ATTACHMENT 2b
Household Member Interview
Household Member Interview for Telephone Interviewing
Form Approved
OMB No. 0920-0805
Exp. Date 02/29/2012
IF SCREENER RESPONDENT IS SAMPLED FOR DETAILED INTERVIEW AND NO BREAK OCCURS BETWEEN SCREENER AND DETAILED INTERVIEW, SKIP TO CONSENT1.
INTRO
Hello,
my name is [INTERVIEWER NAME]. I’m calling on behalf of the
Centers for Disease Control and Prevention [IF COMMUNITY =12 FILL
"for the Inter-Tribal Council of Michigan"]. We’re
conducting a study regarding health issues in [IF ENGLISH FILL
LOCALITY1. ELSE IF SPANISH FILL LOCALITY1_SP. ELSE IF HAITIAN CREOLE
FILL LOCALITY1_HC.]. This is a research study. Taking part is up to
you. You don’t have to answer any question you don’t want
to, and you can end the interview at any time. The interview takes
about 15 minutes and any information you give me will be kept secure
and private. There are no risks or benefits to you for
participating. In order to evaluate my performance, my supervisor
may record and listen as I ask the questions. The recordings will be
destroyed when the data collection for the study is completed. Would
you like to participate? I’d like to continue now unless you
have any questions.
READ IF NECESSARY: We are collecting
data to better understand health related behaviors and diseases that
may affect adults in your neighborhood. Researchers are trying to
understand the health issues specific to your neighborhood, so
programs can better fit the needs of the people living there. NORC
is conducting this survey for the Centers for Disease Control and
Prevention (CDC).
IF RESPONDENT REFUSES TO CONTINUE, EXIT THE INTERVIEW AND CODE THE CASE AS A REFUSAL.
1. CONTINUE
99. REFUSE
INTERVIEWER: READ ONLY IF RESPONDENT ASKS TO CONTACT THE IRB
If you want to know more about your rights as a study participant you may call the NORC Institutional Review Board Administrator, toll free, at 866-309-0542.
Thanks again.
IF SCREENER RESPONDENT IS SAMPLED FOR DETAILED INTERVIEW AND NO BREAK OCCURS BETWEEN SCREENER AND DETAILED INTERVIEW, SKIP TO CONSENT1.
USER SHALL NOT BE ABLE TO BACK UP FROM INTRO.
Do not go to INTRO/CONSENT1 on callback if INTRO/CONSENT1=1 from a previous call.
CONSENT 1
Before
we begin, this is a research study. Taking part is up to you. You
don’t have to answer any question you don’t want to, and
you can end the interview at any time. The interview takes about 15
minutes and any information you give me will be kept secure and
private. There are no risks or benefits to you for participating. In
order to evaluate my performance, my supervisor may record and listen
as I ask the questions. The recordings will be destroyed when the
data collection for the study is completed. Would you like to
participate? I’d like to continue now unless you have any
questions.
IF RESPONDENT REFUSES TO CONTINUE, EXIT THE
INTERVIEW AND CODE THE CASE AS A REFUSAL.
1. CONTINUE
99. REFUSE
INTERVIEWER: READ ONLY IF RESPONDENT ASKS TO CONTACT THE IRB
If you want to know more about your rights as a study participant you may call the NORC Institutional Review Board Administrator, toll free, at 866-309-0542.
GENHLTH
1. Would you say that in general your health is:
PLEASE
READ:
1. Excellent
2. Very good
3.
Good
4. Fair, or
5. Poor
77. DON’T KNOW
99. REFUSE
PHYSHLTH
2. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
INTERVIEWER:
ENTER “00” FOR NONE.
|___|___|
NUMBER OF DAYS
77. DON’T KNOW
99. REFUSE
RANGE 0-30, 77, 99
MENTHLTH
3. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
INTERVIEWER:
ENTER “00” FOR NONE.
|___|___| NUMBER OF DAYS
77. DON’T KNOW
99. REFUSE
RANGE 0-30, 77, 99
IF PHYSHLTH and MENTHLTH = “00” GO TO HLTHPLAN
POORHLTH
4.
During the past 30 days, for about how many days did poor physical
or mental health keep you from doing your usual activities, such as
self-care, work, or recreation?
INTERVIEWER:
ENTER “00” FOR NONE
|___|___| NUMBER OF DAYS
77. DON’T KNOW
99. REFUSE
RANGE 0-30, 77, 99
HLTHPLAN
5.
Do you have any kind of health care coverage, including health
insurance, prepaid plans such as HMOs, or government plans such as
Medicare?
1. YES
2. NO
77. DON’T KNOW
99. REFUSE
MEDCOST
6.
Was there a time in the past 12 months when you needed to see a
doctor, but could not because of cost?
1. YES
2. NO
77. DON’T KNOW
99. REFUSE
CHECKUP
7. About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.
1. Within the past year (anytime less than 12 months ago)
2. Within the past 2 years (1 year but less than 2 years ago)
3. Within the past 5 years (2 years but less than 5 years ago)
4. 5 or more years ago
5. Never
77. DON’T KNOW
99. REFUSE
WEIGHT
8. About how much do you weigh without shoes?
INTERVIEWER:
ROUND FRACTIONS UP
ENTER 0 IF RESPONDENT ANSWERS IN KILOGRAMS AT
WEIGHT
|___|___|___| WEIGHT IN POUNDS
777. DON’T KNOW
999. REFUSE
WEIGHT: SKIP TO WEIGHT_KILO IF WEIGHT = 0.
WEIGHT_KILO
8A. |___|___|___| KILOGRAMS
777. DON’T KNOW
999. REFUSE
IF WEIGHT_KILO = 0:
DISPLAY ERROR MESSAGE: “Weight cannot be 0 in both pounds and kilograms.”
