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Family Core (23 minutes)
Page 1 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.010_01.000 Instrument Variable Name:
QuestionText:
NAME_FNAME
All persons
SkipInstructions:
<999> if PCNT = 0, [goto ERR1_NAME_FNAME]
elseif POS2 or POS3 ne 0, [goto HHRESP]
else, [goto MISPERS_MCHILD]
if name on fake/false name list
[goto ERR2_NAME_FNAME];
else [goto NAME_MNAME]
HHC.010_02.000 Instrument Variable Name:
QuestionText:
NAME_MNAME
Household
Composition
QuestionnaireFileName:
Household
Composition
QuestionnaireFileName:
Household
Composition
* Enter Middle Name.
* Probe for middle name or middle initial if not reported.
* Press "ENTER" to skip to last name if no middle name.
UniverseText:
First name is not blank
SkipInstructions:
GOTO NAME_LNAME
Question ID:
QuestionnaireFileName:
[fill: What are the names of all the persons living or staying here?
Start with the name of the person, or one of the persons, who owns or rents this home.
/What is the name of the next person living or staying here?]
*Enter 999 if no more persons.
UniverseText:
Question ID:
05-May-09
HHC.010_03.000 Instrument Variable Name:
QuestionText:
NAME_LNAME
* If last name is the same as displayed, press "ENTER", otherwise, enter the new last name.
*Enter Last Name.
UniverseText:
There is a name entered for 'first name'
SkipInstructions:
<999> GOTO ERR1_NAME_FNAME
if name on fake/false name list
goto ERR2_NAME_LNAME
else if NAME_FNAME and NAME_LNAME ne D, R
Set ALIAS = NAME_FNAME< >NAME _LNAME,
goto USUALRES
else goto ALIAS
Page 2 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.015_00.000 Instrument Variable Name:
QuestionText:
05-May-09
QuestionnaireFileName:
Household
Composition
USUALRES
QuestionnaireFileName:
Household
Composition
ASKURE
QuestionnaireFileName:
Household
Composition
ALIAS
How shall I refer to [fill: you/this person] for the rest of the interview?
UniverseText:
Persons who don't know or refused to give first or last name.
SkipInstructions:
[goto USUALRES]
Question ID:
HHC.020_00.000 Instrument Variable Name:
QuestionText:
[fill: Do you/Does ALIAS] usually live here?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All non-deleted persons
SkipInstructions:
<1> [goto NAME_FNAME]
<2,R,D> [goto ASKURE]
Question ID:
HHC.030_00.000 Instrument Variable Name:
QuestionText:
[fill1: Do you/Does ALIAS] have some other place where [fill2: he/she] usually lives?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
If the usual residence is not here, or 'don't know', or 'refused'.
SkipInstructions:
<1> [goto NOLIST]
<2, R, D> [goto NAME_FNAME]
Question ID:
HHC.035_00.000 Instrument Variable Name:
QuestionText:
QuestionnaireFileName:
Household
Composition
Since [fill1: you do/ALIAS does] not usually live here and [fill2: have/has] another residence elsewhere, [fill3:
you/he/she] will not be included in this interview.
* Enter <1> to continue to the next person.
1
NOLIST
To continue
UniverseText:
Person living elsewhere
SkipInstructions:
[goto NAME_FNAME]
Page 3 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.050_01.000 Instrument Variable Name:
QuestionText:
MISPERS_MCHILD
QuestionnaireFileName:
Household
Composition
MISPERS_MLODGE
QuestionnaireFileName:
Household
Composition
I have listed living here ...
[fill roster]
Have I missed any babies or small children?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
After completing household roster
SkipInstructions:
<1> empty out '999' in NAME_FNAME
empty out MISPERS_CHILD
empty out MISPERS_MLODGE
empty out MISPERS_MAWAY
empty out MISPERS_MELSE
[goto NAME_FNAME]
<2, R, D> goto MISPERS_MLODGE
Question ID:
05-May-09
HHC.050_02.000 Instrument Variable Name:
QuestionText:
1
2
7
9
* Read if necessary.
I have listed living here ...
[fill roster]
Have I missed any lodgers, boarders, or persons you employ who live here?
Yes
No
Refused
Don't know
UniverseText:
Not missing any children or R or D
SkipInstructions:
<1> empty out '999' in NAME_FNAME
empty out MISPERS_CHILD
empty out MISPERS_MLODGE
empty out MISPERS_MAWAY
empty out MISPERS_MELSE
[goto NAME_FNAME]
<2,R,D> goto MISPERS_MAWAY
Page 4 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.050_03.000 Instrument Variable Name:
QuestionText:
MISPERS_MAWAY
QuestionnaireFileName:
Household
Composition
* Read if necessary.
I have listed living here...
[fill roster]
Have I missed anyone who USUALLY lives here, but is now away from home traveling or in a hospital?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
No 'lodgers' living here or R or D
SkipInstructions:
<1> empty out '999' in NAME_FNAME
empty out MISPERS_CHILD
empty out MISPERS_MLODGE
empty out MISPERS_MAWAY
empty out MISPERS_MELSE
[goto NAME_FNAME]
<2,R,D> goto MISPERS_MELSE
Question ID:
05-May-09
HHC.050_04.000 Instrument Variable Name:
QuestionText:
1
2
7
9
MISPERS_MELSE
* Read if necessary.
I have listed living here...
[fill roster]
Have I missed anyone else staying here?
Yes
No
Refused
Don't know
UniverseText:
Nobody is away from home or R or D
SkipInstructions:
<1> empty out '999' in NAME_FNAME
empty out MISPERS_CHILD
empty out MISPERS_MLODGE
empty out MISPERS_MAWAY
empty out MISPERS_MELSE
[goto NAME_FNAME]
<2,R,D> if PCNT = 0, goto EXIT
elseif PCNT = 1
store Yes (1) in LIVEAT, goto OTHLIV
else goto LIVEAT
QuestionnaireFileName:
Household
Composition
Page 5 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.060_00.000 Instrument Variable Name:
QuestionText:
LIVEAT
05-May-09
QuestionnaireFileName:
Household
Composition
QuestionnaireFileName:
Household
Composition
Do all the persons I have listed live AND eat together?
*Read names if necessary.
[fill roster]
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
Person count is greater than one
SkipInstructions:
<1,R,D> [goto OTHLIV]
<2> [goto XACCESS]
Question ID:
HHC.070_00.000 Instrument Variable Name:
QuestionText:
Do the people who do not live and eat here have direct access from the outside or through a common hallway to a separate
living quarters?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons don't eat and live together
SkipInstructions:
<1> [goto TABX]
<2,R,D> [goto OTHLIV]
Question ID:
XACCESS
HHC.090_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
OTHLIV
QuestionnaireFileName:
Do members of any other household on the property live and eat with members of this household?
Yes
No
Refused
Don't know
UniverseText:
All
SkipInstructions:
<1> [goto ERR_OTHLIV]
<2,R D> if PCNT = 1, [goto SEX]
else [goto HHRESP]
Household
Composition
Page 6 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.100_00.000 Instrument Variable Name:
QuestionText:
05-May-09
HHRESP
QuestionnaireFileName:
Household
Composition
* Ask if necessary
With whom am I speaking?
* Enter the line number of the respondent. If more than one, enter the number of the one you consider to be the main
respondent.
UniverseText:
All households with more than one nondeleted person in parent cases or more than one nondeleted person in
spawn cases and no household/family demographic respondent identified yet.
SkipInstructions:
<1-25>
If deleted PX [goto ERR1_HHRESP]
elseif out of bound [goto ERR2_HHRESP]
elseif ADC = 1 [goto HHREF_A]
else [goto SEX]
Question ID:
HHC.110_00.000 Instrument Variable Name:
QuestionText:
SEX
QuestionnaireFileName:
Household
Composition
* Ask if not apparent.
* If don’t know or refused enter your best guess.
[Are you/Is ALIAS] male or female?
1
Male
Female
2
UniverseText:
All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions:
<1,2> [goto AGEDOB_1]
Question ID:
HHC.120_01.000 Instrument Variable Name:
QuestionText:
AGEDOB_1
QuestionnaireFileName:
1 of 5
What is [fill: your/ALIAS's] age?
* Enter number for age.
01-120
Age in years
UniverseText:
All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions:
<001-120> [goto AGEDOB_2]
[goto AGEDOB_3]
Household
Composition
Page 7 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.120_02.000 Instrument Variable Name:
QuestionText:
05-May-09
AGEDOB_2
QuestionnaireFileName:
Household
Composition
AGEDOB_3
QuestionnaireFileName:
Household
Composition
2 of 5
* Enter number for age time period.
1
Days
Weeks
Months
Years
2
3
4
UniverseText:
Valid age - number entered
SkipInstructions:
<1-4> [goto AGEDOB_3]
Question ID:
HHC.120_03.000 Instrument Variable Name:
QuestionText:
3 of 5
And what is [fill: your/ALIAS's] date of birth?
Please give month, day, and year for the date of birth.
* Enter month of birth.
01
02
03
04
05
06
07
08
09
10
11
12
97
99
January
February
March
April
May
June
July
August
September
October
November
December
Refused
Don't know
UniverseText:
All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions:
<1-12,R,D> [goto AGEDOB_4]
Page 8 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.120_04.000 Instrument Variable Name:
QuestionText:
05-May-09
AGEDOB_4
QuestionnaireFileName:
Household
Composition
4 of 5
* Enter day of birth
01-31
Day of the month
UniverseText:
All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions:
<1-31,R,D>
Only allow valid days for month entered.
If days not valid, [goto ERR_AGEDOB_4]
ELSE [goto AGEDOB_5]
Question ID:
HHC.120_05.000 Instrument Variable Name:
QuestionText:
AGEDOB_5
QuestionnaireFileName:
Household
Composition
5 of 5
* Enter year of birth.
1880-2030
Year of birth
Refused
9997
UniverseText:
All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions:
<1880 - 2030, R,D> [goto AGECAL]
Question ID:
HHC.124_00.000 Instrument Variable Name:
QuestionText:
DOBVER
QuestionnaireFileName:
Household
Composition
There is a difference between the age the computer calculated from [fill: your/ALIAS's] date-of-birth and the age that you
gave me.
I recorded [fill: your/ALIAS's] date-of-birth as [AGEDOB_3] [AGEDOB_4], [AGEDOB _5]. Is that [fill: your/ALIAS's]
correct date-of-birth?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Age reported is not equal to age calculated from date of birth.
SkipInstructions:
<1,R,D> [goto INTWKCK1]
<2> [goto AGEDOB_3]
Page 9 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.130_00.000 Instrument Variable Name:
QuestionText:
AGEPIC
QuestionnaireFileName:
Household
Composition
[fill1: Are you/Would you say ALIAS is] [fill2: less than 1 year old/AGE3 years old?]
1
AGE=AGE3 (or less than 1 years old)
AGE=AGE4
Neither is correct
Refused
Don't know
2
3
7
9
UniverseText:
Able to narrow age to two options
SkipInstructions:
<1,2> [goto INTWKCK1]
<3,R,D> if AGEDOB_1 = R, [goto AGEGES2]
elseif AGEDOB_1 = D, [goto AGEGES1_NUM]
Question ID:
05-May-09
HHC.150_01.000 Instrument Variable Name:
QuestionText:
AGEGES1_NUM
QuestionnaireFileName:
Household
Composition
1 of 2
What is your best guess of [fill: your/ALIAS's] age?
* If the respondent gives a range of ages, enter "C" to continue to the screen that will compute an age.
* If the respondent does not know the age, enter your best estimate of the person's age.
000-120
Age (number)
Refused
Don't know
Compute from range
997
999
C
UniverseText:
Age unknown and unable to narrow age down to two age choices and respondent did not refuse AGEDOB_1
SkipInstructions:
<0-120> [goto AGEGES1_TP]
elseif outside range, [goto ERR_AGEGES1_NUM]
[goto AGERNG_N1]
[goto AGEGES2]
Question ID:
HHC.150_02.000 Instrument Variable Name:
QuestionText:
AGEGES1_TP
2 of 2
* Enter time period for age guess.
3
4
Month(s)
Year(s)
UniverseText:
Valid age number
SkipInstructions:
<3, 4> If AGEDOB_5 = D, [goto YEARPIC]
else [goto INTWKCK1]
QuestionnaireFileName:
Household
Composition
Page 10 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.152_00.000 Instrument Variable Name:
QuestionText:
AGEGES2
05-May-09
QuestionnaireFileName:
Household
Composition
Certain sections of this interview depend on knowing if a person is 18 years old or older.
Could you please tell me if [fill: you are/ALIAS is] at least 18 years old?
1
Less than 18
18 or older
Refused
Don't know
2
7
9
UniverseText:
(Age unknown and unable to narrow to two age choices and respondent refused or didn't know age at
AGEDOB_1) or (Refused to or did not guess age)
SkipInstructions:
<1> [goto LESS18]
<2,R,D> [goto GREAT18]
Question ID:
HHC.154_00.000 Instrument Variable Name:
QuestionText:
LESS18
QuestionnaireFileName:
Household
Composition
* Enter your best estimate of [ALIAS's] age.
* Enter age "0" to 17
* Enter "0" if less than 1 year old.
000
Less than one year old
1 to 17 years of age
001 < 17
UniverseText:
Person estimated less than eighteen years of age
SkipInstructions:
<0-17> [goto AGEDOB_1, to collect information about next person in roster]
else, [goto INTWKCK1]
Question ID:
HHC.156_00.000 Instrument Variable Name:
QuestionText:
GREAT18
QuestionnaireFileName:
* Enter your best estimate of [ALIAS’s] age.
* Enter age 18 or greater.
018-120
Age in years
UniverseText:
Person estimated age (18 or older)
SkipInstructions:
<18-120> [goto AGEDOB_1, to collect information about next person in roster]
else, [goto INTWKCK1]
Household
Composition
Page 11 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.160_01.000 Instrument Variable Name:
QuestionText:
05-May-09
AGERNG_N1
QuestionnaireFileName:
Household
Composition
1 of 4
* Enter lower age of the range in months or years.
000-120
Age in years
UniverseText:
Computing age when not given the year the subject was born or the subject's age.
SkipInstructions:
<0-120> [goto AGERNG _T1]
Question ID:
HHC.160_02.000 Instrument Variable Name:
QuestionText:
AGERNG_T1
QuestionnaireFileName:
Household
Composition
QuestionnaireFileName:
Household
Composition
QuestionnaireFileName:
Household
Composition
2 of 4
* Enter lower age time period.
3
Month(s)
Year(s)
4
UniverseText:
First age number has been entered for range.
SkipInstructions:
goto AGERNG_N2
Question ID:
HHC.160_03.000 Instrument Variable Name:
QuestionText:
AGERNG_N2
3 of 4
* Enter higher age of the range in months or years.
000-120
Age in years
UniverseText:
First age number and time period has been entered for range.
SkipInstructions:
<0-120> [goto AGERNG _T2]
Question ID:
HHC.160_04.000 Instrument Variable Name:
QuestionText:
AGERNG_T2
4 of 4
* Enter higher age time period.
3
4
Month(s)
Year(s)
UniverseText:
Second age number has been entered for range.
SkipInstructions:
If LOWER > HIGHER, [goto ERR_AGERNG_T2]
<3,4> if AGEDOB_5 = Don't know, [goto YEARPIC]
else, [goto INTWKCK1]
Page 12 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.165_01.000 Instrument Variable Name:
QuestionText:
05-May-09
YEARPIC
QuestionnaireFileName:
Would you say that [fill: you were/ALIAS was] born in:
1
Low guess for year born
High guess for year born
Neither is correct
Refused
Don't know
2
3
7
9
UniverseText:
Person's age is known and birth year answered with 'don't know'
SkipInstructions:
<1,2,3,R,D> [goto AGEDOB_1, to collect information about next person in roster]
else, [goto INTWKCK1]
Question ID:
Household
Composition
HHC.165_03.000 Instrument Variable Name:
QuestionText:
1
2
INTWKCK
QuestionnaireFileName:
Was [ALIAS] born on or after [STARTDATE]?
Yes
No
UniverseText:
Child's age = 0 and date of birth not known
SkipInstructions:
<1> [goto ERR_INTWKCK]
then, [goto AGEDOB_1 to collect information about next person in roster]
else, [goto NATOR]
<2> [goto AGEDOB_1 to collect information about next person in roster]
else, [goto NATOR]
Household
Composition
Page 13 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.170_00.000 Instrument Variable Name:
QuestionText:
05-May-09
NATOR
QuestionnaireFileName:
Household
Composition
(book) H1.
[fill1: Do you/Does ALIAS] consider [fill2: yourself/himself/herself] to be Hispanic or Latino?
* Read if necessary.
Puerto Rican
Cuban/Cuban American
Dominican (Republic)
Mexican
Mexican American
Central or South American
Other Latin American
Other Hispanic/Latino
Where did [your/ALIAS's] ancestors come from?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions:
<1> [goto HISPAN]
<2,R,D> [goto NATOR for next person in roster]
else [goto RACE]
Question ID:
HHC.180_01.000 Instrument Variable Name:
QuestionText:
HISPAN
QuestionnaireFileName:
Household
Composition
(book) H1
Please give me the number of the group that represents [fill: your/ ALIAS’s] Hispanic origin or ancestry.
You may choose up to five (5), if applicable.
* If a nonhispanic group is named, backup to previous screen and change the answer from "yes" to "no".
Enter all that apply, separate with commas.
01
02
03
04
05
06
07
08
97
99
Puerto Rican
Cuban/Cuban American
Dominican (Republic)
Mexican
Mexican American
Central or South American
Other Latin American
Other Hispanic/Latino/Spanish
Refused
Don't know
UniverseText:
National origin was answered yes to being Hispanic or Latino
SkipInstructions:
<1-6> [goto NATOR (for the next person)] else [goto RACE]
<7> [goto HIS_SP2]
<8> [goto HIS_SP3]
Page 14 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.190_00.000 Instrument Variable Name:
QuestionText:
05-May-09
HIS_SP2
QuestionnaireFileName:
Household
Composition
* Probe for the country.
* If any of the following are mentioned, backup to previous screen and correct the entry.
Puerto Rican
Cuban/Cuban American
Dominican (Republic)
Mexican
Mexican American
Central or South American (REFER TO HELP SCREEN)
* (F1) For a list of Central or South American countries.
* Specify the other Latin American.
UniverseText:
HISPAN answered from selection 7 for Hispanic origin.
SkipInstructions:
[goto NATOR (for the next person)]
else [goto RACE]
Question ID:
HHC.195_00.000 Instrument Variable Name:
QuestionText:
HIS_SP3
QuestionnaireFileName:
* Probe for the country.
* If any of the following are mentioned, backup to previous screen and correct the entry.
Puerto Rican
Cuban/Cuban American
Dominican (Republic)
Mexican
Mexican American
Central or South American (REFER TO HELP SCREEN)
* (F1) For a list of Central or South American countries.
* Specify the other Hispanic/Latino.
UniverseText:
HISPAN answer from selection 8 (other Hispanic/Latino) origin
SkipInstructions:
[goto NATOR (for the next person)]
else [goto RACE]
Household
Composition
Page 15 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.200_01.000 Instrument Variable Name:
QuestionText:
RACE
05-May-09
QuestionnaireFileName:
Household
Composition
( Book) H2
What race or races [fill1: Do you/Does ALIAS] consider [fill2: yourself/himself/herself] to be? Please select 1 or more of
these categories.
* Enter all that apply, separate with commas.
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
97
99
White
Black/African American
Indian (American)
Alaska Native
Native Hawaiian
Guamanian
Samoan
Other Pacific Islander
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Some other race
Refused
Don't know
UniverseText:
All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions:
<1-7, 9-14> If more than one selected, [goto MLTRAC, then goto RACE for next person in roster]
else [goto NOWAF_A]
<8> [goto RAC_SP1]
<15> [goto RAC_SP2]
<16> [goto RAC_SP3]
[goto RACE, for the next person in roster]
else [goto NOWAF_A]
Page 16 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.210_00.000 Instrument Variable Name:
QuestionText:
05-May-09
RAC_SP1
QuestionnaireFileName:
Household
Composition
* Specify the other pacific islander.
REM * If any of the following are mentioned, go back to RACE screen to correct.
* If the respondent’s answer could not be found, clear entry, type ‘ZZ’.
White
Black/African American
Indian (American)
Alaska Native
Native Hawaiian
Guamanian
Samoan
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
* If the respondent's answer could not be found, type 'ZZ' to enable you to type an entry.
UniverseText:
RACE= 8 (other Pacific Islander)
SkipInstructions:
If more than one selected, [goto MLTRAC]
If 'ZZ' entered [goto RAC_SP1A]
then [goto RACE for next person on the roster]
else [goto NOWAF_A]
Question ID:
HHC.212_00.000 Instrument Variable Name:
QuestionText:
RAC_SP2
QuestionnaireFileName:
* Specify the other Asian.
* If any of the following are mentioned, backup to previous item and correct the entry.
White
Asian Indian
Black/African American Chinese
Indian (American)
Filipino
Alaska Native
Japanese
Native Hawaiian
Korean
uamanian
Vietnamese
Samoan
* If the respondent's answer could not be found, type 'ZZ' to enable you to type an entry.
UniverseText:
RACE = other Asian listed
SkipInstructions:
If more than one selected [goto MLTRAC]
then [goto RACE] for next person on the roster
else [goto NOWAF_A]
Household
Composition
Page 17 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.214_00.000 Instrument Variable Name:
QuestionText:
RAC_SP3
05-May-09
QuestionnaireFileName:
Household
Composition
* Specify the other race.
* If any of the following are mentioned, backup to previous item and correct the entry.
White
Asian Indian
Black/African American Chinese
Indian (American)
Filipino
Alaska Native
Japanese
Native Hawaiian
Korean
Guamanian
Vietnamese
Samoan
* If the respondent's answer could not be found, type 'ZZ' to enable you to type an entry.
UniverseText:
RACE answered some other race.
SkipInstructions:
<30 chars long> If more than one selected [goto MLTRAC] then [goto RACE] for next person on the roster
Else [goto NOWAF_A ]
Question ID:
HHC.220_00.000 Instrument Variable Name:
QuestionText:
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
97
99
MLTRAC
QuestionnaireFileName:
Household
Composition
Which one of these groups, that is [Read Groups] would you say BEST represents [fill: your/ALIAS's] race?
White
Black/African American
Indian (American)
Alaska Native
Native Hawaiian
Guamanian
Samoan
Other Pacific Islander
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Other Race
Refused
Don't know
UniverseText:
More than on race entered
SkipInstructions:
<1-16,R,D> [goto NOWAF_A]
else, [goto ERR_MLTRAC]
Page 18 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.230_01.000 Instrument Variable Name:
QuestionText:
05-May-09
NOWAF_A
QuestionnaireFileName:
Household
Composition
[fill: Is anyone in the household/Are you/Is ALIAS] now on full-time active duty with the Armed Forces?
[display eligible persons]
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
If household contains 1 or more persons 18-64 years old
SkipInstructions:
If no person eq (18-64) years of age [goto EXIT]
< 2,R,D> if POS2 or POS3 ne 0, [goto ADC]
else [goto HHREF_A]
if NOWAF_A eq <1> and ADULTCNT eq <1> [goto EXIT]
else [goto NOWAF2_B]
Question ID:
HHC.230_03.000 Instrument Variable Name:
QuestionText:
NOWAF2_B
QuestionnaireFileName:
Household
Composition
Who is this? (Anyone else)
* Enter line numbers as appropriate.
* Enter all that apply, separate with commas.
1
Armed Forces
Not Armed Forces
Refused
2
7
UniverseText:
At least 1 person in the AF & more than 1 person eligible to be in the AF
SkipInstructions:
<1-25> if all PX have HHSTAT = D or HHSTAT3 = A [goto EXIT]
elseif POS2 and POS3 ne 0 [goto ADC]
else [goto HHREF_A]
Invalid person # selected [goto ERR_NOWAF2_B]
Question ID:
HHC.240_00.000 Instrument Variable Name:
QuestionText:
EXIT
QuestionnaireFileName:
Household
Composition
Not every household in our survey is asked all questions. I have all the information about your household that I need at
this time. Thank you for your assistance.
* Enter (1) to proceed.
1
Proceed
UniverseText:
All persons are in the Armed Forces or everybody is either deleted or in the AF or All non-Armed Forces persons
are not Black or Hispanic and not marked for an interview
SkipInstructions:
<1> [goto VISITCNT]
Page 19 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.250_01.000 Instrument Variable Name:
QuestionText:
05-May-09
HHREF_A
QuestionnaireFileName:
Household
Composition
* [fill: You have/ALIAS has] has been selected as the household reference person. Is this household member an
appropriate choice? Preferably a civilian adult?
[Display all non-deleted household members ge 14 years of age]
* Press shift F1 to see full roster information.
1
Yes
No
2
UniverseText:
If more than one non-deleted person in the HH
SkipInstructions:
<1> [goto RPREL]
<2> [goto HHREF_B]
Question ID:
HHC.250_02.000 Instrument Variable Name:
QuestionText:
HHREF_B
* Select another household member for the reference person.
* Enter the line number of the Household Reference person.
UniverseText:
Selecting another Reference person
SkipInstructions:
<1-25> GOTO RPREL
QuestionnaireFileName:
Household
Composition
Page 20 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.260_00.000 Instrument Variable Name:
QuestionText:
RPREL
05-May-09
QuestionnaireFileName:
(book) H3.
What is [fill1: your/ALIAS's] relationship to [fill2: Reference Person's name/you]
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
97
99
Household reference person
Spouse (husband/wife)
Unmarried Partner
Child (biological/adoptive/in-law/step/foster)
Child of partner
Grandchild
Parent (biological/adoptive/in-law/step/foster)
Brother/sister (biological/adoptive/in-law/step/foster)
Grandparent (Grandmother/Grandfather)
Aunt/Uncle
Niece/Nephew
Other relative
Housemate/roommate
Roomer/Boarder
Other nonrelative
Legal guardian
Ward
Refused
Don't know
UniverseText:
All where RPREL NE Reference Person
SkipInstructions:
Loop through all non-deleted PX
<2, 3> if selected for more than one PX [goto ERR4_RPREL]
elseif AGE < 14 [goto ERR1_RPREL]
<4> [goto DEGREE1]
<5> if loop is completed and no PX has RPREL = 3 [goto ERR5_RPREL] endif
<6> if AGEDIFF < 25 [goto ERR2_RPREL] endif
<7> [goto DEGREE2]
<8> [goto DEGREE3]
<9> if AGEDIFF < 25 [goto ERR3_RPREL] endif
<10-17,R,D> end loop
if UNRELTAL > 1 [GOTO FAMNUM]
else [goto HHCHANGE]
Household
Composition
Page 21 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.260_01.000 Instrument Variable Name:
QuestionText:
RPREL
05-May-09
QuestionnaireFileName:
Household
Composition
(book) H3.
