more about how to conduct the
Primary Health Care Patient Surveys. As noted, the surveys are about the health needs of people who use health
centers like this one.
Compensation for Participation
If you participate, you will be provided with $50 cash as a thank you for your time.
Risks of Study Participation
There are two risks involved in study participation. One risk is that the questions we ask might make you feel
uncomfortable or upset. If you feel uncomfortable or upset you may ask the interviewer to take a break or skip any
of the questions. The other risk is that someone might find out what you tell us during the interview. To avoid that,
we will do the interview in private where no one can hear your answers. We will also create and use a number
instead of your name to identify your interview. This will prevent anyone from finding out what your answers were.
Your Privacy
Anything you tell me is private. The privacy of your answers is very important, so let me say a little more about it.
Everyone involved in this research has signed an agreement stating they will protect the privacy of the information
you provide. The information that you tell me will not be shared with anyone at this health care center.
Append-5
Questions
If you have any questions about these studies or the pretest, you may call Tim Flanigan at 1(800) 334-8571 Ext
27743. If you have any questions about your rights as a study participant, you may call RTI’s Office of Research
Protections toll-free at (1-866-214-2043).
Do you have any questions that might help you decide whether or not you want to participate in the pretest?
By signing below, you are agreeing to participate. Please sign only if:
You understand the information about the research described in this consent form,
You have had all of your questions answered fully, and
You want to participate.
You will be given a copy of this consent form to keep.
Respondent’s Signature: ______________________________________________
Date: _________
Interviewer’s Signature: ______________________________________________
Date: _________
Append-6
Informed Consent Form for Parent/Guardian
Pretest Participation in Proxy Interview for Accompanied Children
Primary Health Care Patient Surveys
About the Surveys
The Primary Health Care Patient Surveys are research studies that are being conducted by RTI International. The
surveys are sponsored by the Bureau of Primary Health Care within the Health Resources and Services
Administration (HRSA). They are about people who receive health care at places like this health care center. The
surveys will try to find out what kinds of health problems people come to health centers with and how well the
health centers are meeting the needs of the people who use them. Prior to conducting these surveys we want to find
out whether the questions we plan to ask can be understood. The purpose of this pretest is to test how well the
questions work. Your child, CHILD’S NAME, is one of about 45 people that RTI has selected to be included.
Because CHILD’S NAME is less than 13 years old, we would like to ask you to answer questions about his/her
health and the services that he/she receives at this health care center.
Participation
If you agree to participate, you will be asked some questions about your child’s health and the services that he/she
receives at this health care center. Some of the questions may be personal, such as questions about your child’s drug
or alcohol use and his/her feelings. There also may be questions about HIV/AIDS. Most of the questions, however,
are about less sensitive things like health care received and whether or not your child has certain health conditions
like asthma or diabetes. As much as possible, try thinking out loud as you answer these questions. I will ask some
follow-up questions to find out how you arrive at your answers. Please let me know if a question doesn’t make
sense or makes you feel uncomfortable. Some people will get a shorter interview, while others will take a bit longer.
The interview may last about one hour.
Voluntary Participation
You may choose whether or not you would like to participate. If you choose not to participate it will not affect any
services your child or your family may receive at the health center or from any other programs. If you do not want to
answer some of the questions you are asked, that is okay. If you decide not to finish the questions, that is okay too. It
is possible that some questions may make you uncomfortable or feel various emotions. If you need to take a break at
any time, just let me know.
Benefits
There are not any direct benefits to you. However, you will be helping us learn more about how to conduct the
research for the Primary Health Care Patient Surveys. As noted, the surveys are about the health needs of people
who use health centers like this one.
Compensation for Participation
If you participate, you will be provided with $50 cash as a thank you for your time.
Risks of Study Participation
There are two risks involved in study participation. One risk is that the questions we ask might make you feel
uncomfortable or upset. If you feel uncomfortable or upset, you may ask the interviewer to take a break or to skip
any of the questions. The other risk is that someone might find out what you tell us during the interview. To avoid
that, we will do the interview in private where no one can hear your answers. Also, we will create and use a number
and instead of your name to identify your interview. This will prevent anyone from finding out what your answers
were.