GO TO WEIGHT
If WEIGHT<>0 and (WEIGHT<75 or WEIGHT>500), GO TO WGTCONF.
If WEIGHT_KILO <>blank and (WEIGHT_KILO<34 or WEIGHT_KIL0>227), GO TO WGTCONF.
WGTCONF
Just to confirm that I entered it correctly, I have [IF WEIGHT<>0 FILL, "[WEIGHT] pounds", ELSE IF WEIGHT=0 FILL "[WEIGHT_KILO] kilograms"]. Is that correct?
1. YES [GO TO HEIGHTF]
2. NO [GO TO WEIGHT]
HEIGHT
9. About how tall are you without shoes?
INTERVIEWER:
ROUND FRACTIONS DOWN
ENTER 0 IF RESPONDENT ANSWERS IN
CENTIMETERS AT HEIGHTF AND HEIGHTIN
HEIGHTF
a.
FEET |___|___|
77. DON’T KNOW
99. REFUSE
HEIGHTIN
b.
INCHES |___|___|
77. DON’T KNOW
99.
REFUSE
HEIGHTF RANGE 0-8, 77, 99
HEIGHTIN RANGE 0-96, 77, 99
SKIP TO HEIGHTCENT IF HEIGHTF AND HEIGHTIN = 0.
HEIGHTCENT
9A. CENTIMETERS |___|___|___|
777. DON’T KNOW
999. REFUSE
RANGE 0-244, 777, 999
IF HEIGHTCENT = 0:
DISPLAY ERROR MESSAGE: “Height cannot be 0 in feet, inches and centimeters.”
GO TO HEIGHTF
If HEIGHTF<>0 AND (HEIGHTF<3 OR HEIGHTF>7), GO TO HGTCONF.
IF HEIGHTIN<>0 AND (HEIGHTIN<36 OR HEIGHTIN>84), GO TO HGTCONF.
IF HEIGHTCENT<>blank AND (HEIGHTCENT<91 OR HEIGHTCENT>213), GO TO HGTCONF.
HGTCONF
Just to confirm that I entered it correctly, I have
[IF HEIGHTF<>0 AND (HEIGHTF<3 OR HEIGHTF>7 FILL, "[HEIGHTF] feet tall",
ELSE IF HEIGHTIN<>0 AND (HEIGHTIN<36 OR HEIGHTIN>84) FILL "[HEIGHTIN] inches tall"]
ELSE IF HEIGHTCENT<>blank AND (HEIGHTCENT<91 OR HEIGHTCENT>213) FILL "[HEIGHTCENT] centimeters tall"].
1. YES [GO TO EMPLOY]
2. NO [GO TO HEIGHTF]
EMPLOY
10. Are you currently . . .?
PLEASE
READ ALL
1. Employed for wages [GO TO JOBACTIV]
2. Self-employed [GO TO JOBACTIV]
3. Out of work for more than 1 year [GO TO EMPLOY5]4. Out of work for less than 1 year [GO TO EMPLOY5]5. Homemaker [GO TO EMPLOY6]6. Student [GO TO EMPLOY6]
7. Retired, or [GO TO EMPLOY5]
8. Unable to work [GO TO EMPLOY6]
77. DON’T KNOW
99. REFUSE
JOBACTIV
11.
When you are at work, which of the following best describes what you
do? Would you say…
INTERVIEWER: IF RESPONDENT HAS
MULTIPLE JOBS, INCLUDE ALL JOBS.
Mostly sitting or standing
Mostly walking
Mostly heavy labor or physically demanding work
DON’T KNOW
99. REFUSE
EMPLOY3
12.
At your main
job or business, how are you generally paid for the work you do? Are
you:
INTERVIEWER NOTE: IF PAID IN MULTIPLE WAYS AT THEIR MAIN JOB, SELECT OPTION 4 (PAID SOME OTHER WAY).
1. Paid by salary
2. Paid by the hour
3. Paid by the job/task (e.g. commission, piecework)
4. Paid some other way
77. DON’T KNOW
99. REFUSE
EMPLOY4
13.
About how many hours do you work per week at all of your jobs and
businesses combined?
INTERVIEWER: ENTER "96"
FOR "96 OR MORE".
|___|___| Hours
97. DON’T KNOW
98. DOES NOT WORK
99. REFUSE
INTERVIEWER: ENTER "96" FOR "96 OR MORE".
RANGE 1-97, 99
ANY RESPONSE SKIPS TO EXERANY.
EMPLOY5
14. Thinking about the last time you worked, at your main job or business, how were you generally paid for the work you do? Were you:
1. Paid by salary
2. Paid by the hour
3. Paid by the job/task (e.g. commission, piecework)
4. Paid some other way
77. DON’T KNOW
99. REFUSE
EMPLOY6
15. Thinking about the last time you worked, about how many hours did you work per week at all of your jobs and businesses combined?
|___|___| Hours
97. DON’T KNOW
98. DOES NOT WORK
99. REFUSE
RANGE 1-99
EXERANY
16. During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
1.
YES
2. NO
77. DON’T KNOW
99. REFUSE
ACTVE_INTRO
We are interested in two types of physical activity – vigorous and moderate. Vigorous activities cause large increases in breathing or heart rate while moderate activities cause small increases in breathing or heart rate.
MODEXER
17. Now thinking about the moderate activities you do [IF EMPLOY =1 OR 2 THEN FILL :"when you are not working"] in a usual week, do you do moderate activities for at least 10 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that causes some increase in breathing or heart rate?
1. YES
2. NO [GO TO VIGEXER]
77. DON’T KNOW [GO TO VIGEXER]
99. REFUSE [GO TO VIGEXER]
MODEXDAY
18. How many days per week do you do these moderate activities for at least 10 minutes at a time?
DAYS PER WEEK |___|___|
77. DON’T KNOW
99. REFUSE
RANGE 1-7, 77, 99
IF MODEXDAY IS 77, OR 99, GO TO MODEXTM
MODEXTM
19.