What is [fill1: your/ALIAS's] relationship to [fill2: Reference Person's name/you]
UniverseText:
All where RPREL NE Reference Person
SkipInstructions:
Loop through all non-deleted PX
<2, 3> if selected for more than one PX [goto ERR4_RPREL]
elseif AGE < 14 [goto ERR1_RPREL]
<4> [goto DEGREE1]
<5> if loop is completed and no PX has RPREL = 3 [goto ERR5_RPREL] endif
<6> if AGEDIFF < 25 [goto ERR2_RPREL] endif
<7> [goto DEGREE2]
<8> [goto DEGREE3]
<9> if AGEDIFF < 25 [goto ERR3_RPREL] endif
<10-17,R,D> end loop
if UNRELTAL > 1 [GOTO FAMNUM]
else [goto HHCHANGE]
Question ID:
HHC.270_00.000 Instrument Variable Name:
QuestionText:
1
2
3
4
5
7
9
DEGREE1
QuestionnaireFileName:
Household
Composition
[fill1: Are you/Is ALIAS] [fill2: Reference Person's name's/your] biological (natural), adoptive, step, or foster [fill3:
son/daughter] or [fill4: son/daughter]-in-law?
Biological (natural) {son/daughter]
Adoptive {son/daughter}
Step {son/daughter]
Foster {son/daughter}
{son/daughter]-in-law
Refused
Refused
Don't know
UniverseText:
RPREL=(4) child
SkipInstructions:
<1> if AGEDIFF < 12 [goto ERR1_DEGREE1]
else [goto RPREL]
<2-5,R,D> [goto RPREL]
Page 22 of 22
DRAFT 2010 NHIS Questionnaire - Household Composition
Household Composition
Document Version Date:
Question ID:
HHC.280_00.000 Instrument Variable Name:
QuestionText:
DEGREE2
QuestionnaireFileName:
Household
Composition
[fill1: Are you/Is ALIAS] [fill2: Reference Person's name's/your] biological (natural), adoptive, step, or foster [fill3:
mother/father] or [fill4: mother/father]-in-law?
1
Biological (natural) {mother/father]
Adoptive {mother/father}
Step {mother/father]
Foster {mother/father}
{mother/father]-in-law
Refused
Don't know
2
3
4
5
7
9
UniverseText:
RPREL=(7) parent
SkipInstructions:
<1> if AGEDIFF <12 [goto ERR_DEGREE2]
elseif additional PX's remain [goto RPREL]
elseif UNRELTAL >1 [goto FAMNUM]
else [goto HHCHANGE]
<2-5,R,D> if additional PX's remain [goto RPREL]
elseif UNRELTAL >1 [goto FAMNUM]
else [goto HHCHANGE]
Question ID:
05-May-09
HHC.290_01.000 Instrument Variable Name:
QuestionText:
1
2
3
4
5
6
7
9
DEGREE3
QuestionnaireFileName:
Household
Composition
[fill1: Are you/Is ALIAS] [fill2: Reference Person's name's/your] full, half, adoptive, step, or foster [fill3: brother/sister]
or [fill4: brother/sister]-in-law?
Full {brother/sister}
Half {brother/sister}
Adopted {brother/sister}
Step {brother/sister]
Foster {brother/sister}
{brother/sister]-in-law
Refused
Don't know
UniverseText:
All siblings
SkipInstructions:
<1-6,R,D> [goto RPREL]
Page 1 of 4
DRAFT 2010 NHIS Questionnaire - Coverage
Coverage
Document Version Date:
Question ID:
COV.330_01.000 Instrument Variable Name:
QuestionText:
05-May-09
TELENUM
QuestionnaireFileName:
Coverage
What is the telephone number here?
* Enter the area code and the number, or enter "N" if no phone.
1
Gave telephone number
No telephone
Refused
Don't know
2
7
9
UniverseText:
SkipInstructions:
Question ID:
<2000000000 - 9999999999, D, R> store in HPHONE1, GOTO INSIDE
<0-1999999999> GOTO ERR_TELENUM
GOTO HOWLONG_1
COV.331_00.000 Instrument Variable Name:
QuestionText:
CURWRK
QuestionnaireFileName:
Family
?[F1]
Is there at least one telephone INSIDE your home that is currently working and is not a cell phone?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with a phone
SkipInstructions:
<1,Refused,Don't know> go to RNOSERV
<2> goto RH1LNGDY_1
Question ID:
COV.332_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
RNOSERV
QuestionnaireFileName:
Family
Not including cell phones, have you or your family been without telephone service for one week or more DURING THE
PAST 12 MONTHS? Do not include interruptions of phone service due to weather or natural disasters.
Yes
No
Refused
Don't know
UniverseText:
No phone in home that is working and not a cellular phone (or refused to provide or said don't know this
information)
SkipInstructions:
<1> goto RH1LNGDY_1
<2, Refused, Don't know> goto TELCEL
Page 2 of 4
DRAFT 2010 NHIS Questionnaire - Family
Coverage
Document Version Date:
Question ID:
COV.333_01.000 Instrument Variable Name:
QuestionText:
05-May-09
RH1LNGDY_1
QuestionnaireFileName:
Family
?[F1]
Not including cell phones, how long were you or your family without telephone service in the PAST 12 MONTHS?
* Enter number for time without telephone service.
* If less than one week, enter '0'.
000
Less than 1 week
1-365
Refused
Don't know
001-365
997
999
UniverseText:
Respondents with no phone or who have no working land-line phone or who have been without land-line phone
service for one week or more during the past 12 months.
SkipInstructions:
<1-365> goto RH1LNGDY_2
<0,Refused, Don't know> goto TELCEL
Question ID:
COV.333_02.000 Instrument Variable Name:
QuestionText:
RH1LNGDY_2
QuestionnaireFileName:
Family
?[F1]
* Enter time period for time without telephone service.
0
Less than 1 week
Day(s)
Week(s)
Months(s)
Refused
Don't know
1
2
3
7
9
UniverseText:
Gave number at RH1LNGDY_1
SkipInstructions:
<1> if RH1LNGDY_1 lt '7' goto ERR1_RH1LNGDY_2 else goto TELCEL
<2> if RH1LNGDY_1 gt '52' goto ERR2_RH1LNGDY_2 else goto TELCEL
<3> if RH1LNGDY_1 gt '12' goto ERR3_RH1LNGDY_2 else goto TELCEL
Question ID:
COV.334_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
TELCEL
QuestionnaireFileName:
Do you or anyone in your family have a working cell phone?
Yes
No
Refused
Don't know
UniverseText:
All families
SkipInstructions:
<1> goto WRKCEL
<2, Refused, Don't know> if CURWRK = '1' and RNOSERV = '1'
goto CELLOUT
elseif POS2 = '0'
goto hhc.NAME_FNAME
else
goto hhc.ADC
Family
Page 3 of 4
DRAFT 2010 NHIS Questionnaire - Family
Coverage
Document Version Date:
Question ID:
COV.335_00.000 Instrument Variable Name:
QuestionText:
05-May-09
WRKCEL
QuestionnaireFileName:
Family
How many working cell phones do you or people in your family have?
01-10
1-10 phones
Refused
Don't know
97
99
UniverseText:
Families with a working cell phone
SkipInstructions:
<1-10, Refused, Don't know> if CURWRK = '1' and RNOSERV = '1'
goto CELLOUT
elseif CURWRK = '1' and RNOSERV = '2', 'Refused', or 'Don't know'
goto PHONEUSE
elseif POS2 = '0'
goto hhc.NAME_FNAME
else
goto hhc.ADC
Question ID:
COV.336_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
CELLOUT
QuestionnaireFileName:
Family
During the most recent time you or your family were without telephone service, did you have a working cell phone?
Yes
No
Refused
Don't know
UniverseText:
Families with no cell phone, or Refused or Don't know whether they had working cell phone and have a current
working land-line that was out of service in the past 12 months, or who have a least one working cell phone or
Refused or Don't know number of working cell phones and have current working land-line that was out of service
in the past 12 months
SkipInstructions:
<1, 2, Refused, Don't know> if TELCEL = '1'
goto PHONEUSE
elseif POS2 = '0'
goto hhc.NAME_FNAME
else
goto hhc.ADC
Page 4 of 4
DRAFT 2010 NHIS Questionnaire - Family
Coverage
Document Version Date:
Question ID:
COV.337_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PHONEUSE
Of all the telephone calls that you or your family receives, are…
*Read categories below.
1
2
3
7
9
All or almost all calls received on cell phones
Some received on cell phones and some on regular phones
Very few or none on cell phones
Refused
Don't know
UniverseText:
Working cell phone and working land-line in family
SkipInstructions:
<1-3, Refused, Don't know> if POS2 = '0'
goto hhc.NAME_FNAME
else
goto hhc.ADC
QuestionnaireFileName:
Family
Page 1 of 7
DRAFT 2010 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:
Question ID:
FAU.010_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FDMED12M
QuestionnaireFileName:
Family
? [F1]
The following questions are about the use of health care. Do not include dental care.
DURING THE PAST 12 MONTHS, [fill: have you delayed seeking medical care/has medical care been delayed for
anyone in the family] because of worry about the cost?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PDMED12M and goto FNMED12M; else, goto
PDMED12M]
<2,R,D> [goto FNMED12M]
Question ID:
FAU.020_00.000 Instrument Variable Name:
QuestionText:
PDMED12M
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
For which family member was medical care delayed?
(Anyone else?)
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one had medical care delayed due to worry about the cost during
the past 12 months
SkipInstructions:
goto FNMED12M
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FAU.030_00.000 Instrument Variable Name:
QuestionText:
FNMED12M
QuestionnaireFileName:
Family
? [F1]
DURING THE PAST 12 MONTHS, was there any time when [fill1: you/someone in the family] needed medical care, but
did not get it because [fill2: you/the family] couldn't afford it?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PNMED12M and goto FHOSPYR; else, goto
PNMED12M]
<2,R,D> [goto FHOSPYR]
Page 2 of 7
DRAFT 2010 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:
Question ID:
FAU.040_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PNMED12M
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who didn't get needed care?
(Anyone else?)
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one didn't get medical care due to cost during the past 12 months
SkipInstructions:
goto FHOSPYR
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FAU.050_00.000 Instrument Variable Name:
QuestionText:
FHOSPYR
QuestionnaireFileName:
Family
?[F1]
[fill1: were you/Including all infants born in a hospital, has anyone in the family] been hospitalized OVERNIGHT in the
past 12 months? Do not include an overnight stay in the emergency room.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PHOSPYR and goto HOSPNO; else, goto PHOSPYR]
<2,R,D> [goto FHCHM2W]
Question ID:
FAU.060_00.000 Instrument Variable Name:
QuestionText:
PHOSPYR
QuestionnaireFileName:
Family
*Ask or verify. Enter applicable line number(s), separate with commas.
Who was in a hospital overnight?
(Anyone else?)
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with two or more persons and at least one was a patient overnight during the past 12 months
(excluding ER)
SkipInstructions:
goto HOSPNO
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 3 of 7
DRAFT 2010 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:
Question ID:
FAU.070_00.000 Instrument Variable Name:
QuestionText:
HOSPNO
05-May-09
QuestionnaireFileName:
Family
? [F1]
How many different times did [fill: you/ALIAS] stay in any hospital overnight or longer DURING THE PAST 12
MONTHS?
001-365
1-365 times
Refused
Don't know
997
999
UniverseText:
All persons who had an overnight hospital stay during the past 12 months (excluding ER)
SkipInstructions:
<1-10> [goto HPNITE]
<11-365> [goto ERR_HOSPNO]
[goto HPNITE]
Question ID:
FAU.110_00.000 Instrument Variable Name:
QuestionText:
HPNITE
QuestionnaireFileName:
Family
? [F1]
Altogether how many nights [fill: were you/was ALIAS] in the hospital DURING THE PAST 12 MONTHS?
001-365
997
999
1-365 nights
Refused
Don't know
UniverseText:
All persons who had an overnight hospital stay during the past 12 months (excluding ER)
SkipInstructions:
<1-50,R,D> [goto next person selected at PHOSPYR; if no more persons, goto FHCM2W]
<51-365> [goto ERR1_HPNITE]
if HOSPNO gt HPNITE, goto ERR2_HPNITE
Page 4 of 7
DRAFT 2010 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:
Question ID:
FAU.120_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FHCHM2W
QuestionnaireFileName:
Family
? [F1]
* Hand calendar card.
These next questions are about health care received during the 2 WEEKS outlined on that calendar. Include care from
ALL types of medical doctors, such as dermatologists, psychiatrists, ophthalmologists, and general practitioners. Also
include
care from OTHER health professionals such as nurses, physical therapists, and chiropractors.
Do not include dental care. Do not include care while an overnight patient in a hospital.
During those 2 WEEKS, did [fill: you/anyone in the family] receive care AT HOME from a nurse or other health care
professional?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PHCHM2W and goto PHCHMN2W; else, goto
PHCHM2W]
<2,R,D> [goto FHCPH2W]
Question ID:
FAU.130_00.000 Instrument Variable Name:
QuestionText:
PHCHM2W
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received care at home?
(Anyone else?)
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with two or more persons and at least one received care at home from a health care professional during
the past 2 weeks (excluding dental care)
SkipInstructions:
goto PHCHMN2W
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 5 of 7
DRAFT 2010 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:
Question ID:
FAU.140_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PHCHMN2W
QuestionnaireFileName:
Family
How many home visits did [fill: you/ ALIAS] receive during those 2 WEEKS?
* Enter '50' for 50 or more visits.
01-50
1-50 home visits
Refused
Don't know
97
99
UniverseText:
All persons who received care at home from a health care professional during the past 2 weeks (excluding dental
care)
SkipInstructions:
<1-14,R,D> [repeat for all eligible persons, then goto FHCPH2W]
<15-50> [goto ERR_PHCPHMN2W]
Question ID:
FAU.150_00.000 Instrument Variable Name:
QuestionText:
FHCPH2W
QuestionnaireFileName:
Family
During those 2 WEEKS, did [fill: you/anyone in the family] get any medical advice or test results over the PHONE from a
doctor, nurse, or other health care professional?
Do not include phone calls to make appointments, for billing questions or for prescription refills.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PHCPH2W and goto PHCPHN2W; else, goto
PHCPH2W]
<2,R,D> [goto FHCDV2W]
Question ID:
FAU.160_00.000 Instrument Variable Name:
QuestionText:
PHCPH2W
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who was the phone call about?
(Anyone else?)
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with two or more persons and at least one received medical advice or test results over the phone
during the past 2 weeks (excluding calls for appointments, billing questions, or prescription medicines)
SkipInstructions:
goto PHCPHN2W
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 6 of 7
DRAFT 2010 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:
Question ID:
FAU.170_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PHCPHN2W
QuestionnaireFileName:
Family
During those 2 WEEKS, how many telephone calls [fill: did you make/were made about ALIAS]?
* Enter '50' for 50 or more phone calls.
01-50
1-50 calls
Refused
Don't know
97
99
UniverseText:
All persons for whom medical advice or test results were received over the phone from a health care professional
during the past 2 weeks (excluding calls for appointments, billing questions, or prescription refills)
SkipInstructions:
<1-14,R,D> [repeat for all eligible persons, then goto FHCDV2W]
<15-50> [goto ERR_PHCPHN2W]
Question ID:
FAU.180_00.000 Instrument Variable Name:
QuestionText:
FHCDV2W
QuestionnaireFileName:
Family
During those 2 WEEKS, did [fill1: you/anyone in the family] see a doctor or other health care professional at a doctor's
OFFICE, a clinic, an emergency room, or some other place?
[fill2: Do not include times during an overnight hospital stay.]
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PHCDV2W and goto PHCDVN2W; else, goto
PHCDV2W]
<2,R,D> [goto F10DVYR]
Question ID:
FAU.190_00.000 Instrument Variable Name:
QuestionText:
PHCDV2W
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received care?
(Anyone else?)
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with two or more persons and at least one saw a health care professional in an office, clinic,
emergency room, or some other place during the past 2 weeks (excluding visits during overnight hospital stays)
SkipInstructions:
goto PHCDVN2W
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 7 of 7
DRAFT 2010 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:
Question ID:
FAU.200_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PHCDVN2W
QuestionnaireFileName:
Family
How many times did [fill: you/ALIAS] visit a doctor or other health care professional during those 2 WEEKS?
* Enter '50' for 50 or more visits.
01-50
1-50 times
Refused
Don't know
97
99
UniverseText:
All persons who visited a health care professional during the past 2 weeks (excluding overnight hospital stays)
SkipInstructions:
<1-14,R,D> [repeat for all eligible persons, then goto F10DVYR]
<15-50> [goto ERR_PHCDVN2W]
Question ID:
FAU.210_00.000 Instrument Variable Name:
QuestionText:
F10DVYR
QuestionnaireFileName:
Family
During the past 12 MONTHS did [fill: you/any member of the family] receive care from doctors or other health care
professionals 10 or more times? Do not include telephone calls.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in P10DVYR and goto FHICOV; else, goto P10DVYR]
<2,R,D> [goto FHICOV]
Question ID:
FAU.220_00.000 Instrument Variable Name:
QuestionText:
P10DVYR
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received care 10 or more times?
(Anyone else?)
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with two or more persons and at least one received care 10 or more times from a health care
professional during the past 12 months (excluding telephone calls)
SkipInstructions:
goto FHICOV
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 1 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.050_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FHICOV
QuestionnaireFileName:
Family
(book) F12 and (book) F14
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.
[fill:Are you/Is anyone in the family] covered by any kind of health insurance or some other kind of health care plan?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1,R,D> [goto HIKIND]
<2> [if AGE ge 65, goto MCAREPRB; else, goto MCAIDPRB]
Question ID:
FHI.070_00.000 Instrument Variable Name:
QuestionText:
(book) F12 and (book) F14
HIKIND
QuestionnaireFileName:
Family
? [F1]
What kind of health insurance or health care coverage [fill: do you/does ALIAS] 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.
* Enter all that apply, separate with commas.
01
02
03
04
05
06
07
08
09
10
11
97
99
Private health insurance
Medicare
Medi-Gap
Medicaid
SCHIP (CHIP/Children's Health Insurance Program)
Military health care (TRICARE/VA/CHAMP-VA)
Indian Health Service
State-sponsored health plan
Other government program
Single service plan (e.g., dental, vision, prescriptions)
No coverage of any type
Refused
Don't know
UniverseText:
All persons in families where FHICOV= yes, don't know, or refused
SkipInstructions:
[goto HCSPFYR]
<1-10> [if AGE ge 65 and HIKIND ne 2, goto MCAREPRB; else, if HIKIND ne 10 goto SINCOV; else, goto
HICHANGE]
<11> [if HIKIND = 1-10, goto ERR_HIKIND; else, if AGE ge 65 goto MCAREPRB; else, goto MCAIDPRB]
Page 2 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.072_00.000 Instrument Variable Name:
QuestionText:
05-May-09
MCAREPRB
QuestionnaireFileName:
Family
(book) F13
People covered by Medicare have a card that looks like this.
[fill: Are you/Is ALIAS] covered by Medicare?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons 65 years of age or older in families not covered by health insurance or Medicare was not selected for
those persons at HIKIND
SkipInstructions:
if HIKIND ne 10, goto SINCOV; else, goto HICHANGE
Question ID:
FHI.073_00.000 Instrument Variable Name:
QuestionText:
MCAIDPRB
QuestionnaireFileName:
Family
(book F14)
* Refer to flashcard F14 for state Medicaid names.
There is a program called Medicaid that pays for health care for persons in need. In this State it is also called (* fill State
name). [fill: Are you/Is ALIAS] covered by Medicaid?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons less than 65 years of age with no insurance coverage of any type
SkipInstructions:
goto SINCOV
Question ID:
FHI.074_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
SINCOV
QuestionnaireFileName:
Family
[fill: Do you/Does ALIAS] have any type of insurance that pays for only one type of service such as dental, vision, or
prescriptions?
Yes
No
Refused
Don't know
UniverseText:
All persons in families not covered by health insurance or single service plan was not selected for those persons at
HIKIND
SkipInstructions:
goto HICHANGE
Page 3 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.075_00.000 Instrument Variable Name:
QuestionText:
05-May-09
HICHANGE
QuestionnaireFileName:
Family
QuestionnaireFileName:
Family
I have recorded [fill1: you are/ALIAS is] [fill 2: covered by:
fill3: ^HIKIND] / not covered by health insurance.]
Is this correct?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons
SkipInstructions:
<1,R,D> [repeat for all eligible persons, then goto MCPART]
<2> [goto ERR_HICHANGE]
Question ID:
FHI.090_00.000 Instrument Variable Name:
QuestionText:
MCPART
{if subject ne respondent}:
Earlier I recorded that ALIAS is covered by Medicare. May I please see ALIAS’s Medicare card to determine the type of
coverage?
{if subject eq respondent}:
* Read if necessary.
What type of Medicare coverage do you have? Is it Part A - hospital insurance, Part B - medical insurance, or both?
* Fill in appropriate coverage type below.
1
Part A - Hospital only
Part B - Medical only
Both Part A and Part B
Refused
Don't know
2
3
7
9
UniverseText:
All persons with Medicare
SkipInstructions:
<1-3> [goto MCCARD]
[prefill MCCARD with a "2" and goto MCCHOICE]
Question ID:
FHI.092_00.000 Instrument Variable Name:
QuestionText:
1
2
MCCARD
QuestionnaireFileName:
Family
* Do not read. Was the type of coverage obtained from a Medicare card or some other form of documentation?
Yes
No
UniverseText:
All persons with Part A Medicare coverage, Part B Medicare coverage, or both
SkipInstructions:
if MCPART = 1, goto MCPARTD; else, goto MCCHOICE
Page 4 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.095_00.000 Instrument Variable Name:
QuestionText:
05-May-09
MCCHOICE
QuestionnaireFileName:
Family
? [F1]
Medicare Advantage is the new name for Medicare Plus Choice plans. [fill: Are you/Is ALIAS] enrolled in a Medicare
Advantage plan?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for Part
B coverage
SkipInstructions:
goto MCHMO
Question ID:
FHI.100_00.000 Instrument Variable Name:
QuestionText:
MCHMO
QuestionnaireFileName:
Family
? [F1]
[fill: Are you/Is ALIAS] under a Medicare managed care arrangement, such as an HMO, that is, a Health Maintenance
Organization? (With an HMO, you must generally receive care from HMO doctors, otherwise the expense is not covered
unless you were referred by the HMO or there was a medical emergency).
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for Part
B coverage
SkipInstructions:
<1> [goto MCNAME]
<2,R,D> [goto MCREF]
Question ID:
FHI.110_00.000 Instrument Variable Name:
QuestionText:
MCNAME
QuestionnaireFileName:
Family
? [F1]
What is the name of the HMO?
* Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim
7
9
Verbatim response
Refused
Don't know
UniverseText:
All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for part
B coverage, and are enrolled under a Medicare managed care arrangement
SkipInstructions:
goto MCREF
Page 5 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.114_00.000 Instrument Variable Name:
QuestionText:
05-May-09
MCREF
QuestionnaireFileName:
Family
? [F1]
Under [fill1: your/ALIAS's] Medicare plan, if [fill2: you need/he needs/she needs] to go to a different doctor or place for
special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for Part
B coverage
SkipInstructions:
goto MCPAYPRE
Question ID:
FHI.116_00.000 Instrument Variable Name:
QuestionText:
MCPAYPRE
QuestionnaireFileName:
Family
Besides [fill1: your/ALIAS's] Medicare insurance, [fill2: are you/is ALIAS] paying an additional monthly or yearly
premium to receive a more comprehensive health benefit plan?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for Part
B coverage
SkipInstructions:
goto MCPARTD
Question ID:
FHI.118_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
MCPARTD
QuestionnaireFileName:
Family
[Fill 1: Are you/Is ALIAS] enrolled in Medicare Part D, also known as the Medicare Prescription Drug Plan?
Yes
No
Refused
Don't know
UniverseText:
All persons with Medicare
SkipInstructions:
<1,2,7,9> [goto MCPART for next person with Medicare; else goto MACHMD]
Page 6 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.120_00.000 Instrument Variable Name:
QuestionText:
(book F14)
05-May-09
MACHMD
QuestionnaireFileName:
Family
? [F1]
* Refer to flashcard F14 for state Medicaid names.
The next questions are about Medicaid coverage. In this State it is also called (* fill State Name). [fill1: You are/ALIAS
is] listed as having Medicaid coverage. Can [fill2: you/ALIAS] go to ANY doctor who will accept Medicaid or MUST
[fill3: you/he/she] choose from a book or list of doctors or is a doctor assigned?
1
Any doctor
Select from book/list
Doctor is assigned
Refused
Don't know
2
3
7
9
UniverseText:
All persons with Medicaid
SkipInstructions:
<1,R,D> [goto MAPCMD]
<2> [goto MACHMD1]
<3> [goto MACHMD2]
Question ID:
FHI.130_00.000 Instrument Variable Name:
QuestionText:
MACHMD1
QuestionnaireFileName:
Family
* Ask or verify.
What is the name of the health plan that provided the book or list?
*Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All persons with Medicaid who must select a doctor from a book or list of doctors
SkipInstructions:
goto MANAM
Question ID:
FHI.131_00.000 Instrument Variable Name:
QuestionText:
MACHMD2
QuestionnaireFileName:
* Ask or verify.
What is the name of the health plan that assigned the doctor?
*Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim
7
9
Verbatim response
Refused
Don't know
UniverseText:
All persons with Medicaid for whom a doctor is assigned
SkipInstructions:
goto MANAM
Family
Page 7 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.132_00.000 Instrument Variable Name:
QuestionText:
MANAM
05-May-09
QuestionnaireFileName:
Family
? [F1]
* Do not read. Was the Health Plan name obtained from a Health Plan Card or something with the Health Plan name on
it?
1
Yes
No
2
UniverseText:
All persons with Medicaid who must select a doctor from a book or list or for whom a doctor is assigned
SkipInstructions:
goto MAPCMD
Question ID:
FHI.140_00.000 Instrument Variable Name:
QuestionText:
QuestionnaireFileName:
Family
[fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which
[fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care from a
specialist [fill4: you were/he was/she was] referred to.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons with Medicaid
SkipInstructions:
goto MAREF
Question ID:
MAPCMD
FHI.150_00.000 Instrument Variable Name:
QuestionText:
MAREF
QuestionnaireFileName:
Family
? [F1]
Under [fill1: your/ALIAS's] Medicaid plan, if [fill2: you need/he needs/she needs] to go to a different doctor or place for
special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All persons with Medicaid
SkipInstructions:
goto MACHMD for the next person with Medicaid; else, goto SSTYPE2
Page 8 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.156_00.000 Instrument Variable Name:
QuestionText:
05-May-09
SSTYPE2
QuestionnaireFileName:
Family
(book) F15
* Enter all that apply, separate with commas.
You mentioned that [fill1: you have/ALIAS has] a single-service plan - that is, an insurance plan that provides one
specific type of coverage. What type of service or care does [fill2: your/ALIAS's] single service plan or plans pay for?
01
Accidents
AIDS care
Cancer treatment
Catastrophic care
Dental care
Disability insurance
Hospice care
Hospitalization only
Long-term care
Prescriptions
Vision care
Other (specify)
Refused
Don't know
02
03
04
05
06
07
08
09
10
11
12
97
99
UniverseText:
All persons with single service plans
SkipInstructions:
<1-11,R,D> [repeat for all eligible persons, then goto FHICCI6]
<12> [goto SSOTHER]
Question ID:
FHI.157_00.000 Instrument Variable Name:
QuestionText:
Verbatim
7
9
SSOTHER
QuestionnaireFileName:
* Other type of single-service plan
Verbatim response
Refused
Don't know
UniverseText:
All persons with an "other" single service plan
SkipInstructions:
goto SSTYPE2 for the next person with a single service plan; else, goto FHICCI6
Family
Page 9 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.158_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FHICCI6
QuestionnaireFileName:
Family
The next questions are about private health insurance plans [fill1: /including Medi-Gap]. These plans can be obtained
through work, purchased directly, or through a state or local government program or community program.