Your Privacy
Anything you tell me is private. The privacy of your answers is very important, so let me say a little more about it.
Everyone involved in this research has signed an agreement stating they will protect the privacy of the information
you provide. The information that you tell me will not be shared with anyone at this health care center.
Append-7
Questions
If you have any questions about these studies or the pretest, you may call Tim Flanigan at 1(800) 334-8571 Ext
27743. If you have any questions about your rights as a study participant, you may call RTI’s Office of Research
Protections toll-free at (1-866-214-2043).
Do you have any questions that might help you decide whether or not you want to participate in the pretest?
By signing below, you are agreeing to participate. Please sign only if:
You understand the information about the research described in this consent form,
You have had all of your questions answered fully, and
You want to participate.
You will be given a copy of this consent form to keep.
Respondent’s Signature: ______________________________________________
Date: _________
Interviewer’s Signature: ______________________________________________
Date: _________
Append-8
Parent/Guardian Permission Form for
Accompanied Adolescent (Ages 13–17) Pretest Participation
Primary Health Care Patient Surveys
About the Surveys
The Primary Health Care Patient Surveys are research studies being conducted by RTI International. The surveys are
sponsored by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA).
They are about people who receive health care at places like this health care center. The surveys will try to find out
what kinds of health problems people come to health centers with and how well the health centers are meeting the
needs of the people who use them. Prior to conducting these surveys we want to find out whether the questions we
plan to ask can be understood. The purpose of this pretest is to test how well the questions work. Your child is one
of about 45 people that RTI has selected to participate.
Participation
If your child agrees to participate, he/she will be asked some questions about his/her health and the services that you
receive at this health care center. Some of the questions may be personal, such as questions about your child’s drug
or alcohol use and his/her feelings. There also may be questions about HIV/AIDS. Most of the questions are about
less sensitive things like health care received and whether your child has certain health conditions like asthma or
diabetes. As much as possible, we will ask your child to try thinking out loud as he/she answers these questions. I
will ask some him/ her follow-up questions to find out how he/she arrived at his/her answers. I will ask him/her to
let me know if a question doesn’t make sense or makes him/her feel uncomfortable. Some people will get a shorter
interview, while others will take a bit longer. The interview may last about one hour.
Voluntary Participation
Your child may choose whether or not he/she would like to participate. If you choose not to give us permission or if
your child chooses not to participate, it will not affect any services your child or your family may receive at the
health center or from any other programs. If your child does not want to answer some of the questions he/she is
asked, that is okay. If your child decides not to finish the questions, that is okay too. It is possible that some
questions may make your child uncomfortable or feel various emotions. If he/she needs to take a break at any time,
he/she should just let me know.
Benefits
There are not any direct benefits to your child. However, your child will be helping us learn more about how to
conduct the research for the Primary Health Care Patient Surveys. As noted, the surveys are about the health needs
of people who use health centers like this one.
Compensation for Participation
In addition, if your child participates, he/she will be provided with $50 cash to thank him/her for their time.
Risks of Study Participation
There are two risks involved in study participation. One risk is that the questions we ask might make your child feel
uncomfortable or upset. If your child feels uncomfortable or upset, he/she may ask the interviewer to take a break or
to skip any of the questions. The other risk is that someone might find out what your child told us during the
interview. To avoid that, we will do the interview in private where no one can hear his/her answers. We will also
create and use a number instead of your child’s name to identify your child’s interview. This will prevent anyone
from finding out what your child’s answers were.
Your Child’s Privacy
Anything your child tells me is private. The privacy of his/her answers is very important, so let me say a little more
about it. Everyone involved in this research has signed an agreement stating they will protect the privacy of the
information provided. The information that your child tells me will not be shared with you or anyone at this health
care center.
Append-9
Questions
If you have any questions about these studies or the pretest, you may call Tim Flanigan at 1(800) 334-8571 Ext
27743. If you have any questions about your rights as a study participant, you may call RTI’s Office of Research
Protections toll-free at (1-866-214-2043).