On days when you do moderate activities for at least 10 minutes at a
time, how much total time per day do you spend doing these
activities?
INTERVIEWER: ENTER RESPONSE AS GIVEN BY THE R. IF THEY RESPOND IN MINUTES (SUCH AS 90 MINUTES) ENTER 90 MINUTES, NOT 1 HOUR AND 30 MINUTES.
MODEXTM_HRS
HOURS |___|___|
77. DON’T KNOW [GO TO VIGEXER, FILL MODEXTM_MIN=7777]
99. REFUSE [GO TO VIGEXER, FILL MODEXTM_MIN=9999]
HOURS RANGE 0-10, 77, 99
MODEXTM_MIN
MINUTES |___|___|___|
7777. DON’T KNOW [GO TO VIGEXER]
9999. REFUSE [GO TO VIGEXER]
MINUTES RANGE 0-600, 7777, 9999
IF (MODEXTM_HRS > 2) OR (MODEXTM_MIN > 120) OR (MODEXTM_HRS=2 AND MODEXTM_MIN>0) GO TO MODEXCONF
MODEXCONF
19A. Just to confirm that I entered it correctly, I have [MODEXTM HOURS /MODEXTM MINUTES]. Is that correct?
1. YES [GO TO VIGEXER]
2. NO [GO TO MODEXTM]
VIGEXER
20. Now thinking about the vigorous activities you do [IF EMPLOY =1 OR 2 THEN FILL "when you are not working"] in a usual week, do you do vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate?
1. YES
2. NO [GO TO FOOD_INTRO]
77. DON’T KNOW [GO TO FOOD_INTRO]
99. REFUSE [GO TO FOOD_INTRO]
VIGEXDAY
21. How many days per week do you do these vigorous activities for at least 10 minutes at a time?
DAYS PER WEEK |___|___|
77. DON’T KNOW
99. REFUSE
RANGE 1-7, 77, 99
IF VIGEXDAY IS NOT 77, OR 99, GO TO VIGEXTM
VIGEXTM
22.
On days when you do vigorous activities for at least 10 minutes at a
time, how much total time per day do you spend doing these
activities?
INTERVIEWER:
ENTER RESPONSE AS GIVEN BY THE R. IF THEY RESPOND IN MINUTES (SUCH
AS 90 MINUTES) ENTER 90 MINUTES, NOT 1 HOUR AND 30 MINUTES.
VIGEXTM_HRS
HOURS |___|___|
77.
DON’T KNOW [GO TO FOOD_INTRO, FILL VIGEXTM_MIN=7777]
99. REFUSE [GO TO FOOD_INTRO, FILL VIGEXTM_MIN=9999]
HOURS RANGE 0-10, 77, 99
MINUTES |___|___|___|
77. DON’T KNOW [GO TO FOOD_INTRO]
99. REFUSE [GO TO FOOD_INTRO]
MINUTES RANGE 0-600, 7777, 9999
IF (VIGEXTM_HRS > 2) OR (VIGEXTM_MIN > 120) OR (VIGEXTM_HRS=2 AND VIGEXTM_MIN>0) GO TO VIGEXCONF GO TO VIGEXCONF
VIGEXCONF
22A. Just to confirm that I entered it correctly, I have [VIGEXCONF HOURS / VIGEXCONF MINUTES]. Is that correct?
1. YES [GO TO FOOD_INTRO]
2. NO [GO TO VIGEXTM]
HOURS RANGE 0-10, 77, 99
MINUTES RANGE 0-600, 7777, 9999
FOOD_INTRO
These next questions are about the foods you usually eat or drink. Please tell me how often you eat or drink each one, for example, twice a week, three times a month, and so forth.
Remember, I am only interested in the foods you eat. Include all foods you eat, both at home and away from home.
FRUITJU
23. How often do you drink fruit juices such as orange, grapefruit, or tomato?
READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”
INTERVIEWER: ENTER “000” FOR “NEVER”. CONFIRM ENTRY WITH RESPONDENT
NUMBER OF TIMES |___|___|___|___|
7777. DON’T KNOW [GO TO FRUIT, FILL FRUITJU2 = 77]
9999. REFUSE [GO TO FRUIT, FILL FRUITJU2 = 99]
IF FRUITJU = 000 GO TO FRUIT
FRUITJU2
23A. FRUIT JUICE MODE
1. PER DAY
2. PER WEEK
3. PER MONTH
4. PER YEAR
77. DON’T KNOW
99. REFUSE
IF [FRUITJU NUMBER OF TIMES / FRUITJU2 MODE]
> 3 TIMES PER DAY OR
> 21 TIMES PER WEEK OR
> 90 TIMES PER MONTH OR
> 1095 TIMES PER YEAR
GO TO FRUITJUCONF
ELSE, GO TO FRUIT
FRUITJUCONF
23B. Just to confirm that I entered it correctly, I have [FRUITJU NUMBER OF TIMES / FRUITJU2 MODE]. Is that correct?
1. YES [GO TO FRUIT]
2. NO [GO TO FRUITJU]
FRUIT
24. Not counting juice, how often do you eat fruit?
READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”
INTERVIEWER: ENTER “000” FOR “NEVER”. CONFIRM ENTRY WITH RESPONDENT.