[fill2: We have the following persons listed as being covered by such plans:
* Read names.
(display roster of eligible persons)]
* Enter 1 to continue
1
Continue
UniverseText:
All families with at least one person covered by private health insurance
SkipInstructions:
goto HIPNAM1
Question ID:
FHI.160_00.000 Instrument Variable Name:
QuestionText:
HIPNAM1
QuestionnaireFileName:
Family
It is important that we record the complete and accurate name of each health insurance plan. What is the COMPLETE
name of the first plan?
Do NOT include plans that only provide extra cash while in the hospital or plans that pay for only one type of service,
such as nursing home care, accidents, or dental care.
* Read if necessary: Do you have your health plan card or something with the plan name on it?
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All families with at least one person covered by private health insurance
SkipInstructions:
[goto PCARD1]
[prefill PCARD1 with a "2" and goto HIPNAM1B]
Question ID:
FHI.160_01.000 Instrument Variable Name:
QuestionText:
1
2
PCARD1
QuestionnaireFileName:
Family
* Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on it?
Yes
No
UniverseText:
All private health insurance plans where the plan name was entered at HIPNAM1
SkipInstructions:
goto HIPNAM1B
Page 10 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.170_00.000 Instrument Variable Name:
05-May-09
HIPNAM1B
QuestionnaireFileName:
Family
QuestionText:
* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by this plan?
* Indicate each family member covered by this plan.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with a private health insurance plan and the plan name, refused, or don't know was entered at
HIPNAM1
SkipInstructions:
[if HIPNAM1= R or D, goto STNAME]
goto MORPLAN
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FHI.171_00.000 Instrument Variable Name:
QuestionText:
MORPLAN
QuestionnaireFileName:
Family
* Ask if necessary
Are there any more private health insurance plans?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families where a private health insurance plan name was entered at HIPNAM1 or a person number was entered
at HIPNAM1B
SkipInstructions:
<1> [goto HIPNAM2]
<2,R,D> [if no persons selected at HIPNAM1B, goto FHICCI8; else, if persons selected at HIPNAM1B, but not
all persons with HIKIND = 1 or 3 selected at HIPNAM1B, goto HIVER1]
Question ID:
FHI.172_00.000 Instrument Variable Name:
QuestionText:
HIPNAM2
QuestionnaireFileName:
What is the name of the next plan?
*Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim
7
9
Verbatim response
Refused
Don't know
UniverseText:
All families with a second private health insurance plan
SkipInstructions:
[goto PCARD2]
[prefill PCARD2 with a "2" and goto HIPNAM2B]
Family
Page 11 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.172_01.000 Instrument Variable Name:
QuestionText:
05-May-09
PCARD2
QuestionnaireFileName:
* Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on it?
1
Yes
No
2
UniverseText:
All private health insurance plans where the plan name was entered at HIPNAM2
SkipInstructions:
goto HIPNAM2B
Question ID:
Family
FHI.173_00.000 Instrument Variable Name:
QuestionText:
HIPNAM2B
QuestionnaireFileName:
Family
* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by that plan?
* Indicate each family member covered by this plan.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with a second private health insurance plan and the plan name, refused, or don't know was entered at
HIPNAM2
SkipInstructions:
[if HIPNAM2 eq R or D and persons selected at HIPNAM1B, but not all persons with HIKIND eq 1 or 3
selected at HIPNAM1B, goto HIVER1; else, if HIPNAM2 eq R or D and persons selected at HIPNAM1B, and all
persons with HIKIND eq 1 or 3 selected at HIPNAM1B, goto FHICCI8; else, if HIPNAM2 eq R or D and persons
not selected at HIPNAM1B, goto FHICCI8; else, if a health plan name recorded in HIPNAM2, goto MORPLAN2]
goto MORPLAN2
Question ID:
FHI.174_00.000 Instrument Variable Name:
QuestionText:
MORPLAN2
QuestionnaireFileName:
Family
* Ask if necessary
Are there any more private health insurance plans?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families where a private health insurance plan name was entered at HIPNAM2 or a person number was entered
at HIPNAM2B
SkipInstructions:
<1> [goto HIPNAM3]
<2,R,D> [if persons selected at HIPNAM2B or HIPNAM1B, but not all persons with HIKIND eq 1 or 3 selected
at HIPNAM2B or HIPNAM1B, goto HIVER1; else, goto FHICCI8]
Page 12 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.175_00.000 Instrument Variable Name:
QuestionText:
05-May-09
HIPNAM3
QuestionnaireFileName:
Family
What is the name of the next plan?
*Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All families with a third private health insurance plan
SkipInstructions:
[goto PCARD3]
[prefill PCARD3 with a "2" and goto HIPNAM3B]
Question ID:
FHI.175_01.000 Instrument Variable Name:
QuestionText:
PCARD3
QuestionnaireFileName:
* Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on it?
1
Yes
No
2
UniverseText:
All private health insurance plans where the plan name was entered at HIPNAM3
SkipInstructions:
goto HIPNAM3B
Question ID:
Family
FHI.176_00.000 Instrument Variable Name:
HIPNAM3B
QuestionnaireFileName:
Family
QuestionText:
* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by that plan?
* Indicate each family member covered by this plan.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with a third private health insurance plan and the plan name, refused, or don't know was entered at
HIPNAM3
SkipInstructions:
[if HIPNAM3 eq R or D and persons selected at HIPNAM1B or HIPNAM2B, but not all persons with
HIKIND eq 1 or 3 selected at HIPNAM1B or HIPNAM2B, goto HIVER1; else, if HIPNAM3 eq R or D and
persons selected at HIPNAM1B or HIPNAM2B, and all persons with HIKIND eq 1 or 3 selected at HIPNAM1B
or HIPNAM2B, goto FHICCI8; else, if HIPNAM3 eq R or D and persons not selected at HIPNAM1B and
HIPNAM2B, goto FHICCI8; else, if the health plan name was entered at HIPNAM3, goto MORPLAN3]
goto MORPLAN3
Page 13 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.177_00.000 Instrument Variable Name:
QuestionText:
05-May-09
MORPLAN3
QuestionnaireFileName:
Family
* Ask if necessary
Are there any more private health insurance plans?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families where a private health insurance plan name was entered at HIPNAM3 or a person number was entered
at HIPNAM3B
SkipInstructions:
<1> [goto HIPNAM4]
<2,R,D> [if persons selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, but not all persons with HIKIND eq
1 or 3 selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, goto HIVER1; else, goto FHICCI8]
Question ID:
FHI.178_00.000 Instrument Variable Name:
QuestionText:
HIPNAM4
QuestionnaireFileName:
Family
What is the name of the next plan?
*Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All families with a fourth private health insurance plan
SkipInstructions:
[goto PCARD4]
[prefill PCARD4 with a "2" and goto HIPNAM4B]
Question ID:
FHI.178_01.000 Instrument Variable Name:
QuestionText:
1
2
PCARD4
QuestionnaireFileName:
Family
* Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on it?
Yes
No
UniverseText:
All private health insurance plans where the plan name was entered at HIPNAM4
SkipInstructions:
goto HIPNAM4B
Page 14 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.179_00.000 Instrument Variable Name:
05-May-09
HIPNAM4B
QuestionnaireFileName:
Family
QuestionText:
* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by that plan?
* Indicate each family member covered by this plan.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with a fourth private health insurance plan and the plan name, refused, or don't know was entered at
HIPNAM4
SkipInstructions:
[if HIPNAM4 eq R or D and persons selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, but not all
persons with HIKIND eq 1 or 3 selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, goto HIVER1; else, goto
FHICCI8]
goto FHICCI8
Question ID:
FHI.180_00.000 Instrument Variable Name:
QuestionText:
HIVER1
QuestionnaireFileName:
Family
? [F1]
[fill1: You are/ALIAS is] listed as having private insurance but [fill2: were/was] not mentioned as being covered by any of
the plans we just discussed. [fill3: Are you/Is ALIAS] covered by private insurance?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All persons who have private health insurance coverage, but were not mentioned as being covered by any of the
reported plans
SkipInstructions:
<1> [ goto HIVER2]
<2,R,D> [goto ERR_HIVER1]
Page 15 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.190_00.000 Instrument Variable Name:
QuestionText:
05-May-09
HIVER2
QuestionnaireFileName:
Family
? [F1]
* Enter all that apply, separate with commas.
Is [fill: your/ALIAS's] health insurance plan the same as one of those already mentioned?
1
1st plan mentioned (^HIPNAM1)
2nd plan mentioned (^HIPNAM2)
3rd plan mentioned (^HIPNAM3)
4th plan mentioned (^HIPNAM4)
Some other plan not already mentioned
Refused
Don't know
2
3
4
5
7
9
UniverseText:
All persons for whom it was verified they have private health insurance coverage, but were not mentioned as being
covered by any of the reported plans
SkipInstructions:
<1-4> [update responses for HIPNAM1B/HIPNAM2B/HIPNAM3B/HIPNAM4B and goto FHICCI8]
<5> [if 4 plans were reported, ignore this 5th plan and goto FHICCI8; else, goto HIPNAM2, or HIPNAM3, or
HIPNAM4 accordingly to enter information on this plan]
[goto FHICCI8]
Question ID:
FHI.195_01.000 Instrument Variable Name:
QuestionText:
FHICCI8
QuestionnaireFileName:
Family
[fill1: Now I am going to ask some questions about the [fill2: plan/plans] you just told me about [fill3: /,starting with
[fill4: ^HIPNAM1/Plan1]]./Next I would like to ask you about [fill5: ^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 2/Plan
3/Plan 4]].
* Enter 1 to continue.
1
Continue
UniverseText:
All families where a private health insurance plan was reported
SkipInstructions:
goto FHI200
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Page 16 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.200_01.000 Instrument Variable Name:
QuestionText:
05-May-09
FHI200
QuestionnaireFileName:
Family
? [F1]
Health insurance plans are usually obtained in one person's name even if other family members are covered. That person
is called the policyholder. In whose name is this plan?
* Enter line number of family member (from list below) in whose name this plan is held.
* Enter 0 if the policyholder is not on the family roster."
00
Policyholder not on family roster
Two-digit person number
Refused
Don't know
01-25
97
99
UniverseText:
All private health insurance plans
SkipInstructions:
goto PLNWRK
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Question ID:
FHI.210_01.000 Instrument Variable Name:
QuestionText:
(book) F16
PLNWRK
QuestionnaireFileName:
Family
? [F1]
Which one of these categories best describes how this plan was obtained?
01
02
03
04
05
06
07
97
99
Through employer
Through union
Through workplace, but don't know if employer or union
Through workplace, self-employed or professional association
Purchased directly
Through a state/local government or community program
Other, specify
Refused
Don't know
UniverseText:
All private health insurance plans
SkipInstructions:
<1-6,R,D> [goto PLNPAY]
<7> [goto PLNWKSP]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Page 17 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.211_01.000 Instrument Variable Name:
QuestionText:
PLNWKSP
05-May-09
QuestionnaireFileName:
Family
*Read if necessary.
How was this plan obtained?
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All private health insurance plans where the plan was obtained through an "other" source
SkipInstructions:
goto PLNPAY
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Question ID:
FHI.220_10.000 Instrument Variable Name:
QuestionText:
PLNPAY
QuestionnaireFileName:
Family
? [F1]
* Enter all that apply, separate with commas.
Who pays for this health insurance plan?
* If government program is reported, probe for Medicare or Medicaid or SCHIP before entering code 7. If government is
the employer, enter code 2.
01
02
03
04
05
06
07
97
99
Self or family (living in the household)
Employer or union
Someone outside the household
Medicare
Medicaid
Children's Health Insurance Program (CHIP/SCHIP)
State or local government or community program
Refused
Don't know
UniverseText:
All private health insurance plans
SkipInstructions:
<1> [goto HICOSTN]
<2-7,R,D> [if PLNPAY=1, goto HICOSTN; else, goto PLNMGD]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Page 18 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.230_11.000 Instrument Variable Name:
QuestionText:
1 of 2
05-May-09
HICOSTN
QuestionnaireFileName:
Family
? [F1]
How much [fill1: do you/does your family] currently spend for health insurance premiums for [fill2:
^HIPNAM1/^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4]? Please include payroll deductions for
premiums.
*Enter dollar amount for premium payments.
00001-99995
$1-$99,995
Refused
Don't know
99997
99999
UniverseText:
All private health insurance plans paid for by self or family
SkipInstructions:
<1-99995> [goto HICOSTT]
[store "R" in HICOSTT and goto PLNMGD]
[store "D" in HICOSTT and goto PLNMGD]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Question ID:
FHI.230_12.000 Instrument Variable Name:
QuestionText:
2 of 2
HICOSTT
QuestionnaireFileName:
Family
? [F1]
* Enter time period for premium payments.
01
02
03
04
05
06
07
08
97
99
Once a week
Once every 2 weeks
Once a month
Twice a month
Every 2 months
Quarterly (every 3 months)
Once a year
Twice a year
Refused
Don't know
UniverseText:
All private health insurance plans with a valid response to HICOSTN
SkipInstructions:
goto PLNMGD
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Page 19 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.240_01.000 Instrument Variable Name:
QuestionText:
05-May-09
PLNMGD
QuestionnaireFileName:
Family
? [F1]
Is [fill: ^HIPNAM1/^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4] an HMO (Health Maintenance
Organization), an IPA (Individual Practice Association), a PPO (Preferred Provider Organization), a POS (Point-OfService), fee-for-service, or indemnity or is it some other kind of plan?
1
HMO/IPA
PPO
POS
Fee-for-service/indemnity
Other
Refused
Don't know
2
3
4
5
7
9
UniverseText:
All private health insurance plans
SkipInstructions:
goto HDHP
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Question ID:
FHI.241_01.000 Instrument Variable Name:
QuestionText:
HDHP
QuestionnaireFileName:
Family
?[F1]
[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.
1
2
7
9
Less than [$1,100/$2,200]
[$1,100/$2,200] or more
Refused
Don't know
UniverseText:
All private health insurance plans
SkipInstructions:
1,R,D [goto MGCHMD]
2 [goto HSAHRA]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Page 20 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.242_01.000 Instrument Variable Name:
QuestionText:
HSAHRA
05-May-09
QuestionnaireFileName:
Family
?[F1]
With this plan, is there a special account or fund that can be used to pay for medical expenses? The accounts are
sometimes referred to as Health Savings Accounts (HSAs), Health Reimbursement Accounts (HRAs), Personal Care
accounts, Personal Medical funds, or Choice funds, and are different from Flexible Spending Accounts.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All high deductible private health plans
SkipInstructions:
1,2,R,D [goto MGCHMD]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Question ID:
FHI.243_01.000 Instrument Variable Name:
QuestionText:
MGCHMD
QuestionnaireFileName:
Family
Under this plan, can [fill1:you/ALIAS/the family members with this plan] choose ANY doctor or MUST
[fill2:you/he/she/they] choose one from a specific group or list of doctors?
1
Any doctor
Select from group/list
Refused
Don't know
2
7
9
UniverseText:
All private health insurance plans
SkipInstructions:
<1> [goto MGPRMD]
<2> [goto MGPYMD]
[goto MGPREF]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Question ID:
FHI.244_01.000 Instrument Variable Name:
QuestionText:
1
2
7
9
MGPRMD
QuestionnaireFileName:
Family
[fill: Do you/Does ALIAS/Do the family members with this plan] have the option of choosing a doctor from a preferred or
select list at a lower cost?
Yes
No
Refused
Don't know
UniverseText:
All private health insurance plans where covered persons can choose any doctor
SkipInstructions:
goto MGPREF
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Page 21 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.246_01.000 Instrument Variable Name:
QuestionText:
05-May-09
MGPYMD
QuestionnaireFileName:
Family
If [fill1: you select/ALIAS selects/the family members with this plan select] a doctor who is not in the plan, will [fill2:
^HIPNAM1/^HIPNAM2/^HIPNAM3/^ HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4] pay for any or part of the cost?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All private health insurance plans where covered persons must select from a group or list of doctors
SkipInstructions:
goto MGPREF
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Question ID:
FHI.248_01.000 Instrument Variable Name:
QuestionText:
MGPREF
QuestionnaireFileName:
Family
? [F1]
When [fill1: you need/ALIAS needs/the family members with this plan need] to go to a different doctor or place for
special care, [fill2: do you/does ALIAS/do they] need approval or a referral? Do not include emergency care.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All private health insurance plans
SkipInstructions:
goto PRRXCOV
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Question ID:
FHI.249_01.000 Instrument Variable Name:
QuestionText:
PRRXCOV
QuestionnaireFileName:
Family
Does [fill1: ^HIPNAM1/^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4] pay for any of the costs for
medicines prescribed by a doctor?
* Read if necessary: Does this plan have a drug benefit?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All private health insurance plans
SkipInstructions:
goto PRDNCOV
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Page 22 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.249_05.000 Instrument Variable Name:
QuestionText:
05-May-09
PRDNCOV
QuestionnaireFileName:
Family
Does [fill 1: ^HIPNAM1 or ^HIPNAM2, or ^HIPNAM3, or ^HIPNAM4 or Plan 1 or Plan 2 or Plan 3 or Plan 4] pay for
any of the costs for dental care?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All private health insurance plans
SkipInstructions:
goto FHICCI8 for the next private health insurance plan; else, goto STNAME1
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.
Question ID:
FHI.250_00.000 Instrument Variable Name:
QuestionText:
STNAME1
QuestionnaireFileName:
Family
Earlier I recorded that [fill: you are/ALIAS is] covered by the Children’s Health Insurance Program (CHIP/SCHIP). What
is the name of the plan?
* Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All persons with SCHIP
SkipInstructions:
goto STDOC1
Question ID:
FHI.251_00.000 Instrument Variable Name:
QuestionText:
1
2
3
7
9
STDOC1
QuestionnaireFileName:
Family
Under the [fill1:^STNAME1/SCHIP plan] can [fill2: you/ALIAS] go to ANY doctor who will accept this plan or MUST
[fill3: you/he/she] choose from a book or list of doctors or is the doctor assigned?
Any doctor
Select from book/list
Doctor is assigned
Refused
Don't know
UniverseText:
All persons with SCHIP
SkipInstructions:
goto STPCMD1
Page 23 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.252_00.000 Instrument Variable Name:
QuestionText:
STPCMD1
QuestionnaireFileName:
Family
[fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which
[fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care from a
specialist [fill4: you were/he was/she was] referred to.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons with SCHIP
SkipInstructions:
goto STREF1
Question ID:
05-May-09
FHI.253_00.000 Instrument Variable Name:
QuestionText:
STREF1
QuestionnaireFileName:
Family
? [F1]
Under [fill1: ^STNAME1/this SCHIP plan], if [fill2: you need/ALIAS needs] to go to a different doctor or place for
special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons with SCHIP
SkipInstructions:
goto STNAME1 for the next person with SCHIP; else, goto STNAME2
Question ID:
FHI.257_00.000 Instrument Variable Name:
QuestionText:
STNAME2
QuestionnaireFileName:
Earlier I recorded that [fill: you are/ALIAS is] covered by a state sponsored health plan. What is the name of the plan?
* Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim
7
9
Family
Verbatim response
Refused
Don't know
UniverseText:
All persons covered by a state sponsored health plan
SkipInstructions:
goto STDOC2
Page 24 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.258_00.000 Instrument Variable Name:
QuestionText:
05-May-09
STDOC2
Any doctor
Select from book/list
Doctor is assigned
Refused
Don't know
2
3
7
9
UniverseText:
All persons covered by a state sponsored health plan
SkipInstructions:
goto STPCMD2
FHI.259_00.000 Instrument Variable Name:
QuestionText:
STPCMD2
QuestionnaireFileName:
Family
[fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which
[fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care from a
specialist [fill4: you were/he was/she was] referred to.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons covered by a state sponsored health plan
SkipInstructions:
goto STREF2
Question ID:
Family
Under the [fill1:^STNAME2/state sponsored plan] can [fill2: you/ALIAS] go to ANY doctor who will accept this plan or
MUST [fill3: you/he/she] choose from a book or list of doctors or is the doctor assigned?
1
Question ID:
QuestionnaireFileName:
FHI.260_00.000 Instrument Variable Name:
QuestionText:
STREF2
QuestionnaireFileName:
Family
? [F1]
Under [fill1:^STNAME2/this state sponsored plan], if [fill2: you need/ALIAS needs] to go to a different doctor or place
for special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All persons covered by a state sponsored health plan
SkipInstructions:
goto STNAME2 for the next person with a state sponsored health plan; else, goto STNAME3
Page 25 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.264_00.000 Instrument Variable Name:
QuestionText:
STNAME3
05-May-09
QuestionnaireFileName:
Family
Earlier I recorded that [fill: you are/ALIAS is] covered by an other government program. What is the name of the plan?
* Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All persons covered by an "other" government plan
SkipInstructions:
goto STDOC3
Question ID:
FHI.265_00.000 Instrument Variable Name:
QuestionText:
STDOC3
Family
Under the [fill1:^STNAME3/other government plan] can [fill2: you/ALIAS] go to ANY doctor who will accept this plan
or MUST [fill3:you/he/she] choose from a book or list of doctors or is the doctor assigned?
1
Any doctor
Select from book/list
Doctor is assigned
Refused
Don't know
2
3
7
9
UniverseText:
All persons covered by an "other" government plan
SkipInstructions:
goto STPCMD3
Question ID:
QuestionnaireFileName:
FHI.266_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
STPCMD3
QuestionnaireFileName:
Family
[fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which
[fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care from a
specialist [fill4: you were/he was/she was] referred to.
Yes
No
Refused
Don't know
UniverseText:
All persons covered by an "other" government plan
SkipInstructions:
goto STREF3
Page 26 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.267_00.000 Instrument Variable Name:
QuestionText:
05-May-09
STREF3
QuestionnaireFileName:
Family
? [F1]
Under [fill1:^ STNAME3/this other government plan], if [fill2: you need/ALIAS needs] to go to a different doctor or
place for special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons covered by an "other" government plan
SkipInstructions:
goto STNAME3 for the next person with an "other" government plan; else, goto MILSPC
Question ID:
FHI.270_00.000 Instrument Variable Name:
QuestionText:
MILSPC
QuestionnaireFileName:
Family
? [F1]
* Enter all that apply, separate with commas.
Earlier I recorded that [fill1: you are/ALIAS is] covered by military health care. What types of military health care [fill2:
are you/is ALIAS] covered by?
1
TRICARE
VA
CHAMP-VA
Other military coverage (specify)
Refused
Don't know
2
3
4
7
9
UniverseText:
All persons with military health care
SkipInstructions:
<1> [goto MILMAN]
<2,3,R,D> [repeat question for next person with military health care; else, goto HILAST]
<4> [goto MILSPCOT]
Question ID:
FHI.271_00.000 Instrument Variable Name:
QuestionText:
Verbatim
7
9
MILSPCOT
QuestionnaireFileName:
Family
* Other military coverage
Verbatim response
Refused
Don't know
UniverseText:
All persons with "other" military coverage
SkipInstructions:
if MILSPC eq 1, goto MILMAN; else, goto MILSPC for the next person with military health care; else, goto
HILAST
Page 27 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.275_00.000 Instrument Variable Name:
QuestionText:
05-May-09
MILMAN
QuestionnaireFileName:
Family
? [F1]
Is [fill: your/ALIAS's] TRICARE plan, TRICARE prime, TRICARE Extra, TRICARE Standard or TRICARE for Life?
1
TRICARE Prime
TRICARE Extra
TRICARE Standard
TRICARE for life
TRICARE other (specify)
Refused
Don't know
2
3
4
5
7
9
UniverseText:
All persons with TRICARE coverage
SkipInstructions:
<1-4,R,D> [goto MILSPC for the next person with military health care; else, goto HILAST]
<5> [goto MILMANOT]
Question ID:
FHI.276_00.000 Instrument Variable Name:
QuestionText:
MILMANOT
QuestionnaireFileName:
* Other type of TRICARE coverage
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All persons with "other" type of TRICARE coverage
SkipInstructions:
goto MILSPC for the next person with military health care; else, goto HILAST
Question ID:
Family
FHI.280_00.000 Instrument Variable Name:
QuestionText:
(book) F17
HILAST
QuestionnaireFileName:
Family
? [F1]
Not including Single Service Plans, about how long has it been since [fill: you/ALIAS] last had health care coverage?
1
2
3
4
5
7
9
6 months or less
More than 6 months, but not more than 1 year ago
More than 1 year, but not more than 3 years ago
More than 3 years
Never
Refused
Don't know
UniverseText:
All persons without known health insurance or with only single service plans
SkipInstructions:
goto HISTOP
Page 28 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.290_00.000 Instrument Variable Name:
QuestionText:
05-May-09
HISTOP
QuestionnaireFileName:
Family
(book) F18
[fill1: Which of these are reasons [fill2: you/ALIAS] stopped being covered?/Which of these are reasons [fill3:you
do/ALIAS does] not have health insurance?]
* Enter up to 5 reasons, separate with commas.
01
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)
Other (specify)
Refused
Don't know
02
03
04
05
06
07
08
09
10
97
99
UniverseText:
All persons without known health insurance or with only single service plans
SkipInstructions:
<1-9,R,D> [goto HCSPFYR]
<10> [goto HISTOPOT]
Question ID:
FHI.291_00.000 Instrument Variable Name:
QuestionText:
HISTOPOT
QuestionnaireFileName:
Family
? [F1]
* Other reason for not having coverage
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All persons without known health insurance and an "other" reason for stopping or not having coverage
SkipInstructions:
goto HISTOP for the next person without known health insurance coverage or only single service plans; else, goto
HCSPFYR
Question ID:
FHI.300_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
HINOTYR
QuestionnaireFileName:
Family
In the PAST 12 MONTHS, was there any time when [fill: you/ALIAS] did NOT have ANY health insurance or coverage?
Yes
No
Refused
Don't know
UniverseText:
All persons with known health insurance coverage except single service plans
SkipInstructions:
<1> [goto HINOTMYR]
<2,R,D> [goto HCSPFYR]
Page 29 of 29
DRAFT 2010 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:
Question ID:
FHI.310_00.000 Instrument Variable Name:
QuestionText:
05-May-09
HINOTMYR
QuestionnaireFileName:
Family
In the PAST 12 MONTHS, about how many months [fill: were you/was ALIAS] without coverage?
* If less than 1 month, enter '1'.
01-12
1-12 months
Refused
Don't know
97
99
UniverseText:
All persons with known health insurance coverage, but did not have health insurance for some period of time in
the past 12 months
SkipInstructions:
goto HINOTYR for the next person with known health insurance coverage, except single service plans; else, goto
HCSPFYR
Question ID:
FHI.320_00.000 Instrument Variable Name:
QuestionText:
HCSPFYR
QuestionnaireFileName:
Family
(book) F19
The next question is about money that [fill1: you have/your family has] spent out of pocket on medical care. We do NOT
want you to count health insurance premiums, over the counter drugs, or costs that you will be reimbursed for. In the
PAST 12 MONTHS, about how much did [fill2: you/your family] spend for medical care and dental care?