Do you have any questions that might help you decide whether or not you want your child to participate in the
pretest?
By signing below, you are giving permission for your child to participate in the research described above. Please
sign only if:
You understand the information about the research described in this consent form,
You have had all of your questions answered fully, and
You give permission for your child to participate.
You will be given a copy of this consent form to keep.
Name of Child: ______________________________________________
Parent/Guardian’s Signature: ______________________________________________
Interviewer’s Signature: ______________________________________________
Append-10
Date: _________
Date: _________
Assent Form for Accompanied
Adolescent (Ages 13 – 17) Pretest Participation
Primary Health Care Patient Surveys
About the Surveys
The Primary Health Care Patient Surveys are research studies being conducted by RTI International. The surveys are
sponsored by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA).
They are about people who receive health care at places like this health care center. The surveys will try to find out what
kinds of health problems people come to health centers with and how well the health centers are meeting the needs of
the people who use them. Prior to conducting the surveys we want to want find out whether the questions we plan to ask
can be understood. The purpose of this pretest is to test how well the questions work. You are one of about 45 people
that RTI has selected to participate.
Participation
(NAME OF PARENT/GUARDIAN) said it is okay for me to invite you to talk with me about your health and the
services that you receive at this health care center. If it is okay with you, I would like to ask you some questions. Some
of the questions may be personal, such as questions about drug or alcohol use and your feelings. There also may be
questions about HIV/AIDS. Most of the questions are about less sensitive things like health care received and whether
or not you have certain health conditions like asthma or diabetes. As much as possible, try thinking out loud as you
answer these questions. I will ask some follow-up questions to find out how you arrive at your answers. Please let me
know if a question doesn’t make sense or makes you feel uncomfortable. Some people will get a shorter interview,
while others will take a bit longer. The interview may last about one hour.
Voluntary Participation
You may choose whether or not you would like to participate. If you choose not to participate it will not affect any
services you may receive at the health center or from any other programs. If you do not want to answer some of the
questions you are asked, that is okay. If you decide not to finish the questions, that is okay too. It is possible that some
questions may make you uncomfortable or feel various emotions. If you need to take a break at any time, just let me
know.
Benefits
There are not any direct benefits to you. However, you will be helping us learn more about how to conduct the Primary
Health Care Patient Surveys. As noted, the surveys are about the health needs of people who use health centers like this
health care center.
Compensation for Participation
If you participate, you will be provided with $50 cash as a thank you for your time.
Risks of Study Participation
There are two risks involved in study participation. One risk is that the questions we ask might make you feel
uncomfortable or upset. If you feel uncomfortable or upset you may ask the interviewer to take a break or skip any of
the questions. The other risk is that someone might find out what you tell us during the interview. To avoid that, we
will do the interview in private where no one can hear your answers. We will also create and use a number instead of
your name to identify your interview. This will prevent anyone from finding out what your answers were.
Your Privacy
Anything you tell me is private. The privacy of your answers is very important, so let me say a little more about it.
Everyone involved in this research has signed an agreement stating they will protect the privacy of the information you
provide. The information that you tell me will not be shared with anyone at this health care center. Your
parent/guardian will not see your answers, and we will not discuss any of your answers with them.
Questions
If you have any questions about these studies or the pretest, you may call Tim Flanigan at 1(800) 334-8571 Ext 27743.
If you have any questions about your rights as a study participant, you may call RTI’s Office of Research Protections
toll-free at (1-866-214-2043).
Append-11
Do you have any questions that might help you decide whether or not you want to participate in the pretest?
By signing below, you are agreeing to participate. Please sign only if:
You understand the information about the research described in this consent form,
You have had all of your questions answered fully, and
You want to participate.
You will be given a copy of this consent form to keep.
Respondent’s Signature: ______________________________________________
Date: _________
Interviewer’s Signature: ______________________________________________
Date: _________
Append-12
| File Type | application/pdf |
| File Title | Microsoft Word - Cognitive_Interview _Report_1st round _2_.doc |
| Author | acash |
| File Modified | 2009-06-25 |
| File Created | 2009-06-25 |