NUMBER OF TIMES |___|___|___|___|
7777. DON’T KNOW [GO TO GREENSAL, FILL FRUIT2 = 77]
9999. REFUSE [GO TO GREENSAL, FILL FRUIT2 = 99]
IF FRUIT = 000 GO TO GREENSAL
FRUIT2
24A. FRUIT MODE
1. PER DAY
2. PER WEEK
3. PER MONTH
4. PER YEAR
77. DON’T KNOW
99. REFUSE
IF [FRUIT NUMBER OF TIMES / FRUIT2 MODE]
> 3 TIMES PER DAY OR
> 21 TIMES PER WEEK OR
> 90 TIMES PER MONTH OR
> 1095 TIMES PER YEAR
GO TO FRUITCONF
ELSE, GO TO GREENSAL
FRUITCONF
24B. Just to confirm that I entered it correctly, I have [FRUIT NUMBER OF TIMES / FRUIT2 MODE]. Is that correct?
1. YES [GO TO GREENSAL]
2. NO [GO TO FRUIT]
GREENSAL
25. How often do you eat green salad?
READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”
INTERVIEWER: ENTER “000” FOR “NEVER”. CONFIRM ENTRY WITH RESPONDENT.
NUMBER OF TIMES |___|___|___|___|
7777. DON’T KNOW [GO TO POTATO, FILL GREENSAL2 = 77]
9999. REFUSE [GO TO POTATO, FILL GREENSAL2 = 99]
IF GREENSAL = 000 GO TO POTATO
GREENSAL2
25A. GREEN SALAD MODE
1. PER DAY
2. PER WEEK
3. PER MONTH
4. PER YEAR
77. DON’T KNOW
99. REFUSE
IF [GREENSAL NUMBER OF TIMES / GREENSAL2 MODE]> 2 TIMES PER DAY OR
> 14 TIMES PER WEEK OR
> 60 TIMES PER MONTH OR
> 730 TIMES PER YEAR
GO TO GREENSALCONF
ELSE, GO TO POTATO
GREENSALCONF
25B. Just to confirm that I entered it correctly, I have [GREENSAL NUMBER OF TIMES / GREENSAL2 MODE]. Is that correct?
1. YES [GO TO POTATO]
2. NO [GO TO GREENSAL]
POTATO
26. How often do you eat potatoes not including French fries, fried potatoes, or potato chips?
READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”
INTERVIEWER: ENTER “000” FOR “NEVER”. CONFIRM ENTRY WITH RESPONDENT.
NUMBER OF TIMES |___|___|___|___|
7777. DON’T KNOW [GO TO CARROTS, FILL POTATO2 = 77]
9999. REFUSE [GO TO CARROTS, FILL POTATO2 = 99]
IF POTATO = 000 GO TO CARROTS
POTATO2
26A. POTATO MODE
1. PER DAY
2. PER WEEK
3. PER MONTH
4. PER YEAR
77. DON’T KNOW
99. REFUSE
IF [POTATO NUMBER OF TIMES / POTATO2 MODE]
> 1 TIMES PER DAY OR
> 7 TIMES PER WEEK OR
> 30 TIMES PER MONTH OR
> 365 TIMES PER YEAR
GO TO POTATOCONF
ELSE, GO TO CARROTS
POTATOCONF
26B. Just to confirm that I entered it correctly, I have [POTATO NUMBER OF TIMES / POTATO2 MODE]. Is that correct?
1. YES [GO TO CARROTS]
2. NO [GO TO POTATO]
CARROTS
27. How often do you eat carrots?
READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”
INTERVIEWER: ENTER “000” FOR “NEVER”. CONFIRM ENTRY WITH RESPONDENT.
NUMBER OF TIMES |___|___|___|___|
7777. DON’T KNOW [GO TO VEGETABL, FILL CARROTS2 = 77]
9999. REFUSE [GO TO VEGETABL, FILL CARROTS2 = 99]
IF CARROTS = 000 GO TO VEGETABL
CARROTS2
27A. CARROTS MODE
1. PER DAY
2. PER WEEK
3. PER MONTH
4. PER YEAR
77. DON’T KNOW
99. REFUSE
IF [CARROTS NUMBER OF TIMES / CARROTS2 MODE]> 1 TIMES PER DAY OR
> 7 TIMES PER WEEK OR
> 30 TIMES PER MONTH OR
> 365 TIMES PER YEAR
GO TO CARROTSCONF
ELSE, GO TO VEGETABL
CARROTSCONF
27B. Just to confirm that I entered it correctly, I have [CARROTS NUMBER OF TIMES / CARROTS2 MODE]. Is that correct?
1. YES [GO TO VEGETABL]
2. NO [GO TO CARROTS]
VEGETABL
28. Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat? (Example: A serving of vegetables at both lunch and dinner would be two servings.)
READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”
INTERVIEWER: ENTER “000” FOR “NEVER”. CONFIRM ENTRY WITH RESPONDENT.
NUMBER OF TIMES |___|___|___|___|
7777. DON’T KNOW [GO TO SEX, FILL VEGETABL2 = 77]
9999. REFUSE [GO TO SEX, FILL VEGETABL2 = 99]
IF VEGETABL = 000 GO TO SEX
VEGETABL2
28A. VEGETABLES MODE
1. PER DAY
2. PER WEEK
3. PER MONTH
4. PER YEAR
77. DON’T KNOW
99. REFUSE
IF [VEGETABL NUMBER OF TIMES / VEGETABL2 MODE]
> 2 TIMES PER DAY OR
> 14 TIMES PER WEEK OR
> 60 TIMES PER MONTH OR
> 730 TIMES PER YEAR
GO TO VEGETABLCONF
ELSE, GO TO SEX
VEGETABLCONF
28B. Just to confirm that I entered it correctly, I have [VEGETABL NUMBER OF TIMES / VEGETABL2 MODE]. Is that correct?
1. YES [GO TO SEX]
2. NO [GO TO VEGETABL]
SEX
29. ASK ONLY IF NECESSARY: Just to confirm, are you male or female?
1. MALE
2. FEMALE
77. DON’T KNOW
99. REFUSE
IF SEX = 77, 99, BUT GENDER_X WAS GIVEN IN THE SCREENER, USE GENDER_X TO DETERMINE SKIP. IF [GENDER = 77 OR 99] AND [SEX = 77 OR 99] THEN SET 'SEX_UNKNOWN' = 1
DIAB_INTRO
The next questions are about diabetes.