0
Zero
Less than $500
$500 - $1,999
$2,000 - $2,999
$3,000 - $4,999
$5,000 or more
Refused
Don't know
1
2
3
4
5
7
9
UniverseText:
All families
SkipInstructions:
goto FSA
Question ID:
FHI.330_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
FSA
QuestionnaireFileName:
Family
[fill 1: Do you/Does anyone in your family] have a Flexible Spending Account for health expenses? These accounts are
offered by some employers to allow employees to set aside pre-tax dollars of their own money for their use throughout the
year to reimburse themselves for their out-of-pocket expenses for health care. With this type of account, any money
remaining in the account at the end of the year, following a short grace period, is lost to the employee.
Yes
No
Refused
Don't know
UniverseText:
All Families
SkipInstructions:
goto PLBORN
Page 1 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.005_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FLAPLYLM
QuestionnaireFileName:
Family
? [F1]
[fill1: Are/Is]
* Read names
(fill roster of persons age 0-4)
limited in the kind or amount of play activities [fill2: they/he/she] can do because of a physical, mental, or emotional
problem?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with one or more persons less than 5 years of age
SkipInstructions:
<1> [if only one child less than 5 years of age, store the person number in PLAPLYLM and goto PLAPLYUN;
else, goto PLAPLYLM]
<2,R,D> [goto FSPEDEIS]
Question ID:
FHS.010_00.000 Instrument Variable Name:
QuestionText:
PLAPLYLM
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons less than five years of age and at least one is limited in play activities
SkipInstructions:
goto PLAPLYUN
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FHS.020_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
PLAPLYUN
QuestionnaireFileName:
Family
Is [fill: ALIAS] able to take part AT ALL in the usual kinds of play activities done by most children [fill: ALIAS]’s age?
Yes
No
Refused
Don't know
UniverseText:
All persons less than 5 years of age who are limited in play activities
SkipInstructions:
repeat this question for all persons listed at PLAPLYLM, then goto FSPEDEIS
Page 2 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.050_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FSPEDEIS
QuestionnaireFileName:
Family
? [F1]
[fill: Do you/Does/Do any of these family members,
* Read names
(fill roster of persons less than age 18)]
receive Special Educational or Early Intervention Services?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with one or more persons less than 18 years of age
SkipInstructions:
<1> [if only one person less than 18 years of age, store the person number in PSPEDEIS and goto PSPEDEM;
else, goto PSPEDEIS]
<2,R,D> [goto FLAADL]
Question ID:
FHS.060_00.000 Instrument Variable Name:
QuestionText:
PSPEDEIS
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons less than 18 years of age and at least one receives Special Educational or
Early Intervention Services
SkipInstructions:
goto PSPEDEM
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FHS.065_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
PSPEDEM
QuestionnaireFileName:
Family
[fill: Do you/Does ALIAS] receive these services because of an emotional
or behavioral problem?
Yes
No
Refused
Don't know
UniverseText:
All persons less than 18 years of age who receive Special Educational or Early Intervention Services
SkipInstructions:
repeat this question for all persons listed at PSPEDEIS, then goto FLAADL
Page 3 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.070_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FLAADL
QuestionnaireFileName:
Family
? [F1]
Because of a physical, mental, or emotional problem, [fill1: do you/does anyone in the family] need the help of other
persons with PERSONAL CARE NEEDS, such as eating, bathing, dressing, or getting around inside this home?
[fill2: Do not include family members age 2 and under.]
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with one or more persons 3 years of age or older
SkipInstructions:
<1> [if a single-person family, store the person number in PLAADL and goto LABATH; else, goto PLAADL]
<2,R,D> [goto FLAIADL]
Question ID:
FHS.080_00.000 Instrument Variable Name:
QuestionText:
PLAADL
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons 3 years of age or older and at least one needs the help of other persons with
personal care needs
SkipInstructions:
goto LABATH
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FHS.090_01.000 Instrument Variable Name:
QuestionText:
LABATH
QuestionnaireFileName:
[fill: Do you/Does ALIAS] need the help of other persons with...
Bathing or showering?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All persons 3 years of age or older who need help with personal care needs
SkipInstructions:
goto LADRESS
Family
Page 4 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.090_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LADRESS
QuestionnaireFileName:
Family
* Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Dressing?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons 3 years of age or older who need help with personal care needs
SkipInstructions:
goto LAEAT
Question ID:
FHS.090_03.000 Instrument Variable Name:
QuestionText:
LAEAT
QuestionnaireFileName:
Family
* Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Eating?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons 3 years of age or older who need help with personal care needs
SkipInstructions:
goto LABED
Question ID:
FHS.090_04.000 Instrument Variable Name:
QuestionText:
LABED
QuestionnaireFileName:
* Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Getting in or out of bed or chairs?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All persons 3 years of age or older who need help with personal care needs
SkipInstructions:
goto LATOILT
Family
Page 5 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.090_05.000 Instrument Variable Name:
QuestionText:
05-May-09
LATOILT
QuestionnaireFileName:
Family
* Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Using the toilet, including getting to the toilet?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons 3 years of age or older who need help with personal care needs
SkipInstructions:
goto LAHOME
Question ID:
FHS.090_06.000 Instrument Variable Name:
QuestionText:
LAHOME
QuestionnaireFileName:
Family
* Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Getting around inside the home?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons 3 years of age or older who need help with personal care needs
SkipInstructions:
goto LABATH for the next persons listed at PLAADL; else, goto FLAIADL
Question ID:
FHS.150_00.000 Instrument Variable Name:
QuestionText:
FLAIADL
QuestionnaireFileName:
Family
? [F1]
Because of a physical, mental, or emotional problem, do [fill: you/any of these family members
* Read names
(fill roster of persons age 18 or older)]
need the help of other persons in handling ROUTINE NEEDS, such as everyday household chores, doing necessary
business, shopping, or getting around for other purposes?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with one or more persons 18 years of age or older
SkipInstructions:
<1> [if only one person 18 years of age or older, store the person number in PLAIADL and goto FLAWKNOW;
else, goto PLAIADL]
<2,R,D> [goto FLAWKNOW]
Page 6 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.160_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PLAIADL
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons 18 years of age or older and at least one needs the help of other persons in
handling routine needs
SkipInstructions:
goto FLAWKNOW
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FHS.170_00.000 Instrument Variable Name:
QuestionText:
FLAWKNOW
QuestionnaireFileName:
Family
? [F1]
Does a physical, mental, or emotional problem NOW keep [fill: you/any of these family members
* Read names
(fill roster of persons age 18 or older)]
from working at a job or business?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with one or more persons 18 years of age or older
SkipInstructions:
<1> [if only one person 18 years of age or older, store the person number in PLAWKNOW and goto FLAWALK;
else, goto PLAWKNOW]
<2,R,D> [goto FLAWKLIM]
Page 7 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.180_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PLAWKNOW
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons 18 years of age or older and at least one is unable to work due to a physical,
mental, or emotional problem
SkipInstructions:
all persons selected goto FLAWALK; else, goto FLAWKLIM
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FHS.190_00.000 Instrument Variable Name:
QuestionText:
FLAWKLIM
QuestionnaireFileName:
Family
? [F1]
[fill: Are you limited in the kind OR amount of work you/ Is ALIAS limited in the kind OR amount of work he/she/ Are
any of these family members,
* Read names
(fill roster of persons age 18 or older)]
limited in the kind OR amount of work they] can do because of a physical, mental or emotional problem?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with one or more persons 18 years of age or older not listed as being unable to work due to a physical,
mental, or emotional problem
SkipInstructions:
<1> [if only one person 18 years of age or older not selected at PLAWKNOW, store person number in
PLAWKLIM and goto FLAWALK; else, goto PLAWKLIM]
<2,R,D> [goto FLAWALK]
Page 8 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.200_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PLAWKLIM
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
0
Unable to work
Limited in work
Not limited in work
Refused
Don't know
1
2
7
9
UniverseText:
All families with two or more persons 18 years of age or older able to work and at least one is limited in the kind
or amount of work he/she can do
SkipInstructions:
goto FLAWALK
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FHS.210_00.000 Instrument Variable Name:
QuestionText:
FLAWALK
QuestionnaireFileName:
Family
? [F1]
Because of a health problem, [fill: do you/does anyone in the family]
have difficulty walking without using any special equipment?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PLAWALK and goto FLAREMEM; else, goto
PLAWALK]
<2,R,D> [goto FLAREMEM]
Question ID:
FHS.220_00.000 Instrument Variable Name:
QuestionText:
PLAWALK
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with two or more persons and at least one has difficulty walking without using special equipment
SkipInstructions:
goto FLAREMEM
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 9 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.230_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FLAREMEM
QuestionnaireFileName:
Family
? [F1]
[fill1: Are you/Is anyone in the family] LIMITED IN ANY WAY because of difficulty remembering or because
[fill2: you/they] experience periods of confusion?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store person number in PLAREMEM and goto LAHCC; else, goto PLAREMEM]
<2,R,D> [goto FLIMANY]
Question ID:
FHS.240_00.000 Instrument Variable Name:
QuestionText:
PLAREMEM
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one is limited due to difficulty remembering or periods of
confusion
SkipInstructions:
goto FLIMANY
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FHS.250_00.000 Instrument Variable Name:
QuestionText:
FLIMANY
QuestionnaireFileName:
Family
? [F1]
[fill: Are you/ Is ALIAS/ Are any family members
* Read names
(fill roster of applicable persons)]
LIMITED IN ANY WAY in any activities because of physical, mental or emotional problems?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with one or more family members not previously mentioned as having a limitation
SkipInstructions:
<1> [if a one-person family or the respondent is the only person NOT previously mentioned as having a limitation,
store person number in PLIMANY and goto LAHCC; else goto PLIMANY]
<2,R,D> [goto LAHCC]
Page 10 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.260_00.000 Instrument Variable Name:
QuestionText:
PLIMANY
05-May-09
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
0
1
2
7
9
Limitation previously mentioned
Yes, limited in some other way
Not limited in any way
Refused
Don't know
UniverseText:
All families with two or more persons not previously mentioned as having a limitation
SkipInstructions:
goto LAHCC
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 11 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.270_00.000 Instrument Variable Name:
QuestionText:
(book) F1
05-May-09
LAHCC
QuestionnaireFileName:
Family
? [F1]
What conditions or health problems cause [fill: ALIAS]’s limitations?
* Enter all that apply, separate with commas.
* Do not probe except to clarify answer.
01
Vision/problem seeing
Hearing problem
Speech problem
Asthma/breathing problem
Birth defect
Injury
Mental retardation
Other developmental problem (e.g., cerebral palsy)
Other mental, emotional or behavioral problem
Bone, joint, or muscle problem
Epilepsy or seizures
Learning disability
Attention Deficit/Hyperactivity Disorder (ADD/ADHD)
Other impairment/problem (Specify one)
Other impairment/problem (Specify one)
Refused
Don't know/not sure
02
03
04
05
06
07
08
09
10
11
12
13
90
91
97
99
UniverseText:
All persons less than 18 years of age who have at least one reported limitation
SkipInstructions:
<1-4,6-13> [goto appropriate follow-up questions: LHCL01N - LHCL04N, LHCL06N - LHCL13N]
<5> [fill "96" in LHCL05N and fill "6" in LHCL05T]
<90> [goto LAHCC_S1]
<91> [goto LAHCC_S2]
[repeat this question for the next person less than 18 years of age with a reported limitation; if no more
persons less than 18 years of age with a reported limitation, goto LAHCA]
NOTE: This question and all appropriate follow-up questions are asked, in sequence, for each person less than 18
years of age with a reported limitation. The instrument then proceeds to LAHCA.
Question ID:
FHS.271_90.000 Instrument Variable Name:
QuestionText:
LAHCC_S1
QuestionnaireFileName:
Family
* Read if necessary.
What is the other impairment or problem?
Verbatim
7
9
Verbatim response
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to at least one condition not listed at LAHCC
SkipInstructions:
goto LHCL90N
Page 12 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.271_91.000 Instrument Variable Name:
QuestionText:
05-May-09
LAHCC_S2
QuestionnaireFileName:
Family
* Read if necessary.
What is the other impairment or problem?
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to at least one condition not listed at LAHCC
SkipInstructions:
goto LHCL91N
Question ID:
FHS.280_01.000 Instrument Variable Name:
QuestionText:
LHCL01N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a vision problem or problem seeing?
* Enter number for time with a vision problem or problem seeing.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
1-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to a vision problem or problem seeing
SkipInstructions:
<1-95,D> [goto LHCL01T]
<96> [fill "6" in LHCL01T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL01T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 13 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.280_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LHCL01T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with vision problem or problem seeing.
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to a vision problem or problem seeing and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL01T]
if (LHCL01T = 4 and LHCL01N > AGE) or (LHCL01T = 3 and LHCL01N > AGE in months) or (LHCL01T = 2
and LHCL01N > AGE in weeks), goto ERR1_LHCL01T
Question ID:
FHS.282_01.000 Instrument Variable Name:
QuestionText:
LHCL02N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a hearing problem?
* Enter number for time with a hearing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to a hearing problem
SkipInstructions:
<1-95,D> [goto LHCL02T]
<96> [fill "6" in LHCL02T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL02T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 14 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.282_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LHCL02T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with hearing problem.
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to a hearing problem and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL02T]
if (LHCL02T = 4 and LHCL02N > AGE) or (LHCL02T = 3 and LHCL02N > AGE in months) or (LHCL02T = 2
and LHCL02N > AGE in weeks), goto ERR1_LHCL02T
Question ID:
FHS.284_01.000 Instrument Variable Name:
QuestionText:
LHCL03N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a speech problem?
* Enter number for time with a speech problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to a speech problem
SkipInstructions:
<1-95,D> [goto LHCL03T]
<96> [fill "6" in LHCL03T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL03T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 15 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.284_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LHCL03T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with speech problem.
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to a speech problem and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL03T]
if (LHCL03T = 4 and LHCL03N > AGE) or (LHCL03T = 3 and LHCL03N > AGE in months) or (LHCL03T = 2
and LHCL03N > AGE in weeks), goto ERR1_LHCL03T
Question ID:
FHS.286_01.000 Instrument Variable Name:
QuestionText:
LHCL04N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had asthma or a breathing problem?
* Enter number for time with an asthma or breathing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to asthma/breathing problem
SkipInstructions:
<1-95,D> [goto LHCL04T]
<96> [fill "6" in LHCL04T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL04T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 16 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.286_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LHCL04T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with asthma or a breathing problem.
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to asthma/breathing problem and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL04T]
if (LHCL04T = 4 and LHCL04N > AGE) or (LHCL04T = 3 and LHCL04N > AGE in months) or (LHCL04T = 2
and LHCL04N > AGE in weeks), goto ERR1_LHCL04T
Question ID:
FHS.288_01.000 Instrument Variable Name:
QuestionText:
LHCL06N
QuestionnaireFileName:
Family
1 of 2
How long [fill1: have you/has ALIAS] had the injury that caused [fill2:your/his/her] limitation?
* Enter number for time with the injury.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to an injury
SkipInstructions:
<1-95,D> [goto LHCL06T]
<96> [fill "6" in LHCL06T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL06T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 17 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.288_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LHCL06T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with the injury that caused [fill: your/his/her] limitation.
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to an injury and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL06T]
if (LHCL06T = 4 and LHCL06N > AGE) or (LHCL06T = 3 and LHCL06N > AGE in months) or (LHCL06T = 2
and LHCL06N > AGE in weeks), goto ERR1_LHCL06T
Question ID:
FHS.290_01.000 Instrument Variable Name:
QuestionText:
LHCL07N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had mental retardation?
* Enter number for time with mental retardation.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to mental retardation
SkipInstructions:
<1-95,D> [goto LHCL07T]
<96> [fill "6" in LHCL07T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL07T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 18 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.290_02.000 Instrument Variable Name:
QuestionText:
LHCL07T
05-May-09
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with mental retardation.
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to mental retardation and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL07T]
if (LHCL07T = 4 and LHCL07N > AGE) or (LHCL07T = 3 and LHCL07N > AGE in months) or (LHCL07T = 2
and LHCL07N > AGE in weeks), goto ERR1_LHCL07T
Question ID:
FHS.292_01.000 Instrument Variable Name:
QuestionText:
LHCL08N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a developmental problem (e.g. cerebral palsy)?
* Enter number for time with a developmental problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to some other developmental problem
SkipInstructions:
<1-95,D> [goto LHCL08T]
<96> [fill "6" in LHCL08T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL08T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 19 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.292_02.000 Instrument Variable Name:
QuestionText:
LHCL08T
05-May-09
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with developmental problem (e.g. cerebral palsy).
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to some other developmental problem and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL08T]
if (LHCL08T = 4 and LHCL08N > AGE) or (LHCL08T = 3 and LHCL08N > AGE in months) or (LHCL08T = 2
and LHCL08N > AGE in weeks), goto ERR1_LHCL08T
Question ID:
FHS.294_01.000 Instrument Variable Name:
QuestionText:
LHCL09N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a mental, emotional, or behavioral problem?
* Enter number for time with a mental, emotional, or behavioral problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to a mental, emotional, or behavioral problem
SkipInstructions:
<1-95,D> [goto LHCL09T]
<96> [fill "6" in LHCL09T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL09T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 20 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.294_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LHCL09T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with mental, emotional, or behavioral problem.
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to a mental, emotional, or behavioral problem and
1-95, D was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL09T]
if (LHCL09T = 4 and LHCL09N > AGE) or (LHCL09T = 3 and LHCL09N > AGE in months) or (LHCL09T = 2
and LHCL09N > AGE in weeks), goto ERR1_LHCL09T
Question ID:
FHS.296_01.000 Instrument Variable Name:
QuestionText:
LHCL10N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a bone, joint, or muscle problem?
* Enter number for time with a bone, joint, or muscle problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to a bone, joint, or muscle problem
SkipInstructions:
<1-95,D> [goto LHCL10T]
<96> [fill "6" in LHCL10T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL10T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 21 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.296_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LHCL10T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with bone, joint, or muscle problem.
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to a bone, joint, or muscle problem and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL10T]
if (LHCL10T = 4 and LHCL10N > AGE) or (LHCL10T = 3 and LHCL10N > AGE in months) or (LHCL10T = 2
and LHCL10N > AGE in weeks), goto ERR1_LHCL10T
Question ID:
FHS.298_01.000 Instrument Variable Name:
QuestionText:
LHCL11N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had epilepsy or seizures?
* Enter number for time with epilepsy or seizures.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to epilepsy or seizures
SkipInstructions:
<1-95,D> [goto LHCL11T]
<96> [fill "6" in LHCL11T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL11T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 22 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.298_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LHCL11T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with epilepsy or seizures.
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to epilepsy or seizures and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL11T]
if (LHCL11T = 4 and LHCL11N > AGE) or (LHCL11T = 3 and LHCL11N > AGE in months) or (LHCL11T = 2
and LHCL11N > AGE in weeks), goto ERR1_LHCL11T
Question ID:
FHS.300_01.000 Instrument Variable Name:
QuestionText:
LHCL12N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a learning disability?
* Enter number for time with a learning disability.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to a learning disability
SkipInstructions:
<1-95,D> [goto LHCL12T]
<96> [fill "6" in LHCL12T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL12T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 23 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.300_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LHCL12T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with learning disability.
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to a learning disability and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL12T]
if (LHCL12T = 4 and LHCL12N > AGE) or (LHCL12T = 3 and LHCL12N > AGE in months) or (LHCL12T = 2
and LHCL12N > AGE in weeks), goto ERR1_LHCL12T
Question ID:
FHS.302_01.000 Instrument Variable Name:
QuestionText:
LHCL13N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had attention deficit/hyperactivity disorder?
* Enter number for time with attention deficit/hyperactivity disorder.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to Attention Deficit/Hyperactivity Disorder
SkipInstructions:
<1-95,D> [goto LHCL13T]
<96> [fill "6" in LHCL13T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL13T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 24 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.302_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LHCL13T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with attention deficit/hyperactivity disorder.
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to Attention Deficit/Hyperactivity Disorder and 195, D was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL13T]
if (LHCL13T = 4 and LHCL13N > AGE) or (LHCL13T = 3 and LHCL13N > AGE in months) or (LHCL13T = 2
and LHCL13N > AGE in weeks), goto ERR1_LHCL13T
Question ID:
FHS.304_01.000 Instrument Variable Name:
QuestionText:
LHCL90N
QuestionnaireFileName:
Family
1 of 2
How long [fill1: have you/has ALIAS] had [fill2: problem in LAHCC_S1]?
* Enter number for time with [fill1: problem in LAHCC_S1]?
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to the problem entered at LAHCC_S1
SkipInstructions:
<1-95,D> [goto LHCL90T]
<96> [fill "6" in LHCL90T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL90T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 25 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.304_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LHCL90T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with [fill: problem in LAHCC_S1].
1
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
2
3
4
6
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to the problem entered at LAHCC_S1 and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL90T]
if (LHCL90T = 4 and LHCL90N > AGE) or (LHCL90T = 3 and LHCL90N > AGE in months) or (LHCL90T = 2
and LHCL90N > AGE in weeks), goto ERR1_LHCL90T
Question ID:
FHS.306_01.000 Instrument Variable Name:
QuestionText:
LHCL91N
QuestionnaireFileName:
Family
1 of 2
How long [fill1: have you/has ALIAS] had [fill2: problem in LAHCC_S2]?
* Enter number for time with [fill1: problem in LAHCC_S2].
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
95
96
97
99
01-94
95+
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to the problem entered at LAHCC_S2
SkipInstructions:
<1-95,D> [goto LHCL91T]
<96> [fill "6" in LHCL91T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL91T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
Page 26 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.306_02.000 Instrument Variable Name:
QuestionText:
05-May-09
LHCL91T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with [fill: problem in LAHCC_S2].
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to the problem entered at LAHCC_S2 and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL91T]
if (LHCL91T = 4 and LHCL91N > AGE) or (LHCL91T = 3 and LHCL91N > AGE in months) or (LHCL91T = 2
and LHCL91N > AGE in weeks), goto ERR1_LHCL91T
Page 27 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
QuestionText:
FHS.350_00.000 Instrument Variable Name:
LAHCA
05-May-09
QuestionnaireFileName:
(book) F2
What conditions or health problems cause [fill: your/ALIAS’s] limitations?
* Enter all that apply, separate with commas.
* Do not probe except to clarify answer.
01
02
03
04
05
06
07
08
09
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
90
91
97
99
Vision/problem seeing
Hearing problem
Arthritis/rheumatism
Back or neck problem
Fracture, bone/joint injury
Other injury
Heart problem
Stroke problem
Hypertension/high blood pressure
Diabetes
Lung/breathing problem(e.g., asthma and emphysema)
Cancer
Birth defect
Mental retardation
Other developmental problem (e.g. cerebral palsy)
Senility
Depression/anxiety/emotional problem
Weight problem
Missing limbs (fingers, toes or digits), amputee
Kidney, bladder or renal problems
Circulation problems (including blood clots)
Benign tumors, cysts
Fibromyalgia, lupus
Osteoporosis, tendinitis
Epilepsy, seizures
Multiple Sclerosis (MS), Muscular Dystrophy (MD)
Polio(myelitis), paralysis, para/quadriplegia
Parkinson's disease, other tremors
Other nerve damage, including carpal tunnel syndrome
Hernia
Ulcer
Varicose veins, hemorrhoids
Thyroid problems, Grave's disease, gout
Knee problems (not arthritis (03), not joint injury(05))
Migraine headaches (not just headaches)
Other impairment/problem (Specify one)
Other impairment/problem (Specify one)
Refused
Don't know/not sure
Family
Page 28 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
05-May-09
UniverseText:
All persons 18 years of age or older who have at least one reported limitation
SkipInstructions:
<1-12,14-35> [goto appropriate follow-up questions: LHAL01N - LHAL12N, LHAL14N - LHAL35N]
<13> [fill "96" in LHAL13N and fill "6" in LHAL13T]
<90> [goto LAHCA_S1]
<91> [goto LAHCA_S2]
[repeat this question for the next person 18 years of age or older with a reported limitation; if no more
persons 18 years of age or older with a reported limitation, goto PHSTAT]
NOTE: This question and all appropriate follow-up questions are asked, in sequence, for each person 18 years of
age or older with a reported limitation. The instrument then proceeds to PHSTAT.
Question ID:
FHS.351_90.000 Instrument Variable Name:
QuestionText:
LAHCA_S1
QuestionnaireFileName:
Family
* Read if necessary.
What is the other impairment or problem?
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All persons less than 18 years of age who have a limitation due to at least one condition not listed at LAHCC
SkipInstructions:
goto LHAL90N
Question ID:
FHS.351_91.000 Instrument Variable Name:
QuestionText:
LAHCA_S2
QuestionnaireFileName:
Family
* Read if necessary.
What is the other impairment or problem?
Verbatim
7
9
Verbatim response
Refused
Don't know
UniverseText:
All persons less than 18 years of age who have a limitation due to at least one condition not listed at LAHCC
SkipInstructions:
goto LHAL91N
Page 29 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.360_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL01N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a vision problem or problem seeing?
* Enter number for time with a vision problem or problem seeing.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to a vision problem or problem seeing
SkipInstructions:
<1-95,D> [goto LHAL01T]
<96> [fill "6" in LHAL01T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL01T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.360_02.000 Instrument Variable Name:
QuestionText:
LHAL01T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with vision problem or problem seeing.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to a vision problem or problem seeing and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL01T]
if LHAL01T = 4 and LHAL01N > AGE, goto ERR1_LHAL01T
Page 30 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.362_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL02N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a hearing problem?
* Enter number for time with a hearing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to a hearing problem
SkipInstructions:
<1-95,D> [goto LHAL02T]
<96> [fill "6" in LHAL02T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL02T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.362_02.000 Instrument Variable Name:
QuestionText:
LHAL02T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with hearing problem.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to a hearing problem and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL02T]
if LHAL02T = 4 and LHAL02N > AGE, goto ERR1_LHAL02T
Page 31 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.364_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL03N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had arthritis or rheumatism?
* Enter number for time with arthritis or rheumatism.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to arthritis/rheumatism
SkipInstructions:
<1-95,D> [goto LHAL03T]
<96> [fill "6" in LHAL03T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL03T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.364_02.000 Instrument Variable Name:
QuestionText:
LHAL03T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with arthritis or rheumatism.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since Birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to arthritis/rheumatism and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL03T]
if LHAL03T = 4 and LHAL03N > AGE, goto ERR1_LHAL03T
Page 32 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.366_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL04N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a back or neck problem?
* Enter number for time with a back or neck problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to a back or neck problem
SkipInstructions:
<1-95,D> [goto LHAL04T]
<96> [fill "6" in LHAL04T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL04T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.366_02.000 Instrument Variable Name:
QuestionText:
LHAL04T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with back or neck problem.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to a back or neck problem and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL04T]
if LHAL04T = 4 and LHAL04N > AGE, goto ERR1_LHAL04T
Page 33 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.368_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL05N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a fracture, bone, or joint injury?
* Enter number for time with a fracture, bone or joint injury.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to a fracture or bone/joint injury
SkipInstructions:
<1-95,D> [goto LHAL05T]
<96> [fill "6" in LHAL05T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL05T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.368_02.000 Instrument Variable Name:
QuestionText:
LHAL05T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with fracture, bone, or joint injury.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to a fracture or bone/joint injury and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL05T]
if LHAL05T = 4 and LHAL05N > AGE, goto ERR1_LHAL05T
Page 34 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.370_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL06N
QuestionnaireFileName:
Family
1 of 2
How long [fill1: have you/has ALIAS] had the other injury that caused [fill2: your/his/her] limitation?
* Enter number for time with the injury.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to some "other" injury
SkipInstructions:
<1-95,D> [goto LHAL06T]
<96> [fill "6" in LHAL06T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL06T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.370_02.000 Instrument Variable Name:
QuestionText:
LHAL06T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with other injury that caused [fill: your/his/her] limitation.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to some "other" injury and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL06T]
if LHAL06T = 4 and LHAL06N > AGE, goto ERR1_LHAL06T
Page 35 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.372_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL07N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a heart problem?
* Enter number for time with a heart problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to a heart problem
SkipInstructions:
<1-95,D> [goto LHAL07T]
<96> [fill "6" in LHAL07T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL07T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.372_02.000 Instrument Variable Name:
QuestionText:
LHAL07T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with heart problem.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to a heart problem and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL07T]
if LHAL07T = 4 and LHAL07N > AGE, goto ERR1_LHAL07T
Page 36 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.374_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL08N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a stroke problem?
* Enter number for time with a stroke problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to a stroke problem
SkipInstructions:
<1-95,D> [goto LHAL08T]
<96> [fill "6" in LHAL08T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL08T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.374_02.000 Instrument Variable Name:
QuestionText:
LHAL08T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with stroke problem.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to a stroke problem and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL08T]
if LHAL08T = 4 and LHAL08N > AGE, goto ERR1_LHAL08T
Page 37 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.376_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL09N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had hypertension or high blood pressure?
* Enter number for time with hypertension or high blood pressure.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to hypertension/high blood pressure
SkipInstructions:
<1-95,D> [goto LHAL09T]
<96> [fill "6" in LHAL09T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL09T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.376_02.000 Instrument Variable Name:
QuestionText:
LHAL09T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with hypertension or high blood pressure.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to hypertension/high blood pressure and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL09T]
if LHAL09T = 4 and LHAL09N > AGE, goto ERR1_LHAL09T
Page 38 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.378_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL10N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had diabetes?
* Enter number for time with diabetes.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to diabetes
SkipInstructions:
<1-95,D> [goto LHAL10T]
<96> [fill "6" in LHAL10T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL10T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.378_02.000 Instrument Variable Name:
QuestionText:
LHAL10T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with diabetes.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to diabetes and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL10T]
if LHAL10T = 4 and LHAL10N > AGE, goto ERR1_LHAL10T
Page 39 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.380_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL11N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a lung problem or breathing problem (e.g., asthma and emphysema)?
* Enter number for time with a lung problem or breathing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to a lung/breathing problem
SkipInstructions:
<1-95,D> [goto LHAL11T]
<96> [fill "6" in LHAL11T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL11T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.380_02.000 Instrument Variable Name:
QuestionText:
LHAL11T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with lung problem or breathing problem (e.g., asthma and emphysema).
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to a lung/breathing problem and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL11T]
if LHAL11T = 4 and LHAL11N > AGE, goto ERR1_LHAL11T
Page 40 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.382_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL12N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had cancer?
* Enter number for time with cancer.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to cancer
SkipInstructions:
<1-95,D> [goto LHAL12T]
<96> [fill "6" in LHAL12T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL12T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.382_02.000 Instrument Variable Name:
QuestionText:
LHAL12T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with cancer.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to cancer and 1-95, D was entered for the "number"
part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL12T]
if LHAL12T = 4 and LHAL12N > AGE, goto ERR1_LHAL12T
Page 41 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.384_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL14N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had mental retardation?
* Enter number for time with mental retardation.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to mental retardation
SkipInstructions:
<1-95,D> [goto LHAL14T]
<96> [fill "6" in LHAL14T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL14T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.384_02.000 Instrument Variable Name:
QuestionText:
LHAL14T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with mental retardation.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to mental retardation and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL14T]
if LHAL14T = 4 and LHAL14N > AGE, goto ERR1_LHAL14T
Page 42 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.386_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL15N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a developmental problem (e.g. cerebral palsy)?
* Enter number for time with a developmental problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to some other developmental problem
SkipInstructions:
<1-95,D> [goto LHAL15T]
<96> [fill "6" in LHAL15T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL15T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.386_02.000 Instrument Variable Name:
QuestionText:
LHAL15T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with developmental problem (e.g. cerebral palsy).
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to some other developmental problem and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL15T]
if LHAL15T = 4 and LHAL15N > AGE, goto ERR1_LHAL15T
Page 43 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.388_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL16N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had senility?
* Enter number for time with senility.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to senility
SkipInstructions:
<1-95,D> [goto LHAL16T]
<96> [fill "6" in LHAL16T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL16T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.388_02.000 Instrument Variable Name:
QuestionText:
LHAL16T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with senility.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to senility and 1-95, D was entered for the "number"
part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL16T]
if LHAL16T = 4 and LHAL16N > AGE, goto ERR1_LHAL16T
Page 44 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.390_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL17N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had depression, anxiety, or an emotional problem?
* Enter number for time with depression, anxiety or an emotional problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to depression/anxiety/emotional problem
SkipInstructions:
<1-95,D> [goto LHAL17T]
<96> [fill "6" in LHAL17T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL17T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.390_02.000 Instrument Variable Name:
QuestionText:
LHAL17T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with depression, anxiety, or an emotional problem.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to depression/anxiety/emotional problem and 1-95,
D was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL17T]
if LHAL17T = 4 and LHAL17N > AGE, goto ERR1_LHAL17T
Page 45 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.392_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL18N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a weight problem?
* Enter number for time with a weight problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to a weight problem
SkipInstructions:
<1-95,D> [goto LHAL18T]
<96> [fill "6" in LHAL18T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL18T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.392_02.000 Instrument Variable Name:
QuestionText:
LHAL18T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with weight problem.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to a weight problem and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL18T]
if LHAL18T = 4 and LHAL18N > AGE, goto ERR1_LHAL18T
Page 46 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.394_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL19N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a missing limb (finger, toe, or digit)?
* Enter number for time with a missing limb.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to missing limbs
SkipInstructions:
<1-95,D> [goto LHAL19T]
<96> [fill "6" in LHAL19T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL19T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.394_02.000 Instrument Variable Name:
QuestionText:
LHAL19T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with missing limb (finger, toe, or digit).
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to missing limbs and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL19T]
if LHAL19T = 4 and LHAL19N > AGE, goto ERR1_LHAL19T
Page 47 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.396_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL20N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a kidney, bladder or renal problem?
* Enter number for time with a kidney, bladder or renal problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to a kidney, bladder, or renal problem
SkipInstructions:
<1-95,D> [goto LHAL20T]
<96> [fill "6" in LHAL20T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL20T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.396_02.000 Instrument Variable Name:
QuestionText:
LHAL20T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with kidney, bladder or renal problem.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to a kidney, bladder, or renal problem and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL20T]
if LHAL20T = 4 and LHAL20N > AGE, goto ERR1_LHAL20T
Page 48 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.398_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL21N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a circulation problem (including blood clots)?
* Enter number for time with a circulation problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to circulation problems
SkipInstructions:
<1-95,D> [goto LHAL21T]
<96> [fill "6" in LHAL21T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL21T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.398_02.000 Instrument Variable Name:
QuestionText:
LHAL21T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with circulation problem (including blood clots).
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to circulation problems and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL21T]
if LHAL21T = 4 and LHAL21N > AGE, goto ERR1_LHAL21T
Page 49 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.400_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL22N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had benign tumors or cysts?
* Enter number for time with benign tumors or cysts.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to benign tumors or cysts
SkipInstructions:
<1-95,D> [goto LHAL22T]
<96> [fill "6" in LHAL22T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL22T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.400_02.000 Instrument Variable Name:
QuestionText:
LHAL22T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with benign tumors or cysts.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to benign tumors or cysts and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL22T]
if LHAL22T = 4 and LHAL22N > AGE, goto ERR1_LHAL22T
Page 50 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.402_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL23N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had fibromyalgia or lupus?
* Enter number for time with fibromyalgia or lupus.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to fibromyalgia or lupus
SkipInstructions:
<1-95,D> [goto LHAL23T]
<96> [fill "6" in LHAL23T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL23T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.402_02.000 Instrument Variable Name:
QuestionText:
LHAL23T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with fibromyalgia or lupus.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to fibromyalgia or lupus and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL23T]
if LHAL23T = 4 and LHAL23N > AGE, goto ERR1_LHAL23T
Page 51 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.404_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL24N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had osteoporosis or tendinitis?
* Enter number for time with osteoporosis or tendinitis.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to osteoporosis or tendinitis
SkipInstructions:
<1-95,D> [goto LHAL24T]
<96> [fill "6" in LHAL24T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL24T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.404_02.000 Instrument Variable Name:
QuestionText:
LHAL24T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with osteoporosis or tendinitis.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to osteoporosis or tendinitis and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL24T]
if LHAL24T = 4 and LHAL24N > AGE, goto ERR1_LHAL24T
Page 52 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.406_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL25N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had epilepsy or seizures?
* Enter number for time with epilepsy or seizures.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to epilepsy or seizures
SkipInstructions:
<1-95,D> [goto LHAL25T]
<96> [fill "6" in LHAL25T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL25T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.406_02.000 Instrument Variable Name:
QuestionText:
LHAL25T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with epilepsy or seizures.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to epilepsy or seizures and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL25T]
if LHAL25T = 4 and LHAL25N > AGE, goto ERR1_LHAL25T
Page 53 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.408_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL26N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had multiple sclerosis (MS) or muscular dystrophy (MD)?
* Enter number for time with multiple sclerosis (MS) or muscular dystrophy (MD)?
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to multiple sclerosis or muscular dystrophy
SkipInstructions:
<1-95,D> [goto LHAL26T]
<96> [fill "6" in LHAL26T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL26T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.408_02.000 Instrument Variable Name:
QuestionText:
LHAL26T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with multiple sclerosis (MS) or muscular dystrophy (MD).
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to multiple sclerosis or muscular dystrophy and 195, D was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL26T]
if LHAL26T = 4 and LHAL26N > AGE, goto ERR1_LHAL26T
Page 54 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.410_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL27N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had polio(myelitis), paralysis or para/quadriplegia?
* Enter number for time with polio (myelitis) paralysis or para/quadriplegia.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to polio, paralysis, or para/quadriplegia
SkipInstructions:
<1-95,D> [goto LHAL27T]
<96> [fill "6" in LHAL27T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL27T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.410_02.000 Instrument Variable Name:
QuestionText:
LHAL27T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with polio(myelitis), paralysis or para/quadriplegia.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to polio, paralysis, or para/quadriplegia and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL27T]
if LHAL27T = 4 and LHAL27N > AGE, goto ERR1_LHAL27T
Page 55 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.412_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL28N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had Parkinson’s disease or tremors?
* Enter number for time with Parkinson's disease or tremors.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to Parkinson's disease or other tremors
SkipInstructions:
<1-95,D> [goto LHAL28T]
<96> [fill "6" in LHAL28T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL28T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.412_02.000 Instrument Variable Name:
QuestionText:
LHAL28T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with Parkinson’s disease or tremors.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to Parkinson's disease or other tremors and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL28T]
if LHAL28T = 4 and LHAL28N > AGE, goto ERR1_LHAL28T
Page 56 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.414_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL29N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had nerve damage (including carpal tunnel syndrome)?
* Enter number for time with nerve damage.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to other nerve damage, including carpal tunnel
syndrome
SkipInstructions:
<1-95,D> [goto LHAL29T]
<96> [fill "6" in LHAL29T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL29T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.414_02.000 Instrument Variable Name:
QuestionText:
LHAL29T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with nerve damage (including carpal tunnel syndrome).
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to other nerve damage, including carpal tunnel
syndrome, and 1-95, D was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL29T]
if LHAL29T = 4 and LHAL29N > AGE, goto ERR1_LHAL29T
Page 57 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.416_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL30N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a hernia?
* Enter number for time with a hernia.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to a hernia
SkipInstructions:
<1-95,D> [goto LHAL30T]
<96> [fill "6" in LHAL30T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL30T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.416_02.000 Instrument Variable Name:
QuestionText:
LHAL30T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with hernia.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to a hernia and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL30T]
if LHAL30T = 4 and LHAL30N > AGE, goto ERR1_LHAL30T
Page 58 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.418_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL31N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had an ulcer?
* Enter number for time with an ulcer.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to an ulcer
SkipInstructions:
<1-95,D> [goto LHAL31T]
<96> [fill "6" in LHAL31T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL31T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.418_02.000 Instrument Variable Name:
QuestionText:
LHAL31T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with ulcer.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to an ulcer and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL31T]
if LHAL31T = 4 and LHAL31N > AGE, goto ERR1_LHAL31T
Page 59 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.420_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL32N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had varicose veins or hemorrhoids?
* Enter number for time with varicose veins or hemorrhoids.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to varicose veins or hemorrhoids
SkipInstructions:
<1-95,D> [goto LHAL32T]
<96> [fill "6" in LHAL32T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL32T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.420_02.000 Instrument Variable Name:
QuestionText:
LHAL32T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with varicose veins or hemorrhoids.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to varicose veins or hemorrhoids and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL32T]
if LHAL32T = 4 and LHAL32N > AGE, goto ERR1_LHAL32T
Page 60 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.422_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL33N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a thyroid problem, Grave’s disease or gout?
* Enter number for time with a thyroid problem, Grave's disease or gout.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to thyroid problems, Grave's disease, or gout
SkipInstructions:
<1-95,D> [goto LHAL33T]
<96> [fill "6" in LHAL33T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL33T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.422_02.000 Instrument Variable Name:
QuestionText:
LHAL33T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with thyroid problem, Grave’s disease or gout.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to thyroid problems, Grave's disease, or gout and 195, D was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL33T]
if LHAL33T = 4 and LHAL33N > AGE, goto ERR1_LHAL33T
Page 61 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.424_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL34N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had a knee problem?
* Enter number for time with a knee problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to knee problems
SkipInstructions:
<1-95,D> [goto LHAL34T]
<96> [fill "6" in LHAL34T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL34T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.424_02.000 Instrument Variable Name:
QuestionText:
LHAL34T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with knee problem.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to knee problems and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL34T]
if LHAL34T = 4 and LHAL34N > AGE, goto ERR1_LHAL34T
Page 62 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.426_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL35N
QuestionnaireFileName:
Family
1 of 2
How long [fill: have you/has ALIAS] had migraine headaches?
* Enter number for time with migraine headaches.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to migraine headaches
SkipInstructions:
<1-95,D> [goto LHAL35T]
<96> [fill "6" in LHAL35T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL35T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.426_02.000 Instrument Variable Name:
QuestionText:
LHAL35T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with migraine headaches.
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to migraine headaches and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL35T]
if LHAL35T = 4 and LHAL35N > AGE, goto ERR1_LHAL35T
Page 63 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.450_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL90N
QuestionnaireFileName:
Family
1 of 2
How long [fill1: have you/has ALIAS] had [fill2: LAHCA_S1]?
* Enter number for time with [fill1: LAHCA_S1].
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
1-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to the problem entered at LAHCA_S1
SkipInstructions:
<1-95,D> [goto LHAL90T]
<96> [fill "6" in LHAL90T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL90T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.450_02.000 Instrument Variable Name:
QuestionText:
LHAL90T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with [fill: LAHCA_S1].
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to the problem entered at LAHCA_S1 and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL90T]
if LHAL90T = 4 and LHAL90N > AGE, goto ERR1_LHAL90T
Page 64 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.452_01.000 Instrument Variable Name:
QuestionText:
05-May-09
LHAL91N
QuestionnaireFileName:
Family
1 of 2
How long [fill1: have you/has ALIAS] had [fill2: LAHCA_S2]?
* Enter number for time with [fill1: LAHCA_S2].
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94
01-94
95+
Since birth
Refused
Don't know
95
96
97
99
UniverseText:
All persons 18 years of age or older who have a limitation due to the problem entered at LAHCA_S2
SkipInstructions:
<1-95,D> [goto LHAL91T]
<96> [fill "6" in LHAL91T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL91T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
Question ID:
FHS.452_02.000 Instrument Variable Name:
QuestionText:
LHAL91T
QuestionnaireFileName:
Family
2 of 2
* Enter time period for time with [fill: LAHCA_S2].
1
2
3
4
6
7
9
Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know
UniverseText:
All persons 18 years of age or older who have a limitation due to the problem entered at LAHCA_S2 and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions:
<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL91T]
if LHAL91T = 4 and LHAL91N > AGE, goto ERR1_LHAL91T
Page 65 of 65
DRAFT 2010 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:
Question ID:
FHS.500_00.000 Instrument Variable Name:
QuestionText:
1
2
3
4
5
7
9
PHSTAT
05-May-09
QuestionnaireFileName:
Would you say [fill: your/ALIAS’s] health in general is excellent, very good, good, fair, or poor?
Excellent
Very good
Good
Fair
Poor
Refused
Don't know
UniverseText:
All persons
SkipInstructions:
repeat for all persons in the family, goto FINJ3M
Family
Page 1 of 8
DRAFT 2010 NHIS Questionnaire - Family
Family Identification
Document Version Date:
Question ID:
FID.100_00.000 Instrument Variable Name:
QuestionText:
05-May-09
HHCHANGE
QuestionnaireFileName:
I have recorded that [your name is {fill fullname}, you are /fill ALIAS is] [fill sex], [fill age] years old, born on [fill
birthdate]. [His/Her] national origin is [fill Hispanic origin], and [his/her] race is [fill race]:
Is this information correct?
1
Yes, this information is correct
No, correction(s) needed/more corrections needed
2
UniverseText:
All nondeleted family members
SkipInstructions:
<1> if no additional PX remain
if SCREENIN = 0 and I_SCRN_STATUS = S [goto EXIT(HHC)]
else [goto FIDCC13]
<2> [goto CWHAT2]
Question ID:
Family
FID.110_00.000 Instrument Variable Name:
QuestionText:
CWHAT2
QuestionnaireFileName:
Family
* Change(s) needed for [ALIAS].
* Enter each number that applies. If a wrong choice, type that choice again.
1
Name
Age or DOB
Sex
National origin
Race
2
3
4
5
UniverseText:
HHCHANGE = 2 (No, not correct)
SkipInstructions:
<1> [goto CHG_NAME_FNAME]
<2> [goto CHG_AGEDOB_1]
<3> [goto CHG_SEX]
<4> [goto CHG_NATOR]
<5> [goto CHG_RACE]
Question ID:
FID.245_00.000 Instrument Variable Name:
QuestionText:
HHCHANGE_1
QuestionnaireFileName:
Family
I have recorded that {your name is/ALIAS is} {fill full name}, age is {fill age}, date of birth is {fill birthdate}, {his/her}
national origin is {fill Hispanic origin}, and {his/her} {fill race} is:
Is this information correct?
UniverseText:
All nondeleted family members with a change made to their demographic information
SkipInstructions:
<1> if no additional PX remain
if SCREENIN = 0 and I_SCRN_STATUS = S, GOTO EXIT(HHC)
else GOTO FIDCC13
<2> GOTO ERR_HHCHANGE_1
Page 2 of 8
DRAFT 2010 NHIS Questionnaire - Family
Family Identification
Document Version Date:
Question ID:
FID.250_00.000 Instrument Variable Name:
QuestionText:
05-May-09
MARITAL
QuestionnaireFileName:
Family
* ASK OR VERIFY
[fill: Are you/Is ALIAS] now married, widowed, divorced, separated, never married, or living with a partner?
1
Married
Widowed
Divorced
Separated
Never Married
Living with partner
Refused
Don't know
2
3
4
5
6
7
9
UniverseText:
All persons, 14 and older, who don't have a marital status yet
SkipInstructions:
<1> [goto SPFLAG]
<2-5, R, D> [goto FIDCCI3]
<6> if LINTAL[FAMINT] = 1 [goto FIDCCI4]
else [goto COHAB1]
Question ID:
FID.260_00.000 Instrument Variable Name:
QuestionText:
SPOUS
QuestionnaireFileName:
Family
QuestionnaireFileName:
Family
* ASK OR VERIFY
Is [fill: your/ALIAS's] spouse living in the household?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
A potential spouse lives in the unit.
SkipInstructions:
<1> If SPOUS2[PX] = null [goto SPOUS2]
else [goto FIDCCI3]
<2,R,D> [goto FIDCCI3]
Question ID:
FID.270_00.000 Instrument Variable Name:
QuestionText:
SPOUS2
* Probe as necessary and enter the line number of the spouse.
[Display all possible spouse candidates]
01-25
Person # of spouse
UniverseText:
Person has an unidentified spouse in the household.
SkipInstructions:
Do not allow line number of the subject to be entered. If so [goto ERR_SPOUS2]
<1-25,R,D> [goto FIDCCI3]
Page 3 of 8
DRAFT 2010 NHIS Questionnaire - Family
Family Identification
Document Version Date:
Question ID:
FID.280_00.000 Instrument Variable Name:
QuestionText:
COHAB1
Family
QuestionnaireFileName:
Family
QuestionnaireFileName:
Family
Yes
No
Refused
Don't know
2
7
9
UniverseText:
Marital status is "living with a partner."
SkipInstructions:
<1> [goto COHAB2]
<2,R,D> if COHAB3[PX] = null [goto COHAB3]
else [goto FIDCCI3]
FID.290_00.000 Instrument Variable Name:
QuestionText:
COHAB2
What is [fill: your/ALIAS's] current legal marital status?
1
Married
Widowed
Divorced
Separated
Refused
Don't know
2
3
4
7
9
UniverseText:
Person has been married.
SkipInstructions:
<1-4,R,D> If COHAB3[PX] = null [goto COHAB3]
else [goto FIDCCI3]
Question ID:
QuestionnaireFileName:
[fill: Have you/Has ALIAS] ever been married?
1
Question ID:
05-May-09
FID.300_00.000 Instrument Variable Name:
QuestionText:
COHAB3
* Probe as necessary and enter the line number of the cohabiting partner.
[Display all possible cohabitation candidates]
01-25
Person number
UniverseText:
Co-habitating partner has yet to be identified.
SkipInstructions:
If line number of the subject is entered [goto ERR_COHAB3]
<1-25,R,D> [goto FIDCCI3]
Page 4 of 8
DRAFT 2010 NHIS Questionnaire - Family
Family Identification
Document Version Date:
Question ID:
FID.322_00.000 Instrument Variable Name:
QuestionText:
05-May-09
DEGREE4
Family
I noted that [father's fullname] is the father of [child's fullname]. Is [child's fullname] his biological, adoptive, step, foster,
or [fill: son/daughter] in law?
1
Biological
Adoptive
Step
Foster
-in-law
Refused
Don't know
2
3
4
5
7
9
UniverseText:
When the reference person is the person in question's parent.
SkipInstructions:
<1> if AGEDIFF <12 [goto ERR_DEGREE4]
if ERR_DEGREE4 = 1 [goto FIDCCI4B]
else reset DEGREE4 [goto DEGREE4] endif
else [goto FIDCCI4B]
<2-5,R,D> [goto FIDCCI4B]
Question ID:
QuestionnaireFileName:
FID.324_00.000 Instrument Variable Name:
QuestionText:
1
2
3
4
5
7
9
DEGREE5
QuestionnaireFileName:
Family
I noted that [mother's fullname] is the mother of [child's fullname]. Is [child's fullname] her biological, adoptive, step,
foster, or [fill: son/daughter] in law?
Biological
Adoptive
Step
Foster
-in-law
Refused
Don't know
UniverseText:
When the reference person is the person in question's parent.
SkipInstructions:
<1> if AGEDIFF <12 [goto ERR_DEGREE5]
if yes, continue the interview [goto FIDCCI4B]
else, reset DEGREE5 [goto DEGREE5] endif
else [goto FIDCCI4B]
<2-5,R,D> [goto FIDCCI4B]
Page 5 of 8
DRAFT 2010 NHIS Questionnaire - Family
Family Identification
Document Version Date:
Question ID:
FID.326_00.000 Instrument Variable Name:
QuestionText:
05-May-09
MOTHER
QuestionnaireFileName:
Family
* Ask or verify
Is [fill: your/ALIAS's] mother a household member? (Include biological (natural), adoptive, step, or foster mother or
mother-in-law)
* Enter the line number of the mother or mother-in-law.
If the mother or mother-in-law is not a household member, enter "0".
If the person has no parents present but has a legal guardian, enter "96".
* Choose mother over mother-in-law if both are present.
00
Mother not a household member
Person number of mother
Has legal guardian
Refused
Don't know
01-25
96
97
99
UniverseText:
Potential mother in the Family, mother not already identified
SkipInstructions:
<01-25> [goto MOTHERCK_A]
<0,R,D> [goto FIDCCI5]
<96> [goto GUARD]
Question ID:
FID.330_01.000 Instrument Variable Name:
QuestionText:
1
2
3
4
5
7
9
MOTHERCK_A
QuestionnaireFileName:
Family
[fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster mother or mother-in-law?
Biological mother
Adoptive mother
Step mother
Foster mother
Mother-in-law
Refused
Don't know
UniverseText:
Mother is in the immediate family.
SkipInstructions:
<1> If AGEDIFF <12 [goto ERR_MOTHERCK_A]
if <1> [goto FIDCCI5]
elseif <2> [goto MOTHER]
elseif <3>, reset MOTHERCK_A [goto MOTHERCK_A]
else [goto FIDCCI5]
<2-5,R,D> [goto FIDCCI5]
Page 6 of 8
DRAFT 2010 NHIS Questionnaire - Family
Family Identification
Document Version Date:
Question ID:
FID.330_02.000 Instrument Variable Name:
QuestionText:
05-May-09
MOM_CKFG
Family
[fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster mother or mother-in-law?
UniverseText:
Mother is in the immediate family.
SkipInstructions:
<1> If AGEDIFF <12 [goto ERR_MOTHERCK_A]
if <1> [goto FIDCCI5]
elseif <2> [goto MOTHER]
elseif <3>, reset MOTHERCK_A [goto MOTHERCK_A]
else [goto FIDCCI5]
<2-5,R,D> [goto FIDCCI5]
Question ID:
QuestionnaireFileName:
FID.340_00.000 Instrument Variable Name:
QuestionText:
FATHER
QuestionnaireFileName:
Family
* Ask or verify
Is [fill: your/ALIAS's] father a household member? (Include biological (natural), adoptive, step, or foster father or fatherin-law).
* Enter the line number of the father or father-in-law.
* If the father is not a household member, enter '0'.
* If the person has no parents present but has a legal guardian, enter '96'.
* Choose father over father-in-law if both are present.