DIABETES
30. Have you ever been told by a doctor that you have diabetes?
1. YES [IF GENDER=FEMALE GO TO DIABPREG; ELSE GO TO BLDSUGAR AND FILL DIABPREG=3]
2. NO [GO TO BPHIGH]
3. NO, PRE-DIABETES OR BORDERLINE DIABETES [GO TO BPHIGH]
77. DON’T KNOW [GO TO BPHIGH]
99. REFUSE [GO TO BPHIGH]
DIABPREG
30A. Was this only when you were pregnant?
1. YES [GO TO BPHIGH]
2. NO
3. MALE
77. DON’T KNOW
99. REFUSE
BLDSUGAR
31. About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a health professional.
1. |___|___| TIMES PER DAY
2. |___|___| TIMES PER WEEK
3. |___|___| TIMES PER MONTH
4. |___|___| TIMES PER YEAR
888. NEVER
777. DON’T KNOW
999. REFUSE
FEETCHK2
32. About how often do you check your feet for any sores or irritations? Include times when checked by a family member or friend, but do not include times when checked by a health professional.
1. |___|___| TIMES PER DAY
2. |___|___| TIMES PER WEEK
3. |___|___| TIMES PER MONTH
4. |___|___| TIMES PER YEAR
555. NO FEET
888. NEVER
777. DON’T KNOW
999. REFUSE
DOCTDIAB
33. About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
INTERVIEWER: ENTER “00” FOR NONE AND “76” FOR “76 OR MORE”
|___|___| NUMBER OF TIMES
00. NONE
77. DON’T KNOW
99. REFUSE
RANGE 0 – 77, 99
CHKHEMO
34. A test for “A one C” measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for “A one C”?
INTERVIEWER: ENTER “00” FOR NONE AND “76” FOR “76 OR MORE”
|___|___| NUMBER OF TIMES
77. DON’T KNOW
98. NEVER HEARD OF “A ONE C” TEST [GO TO FEETCHK]
99. REFUSE
RANGE 0 – 77, 98, 99
IF FEETCHK2 = 555 (NO FEET) GO TO EYEEXAM
IF CHKHEMO > 24 GO TO CHKHEMOCONF,, ELSE GO TO FEETCHK
CHKHEMOCONF 34A. Just to confirm that I entered it correctly, I have [CHKHEMO NUMBER] times. Is that correct?
1. YES [IF FEETCHK2 = 555 (NO FEET) GO TO EYEEXAM; ELSE GO TO FEETCHK]
2. NO [GO TO CHKHEMO]
FEETCHK
35. About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
INTERVIEWER: ENTER “00” FOR NONE AND ENTER “76” FOR “76 OR MORE”
|___|___| NUMBER OF TIMES
77. DON’T KNOW
99. REFUSE
RANGE 0 – 77, 99
IF FEETCHK > 24 GO TO FEETCHKCONF,, ELSE GO TO EYEEXAM
FEETCHKCONF,35A. Just to confirm that I entered it correctly, I have [FEETCHK NUMBER] times. Is that correct?
1. YES [GO TO EYEEXAM]
2. NO [GO TO FEETCHK]
EYEEXAM
36. When was the last time you had an eye exam in which your pupils were dilated? This would have made you temporarily sensitive to bright light.
READ IF NECESSARY:
1. Within the past month (anytime less than 1 month ago)
2. Within the past year (1 month but less than 12 months ago)
3. Within the past 2 years (1 year but less than 2 years ago)
4. 2 or more years ago
5. Never
77. DON’T KNOW
99. REFUSE
DIABEDU
37. Have you ever taken a course or class in how to manage your diabetes yourself?
1. YES
2. NO
77. DON’T KNOW
99. REFUSE
BPHIGH
38. The next few questions are about high blood pressure. Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
1. YES [GO TO BPMEDS]
2. NO [GO TO CHOLES_INTRO]
3. TOLD BORDERLINE OR PRE-HYPERTENSIVE [GO TO CHOLES_INTRO]
77. DON’T KNOW [GO TO CHOLES_INTRO]
99. REFUSE [GO TO CHOLES_INTRO]
BPMEDS
39. Are you currently taking medicine for your high blood pressure?
1. YES
2. NO
77. DON’T KNOW
99. REFUSE
HIBPYOU
40. Are you now doing any of the following to help lower or control your high blood pressure?
BPEATHBT
40A. (Are you) changing your eating habits (to help lower or control your high blood pressure)?
1. YES
2. NO
77. DON’T KNOW
99. REFUSE
BPSALT
40B. (Are you) cutting down on salt (to help lower or control your high blood pressure)?
1. YES
2. NO
3. DO NOT USE SALT
77. DON’T KNOW
99. REFUSE
BPALCHOL
40C. (Are you) reducing alcohol use (to help lower or control your high blood pressure)?
1. YES
2. NO
3. DO NOT DRINK
77. DON’T KNOW
99. REFUSE
BPEXER
40D. (Are you) exercising (to help lower or control your high blood pressure)?
1. YES
2. NO
77. DON’T KNOW
99. REFUSE
CHOLES_INTRO
The next few questions are about blood cholesterol.
CHOLESCHK
41. Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
1. YES
2. NO [GO TO CVD_INTRO]
77. DON’T KNOW [GO TO CVD_INTRO]
99. REFUSE [GO TO CVD_INTRO]
CHOLESLAST
42. About how long has it been since you last had your blood cholesterol checked?
READ ONLY IF NECESSARY:
1. Within the past year (anytime less than 12 months ago)
2. Within the past 2 years (1 year but less than 2 years ago)
3. Within the past 5 years (2 years but less than 5 years ago)
4. 5 or more years ago
77. DON’T KNOW
99. REFUSE
CHOLESHI
43. Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high?