00
01-25
96
97
99
Father not in household
Person # of father
Has legal guardian
Refused
Don't know
UniverseText:
Potential Father in Family, not already identified
SkipInstructions:
<1-25> [goto FATHERCK_A]
<0,R,D> [goto FIDCCI4]
<96> [goto GUARD]
Page 7 of 8
DRAFT 2010 NHIS Questionnaire - Family
Family Identification
Document Version Date:
Question ID:
FID.350_01.000 Instrument Variable Name:
QuestionText:
FATHERCK_A
Family
Biological father
Adoptive father
Step father
Foster father
Father-in-law
Refused
Don’t know
2
3
4
5
7
9
UniverseText:
Father has been identified
SkipInstructions:
<1> If AGEDIFF <12 [goto ERR_FATHERCK_A]
if ERRFATHERCK_A = <1> [goto FIDCCI4]
elseif <2> [goto FATHER]
elseif <3> reset FATHERCK_A
[goto FATHERCK_A] endif
else [goto FIDCCI4]
<2-5,R,D> [goto FIDCCI4]
FID.350_02.000 Instrument Variable Name:
QuestionText:
DAD_CKFG
QuestionnaireFileName:
Family
[fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster father or father-in-law?
UniverseText:
Father has been identified
SkipInstructions:
<1> If AGEDIFF <12 [goto ERR_FATHERCK_A]
if ERRFATHERCK_A = <1> [goto FIDCCI4]
elseif <2> [goto FATHER]
elseif <3> reset FATHERCK_A
[goto FATHERCK_A] endif
else [goto FIDCCI4]
<2-5,R,D> [goto FIDCCI4]
Question ID:
QuestionnaireFileName:
[fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster father or father-in-law?
1
Question ID:
05-May-09
FID.360_01.000 Instrument Variable Name:
QuestionText:
GUARD
QuestionnaireFileName:
Family
Who is [fill: your/ALIAS's ] legal guardian?
* Enter the line number of [fill1: your/ALIAS's] guardian.
* If the guardian is not a household member, enter '0'.
00
01-25
97
99
Guardian not a household member
Person # of guardian
Refused
Don't know
UniverseText:
Child identified as a guard at mother or father or, at the FIDCCI5 procedure, it's determined that the child
(AGE<14) has no mother or father in the family.
SkipInstructions:
<0-25,R,D> [goto FIDCCI4]
Page 8 of 8
DRAFT 2010 NHIS Questionnaire - Family
Family Identification
Document Version Date:
Question ID:
FID.380_00.000 Instrument Variable Name:
QuestionText:
Family
Yes, knows family members' health
No, does not know family member's health
Refused
Don't know
2
7
9
UniverseText:
More than one adult
SkipInstructions:
<1-25,R,D>
if SCSEL = 0 [goto FINTRO2]
else [goto KNOWSC2]
FID.390_03.000 Instrument Variable Name:
QuestionText:
FINTRO2
QuestionnaireFileName:
Family
* Enter line number(s) of family members listed that are currently present. Enter up to 10 numbers, separate with commas.
[Display all family members who are not deleted and >17 or emancipated minors]
* If any persons listed are not present, say:
We would like to have all adult family members who are at home take part in the interview. Are (READ NAMES) at
home now?
* If yes, ask: Could they join us?
* If nobody is presently available, enter "96" to proceed to a callback screen.
1
Present
Not present
2
UniverseText:
All nondeleted persons >17 or emancipated minors
SkipInstructions:
<96> [goto FCALLBK1]
if only one PX selected [goto HLTH_BEG]
else [goto FAMRESP]
Question ID:
QuestionnaireFileName:
* Verify or ask
Who in the family would you say knows about the health of all the family members?
[Display all family members who not deleted and > 17 or emancipated minors.]
* Mark all that apply, separate with commas.
1
Question ID:
KNOW2
05-May-09
FID.390_04.000 Instrument Variable Name:
QuestionText:
01-25
FAMRESP
QuestionnaireFileName:
Family
* Ask if necessary: With whom am I speaking?
* Enter the line number of the person you consider to be the main respondent for this family's health questions.
Person # of Family Respondent
UniverseText:
More than 1 adult present.
SkipInstructions:
goto HLTH_BEG
Page 1 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.010_00.000
QuestionText:
Instrument Variable Name:
FINJ3M
05-May-09
QuestionnaireFileName:
Family
? [F1]
The next set of questions is about INJURIES AND POISONINGS. People can be injured or poisoned unexpectedly,
accidentally or on purpose. They may have hurt themselves or others may have caused them to be hurt.
DURING THE PAST THREE MONTHS, that is since [fill1: (date 91 days before today's date)], [fill2: did you/did you or
anyone in your family] have an injury where any part of [fill3: your/the] body was hurt, for example, with a [fill4: (random
set of injury examples)]?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in WFINJ3M and goto TFINJ3M; else, goto WFINJ3M]
<2,R,D> [goto FPOI3M]
Question ID:
FIJ.012_00.000
QuestionText:
Instrument Variable Name:
WFINJ3M
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who was this?
(Anyone else?)
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one person was injured during the past 3 months
SkipInstructions:
[goto FPOI3M]
else, goto TFINJ3M
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIJ.014_00.000
QuestionText:
Instrument Variable Name:
TFINJ3M
QuestionnaireFileName:
Family
? [F1]
DURING THE PAST THREE MONTHS, how many different times [fill: were you/was ALIAS] injured?
01-91
97
99
1-91 times
Refused
Don't know
UniverseText:
All persons injured during the past 3 months
SkipInstructions:
<1-10,D> [goto MFINJ3M]
[goto TFINJ3M for the next person with a reported injury episode; if no more persons with an injury episode,
goto FPOI3M]
<11-91> [goto ERR_TFINJ3M]
Page 2 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.016_00.000
QuestionText:
Instrument Variable Name:
05-May-09
MFINJ3M
QuestionnaireFileName:
Family
? [F1]
Did [fill1: you /ALIAS] talk to or see a medical professional about [fill2: any of these
injuries/this injury/your injury or injuries/his injury or injuries/her injury or injuries]?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons with at least one or an unknown number of injury episodes during the past 3 months
SkipInstructions:
<1> [if TFINJ3M eq 1, fill "1" in MTFINJ3M and goto IPDATEM; else, goto MTFINJ3M]
<2,R,D> [goto TFINJ3M for the next person with a reported injury episode; if no more persons with an injury
episode, goto FPOI3M]
Question ID:
FIJ.018_00.000
QuestionText:
Instrument Variable Name:
MTFINJ3M
QuestionnaireFileName:
Family
? [F1]
Of [fill1: the ^TFINJ3M/all the] times that [fill2: you were/ALIAS was] injured, how many of
those times was the injury serious enough that a medical professional was consulted?
01-91
1-91 times
Refused
Don't know
97
99
UniverseText:
All persons who consulted a medical professional for their injury episode(s)
SkipInstructions:
<1-91> [If MTFINJ3M gt TFINJ3M, goto ERR1_MTFINJ3M; else, if MTFINJ3M gt 3 and TFINJ3M eq D, goto
ERR2_MTFINJ3M; else, goto IPDATEM]
[goto TFINJ3M for the next person with a reported injury episode; if no more persons with an injury
episode, goto FPOI3M]
Question ID:
FIJ.020_00.000
QuestionText:
Instrument Variable Name:
FPOI3M
QuestionnaireFileName:
Family
? [F1]
DURING THE PAST THREE MONTHS, that is since [fill1: (date 91 days before today's date)], [fill2: were you/ were
you or anyone in your family] poisoned by swallowing or breathing in a harmful substance such as bleach, carbon
monoxide, or too many pills or drugs? Do not include food poisoning, sun poisoning, or poison ivy rashes.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in WFPOI3M and goto TFPOI3M; else, goto WFPOI3M]
<2,R,D> [goto FDMED12M]
Page 3 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.022_00.000
QuestionText:
Instrument Variable Name:
WFPOI3M
05-May-09
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who was this?
(Anyone else?)
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one person was poisoned during the past 3 months
SkipInstructions:
[goto FDMED12M]
else, goto TFPOI3M
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIJ.024_00.000
QuestionText:
Instrument Variable Name:
TFPOI3M
QuestionnaireFileName:
Family
? [F1]
DURING THE PAST THREE MONTHS, how many different times [fill: were you/was ALIAS] poisoned? Do not
include food poisoning, sun poisoning, or poison ivy rashes.
01-91
1-91 times
Refused
Don't know
97
99
UniverseText:
All persons poisoned during the past 3 months
SkipInstructions:
<1-10,D> [goto MFPOI3M]
[goto TFPOI3M for next person with a reported poisoning episode; if no more persons with a poisoning
episode, goto FDMED12M]
<11-91> [goto ERR_TFPOI3M]
Question ID:
FIJ.026_00.000
QuestionText:
Instrument Variable Name:
MFPOI3M
QuestionnaireFileName:
Family
? [F1]
Did [fill1: you /ALIAS] talk to or see a medical professional about [fill2: any of these
poisonings/this poisoning/your poisoning or poisonings/his poisoning or poisonings/her poisoning or poisonings]?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All persons with at least one or an unknown number of poisoning episodes during the past 3 months
SkipInstructions:
<1> [if TFPOI3M eq 1, fill "1" in MTFPOI3M and goto IPDATEM; else, goto MTFPOI3M]
<2,R,D> [goto TFPOI3M for the next person with a reported poisoning episode; if no more persons with a
poisoning episode, goto FDMED12M]
Page 4 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.028_00.000
QuestionText:
Instrument Variable Name:
05-May-09
MTFPOI3M
QuestionnaireFileName:
Family
? [F1]
Of [fill1: the ^TFPOI3M/all the] times that [fill2: you were/ALIAS was] poisoned, how many of
those times was the poisoning serious enough that a medical professional was consulted?
01-91
97
99
1-91 times
Refused
Don't know
UniverseText:
All persons who consulted a medical professional for their poisoning episode(s)
SkipInstructions:
<1-91> [If MTFPOI3M gt TFPOI3M, goto ERR1_MTFPOI3M; else, if MTFPOI3M gt 3 and TFPOI3M eq D,
goto ERR2_MTFPOI3M; else, goto IPDATEM]
[goto TFPOI3M for the next person with a reported poisoning episode; if no more persons with a
poisoning episode, goto FDMED12M]
Page 5 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.050_01.000
QuestionText:
Instrument Variable Name:
IPDATEM
05-May-09
QuestionnaireFileName:
Family
1 of 3
* Please hand the calendar card to the respondent.
{if only 1 injury/poisoning episode for the person}
When did [fill1: your/ALIAS’s] [fill2: injury/poisoning] happen for which a medical professional was consulted?
{first of multiple injury/poisoning episodes for the person}
Now I’m going to ask a few questions about the [fill3: ^MTFINJ3M/^MTFPOI3M] times [fill4: you were/ALIAS was]
[fill5: injured/poisoned] for which a medical professional was consulted. Starting with the most recent time, when did this
[fill2: injury/poisoning] happen?
{second plus of multiple injury/poisoning episodes for the person}
You just told me about [fill1: your/ALIAS’s] [fill6: (month, day of previous event)] [fill7:most recent/second most
recent/third most recent/fourth most recent][fill2: injury/poisoning]. What was the date of the [fill2: injury/poisoning]
before that for which a medical professional was consulted?
* Enter month.
01
January
February
March
April
May
June
July
August
September
October
November
December
Refused
Don't know
02
03
04
05
06
07
08
09
10
11
12
97
99
UniverseText:
All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions:
<1-12> [goto IPDATED]
[goto IPHOW]
[goto IPDATENO]
Question ID:
FIJ.050_02.000
QuestionText:
Instrument Variable Name:
IPDATED
QuestionnaireFileName:
2 of 3
* Enter day.
01-31
97
99
1-31
Refused
Don't know
UniverseText:
All injury/poisoning episodes where a valid month of episode was entered
SkipInstructions:
<1-31> [goto IPDATEY]
[goto IPHOW]
[goto IPDATEMT]
Family
Page 6 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.050_03.000
QuestionText:
Instrument Variable Name:
05-May-09
IPDATEY
QuestionnaireFileName:
Family
3 of 3
* Enter year.
Year
Year
Refused
Don't know
9997
9999
UniverseText:
All injury/poisoning episodes where a valid day of episode was entered
SkipInstructions:
if IPDATEM, IPDATED and IPDATEY result in a future date; goto ERR_IPDATEY; else, if IPDATEM,
IPDATED and IPDATEY result in a date prior to the start date of the 91 day reference period, goto
ERR1_IPDATEY; else, goto IPHOW
Question ID:
FIJ.051_01.000
QuestionText:
Instrument Variable Name:
IPDATENO
QuestionnaireFileName:
Family
1 of 2
Can you tell me approximately how long ago [fill1: your/ALIAS’s] [fill2: injury/poisoning] happened?
*Enter number for time since event.
001-096
001-096
Refused
Don't know
097
099
UniverseText:
All injury/poisoning episodes where don't know was entered for month of episode
SkipInstructions:
<1-91> [goto IPDATETP]
[goto IPHOW]
Question ID:
FIJ.051_02.000
QuestionText:
Instrument Variable Name:
IPDATETP
QuestionnaireFileName:
Family
2 of 2
*Enter number for time period since event.
^IPDATENO…
1
2
3
7
9
Days
Weeks
Months
Refused
Don't know
UniverseText:
All injury/poisoning episodes where don't know was entered for month of episode and 1-91 was entered for the
"number" part of this two-part question
SkipInstructions:
goto IPHOW
Page 7 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.052_00.000
QuestionText:
(book) F3
Instrument Variable Name:
05-May-09
IPDATEMT
QuestionnaireFileName:
Family
? [F1]
Was this in the beginning of [fill: ^IPDATEM (text)], the middle of [fill: ^IPDATEM (text)], or the end of [fill:
^IPDATEM (text)]?
1
Beginning
Middle
End
Refused
Don't know
2
3
7
9
UniverseText:
All injury/poisoning episodes where don't know was entered for day of episode
SkipInstructions:
gotoIPHOW
Question ID:
FIJ.060_00.000
QuestionText:
Instrument Variable Name:
IPHOW
QuestionnaireFileName:
Family
? [F1]
[fill1: How did [fill2: your/ALIAS’s] [fill3: injury/poisoning] on [fill4: ^IPDATEM ^IPDATED (starting with most
recent if multiple)] happen?/How did this [fill3: injury/poisoning] happen?] Please describe fully the circumstances or
events leading to the [fill3: injury/poisoning], and any objects, substances, or other people involved.
* Enter the verbatim response, probing for as much detail as possible, including specifically what the person was doing at
the time and all circumstances surrounding the event. Record all volunteered information.
Verbatim
7
9
Verbatim response
Refused
Don't know
UniverseText:
All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions:
[if an injury episode, goto ICAUS; else, if a poisoning episode, goto PPCC]
[if an injury episode, fill "R" in ICAUS and goto IJBODY; else, if a poisoning episode, goto PPCC]
[if an injury episode, fill "D" in ICAUS and goto IJBODY; else, if a poisoning episode, goto PPCC]
Page 8 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.065_00.000
QuestionText:
Instrument Variable Name:
ICAUS
05-May-09
QuestionnaireFileName:
Family
? [F1]
* Do not read.
* Enter the number which best describes the cause of the person’s injury from the list below.
01
02
03
04
05
06
07
97
99
In a motor vehicle
On a bike, scooter, skateboard, skates, skis, horse, etc.
Pedestrian who was struck by a vehicle such as a car or bicycle
In a boat, train, or plane
Fall
Burned or scalded by substances such as hot objects or liquids, fire, or chemicals
Other
Refused
Don't know
UniverseText:
All injury episodes for which a medical professional was consulted and don't know or refused was not entered at
IPHOW
SkipInstructions:
goto IJBODY
Page 9 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.070_00.000
QuestionText:
(book) F4
Instrument Variable Name:
05-May-09
IJBODY
QuestionnaireFileName:
* Enter up to 4 responses, separate with commas.
* Ask or verify.
In this injury, what parts of [fill: your/ALIAS’s] body were hurt?
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
97
99
Ankle
Back
Buttocks
Chest
Ear
Elbow
Eye
Face
Finger/thumb
Foot
Forearm
Groin
Hand
Head (not face)
Hip
Jaw
Knee
Lower leg
Mouth
Neck
Nose
Shoulder
Stomach
Teeth
Thigh
Toe
Upper arm
Wrist
Other, specify
Refused
Don't know
UniverseText:
All injury episodes for which a medical professional was consulted
SkipInstructions:
<1-28> [goto IJTYPE1]
<29> [goto IJBODYOS]
[goto IPEV]
Family
Page 10 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.071_00.000
QuestionText:
Instrument Variable Name:
05-May-09
IJBODYOS
QuestionnaireFileName:
Family
QuestionnaireFileName:
Family
*Read if necessary.
What other parts of the body were hurt?
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All injury episodes where some "other" part of the body was hurt
SkipInstructions:
goto IJTYPE1
Question ID:
FIJ.072_00.000
QuestionText:
(book) F5
Instrument Variable Name:
IJTYPE1
*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill1: your/ALIAS’s] [fill2: first entry--^IJBODY (text) or ^IJBODYOS] hurt?
01
Broken bone or fracture
Sprain, strain, or twist
Cut
Scrape
Bruise
Burn
Insect bite
Animal bite
Other, specify
Refused
Don't know
02
03
04
05
06
07
08
09
97
99
UniverseText:
All injury episodes where at least one part of the body was hurt
SkipInstructions:
<1-8,D> [goto IJTYPE2 for next body part entered at IJBODY; if no more body parts, goto IPEV]
<9> [goto IJTYP1OS]
[goto IPEV]
Question ID:
FIJ.073_00.000
QuestionText:
Instrument Variable Name:
IJTYP1OS
QuestionnaireFileName:
? [F1]
* Read if necessary.
How was [fill1: your/ALIAS’s] [fill2: first entry -- ^IJBODY (text) or ^IJBODYOS] hurt?
Verbatim
7
9
Verbatim response
Refused
Don't know
UniverseText:
All injury episodes where the first body part was hurt in some "other" way
SkipInstructions:
goto IJTYPE2 for next body part; if no more body parts, goto IPEV
Family
Page 11 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.074_00.000
QuestionText:
(book) F5
Instrument Variable Name:
IJTYPE2
05-May-09
QuestionnaireFileName:
Family
*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill1: your/ALIAS’s] [fill2: second entry--^IJBODY (text) or ^IJBODYOS] hurt?
01
Broken bone or fracture
Sprain, strain, or twist
Cut
Scrape
Bruise
Burn
Insect bite
Animal bite
Other, specify
Refused
Don't know
02
03
04
05
06
07
08
09
97
99
UniverseText:
All injury episodes where at least two body parts were hurt and the type of injury or don't know was entered for the
first body part at IJTYPE1
SkipInstructions:
<1-8,D> [goto IJTYPE3 for next body part entered at IJBODY; if no more body parts, goto IPEV]
<9> [goto IJTYP2OS]
[goto IPEV]
Question ID:
FIJ.075_00.000
QuestionText:
Instrument Variable Name:
IJTYP2OS
QuestionnaireFileName:
* Read if necessary.
How else was [fill1: your/ALIAS’s] [fill2: second entry -- ^IJBODY (text) or ^IJBODYOS] hurt?
Verbatim
7
9
Verbatim response
Refused
Don't know
UniverseText:
All injury episodes where the second body part was hurt in some "other" way
SkipInstructions:
goto IJTYPE3 for next body part; if no more body parts, goto IPEV
Family
Page 12 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.076_00.000
QuestionText:
(book) F5
Instrument Variable Name:
IJTYPE3
05-May-09
QuestionnaireFileName:
Family
*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill1: your/ALIAS’s] [fill2: third entry--^IJBODY (text) or ^IJBODYOS] hurt?
01
Broken bone or fracture
Sprain, strain, or twist
Cut
Scrape
Bruise
Burn
Insect bite
Animal bite
Other, specify
Refused
Don't know
02
03
04
05
06
07
08
09
97
99
UniverseText:
All injury episodes where at least three body parts were hurt and type of injury or don't know was entered for the
second body part at IJTYPE2
SkipInstructions:
<1-8,D> [goto IJTYPE4 for next body part entered at IJBODY; if no more body parts, goto IPEV]
<9> [goto IJTYP3OS]
[goto IPEV]
Question ID:
FIJ.077_00.000
QuestionText:
Instrument Variable Name:
IJTYP3OS
QuestionnaireFileName:
* Read if necessary.
How else was [fill1: your/ALIAS’s] [fill2: third entry -- ^IJBODY (text) or ^IJBODYOS] hurt?
Verbatim
7
9
Verbatim response
Refused
Don't know
UniverseText:
All injury episodes where the third body part was hurt in some "other" way
SkipInstructions:
goto IJTYPE4 for next body part; if no more body parts, goto IPEV
Family
Page 13 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.078_00.000
QuestionText:
(book) F5
Instrument Variable Name:
IJTYPE4
05-May-09
QuestionnaireFileName:
Family
*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill1: your/ALIAS’s] [fill2: fourth entry--^IJBODY (text) or ^IJBODYOS] hurt?
01
Broken bone or fracture
Sprain, strain, or twist
Cut
Scrape
Bruise
Burn
Insect bite
Animal bite
Other, specify
Refused
Don't know
02
03
04
05
06
07
08
09
97
99
UniverseText:
All injury episodes where four body parts were hurt and type of injury or don't know was entered for the third body
part at IJTYPE3
SkipInstructions:
<1-8,R,D> [goto IPEV]
<9> [goto IJTYP4OS]
Question ID:
FIJ.079_00.000
QuestionText:
Instrument Variable Name:
IJTYP4OS
QuestionnaireFileName:
Family
* Read if necessary.
How else was [fill1: your/ALIAS’s] [fill2: fourth entry -- ^IJBODY (text) or ^IJBODYOS] hurt?
Verbatim
Verbatim response
Refused
Don't know
7
9
UniverseText:
All injury episodes where the fourth body part was hurt in some "other" way
SkipInstructions:
if a poisoning episode, goto PPCC; else, goto IPEV
Question ID:
FIJ.080_01.000
QuestionText:
Instrument Variable Name:
PPCC
QuestionnaireFileName:
Did [fill: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this poisoning from..
A phone call to a poison control center?
1
2
7
9
Family
Yes
No
Refused
Don't know
UniverseText:
All poisoning episodes for which a medical professional was consulted
SkipInstructions:
<1,2,D> [goto IPEV]
[goto IPHOSP]
Page 14 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.080_02.000
QuestionText:
Instrument Variable Name:
IPEV
05-May-09
QuestionnaireFileName:
Family
* Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
An emergency vehicle, such as an ambulance or fire truck
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions:
<1,2,D> [goto IPER]
[goto IPHOSP]
Question ID:
FIJ.080_03.000
QuestionText:
Instrument Variable Name:
IPER
QuestionnaireFileName:
Family
* Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
A visit to an emergency room
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions:
<1,2,D> [goto IPDO]
[goto IPHOSP]
Question ID:
FIJ.080_04.000
QuestionText:
Instrument Variable Name:
IPDO
QuestionnaireFileName:
Family
? [F1]
* Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
A visit to a doctor’s office or other health clinic
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions:
<1,2,D> [goto IPPCHCP]
[goto IPHOSP]
Page 15 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.080_05.000
QuestionText:
Instrument Variable Name:
05-May-09
IPPCHCP
QuestionnaireFileName:
Family
? [F1]
* Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
A phone call to a doctor, nurse, or other health care professional
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions:
<1,2,D> [goto IPOTH]
[goto IPHOSP]
Question ID:
FIJ.080_06.000
QuestionText:
Instrument Variable Name:
IPOTH
QuestionnaireFileName:
Family
* Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
Any place else?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions:
<1> [goto IPOTHOS]
if [MTFINJ3M= 01-91 and IPEV=2] goto IPVER
<2> [if poisoning and episode and PPCC eq 2 and IPEV eq 2 and IPER eq 2 and IPDO eq 2 and IPPCHCP eq 2,
goto IPVER; else if an injury episode and IPEV eq 2 and IPER eq 2 and IPDO eq 2 and IPPCHCP eq 2, goto
IPVER; else goto IPHOSP]
[goto IPHOSP]
Question ID:
FIJ.081_00.000
QuestionText:
Instrument Variable Name:
IPOTHOS
QuestionnaireFileName:
Family
* Read lead-in if necessary.
Where else did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
Verbatim
7
9
Verbatim response
Refused
Don't know
UniverseText:
All injury/poisoning episodes where medical advice, treatment, or follow-up care was received from some "other"
place
SkipInstructions:
goto IPHOSP
Page 16 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.082_00.000
QuestionText:
Instrument Variable Name:
05-May-09
IPVER
QuestionnaireFileName:
Family
* Please verify.
[fill1: You/ALIAS] DID NOT receive any medical advice, treatment, or follow-up for this [fill2: injury/poisoning]. Is that
correct?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All injury/poisoning episodes for which a medical professional was consulted, but no source of medical advice,
treatment, or follow-up care was selected
SkipInstructions:
<1>[if the person has more injury/poisoning episodes, goto IPDATEM; else, if the person does not have more
injury/poisoning episodes, goto TFINJ3M/TFPOI3M for the next person with an injury/poisoning; else, if no more
family members with an injury/poisoning, go to FPOI3M/FDMED12M]
<2> [if a poisoning episode, goto PPCC for new entries; else, if an injury episode, goto IPEV for new entries]
Question ID:
FIJ.090_00.000
QuestionText:
Instrument Variable Name:
IPHOSP
QuestionnaireFileName:
Family
? [F1]
[fill1: Were you/Was ALIAS] hospitalized for at least one night as a result of this [fill2: injury/poisoning]?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions:
<1> [goto IPIHNO]
<2,R,D> [if an injury episode, goto IMTRAF; if a poisoning episode, goto PPOIS]
Question ID:
FIJ.091_00.000
QuestionText:
Instrument Variable Name:
IPIHNO
QuestionnaireFileName:
Family
? [F1]
How many nights [fill: were you/was ALIAS] in the hospital?
* If still in hospital, ask how many nights up to today.
* Enter '95' for 95 or more nights.
01-94
95
97
99
1-94 nights
95+ nights
Refused
Don't know
UniverseText:
All injury/poisoning episodes for which a medical professional was consulted and resulted in hospitalization
SkipInstructions:
<1-60,R,D> [if ICAUS eq 1-3, goto IMTRAF; else, if ICAUS eq 4-7,R,D, goto IPWHAT; else, if ICAUS eq 5,
goto IFALL]
<61-95> [goto ERR_IPIHNO]
Page 17 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.109_00.000
QuestionText:
Instrument Variable Name:
05-May-09
IMTRAF
QuestionnaireFileName:
Family
? [F1]
* Ask or verify.
Did this accident occur on a public highway, street, or road?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All medically-consulted injury episodes that occurred while in a motor vehicle; on a bike, scooter, skateboard,
skates, skis, horse, etc.; or as a pedestrian who was struck by a vehicle such as a car or bicycle
SkipInstructions:
goto IMVWHO
Question ID:
FIJ.110_00.000
QuestionText:
Instrument Variable Name:
IMVWHO
QuestionnaireFileName:
Family
*Read all categories.
* Ask or verify.
[fill: Were you/Was ALIAS] injured as:
* Read answer categories.