1. YES
2. NO
77. DON’T KNOW
99. REFUSE
CVD_INTRO
Now I would like to ask you some questions about cardiovascular disease.
CVDDRTLD
44. Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me “Yes”, “No” or you’re “Not sure.”
CVDINFAR
44A. (Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me "Yes", "No" or you’re "Not sure.")
(Ever told) you had a heart attack, also called a myocardial infarction?
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
CVDCORHD
44B. (Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me "Yes", "No" or you’re "Not sure.")
(Ever told) you had angina or coronary heart disease?
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
CVDSTROK
44C. (Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me "Yes", "No" or you’re "Not sure.")
(Ever told) you had a stroke?
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
HEART_INTRO
Now I would like to ask you about your knowledge of the signs and symptoms of a heart attack and stroke.
HASYMP
45. Which of the following do you think is a symptom of a heart attack? For each, tell me “Yes”, “No” or you’re “Not sure.”
HASYMP1
45A. (Which of the following do you think is a symptom of a heart attack? For each, tell me "Yes", "No", or you're "Not sure.")
(Do you think) pain or discomfort in the jaw, neck, or back (are symptoms of a heart attack?)
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
HASYMP2
45B. (Which of the following do you think is a symptom of a heart attack? For each, tell me "Yes", "No", or you're "Not sure.")
(Do you think) feeling weak, lightheaded, or faint (are symptoms of a heart attack?)
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
HASYMP3
45C. (Which of the following do you think is a symptom of a heart attack? For each, tell me "Yes", "No", or you're "Not sure.")
(Do you think) chest pain or discomfort (are symptoms of a heart attack?)
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
HASYMP4
45D. (Which of the following do you think is a symptom of a heart attack? For each, tell me "Yes", "No", or you're "Not sure.")
(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a heart attack?)
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
HASYMP5
45E. (Which of the following do you think is a symptom of a heart attack? For each, tell me "Yes", "No", or you're "Not sure.")
(Do you think) pain or discomfort in the arms or shoulder (are symptoms of a heart attack?)
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
HASYMP6
45F. (Which of the following do you think is a symptom of a heart attack? For each, tell me "Yes", "No", or you're "Not sure.")
(Do you think) shortness of breath (is a symptom of a heart attack?)
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
STRKSYMP
46. Which of the following do you think is a symptom of a stroke? For each, tell me “Yes”, “No” or you’re “Not sure.”
STRSYMP1
46A. (Which of the following do you think is a symptom of a stroke? For each, tell me "Yes", "No", or you're "Not sure.")
(Do you think) sudden confusion or trouble speaking (are symptoms of a stroke?)
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
STRSYMP2
46B. (Which of the following do you think is a symptom of a stroke? For each, tell me "Yes", "No", or you're "Not sure.")
(Do you think) sudden numbness or weakness of face, arm, or leg, especially on one side, (are symptoms of a stroke?)
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
STRSYMP3
46C. (Which of the following do you think is a symptom of a stroke? For each, tell me "Yes", "No", or you're "Not sure.")
(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a stroke?)
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
STRSYMP4
46D. (Which of the following do you think is a symptom of a stroke? For each, tell me "Yes", "No", or you're "Not sure.")
(Do you think) sudden chest pain or discomfort (are symptoms of a stroke?)
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
STRSYMP5
46E. (Which of the following do you think is a symptom of a stroke? For each, tell me "Yes", "No", or you're "Not sure.")
(Do you think) sudden trouble walking, dizziness, or loss of balance (are symptoms of a stroke?)
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
STRSYMP6
46F. (Which of the following do you think is a symptom of a stroke? For each, tell me "Yes", "No", or you're "Not sure.")
(Do you think) severe headache with no known cause (is a symptom of a stroke?)
1. YES
2. NO
77. DON’T KNOW/NOT SURE
99. REFUSE
FIRSTAID
47. If you thought someone was having a heart attack or a stroke, what is the first thing you would do:
PLEASE READ ALL:
1. Take them to the hospital
2. Tell them to call their doctor
3. Call 911
4. Call their spouse or a family member, or
5. Do something else
77. DON’T KNOW
99. REFUSE
AGE
48. For the following questions, I'll need to know your age. How old are you?
|___|___|___| CODE AGE IN YEARS
777. DK
999. REF
IF AGE = 777, 999, BUT AGE WAS GIVEN IN THE SCREENER, FILL WITH SCREENER AGECAT RANGE PROVIDED.
RANGE 18 – 120, 777, 999
FLUSHOT
49. A flu shot is an influenza vaccine injected into your arm. During the past 12 months, have you had a flu shot?
1. YES
2. NO
77. DON’T KNOW
99. REFUSE
PNEUMVAC
50. A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person’s lifetime and is different from the flu shot. Have you ever had a pneumonia shot?
1.
YES
2. NO
77. DON’T KNOW
99. REFUSE
BCC_INTRO
The next questions are about breast and cervical cancer.
QUESTIONS BCC_INTRO THROUGH HPVNUM FOR FEMALES ONLY
IF GENDER <> FEMALE SKIP TO SMOKE100
HADMAM
51. A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
1. YES
2. NO [GO TO PROFEXAM]
77. DON’T KNOW [GO TO PROFEXAM]
99. REFUSE [GO TO PROFEXAM]
HOWLONG
52. How long has it been since you had your last mammogram?
READ ONLY IF NECESSARY:
1. Within the past year (anytime less than 12 months ago)
2. Within the past 2 years (1 year but less than 2 years ago)
3. Within the past 3 years (2 years but less than 3 years ago)
4. Within the past 5 years (3 years but less than 5 years ago)
5. 5 or more years ago
77. DON’T KNOW
99. REFUSE
PROFEXAM
53. A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you ever had a clinical breast exam?
1.