1
2
3
4
5
7
9
The driver of a motor vehicle
A passenger in a motor vehicle
A pedestrian
A bicycle rider or tricycle rider
The rider of a scooter, skateboard, skates, or other non-motorized vehicle
Refused
Don't know
UniverseText:
All medically-consulted injury episodes that occurred while in a motor vehicle; on a bike, scooter, skateboard,
skates, skis, horse, etc.; or as a pedestrian who was struck by a vehicle such as a car or bicycle
SkipInstructions:
<1,2> [goto IMVTYP]
<4,5> [goto IHELMT]
<3,R,D> [goto IPWHAT]
Page 18 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.111_00.000
QuestionText:
(book) F6
Instrument Variable Name:
05-May-09
IMVTYP
QuestionnaireFileName:
Family
? [F1]
* Ask or verify.
What type of vehicle [fill: were you/was ALIAS] in?
01
Passenger car
Passenger truck, such as a pickup truck, van, or SUV
Bus
Large commercial truck, such as a semi-truck, big rig, or 18 wheeler
Motorcycle (including mopeds and minibikes)
All terrain vehicle or ski/snow-mobile
Farm equipment (such as a tractor)
Industrial or construction vehicle
Other
Refused
Don't know
02
03
04
05
06
07
08
09
97
99
UniverseText:
All medically-consulted injury episodes that occurred while a driver or passenger of a vehicle
SkipInstructions:
<1,2,4> [goto ISBELT]
<5,6> [goto IHELMT]
<3,7,8,9,R,D> [goto IPWHAT]
Question ID:
FIJ.112_00.000
QuestionText:
Instrument Variable Name:
ISBELT
QuestionnaireFileName:
Family
? [F1]
* Ask or verify.
[fill: Were you/Was ALIAS] restrained at the time of the accident?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All medically-consulted injury episodes that occurred while a driver or passenger of a car or truck
SkipInstructions:
goto IPWHAT
Page 19 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.113_00.000
QuestionText:
Instrument Variable Name:
IHELMT
05-May-09
QuestionnaireFileName:
Family
? [F1]
* Ask or verify.
[fill: Were you/Was ALIAS] wearing a helmet at the time of the accident?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All medically-consulted injury episodes that occurred while riding a bicycle, tricycle, scooter, skateboard, skates,
or other nonmotorized vehicle; a motorcycle; or an all terrain vehicle or ski/snow-mobile
SkipInstructions:
goto IPWHAT
Question ID:
FIJ.130_00.000
QuestionText:
(book) F7
Instrument Variable Name:
IFALL
QuestionnaireFileName:
* Enter up to 2 responses, separate with a comma.
* Ask or verify.
How did [fill: you/ALIAS] fall? Anything else?
01
02
03
04
05
06
07
08
09
10
11
97
99
Stairs, steps, or escalator
Floor or level ground
Curb (including sidewalk)
Ladder or scaffolding
Playground equipment
Sports field, court, or rink
Building or other structure
Chair, bed, sofa, or other furniture
Bathtub, shower, toilet, or commode
Hole or other opening
Other
Refused
Don't know
UniverseText:
All medically-consulted injury episodes that occurred due to a fall
SkipInstructions:
goto IFALLWHY
Family
Page 20 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.131_00.000
QuestionText:
(book) F8
Instrument Variable Name:
05-May-09
IFALLWHY
QuestionnaireFileName:
Family
* Ask or verify.
What caused [fill: you/ALIAS] to fall?
1
Slipping or tripping
Jumping or diving
Bumping into an object or another person
Being shoved or pushed by another person
Losing balance or having dizziness (becoming faint or having a seizure)
Other
Refused
Don't know
2
3
4
5
6
7
9
UniverseText:
All medically-consulted injury episodes that occurred due to a fall
SkipInstructions:
goto IPWHAT
Question ID:
FIJ.140_00.000
QuestionText:
(book) F9
Instrument Variable Name:
PPOIS
QuestionnaireFileName:
Family
? [F1]
* Ask or verify.
What did [fill: your/ALIAS’s] poisoning result from?
1
Swallowing a drug or medical substance mistakenly or in overdose
Swallowing or touching a harmful solid or liquid substance
Inhaling harmful gases or vapors
Eating a poisonous plant or other substance mistaken for food
Being bitten by a poisonous animal
Other, please specify
Refused
Don't know
2
3
4
5
6
7
9
UniverseText:
All poisoning episodes for which a medical professional was consulted
SkipInstructions:
<1-5,R,D> [goto IPWHAT]
<6> [goto PPOISOS]
Question ID:
FIJ.141_00.000
QuestionText:
Instrument Variable Name:
PPOISOS
QuestionnaireFileName:
Family
* Read if necessary.
How did [fill: your/ALIAS’s] poisoning occur?
Verbatim
7
9
Verbatim response
Refused
Don't know
UniverseText:
All medically-consulted poisoning episodes where the poisoning resulted from some "other" reason
SkipInstructions:
goto IPWHAT
Page 21 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.150_00.000
QuestionText:
(book) F10
Instrument Variable Name:
05-May-09
IPWHAT
QuestionnaireFileName:
Family
? [F1]
* Enter up to 2 responses, separate with a comma.
* Ask or verify.
What activity [fill1: were you/was ALIAS] involved in at the time of the [fill2: injury/poisoning]?
01
Driving or riding in a motor vehicle
Working at a paid job
Working around the house or yard
Attending school
Unpaid work (such as volunteer work)
Sports and exercise
Leisure activity (excluding sports)
Sleeping, resting, eating, or drinking
Cooking
Being cared for (hands-on care from other person)
Other, please specify
Refused
Don't know
02
03
04
05
06
07
08
09
10
11
97
99
UniverseText:
All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions:
<1-10,R,D> [goto IPWHER]
<11> [goto IPWHATOT]
Question ID:
FIJ.151_00.000
QuestionText:
Instrument Variable Name:
IPWHATOT
QuestionnaireFileName:
Family
* Read if necessary.
What other activity [fill1: were you/was ALIAS] involved in at the time of the [fill2: injury/poisoning]?
Verbatim
7
9
Verbatim response
Refused
Don't know
UniverseText:
All medically-consulted injury/poisoning episodes that occurred in some "other" place
SkipInstructions:
goto IPWHER
Page 22 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.160_00.000
QuestionText:
(book) F11
Instrument Variable Name:
IPWHER
05-May-09
QuestionnaireFileName:
Family
? [F1]
* Enter up to 2 responses, separate with a comma.
* Ask or verify.
Where [fill1: were you/was ALIAS] when the [fill2: injury/poisoning] happened?
01
Home (inside)
Home (outside)
School (not residential)
Child care center or preschool
Residential institution (excluding hospital)
Health care facility (including hospital)
Street or highway
Sidewalk
Parking lot
Sport facility, athletic field, or playground
Shopping center, restaurant, store, bank, gas station, or other place of business
Farm
Park or recreation area (include bike or jog path)
River, lake, stream, or ocean
Industrial or construction area
Other public building
Other
Refused
Don't know
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
97
99
UniverseText:
All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions:
if AGE lt 5 and the person has more injury/poisoning episodes, goto IPDATEM; else, if AGE lt 5 and the person
does not have more injury/poisoning episodes, goto TFINJ3M/TFPOI3M for the next person with an
injury/poisoning episode; else, if AGE lt 5 and no more family members with an injury/poisoning, goto
FPOI3M/FDMED12M; else, if AGE ge 13, goto IPEMP; else, if AGE ge 5 and AGE le 12, goto IPSTU
Question ID:
FIJ.170_00.000
QuestionText:
Instrument Variable Name:
IPEMP
QuestionnaireFileName:
Family
? [F1]
At the time of this [fill1: injury/poisoning], [fill2: were you/was ALIAS] employed full-time, part-time, or not employed?
1
2
3
7
9
Full-time
Part-time
Not employed
Refused
Don't know
UniverseText:
All medically-consulted injury/poisoning episodes for persons 13 years of age or older
SkipInstructions:
<1,2> [goto IPWKLS]
<3,R,D> [goto IPSTU]
Page 23 of 23
DRAFT 2010 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:
Question ID:
FIJ.171_00.000
QuestionText:
Instrument Variable Name:
IPWKLS
05-May-09
QuestionnaireFileName:
Family
As a result of this [fill1: injury/poisoning], how many days of work did [fill2: you/ALIAS] miss?
1
None
Less than one day
One to five days
Six or more days
Refused
Don't know
2
3
4
7
9
UniverseText:
All medically-consulted injury/poisoning episodes for persons 13 years of age or older who were employed at the
time of the episode
SkipInstructions:
goto IPSTU
Question ID:
FIJ.180_00.000
QuestionText:
Instrument Variable Name:
IPSTU
QuestionnaireFileName:
Family
At the time of this [fill1: injury/poisoning], [fill2: were you/was ALIAS] a full-time student, part-time student or not a
student?
1
Full-time
Part-time
Not a student
Refused
Don't know
2
3
7
9
UniverseText:
All medically-consulted injury/poisoning episodes for persons 5 years of age or older
SkipInstructions:
<1,2> [goto IPSCLS]
<3,R,D> [if person has more injury/poisoning episodes, goto IPDATEM for that person; else if person does not
have more injury/poisoning episodes, goto TFINJ3M/TFPOI3M for next person with an injury/poisoning episode;
else if no more family members with an injury/poisoning, goto FPOI3M/FAU.010]
Question ID:
FIJ.181_00.000
QuestionText:
1
2
3
4
7
9
Instrument Variable Name:
IPSCLS
QuestionnaireFileName:
Family
As a result of this [fill1: injury/poisoning], how many days of school did [fill2: you/ALIAS] miss?
None
Less than one day
One to five days
Six or more days
Refused
Don't know
UniverseText:
All medically-consulted injury/poisoning episodes for persons 5 years of age or older who were students at the
time of the episode
SkipInstructions:
if the person has more injury/poisoning episodes, goto IPDATEM; else, if the person does not have more
injury/poisoning episodes, goto TFINJ3M/TFPOI3M for the next person with an injury/poisoning episode; else, if
no more family members with an injury/poisoning episode, goto FPOI3M/FDMED12M
Page 1 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.010_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FINCINT
QuestionnaireFileName:
Family
* Read the following.
The next questions are about [fill1: your total/your total family] income in [fill2: 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.
1
Enter 1 to continue
UniverseText:
All families
SkipInstructions:
goto FSAL
Question ID:
FIN.030_00.000 Instrument Variable Name:
QuestionText:
FSAL
QuestionnaireFileName:
Family
? [F1]
[fill1: Did you receive income in [fill2: last calendar year in 4-digit format] from wages and salaries?]
[fill3: When answering these questions, please remember that by "combined family income," I mean your income PLUS
the income of all family members living in this household (including cohabiting partners, and armed forces members
living at home).
Did any family members 18 and older, that is * Read names
(fill roster of people ge 18 years of age)
receive income in [fill2: last calendar year in 4-digit format] from...wages and salaries?]
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with one or more persons 18 years of age or older
SkipInstructions:
<1> [if a single-person family, store the person number in PSAL and goto FSEINC; else, goto PSAL]
<2,R,D> [goto FSEINC]
Page 2 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.040_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PSAL
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons 18 years of age or older and at least one received income from wages and
salaries in the last calendar year
SkipInstructions:
goto FSEINC
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIN.050_00.000 Instrument Variable Name:
QuestionText:
FSEINC
QuestionnaireFileName:
Family
[fill1: Did you receive income in [fill2: last calendar year in 4-digit format] from self-employment including business and
farm income?/ Did ALIAS receive income in [fill2: last calendar year in 4-digit format] from self-employment including
business and farm income?/Did any family members 18 and older, that is
*Read names
(fill roster of people ge 18 years of age)
receive income in [fill2: last calendar year in 4-digit format] from...self-employment including business and farm income?]
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with one or more persons 18 years of age or older
SkipInstructions:
<1> [if a single-person family, store the person number in PSEINC and goto FSSRR; else, goto PSEINC]
<2,R,D> [goto FSSRR]
Page 3 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.060_00.000 Instrument Variable Name:
QuestionText:
PSEINC
05-May-09
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons 18 years of age or older and at least one received income from selfemployment in the last calendar year
SkipInstructions:
goto FSSRR
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIN.070_00.000 Instrument Variable Name:
QuestionText:
FSSRR
QuestionnaireFileName:
Family
? [F1]
Did [fill1: you/any family members living here] receive income in [fill2: last calendar year in 4-digit format] from Social
Security or Railroad Retirement?
* Read if necessary: Social Security checks are either automatically deposited in the bank or mailed to arrive on the third
of every month.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PSSRR and goto FSSRRD; else, goto PSSRR]
<2,R,D> [goto FPENS]
Page 4 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.080_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PSSRR
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one received income from Social Security or Railroad
Retirement in the last calendar year
SkipInstructions:
goto FSSRRD
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIN.082_00.000 Instrument Variable Name:
QuestionText:
FSSRRD
QuestionnaireFileName:
Family
Was [fill: your/any family member's *Read names
(fill roster of all persons selected at PSSRR and AGE LE 64)]
Social Security or Railroad Retirement income received as a disability benefit?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with persons less than 65 years of age who received Social Security or Railroad Retirement income in
the last calendar year
SkipInstructions:
<1> [if only one person less than 65 years of age received Social Security or Railroad Retirement income, fill the
person number in PSSRRDB and goto PSSRRD; else, goto PSSRRDB]
<2,R,D> [goto FPENS]
Page 5 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.084_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PSSRRDB
QuestionnaireFileName:
Family
*Ask or verify. Enter applicable line number(s), separate with commas.
Who received Social Security or Railroad Retirement as a disability benefit?
(Anyone else?)
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons less than 65 years of age who received income from Social Security or
Railroad Retirement in the last calendar year and at least one received the income as a disability benefit
SkipInstructions:
goto PSSRRD
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIN.086_00.000 Instrument Variable Name:
QuestionText:
PSSRRD
QuestionnaireFileName:
Family
Did [fill1: you/ALIAS] receive this benefit because [fill2: you are/he is/she is] disabled?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons less than 65 years of age who received Social Security or Railroad Retirement income as a disability
benefit in the last calendar year
SkipInstructions:
repeat for all eligible persons, then goto FPENS
Question ID:
FIN.090_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
FPENS
QuestionnaireFileName:
Family
Did [fill1: you/any family members living here] receive income in [fill2: last calendar year in 4-digit format] from any
disability pension [fill3: other than Social Security or Railroad Retirement]?
Yes
No
Refused
Don't know
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PPENS and goto FOPENS; else, goto PPENS]
<2,R,D> [goto FOPENS]
Page 6 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.100_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PPENS
QuestionnaireFileName:
Family
*Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
*Indicate each family member with this income.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one received income from a disability pension (other than Social
Security or Railroad Retirement) in the last calendar year
SkipInstructions:
goto FOPENS
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIN.102_00.000 Instrument Variable Name:
QuestionText:
FOPENS
QuestionnaireFileName:
Family
Did [fill1: you/any family members living here] receive income from any retirement or survivor pension other [fill2: than
Social Security or Railroad Retirement/than a disability pension/than Social Security, Railroad Retirement, or a disability
pension]?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in POPENS and goto FSSI; else, goto POPENS]
<2,R,D> [goto FSSI]
Question ID:
FIN.104_00.000 Instrument Variable Name:
QuestionText:
POPENS
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with two or more persons and at least one received income from a retirement or survivor pension in
the last calendar year
SkipInstructions:
goto FSSI
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 7 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.110_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FSSI
QuestionnaireFileName:
Family
? [F1]
Did [fill: you/any family members] receive Supplemental Security Income (SSI)?
* Read if necessary: Federal SSI checks are either automatically deposited in the bank or mailed to arrive on the first of
every month.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, fill the person number in PSSI and goto PSSID; else, goto PSSI]
<2,R,D> [goto FTANF]
Question ID:
FIN.120_00.000 Instrument Variable Name:
QuestionText:
PSSI
QuestionnaireFileName:
Family
*Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family received this?
(Anyone else?)
*Indicate each family member with this income.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one received Supplemental Security Income (SSI) in the last
calendar year
SkipInstructions:
goto PSSID
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIN.122_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
PSSID
QuestionnaireFileName:
Did [fill1: you/ALIAS] receive SSI because [fill2: you have/he has/she has] a disability?
Yes
No
Refused
Don't know
UniverseText:
All persons who received SSI in the last calendar year
SkipInstructions:
repeat for all eligible persons, then goto FTANF
Family
Page 8 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.150_00.000 Instrument Variable Name:
QuestionText:
*(book) F23
05-May-09
FTANF
QuestionnaireFileName:
Family
? [F1]
At any time during [fill1: last calendar year in 4-digit format], even for one month, did [fill2: you/any family members
living here] receive any CASH assistance from a state or county welfare program, such as (* fill specific program name)?
* Please do not include food stamps, SSI, energy assistance, or medical assistance payments.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PTANF and goto FOWBEN; else, goto PTANF]
<2,R,D> [goto FOWBEN]
Question ID:
FIN.160_00.000 Instrument Variable Name:
QuestionText:
PTANF
QuestionnaireFileName:
Family
*Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family received this?
(Anyone else?)
*Indicate each family member with this income.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one received cash assistance from a state or county welfare
program in the last calendar year
SkipInstructions:
goto FOWBEN
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIN.164_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
FOWBEN
QuestionnaireFileName:
Family
At any time during [fill1: last calendar year in 4-digit format], did [fill2: you/any family members living here] receive any
OTHER kind of welfare assistance such as help with getting a job, placement in education or job training programs, or
help with transportation or child care?
Yes
No
Refused
Don't know
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in POWBEN and goto FINTRST; else, goto POWBEN]
<2,R,D> [goto FINTRST]
Page 9 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.166_00.000 Instrument Variable Name:
QuestionText:
05-May-09
POWBEN
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one received income from some "other" kind of welfare
assistance in the last calendar year
SkipInstructions:
goto FINTRST
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIN.170_00.000 Instrument Variable Name:
QuestionText:
FINTRST
QuestionnaireFileName:
Family
Did [fill: you/any family members living here] receive income from interest bearing checking accounts, savings accounts,
IRAs or certificates of deposit, money market funds, treasury notes, bonds, or any other investments that earn interest?
* Do not include dividends
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PINTRST and goto FDIVD; else, goto PINTRST]
<2,R,D> [goto FDIVD]
Question ID:
FIN.180_00.000 Instrument Variable Name:
QuestionText:
PINTRST
QuestionnaireFileName:
Family
*Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with two or more persons and at least one received interest income in the last calendar year
SkipInstructions:
goto FDIVD
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 10 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.190_00.000 Instrument Variable Name:
QuestionText:
FDIVD
05-May-09
QuestionnaireFileName:
Family
Did [fill: you/any family members living here] receive income from dividends from stocks or mutual funds, or net rental
income from property, royalties, estates or trusts?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PDIVD and goto FCHLDSP; else, goto PDIVD]
<2,R,D> [goto FCHLDSP]
Question ID:
FIN.200_00.000 Instrument Variable Name:
QuestionText:
PDIVD
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s). Separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one received dividend or net rental income in the last calendar
year
SkipInstructions:
goto FCHLDSP
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIN.210_00.000 Instrument Variable Name:
QuestionText:
FCHLDSP
QuestionnaireFileName:
Family
? [F1]
Did [fill: you/any family members living here] receive income from child support?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PCHLDSP and goto FINCOT; else, goto PCHLDSP]
<2,R,D> [goto FINCOT]
Page 11 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.220_00.000 Instrument Variable Name:
QuestionText:
05-May-09
PCHLDSP
QuestionnaireFileName:
Family
*Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate which child in the family this is for. If that child is no longer residing with this family, enter line number of
custodial parent.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least received income from child support in the last calendar year
SkipInstructions:
goto FINCOT
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIN.230_00.000 Instrument Variable Name:
QuestionText:
FINCOT
QuestionnaireFileName:
Family
Did [fill: you/any family members living here] receive income from any other source such as alimony, contributions from
family/others, VA payments, Worker’s Compensation, or unemployment compensation?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PINCOT and goto FINCTOT; else, goto PINCOT]
<2,R,D> [goto FINCTOT]
Question ID:
FIN.240_00.000 Instrument Variable Name:
QuestionText:
PINCOT
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with two or more persons and at least one received some "other" source of income in the last calendar
year
SkipInstructions:
goto FINCTOT
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 12 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.250_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FINCTOT
QuestionnaireFileName:
Family
[fill1: 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 [fill2: your total income/the total income of all family members] from all sources, before
taxes, in [fill3: last calendar year in 4 digit format]?
* Enter ‘999,995’ if the reported income is greater than $999,995.
000000-999994
999995
999997
999999
$0-$999,994
$999,995+
Refused
Don't know
UniverseText:
All families
SkipInstructions:
<0-999> goto ERR1_FINCTOT
<1000-250000> goto HOUSEOWN
<250001-999995> goto ERR2_FINCTOT
goto FINC50
Question ID:
FIN.255_00.000 Instrument Variable Name:
QuestionText:
FINC50
Family
Was your total [fill: family] income from all sources less than $50,000 or $50,000 or more?
1
Less than $50,000
$50,000 or more
Refused
Don't know
2
7
9
UniverseText:
Respondents who don't know or refuse their income
SkipInstructions:
<1> [goto FINC35]
<2> [goto FINC100]
[HOUSEOWN]
Question ID:
QuestionnaireFileName:
FIN.260_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
FINC35
QuestionnaireFileName:
Was your total [fill: family] income from all sources less than $35,000 or $35,000 or more?
Less than $35,000
$35,000 or more
Refused
Don't know
UniverseText:
The respondent answered Less than $50,000
SkipInstructions:
<1> [goto FINCPOV]
<2,R,D> [goto HOUSEOWN]
Family
Page 13 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.265_00.000 Instrument Variable Name:
QuestionText:
FINCPOV
7
9
UniverseText:
The respondent answered Less than $35,000
SkipInstructions:
<1,2,R,D> [HOUSEOWN]
FIN.270_00.000 Instrument Variable Name:
QuestionText:
FINC100
QuestionnaireFileName:
Family
Was your total [fill: family] income from all sources less than $100,000 or $100,000 or more?
1
Less than $100,000
$100,000 or more
Refused
Don't know
2
7
9
UniverseText:
The respondent answered More than $50,000
SkipInstructions:
<1> [goto FINC75] <2,R,D> [goto HOUSEOWN]
FIN.275_00.000 Instrument Variable Name:
QuestionText:
FINC75
QuestionnaireFileName:
Family
Was your total [fill: family] income from all sources less than $75,000 or $75,000 or more?
1
Less than $75,000
$75,000 or more
Refused
Don't know
2
7
9
UniverseText:
The respondent answered Less than $100,000
SkipInstructions:
<1,2,R,D> [goto HOUSEOWN]
Question ID:
Family
Less than [$10,000/$11,000/$13,000/$14,500/$17,000/$22,000/$26,000/$29,500/$33,500]
[$10,000/$11,000/$13,000/$14,500/$17,000/$22,000/$26,000/$29,500/$33,500] or more
Refused
Don't know
2
Question ID:
QuestionnaireFileName:
Was your total [fill1: family] income from all sources less than [fill2: fill based on poverty threshold] or [fill2: fill based
on poverty threshold] or more?
1
Question ID:
05-May-09
FIN.280_00.000 Instrument Variable Name:
QuestionText:
1
9
UniverseText:
All families
SkipInstructions:
<1,3,R,D> [goto FSSAPL]
<2> [goto FGAH]
3
7
QuestionnaireFileName:
Family
Is this house/apartment owned or being bought, rented, or occupied by some other arrangement by you [fill: /or someone
in your family]?
Owned or being bought
Rented
Other arrangement
Refused
Don't know
2
HOUSEOWN
Page 14 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.282_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FGAH
QuestionnaireFileName:
Family
? [F1]
[fill: Are you/Is anyone in your family] paying lower rent because the Federal, State, or local government is paying part of
the cost?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families that rent their house/apartment
SkipInstructions:
goto FSSAPL
Question ID:
FIN.300_00.000 Instrument Variable Name:
QuestionText:
FSSAPL
QuestionnaireFileName:
Family
[fill: Have you EVER applied for Supplemental Security Income or SSI, even if the claim was denied?/Have any family
members living here EVER applied for Supplemental Security Income (SSI)? This includes people who applied for
benefits, even if the claim was denied.]
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PSSAPL and goto FSDAPL; else, goto PSSAPL]
<2,R,D> [goto FSDAPL]
Question ID:
FIN.310_00.000 Instrument Variable Name:
QuestionText:
PSSAPL
QuestionnaireFileName:
Family
*Ask or verify. Enter applicable line number(s), separate with a comma.
Who in the family applied for it?
(Anyone else?)
* Indicate each family member who applied for SSI benefits.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with two or more persons and at least one applied for SSI
SkipInstructions:
goto FSDAPL
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 15 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.330_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FSDAPL
QuestionnaireFileName:
Family
[fill: Have you EVER APPLIED for disability benefits from Social Security even if the claim was denied?/Have any
family members living here EVER applied for disability benefits from Social Security? This includes people who applied
for benefits, even if the claim was denied.]
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All Families
SkipInstructions:
<1> [if a single-person family, store the person number in PSDAPL and goto TANFMYR; else, goto PSDAPL]
<2,R,D> [goto TANFMYR]
Question ID:
FIN.340_00.000 Instrument Variable Name:
QuestionText:
PSDAPL
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family applied for it?
(Anyone else?)
* Indicate each family member who applied for Social Security Disability benefits.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one applied for Social Security Disability benefits
SkipInstructions:
goto TANFMYR
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIN.350_00.000 Instrument Variable Name:
QuestionText:
TANFMYR
QuestionnaireFileName:
Family
? [F1]
Earlier I recorded that [fill1: you/ALIAS] received cash assistance from programs such as welfare or public assistance in
[fill2: last calendar year in 4-digit format]. During [fill2: last calendar year in 4-digit format], about how many months did
[fill1: you/ALIAS] receive this assistance?
*Enter '1' if less than one month.
01-12
97
99
1-12 months
Refused
Don't know
UniverseText:
All persons who received cash assistance from public assistance programs in the last calendar year
SkipInstructions:
repeat for all eligible persons, then goto FFSTIP
Page 16 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.360_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FFSTIP
QuestionnaireFileName:
Family
? [F1]
[fill1: Were you/Was anyone in the family] authorized to receive food stamps (which includes a food stamp card or
voucher, or cash grants from the state for food) at anytime during [fill2: last calendar year in 4-digit format]?
*An authorized person is one whose name appears on a certification card.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families
SkipInstructions:
<1> [if a single-person family, store the person number in PFSTP and goto FSTPMYR; else, goto PFSTP]
<2,R,D> [goto FINWIC]
Question ID:
FIN.370_00.000 Instrument Variable Name:
QuestionText:
PFSTP
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who was authorized to receive food stamps?
* Indicate family members who were authorized to receive food stamps.
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with two or more persons and at least one was authorized to receive food stamps in the last calendar
year
SkipInstructions:
goto FSTPMYR
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Question ID:
FIN.380_00.000 Instrument Variable Name:
QuestionText:
FSTPMYR
QuestionnaireFileName:
During [fill1: last calendar year in 4-digit format], about how many months [fill2: were you/was ALIAS] authorized to
receive food stamps?