YES
2. NO [GO TO HADPAP]
77. DON’T KNOW [GO TO HADPAP]
99. REFUSE [GO TO HADPAP]
LENGEXAM
54. How long has it been since your last breast exam?
READ ONLY IF NECESSARY:
1. Within the past year (anytime less than 12 months ago)
2. Within the past 2 years (1 year but less than 2 years ago)
3. Within the past 3 years (2 years but less than 3 years ago)
4. Within the past 5 years (3 years but less than 5 years ago)
5. 5 or more years ago
77. DON’T KNOW
99. REFUSE
HADPAP
55. A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?
1. YES
2. NO [GO TO HADHYST]
77. DON’T KNOW [GO TO HADHYST]
99. REFUSE [GO TO HADHYST]
LASTPAP
56. How long has it been since you had your last Pap test?
READ ONLY IF NECESSARY:
1. Within the past year (anytime less than 12 months ago)
2. Within the past 2 years (1 year but less than 2 years ago)
3. Within the past 3 years (2 years but less than 3 years ago)
4. Within the past 5 years (3 years but less than 5 years ago)
5. 5 or more years ago
77. DON’T KNOW
99. REFUSE
HADHYST
57. Have you had a hysterectomy?
READ ONLY IF NECESSARY: A hysterectomy is an operation to remove the uterus (womb).
INTERVIEWER: IF R HAD PARTIAL HYSTERECTOMY CODE AS “YES”
1. YES
2. NO
77. DON’T KNOW
99. REFUSE
HPVSHOT
58. A vaccine to prevent the human papilloma virus or HPV infection is available and is called cervical cancer or genital warts vaccine, HPV shot, GARDASIL or CERVARIX®. Have you ever had the HPV vaccination?
1. YES
2. NO [GO TO SMOKE100]
3. DOCTOR REFUSED WHEN ASKED [GO TO SMOKE100]
4. NO, NEVER HEARD ABOUT IT / NEVER OFFERED TO YOU [GO TO SMOKE100]
77. DON’T KNOW [GO TO SMOKE100]
99. REFUSE [GO TO SMOKE100]
HPVNUM
59. How many HPV shots did you receive?
|___|___| NUMBER OF SHOTS
03. ALL SHOTS
77. DON’T KNOW
99. REFUSE
RANGE 1 – 3, 77, 99
SMOKE100
60. The next questions are about cigarette smoking. Have you smoked at least 100 cigarettes in your entire life?
INTERVIEWER: 5 PACKS = 100 CIGARETTES
1. YES
2. NO [GO TO HEPBTEST]
77. DON’T KNOW [GO TO HEPBTEST]
99. REFUSE [GO TO HEPBTEST]
SMOKEDAY
61. Do you now smoke cigarettes everyday, some days, or not at all?
1. EVERYDAY
2. SOME DAYS
3. NOT AT ALL [GO TO HEPBTEST]
77. DON’T KNOW [GO TO HEPBTEST]
99. REFUSE [GO TO HEPBTEST]
SMOKEQUIT
62. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
1.
YES
2. NO
77. DON’T KNOW
99. REFUSE
HEPBTEST
63. Have you ever had a blood test for hepatitis B?
1.
YES
2. NO [GO TO HEPBTOLD]
77. DON’T KNOW [GO
TO HEPBTOLD]
99. REFUSE [GO TO HEPBTOLD]
HEPBWHERE
64. Where were you tested for hepatitis B?
MARK ALL THAT APPLY
1.
Your doctor’s office/lab
2. In the hospital (as an
overnight patient)
3. At a clinic (other than your doctor’s
office)
4. In a community screening program
5.
Other site (such blood bank, military installation, prison or
jail, mobile clinic, emergency room, etc)
77. DON’T KNOW
99. REFUSE
HEPBWHY
65. Why were you tested for hepatitis B?
MARK ALL THAT APPLY
1.
You had symptoms (such as yellow eyes, abdominal pain, etc)
2.
You had an abnormal lab test
3. You or someone else was
concerned you might be at risk of having hepatitis B
4. You
were pregnant and testing was part of your care
5. You were
donating blood
6. You were in a special screening program
7. Doctor ordered the test
8.
Other reason
77. DON’T KNOW
99. REFUSE
DISPLAY OPTION 4 IF SEX = 2 ; ELSE IF SEX = 1, 77 OR 99 OPTION 4 SHOULD NOT APPEAR.
HEPBTOLD
66. Have you ever been told by a medical doctor, nurse, or other health professional that you have hepatitis B?
1.
YES
2. NO [GO TO HEPCTEST]
77. DON’T KNOW [GO
TO HEPCTEST]
99. REFUSE [GO TO HEPCTEST]
HEPBAGO_Y
67. How long ago did you first learn you had hepatitis B?
ANSWER IN YEARS OR MONTHS
|___|___| YEARS
HEPBAGO_M
|___|___|
MONTHS
77. DON’T KNOW
99. REFUSE
HEPBDOC
68. Are you currently seeing a doctor for your hepatitis B?
1.
YES
2. NO
77. DON’T KNOW
99. REFUSE
HEPBMED
69. Have you ever taken any medications such as pills or shots prescribed by a doctor for hepatitis B?
1.
YES
2. NO
77. DON’T KNOW
99. REFUSE
HEPCTEST
70. Have you ever had a blood test for hepatitis C?
1.
YES
2. NO [GO TO HEPCTOLD]
77. DON’T KNOW [GO
TO HEPCTOLD]
99. REFUSE [GO TO HEPCTOLD]
HEPCWHERE
71. Where were you tested for hepatitis C?
MARK ALL THAT APPLY
1.
Your doctor’s office/lab
2. In the hospital (as an
overnight patient)
3. At a clinic (other than your doctor’s
office)
4.