* Enter '1' if less than 1 month
01-12
97
99
Family
1-12 months
Refused
Don't know
UniverseText:
All persons authorized to receive food stamps in the last calendar year
SkipInstructions:
goto FINWIC
Page 17 of 17
DRAFT 2010 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:
FIN.384_00.000 Instrument Variable Name:
QuestionText:
FINWIC
05-May-09
QuestionnaireFileName:
Family
? [F1]
At any time during [fill1: last calendar year in 4-digit format] did [fill2: you/anyone in your family] receive benefits from
the WIC program, that is, the Women, Infants and Children program?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with females 12-55 years of age or children 0-5 years of age
SkipInstructions:
<1> [if a single-person family, store the person number in PWIC and goto FMSSN; else, goto PWIC]
<2,R,D> [goto FMSSN]
Question ID:
FIN.385_00.000 Instrument Variable Name:
QuestionText:
PWIC
QuestionnaireFileName:
Family
* Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family received this?
(Anyone else?)
* Indicate family members who were authorized to receive WIC benefits.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with two or more persons who are female and between the ages of 12-55 or children between the ages
of 0-5, and at least one received WIC benefits in the last calendar year
SkipInstructions:
goto FMSSN
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 1 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
Question ID:
FSD.001_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
PLBORN
[fill: Were you/Was ALIAS] born in the United States?
Yes
No
Refused
Don't know
UniverseText:
All persons
SkipInstructions:
<1> [store "1" in CITIZEN and goto PLBORN1]
<2> [goto PLBORN2]
[goto CITIZEN]
05-May-09
QuestionnaireFileName:
Family
Page 2 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
Question ID:
QuestionText:
01
02
03
04
05
06
07
08
09
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
43
44
45
46
47
FSD.002_00.000 Instrument Variable Name:
In what state [fill: were you/was ALIAS] born?
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
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
PLBORN1
05-May-09
QuestionnaireFileName:
Family
Page 3 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
48
49
50
51
57
Washington
West Virginia
Wisconsin
Wyoming
United States (state unknown)
UniverseText:
All persons born in the United States
SkipInstructions:
<1-51,57> [goto HEADST]
05-May-09
Page 4 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
Question ID:
QuestionText:
FSD.003_00.000 Instrument Variable Name:
05-May-09
PLBORN2
In what country [fill: were you/was ALIAS] born?
* Please record country of birth. If country not found, type "ZZ"
060
061
062
063
064
065
066
067
068
069
070
071
072
073
074
075
076
077
078
079
080
081
082
083
084
085
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
AMERICAN SAMOA
AM SAMOA
BAKER ISLAND
GUAM
HOWLAND ISLAND
JARVIS ISLAND
JOHNSTON ATOLL
KINGMAN REEF
MANUA ISLANDS
MIDWAY ISLANDS
NAVASSA ISLAND
NORTHERN MARIANAS
PALMYRA ATOLL
PUERTO RICO
ROTA
SAIPAN
SAND ISLAND
ST CROIX
ST JOHN
ST THOMAS
TINIAN
US OUTLYING AREA
US VIRGIN ISLANDS
USVI
VIRGIN ISLANDS
WAKE ISLAND
ABROAD
ABU DHABI
ADEN
AFGHANISTAN
AFRICA
ALBANIA
ALBERTA
ALGERIA
ALGIERS
ALSACE-LORRAINE
AMSTERDAM
ANEGADA
ANGOLA
ANGUILLA
ANGUILLA BWI
ANOJOUAN
ANTARCTICA
ANTIGUA
ANTIGUA & BARBUDA
ANTIGUA WI
QuestionnaireFileName:
Family
Page 5 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
ANTILLES
ARAB PALESTINE
ARABIA
ARGENTINA
ARMENIA
ARUBA
ARUBA DWI
ARUBA NETHERLANDS
ASCENSION ISLAND
ASIA
ASIA MINOR
ASSAM
AT SEA
AUSTRALIA
AUSTRIA
AUSTRIA-HUNGARY
AZERBAIJAN
AZORES ISLANDS
BAHAMAS
BAHAMAS UK
BAHRAIN
BAJA CAL
BAJA CAL SUR
BALBOA
BANGLADESH
BARBADOS
BARBUDA
BAVARIA
BELARUS
BELFAST
BELGIAN CONGO
BELGIUM
BELIZE
BENIN
BERLIN
BERMUDA
BESSARABIA
BHUTAN
BOHEMIA
BOLIVIA
BONAIRE
BORNEO
BOSNIA
BOSNIA & HERZEGOVINA
BOTSWANA
BRASIL
BRAZIL
BRAZZAVILLE
BREMEN
BRITAIN
BRITISH COLUMBIA
BRITISH EAST AFRICA
05-May-09
Page 6 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
BRITISH GUIANA
BRITISH GUYANA
BRITISH HONDURAS
BRITISH HONG KONG
BRITISH ISLES
BRITISH VI
BRITISH VIRGIN IS
BRITISH WEST INDIES
BRITISH WI
BRUNEI
BULGARIA
BURKINA FASO
BURMA
BURUNDI
BWI
BYELARUS
BYELORUSSIA
CAICOS ISLANDS
CAM PHA
CAM RANH
CAMBODIA
CAMEROON
CAN THO
CANADA
CANAL ZONE
CANARY ISLANDS
CANTON & ENDERBURY IS
CANTON ISLAND
CAPE VERDE
CARIBBEAN
CAYMAN ISLANDS
CENTRAL AFRICA
CENTRAL AFRICAN REP
CENTRAL AMERICA
CEYLON
CHAD
CHANNEL ISLANDS
CHIAPAS
CHIHUAHUA
CHILE
CHINA
CHINA HONG KONG
CHRISTMAS ISLAND
CHRISTMAS ISLAND, INDIAN OCEAN
COAHUILA
COLIMA
COLOMBIA
COMOROS
CONGO
COOK ISLANDS
CORAL SEA ISLANDS
CORK
05-May-09
Page 7 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
CORSICA
COSTA RICA
COTE D'IVORIE
CRETE
CRIMEA
CRISTOBAL
CROATIA
CUBA
CURACAO
CYPRUS
CZ
CZECH REPUBLIC
CZECHOSLOVAKIA
DA LAT
DA NANG
DAKAR
DANZIG
DELHI
DEMO PEOPLE'S REP OF KOREA
DEMO REP OF CONGO
DENMARK
DISTRITO FEDERAL
DJIBOUTI
DOM REP
DOMINICA
DOMINICA BWI
DOMINICA WI
DOMINICAN REPUBLIC
DUBAI
DUBLIN
DURANGO
DUTCH EAST INDIES
DUTCH GUIANA
DUTCH INDONESIA
DUTCH NEW GUINEA
EAST PAKISTAN
EAST PRUSSIA
EASTER ISLAND
EASTERN AFRICA
ECUADOR
EGYPT
EIRE
EL SALVADOR
ENGLAND
EQUATORIAL GUINEA
ERITREA
ESPANA
ESTONIA
ETHIOPIA
EUROPA ISLAND
EUROPE
FALKLAND ISLANDS
05-May-09
Page 8 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
FAROE ISLANDS
FEDERAL DISTRICT
FEDERAL REPUBLIC OF YUGOSLAVIA
FEDERATED STATES OF MICRONESIA
FIJI
FILIPINES
FINLAND
FOREIGN COUNTRY
FORMOSA
FRANCE
FRANKFURT
FRENCH GUIANA
FRENCH MOROCCO
FRENCH POLYNESIA
GABON
GALAPAGOS ISLANDS
GALWAY
GAMBIA
GAZA STRIP
GEORGIA
GERMANY
GHANA
GIA DINH
GIBRALTER
GLORIOSO ISLANDS
GOA
GRAND BAHAMA
GRAND CAYMAN
GRAND TURK
GREAT BRITAIN
GREAT COMORE
GREECE
GREENLAND
GRENADA
GUADALAJARA
GUADELOUPE
GUANAJUATO
GUATEMALA
GUERNSEY
GUERRERO
GUIANA
GUINEA
GUINEA-BISSAU
GUYANA
HA DONG
HAI PHONG
HAITI
HAMBURG
HANOI
HANOVER
HAVANA
HEARD & MCDONALD ISLANDS
05-May-09
Page 9 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
HERZEGOVINA
HESSE
HIDALGO
HIGH SEAS
HOLLAND
HONDURAS
HONG KONG
HUNGARY
HYDERABAD
ICELAND
INDIA
INDONESIA
INTERNATIONAL WATERS
IRAN
IRAQ
IRELAND
IRIAN JAYA
IRISH REPUBLIC
ISLE OF MAN
ISRAEL
ITALY
IVORY COAST
JALISCO
JAMAICA
JAN MEYAN
JAPAN
JAVA
JERSEY
JIBUTI
JORDAN
JUAN DE NOVA ISLAND
JUGOSLAVIA
KALININGRAD
KAMPUCHEA
KASHMIR
KAZAKHSTAN
KENYA
KHANH HUNG
KINSHASA
KIRIBATI
KOREA
KORO ISLAND
KUWAIT
KWAJALEIN
KWANTUNG
KYRGYZSTAN
LABRADOR
LABUAN
LAOS
LATAKIA
LATIN AMERICA
LATVIA
05-May-09
Page 10 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430
431
LEBANON
LEEWARD ISLANDS
LESOTHO
LIBERIA
LIBYA
LIECHTENSTEIN
LITHUANIA
LOAS
LONDONDERRY
LONG XUYEN
LORRAINE
LUBECK
LUXEMBOURG
MACAO
MACAU
MACEDONIA
MADAGASCAR
MADEIRA ISLANDS
MAINLAND CHINA
MAJORCA
MALAGASY REPUBLIC
MALAWI
MALAYSIA
MALDIVES
MALI
MALLORCA
MALTA
MACHURIA
MANICA
MANILA
MANITOBA
MARSHALL ISLANDS
MARTINIQUE
MAURITANIA
MAURITIUS
MAYOTTE ISLAND
MELANESIA
MEXICO
MICHOACAN
MICRONESIA
MIDDLE EAST
MOLDAVIA
MOLDOVA
MONACO
MONAGAS
MONGOLIA
MONTENEGRO
MONTSERRAT
MORELOS
MOROCCO
MOZAMBIQUE
MY THO
05-May-09
Page 11 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
N. IRELAND
NAM DINH
NAMIBIA
NAURU
NAYARIT
NEPAL
NETHERLANDS
NETH. ANTILLES
NETH. EAST INDIES
NEVIS ISLAND
NEW BRUNSWICK
NEW CALEDONIA
NEW GUINEA
NEW HEBRIDES
NEW SOUTH WALES
NEW ZEALAND
NEWFOUNDLAND
NHA TRANG
NICARAGUA
NIGER
NIGERIA
NIUE ISLAND
NORFOLK ISLAND
NORTH AFRICA
NORTH AMERICA
NORTH KOREA
NORTH VIETNAM
NORTHERN IRELAND
NORTHERN TERRITORY
NORWAY
NOVA SCOTIA
NUEVO LEON
OAXACA
OCEANIA
OKINAWA
OMAN
ONTARIO
OVERSEAS
PAKISTAN
PALAU
PALESTINE
PANAMA
PANAMA CANAL ZONE
PAPUA NEW GUINEA
PARACEL ISLANDS
PARAGUAY
PELAGOSA
PEOPLE'S REP. OF CHINA
PEOPLE'S REP. OF CONGO
PERSIA
PERU
PHAN THIET
05-May-09
Page 12 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
484
485
486
487
488
489
490
491
492
494
495
496
497
498
499
500
501
502
503
504
505
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
PHILIPPINES
PITCAIRN ISLAND
POLAND
POLYNESIA
PONAPE
PORTUGAL
PORTUGUESE INDIA
PRINCE EDWARD ISLAND
PRINCIPE ISLAND
PRUSSIA
PUEBLA
PUNJAB
PUNJAB, INDIA
PUNJAB, PAKISTAN
QATAR
QUANG LONG
QUEBEC
QUEENSLAND
QUERETARO
QUI NHON
RACH GIA
RAJASTHAN
RED CHINA
REPUBLIC OF CHINA
REPUBLIC OF CYPRUS
REPUBLIC OF IRELAND
REPUBLIC OF KOREA
REPUBLIC OF PANAMA
REP. OF PHILIPPINES
REP. OF SOUTH AFRICA
REPUBLICA DOMINICANA
REUNION ISLAND
RHODESIA
ROC
ROK
ROMANIA
ROTTERDAM
RUMANIA
RUSSIA
RUSSIAN FEDERATION
RWANDA
SAIGON
SALVADOR
SAMOA
SAN ANDRES
SAN LUIS POTOSI
SAN MARINO
SAN SALVADOR
SAO TOME ISLAND
SAO TOME & PRINCIPE
SARAWAK
SASKATCHEWAN
05-May-09
Page 13 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
537
538
539
540
541
542
543
544
545
546
547
548
549
550
551
552
553
554
555
556
557
558
559
560
561
562
563
564
565
566
567
568
569
570
571
572
573
574
575
576
577
578
579
580
581
582
583
584
585
586
587
588
SAUDI ARABIA
SAXONY
SCOTLAND
SENEGAL
SEOUL
SERBIA
SEYCHELLES
SHANGHAI
SHARJAH
SIBERIA
SICILY
SIERRA LEONE
SIKKIM
SINALOA
SINGAPORE
SLAVONIA
SLOVAK REPUBLIC
SLOVAKIA
SLOVENIA
SOLOMAN ISLANDS
SOMALIA
SONORA
SOUTH AFRICA
SOUTH AMERICA
SOUTH AUSTRALIA
SOUTH KOREA
SOUTH VIETNAM
SOUTH WALES
SOUTH YEMEN
SOUTHEAST ASIA
SOUTHERN AFRICA
SOUTHERN RHODESIA
SOVIET UNION
SPAIN
SPRATLEY ISLANDS
SRI LANKA
ST BARTHELEMY
ST BARTS
ST CHRISTOPHER
ST CHRISTOPHER-NEVIS
ST EUSTATIUS
ST HELENA
ST KITTS
ST KITTS-NEVIS
ST LUCIA
ST MAARTEN
ST MARTIN
ST PIERRE & MIQUELON
ST VINCENT
ST VINCENT & THE GRENADINES
SUDAN
SUMATRA
05-May-09
Page 14 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
589
590
591
592
593
594
595
596
597
598
599
600
601
602
603
604
605
606
607
608
609
610
611
612
613
614
615
616
617
618
619
620
621
622
623
624
625
626
627
628
629
630
631
632
633
634
635
636
637
638
639
640
SURINAM
SURINAME
SVALBARD
SWAZILAND
SWEDEN
SWITZERLAND
SYRIA
SYRIAN ARAB REP
TABASCO
TADZHIK
TAHITI
TAIWAN
TAIWAN ROC
TAJIKISTAN
TAMAULIPAS
TANGANYIKA
TANGIER
TANZANIA
TASMANIA
THAILAND
THANH HOA
THE GRENADINES
TIBET
TIJUANA
TLAXCALA
TOBAGO
TOGO
TOGOLAND
TOKELAU
TONGA
TORTOISE ISLANDS
TORTOLA
TRANSVAAL
TRANSYLVANIA
TRIESTE
TRINIDAD
TRINIDAD & TOBAGO
TRIPOLI
TROMELIN ISLAND
TRUK
TUNIS
TUNISIA
TURKEY
TURKMENISTAN
TURKS & CAICOS IS
TURK ISLANDS
TUVALU
TUY HOA
UGANDA
UK
UKRAINE
UKRAINIA
05-May-09
Page 15 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
641
642
643
644
645
646
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
UNION ISLANDS
UNION OF SOUTH AFRICA
UNION OF SOVIET SOCIALIST REPUBLICS
UNITED ARAB EMIRATES
UNITED KINGDOM
UPPER VOLTA
URUGUAY
USSR
USBEKISTAN
VANCOUVER
VANUATU
VATICAN CITY
VENEZUELA
VERACRUZ
VICTORIA
VIETNAM
VINH LONG
VUNG TAU
WALES
WALLIS & FUTUNA ISLANDS
WEST AFRICA
WEST BANK
WEST BENGAL
WEST INDIES
WEST PAKISTAN
WESTERN AUSTRALIA
WESTERN SAHARA
WESTERN SAMOA
WHITE RUSSIA
WINDWARD ISLANDS
WINNIPEG
WURZBERG
YAP
YAR
YEMEN
YEMEN ARAB REPUBLIC
YEREVAN
YUCATAN
YUGOSLAVIA
YUKON TERRITORY
ZACATECAS
ZADAR
ZAIRE
ZAMBIA
ZANZIBAR
ZIMBABWE
ZURICH
ANDORRA
BRITISH INDIAN OCEAN TERRITORY
DEUTSCHLAND
FRENCH SOUTHERN AND ANTARCTIC LANDS
GRENADINES, THE
05-May-09
Page 16 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
693
KOSOVO
MYANMAR
NORTHWEST TERRITORY
NUNAVUT TERRITORY
Country not listed
Refused
Don't know
694
695
696
996
997
999
UniverseText:
All persons not born in the United States
SkipInstructions:
<60-85> [store "2" in CITIZEN and goto USYR]
<100-696,996,R,D> [goto USYR]
Question ID:
05-May-09
FSD.004_00.000 Instrument Variable Name:
QuestionText:
USYR
QuestionnaireFileName:
Family
* Read if necessary.
Earlier I recorded [fill1: your/ALIAS's] date of birth as [fill2: AGEDOB@3(text version) AGEDOB@4, AGEDOB@5].
In what year did [fill3: you/ALIAS] come to the United States to stay?
1880-Current
Year
9997
1880-Current Year
Refused
Don't know
9999
UniverseText:
All persons not born in the United States
SkipInstructions:
<1880-Current Year> [if USYR lt AGEDOB@5, goto ERR2_USYR; else, goto CITIZEN]
[goto USLONG]
NOTE: The "*Read if necessary…Earlier I recorded…" portion of this question is included for persons with
complete date of birth information.
Question ID:
FSD.005_00.000 Instrument Variable Name:
QuestionText:
USLONG
QuestionnaireFileName:
About how long [fill1: have you/has ALIAS] been in the United States?
* Read if necessary: Earlier I recorded that [fill2: you are/ALIAS is] [fill3: AGE] years old.
*Enter '95' for 95 or more years.
*If less than 1 year given as a response, code the answer as '0'.
00-94
95
97
99
00-94 years
95+ years
Refused
Don't know
UniverseText:
All persons not born in the United States and refused or don't know was reported for USYR
SkipInstructions:
<0-95> [if USLONG gt AGE, goto ERR_USLONG; else, goto CITIZEN]
[goto CITIZEN]
Family
Page 17 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
Question ID:
FSD.006_00.000 Instrument Variable Name:
QuestionText:
(book) F20
05-May-09
CITIZEN
QuestionnaireFileName:
Family
?[F1]
[fill: Are you/Is ALIAS] a CITIZEN of the United States?
1
9
Yes, born in one of the 50 United States or the District of Columbia
Yes, born in Puerto Rico, Guam, American Virgin Islands, or other U.S. territory
Yes, born abroad to American parent(s)
Yes, U.S. citizen by naturalization
No, not a citizen of the United States
Refused
Don't know
UniverseText:
All persons not born in the United States or a United States territory
SkipInstructions:
<1> [if PLBORN eq 2, goto ERR1_CITIZEN; else, if PLBORN eq R, goto ERR3_CITIZEN; else, goto HEADST]
<2> [if (PLBORN eq 2 or PLBORN eq R), goto ERR2_CITIZEN; else, goto HEADST]
[goto HEADST]
2
3
4
5
7
Question ID:
FSD.007_00.000 Instrument Variable Name:
QuestionText:
HEADST
QuestionnaireFileName:
Family
?[F1]
Is [fill: ALIAS] now attending Head Start?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons less than 7 years of age
SkipInstructions:
<1> [if no more persons less than 7 years of age, goto EDUC; else, repeat this question for the next eligible person]
<2,R,D> [ goto HEADSTEV]
Question ID:
FSD.008_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
HEADSTEV
QuestionnaireFileName:
Family
Has [fill: ALIAS] ever attended Head Start?
Yes
No
Refused
Don't know
UniverseText:
All persons less than 18 years of age and not currently enrolled in Head Start
SkipInstructions:
if no more persons less than 7 years of age, goto EDUC; else, goto HEADST for the next eligible person
Page 18 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
Question ID:
FSD.010_00.000 Instrument Variable Name:
QuestionText:
(book) F21
05-May-09
EDUC
QuestionnaireFileName:
Family
?[F1]
What is the HIGHEST level of school [fill: you have/ALIAS has] completed or the highest degree [fill: you have/ALIAS
has] received? Please tell me the number from the card.
* Enter highest level of school completed.
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
96
97
99
Never attended/kindergarten only
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
GED or equivalent
High School Graduate
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 degree (Example: MD, DDS, DVM, JD)
Doctoral degree (Example: PhD, EdD)
Child under 5 years old
Refused
Don't know
UniverseText:
All persons 5 years of age or older
SkipInstructions:
repeat for all eligible persons, then goto FMILTRY
Page 19 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
Question ID:
FSD.041_00.000 Instrument Variable Name:
QuestionText:
05-May-09
FMILTRY
QuestionnaireFileName:
Family
[fill: Have you/Has any family member, that is
*Read names
(fill roster of people ge 18 years of age)]
ever been honorably discharged from active duty in the U.S. Army, Navy, Air Force, Marine Corps, or Coast Guard?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All families with persons 18 years of age or older
SkipInstructions:
<1> [if only one person 18 years of age or older, store the person number in PMILTRY and goto DOINGLW; else,
goto PMILTRY]
<2,R,D> [goto DOINGLW]
Question ID:
FSD.042_00.000 Instrument Variable Name:
QuestionText:
PMILTRY
QuestionnaireFileName:
Family
* Ask or verify. Enter all that apply, separate with commas.
Who was this?
* Indicate each family member with honorable discharge.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All families with two or more persons 18 years of age or older and at least one was honorably discharged from
active duty in the U.S. Army, Navy, Air Force, Marine Corps, or Coast Guard
SkipInstructions:
goto DOINGLW
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.
Page 20 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
Question ID:
FSD.050_00.000 Instrument Variable Name:
QuestionText:
(book) F22
05-May-09
DOINGLW
QuestionnaireFileName:
Family
? [F1]
The next few questions are about employment status.
Which of the following [fill: were you/was ALIAS] doing last week?
* Read answer categories.
1
Working for pay at a job or business
With a job or business but not at work
Looking for work
Working, but not for pay, at a family-owned job or business
Not working at a job or business and not looking for work
Refused
Don't know
2
3
4
5
7
9
UniverseText:
All persons 18 years of age or older
SkipInstructions:
<1,4> [goto WRKHRS]
<2,5> [goto WHYNOWRK]
<3,R,D> [goto WRKLYR]
NOTE: A flashcard was added to this question in quarter 3 of 2005.
Question ID:
FSD.060_00.000 Instrument Variable Name:
QuestionText:
WHYNOWRK
QuestionnaireFileName:
Family
?[F1]
What is the main reason [fill1: you/ALIAS] did not [fill2: work last week/have a job or business last week]?
01
02
03
04
05
06
07
08
09
10
97
99
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 job/contract and off-season
On layoff
Disabled
Other
Refused
Don't know
UniverseText:
All persons 18 years of age or older who were either with a job or business but not at work, or not working at a job
or business and not looking for work
SkipInstructions:
<1-3,8-10,R,D> [goto WRKLYR]
<4-7> [goto WRKHRS]
Page 21 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
Question ID:
FSD.070_00.000 Instrument Variable Name:
QuestionText:
05-May-09
WRKHRS1
QuestionnaireFileName:
Family
?[F1]
How many hours [fill: did you work LAST WEEK at ALL jobs or businesses/did ALIAS work LAST WEEK at ALL jobs
or businesses/do you USUALLY work at ALL jobs or businesses/does ALIAS USUALLY work at ALL jobs or
businesses]?
001-168
1-168 hours
Refused
Don't know
997
999
UniverseText:
All persons 18 years of age or older who were working for pay at a job or business, or working, but not for pay, at
a job or business last week, or on a planned vacation from work, or on family or maternity leave, or temporarily
unable to work for health reasons, or have a job/contract and off-season
SkipInstructions:
<1-34,R,D> [goto WRKFTALL]
<35-94> [goto WRKLYR]
<95-168> [goto ERR1_WRKHRS]
Question ID:
FSD.080_00.000 Instrument Variable Name:
QuestionText:
WRKFTALL
QuestionnaireFileName:
Family
?[F1]
[fill: Do you/Does ALIAS] USUALLY work 35 hours or more per week in total at ALL jobs or businesses?
1
Yes
No
Refused
Don't know
2
7
9
UniverseText:
All persons 18 years of age or older who worked less than 35 hours last week or did not know/refused to answer
how many hours they worked last week
SkipInstructions:
[goto WRKLYR]
NOTE ON QUESTIONNAIRE FLOW: The instrument cycles through the appropriate questions from DOINGLW
to WRKFTALL for each eligible person, then proceeds to WRKLYR.
Question ID:
FSD.100_00.000 Instrument Variable Name:
QuestionText:
WRKLYR
QuestionnaireFileName:
?[F1]
Did [fill1: you/ALIAS] work for pay at any time in [fill2: last calendar year in 4-digit format]?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
All persons 18 years of age or older
SkipInstructions:
<1> [goto WRKMYR]
<2,R,D> [goto HIEMPOF]
Family
Page 22 of 22
DRAFT 2010 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
Question ID:
FSD.110_00.000 Instrument Variable Name:
QuestionText:
05-May-09
WRKMYR
QuestionnaireFileName:
Family
How many months in [fill1: last calendar year in 4-digit format] did [fill2: you/ALIAS] have at least one job or business?
* If less than one month, enter '1'.
01
1 month or less
2-12 months
Refused
Don't know
02-12
97
99
UniverseText:
All persons 18 years of age or older who worked last year
SkipInstructions:
goto ERNYR
Question ID:
FSD.120_00.000 Instrument Variable Name:
QuestionText:
ERNYR
QuestionnaireFileName:
Family
?[F1]
What is your best estimate of [fill1: your/ALIAS's] earnings before taxes and deductions from ALL jobs and businesses in
[fill2: last calendar year in 4-digit format]?
Include hourly wages, salaries, tips and commissions.
* Enter '999,995' if the reported income is greater than $999,995.
000001-999994
999995
999997
999999
$1-$999,994
$999,995+
Refused
Don't know
UniverseText:
All persons 18 years of age or older who worked last year
SkipInstructions:
goto HIEMPOF
Question ID:
FSD.130_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
HIEMPOF
QuestionnaireFileName:
Family
Regarding [fill1: your/ALIAS's] job or work last week, was health insurance offered to [fill2: you/ALIAS] through [fill1:
your/ALIAS's] workplace?
Yes
No
Refused
Don't know
UniverseText:
All persons 18 years of age or older who were working for pay at a job or business, or with a job or business, but
not at work, or working, but not for pay, at a family-owned job or business
SkipInstructions:
goto INTROINC
NOTE ON QUESTIONNAIRE FLOW: The instrument cycles through the appropriate questions from WRKLYR
to HIEMPOF for each eligible person, then proceeds to INTROINC.
| File Type | application/pdf |
| File Title | NHISOutputSpecs |
| Author | NCHS User |
| File Modified | 2009-07-29 |
| File Created | 2009-07-29 |