In a community screening program
5. Other site (such blood
bank, military installation, prison or jail, mobile clinic, emergency
room, etc)
77. DON’T KNOW
99. REFUSE
HEPCWHY
72. Why were you tested for hepatitis C?
MARK ALL THAT APPLY
1.
You had symptoms (such as yellow eyes, abdominal pain, etc)
2.
You had an abnormal lab test
3. You or someone else was
concerned you might be at risk of having hepatitis C
4. You
were pregnant and testing was part of your care
5. You were
donating blood
6. Doctor ordered the test
7.
Other reason
77. DON’T KNOW
99. REFUSE
DISPLAY OPTION 4 IF SEX = 2 ; ELSE IF SEX = 1, 77 OR 99 OPTION 4 SHOULD NOT APPEAR.
HEPCTOLD
73. Have you ever been told by a medical doctor, nurse, or other health professional that you have hepatitis C?
1.
YES
2. NO [GO TO DEMOG_INTRO]
77. DON’T KNOW
[GO TO DEMOG_INTRO]
99. REFUSE [GO TO DEMOG_INTRO]
HEPCAGO_Y
74. How long ago did you first learn you had hepatitis C?
|___|___| YEARS
HEPCAGO_M
|___|___|
MONTHS
77. DON’T KNOW
99. REFUSE
HEPCDOC
75. Are you currently seeing a doctor for your hepatitis C?
1.
YES
2. NO
77. DON’T KNOW
99. REFUSE
HEPCMED
76. Have you ever taken any medications such as pills or shots prescribed by a doctor for hepatitis C?
1.
YES
2. NO
77. DON’T KNOW
99. REFUSE
HEPBEHV
The next question is about behaviors or events related to hepatitis. I will read you a list and then you can tell me which ones apply to you.
INTERVIEWER: READ ALL. MARK ALL THAT APPLY
1. You received a blood transfusion before 1992
2. You ever received a blood transfusion outside of the U.S.
3. Your mother had hepatitis B before you were born
4. You ever had sex with a person who had hepatitis
5. You have had sex with other men, even just one time [DISPLAY ONLY IF RESPONDENT IS MALE AND COMMUNITY IS <>2]
6. You have taken street drugs by needle, even just one time
7. At least one of the above is true but you do not want to specify which one
8. None of the above
77. DON’T KNOW
99. REFUSED
DEMOG_INTRO
Thank you for your responses thus far. The next few questions are about you and your household.
BORN
77. Were you born in the United States?
1.
YES
2. NO
77. DON’T KNOW
99. REFUSE
ASK ONLY IF ASKHEP=1.
IF ASKHEP=0 SKIP TO EDUCA.
EDUCA
78. What is the highest grade or year of school you completed?
READ LIST ONLY IF NECESSARY:
1. Never attended school or only attended kindergarten
2. Grades 1 through 8 (Elementary)
3. Grades 9 through 11 (Some high school)
4. Grade 12 or GED (High school graduate)
5. College 1 year to 3 years (Some college or technical school)
6. College 4 years or more (College graduate)
99. REFUSE
HISPANIC
79. Are you Hispanic or Latino?
(HISPANIC OR LATINO INCLUDES MEXICAN, MEXICAN-AMERICAN, CENTRAL AMERICAN, SOUTH AMERICAN OR PUERTO RICAN, CUBAN, OR OTHER SPANISH-CARIBBEAN.)
1. YES
2. NO
77. DON’T KNOW
99. REFUSE
IF HISPANIC = 77, 99, BUT ETHNICITY WAS GIVEN IN THE SCREENER, USE SCREENER ETHNICITY.
RACE
80. We collected some of this information earlier, but I just need to confirm this information here. Which one or more of the following would you say is your race?
PLEASE READ ALL.
MARK ALL THAT APPLY.
1. White
2. Black or African American [IF COMMUNITY=17, THEN DISPLAY 'Haitian or Haitian American']
3. Asian [GO TO ASIAN]
4. Native Hawaiian or Other Pacific Islander
5. American Indian or Alaska Native, or
6. Some other race [GO TO RACEOTH]
77. DON’T KNOW
99. REFUSE
IF RACE = 3, GO TO ASIAN
IF RACE = 1, 4, 5, 77, 99 GO TO HMLANG
IF RACE = 77, 99 BUT RACE_X WAS GIVEN IN THE SCREENER, USE SCREENER RACE.
RACEOTH
80A. Other – specify: __________
GO TO HMLANG
ASIAN
82. Are you …?
PLEASE READ ALL
MARK ALL THAT APPLY
1. Cambodian
2. Chinese
3. Filipino
4. Laotian
5. Thai
6. Vietnamese
7. Hmong
8. Korean
9. Asian Indian
10. Other Asian [GO TO ASIANOTH]
77. DON'T KNOW
99. REFUSED
RESPONSE OPTIONS HERE ARE DYNAMIC. INCLUDE ASIAN SUB-GROUPS APPROPRIATE FOR COMMUNITY BASED ON GRANTEE FEEDBACK. RESPONSE “10. OTHER ASIAN” WILL ALWAYS BE DISPLAYED.
Ask ASIAN only if RACE=3. Do not ask ASIAN if RACE is not 3 regardless of screener race.
ASIANOTH
82A. Other – specify: __________
HMLANG
83. What is the main language that you speak at home?
READ ONLY IF NECESSARY:
1. ENGLISH
2. SPANISH
3. HAITIAN CREOLE
4. VIETNAMESE
5. KHMER
6. CHINESE (CANTONESE OR MANDARIN)
7. KOREAN
8. OTHER [GO TO HMLANGOTH]
RESPONSE OPTIONS HERE ARE DYNAMIC. INCLUDE LANGUAGES APPROPRIATE FOR COMMUNITY BASED ON GRANTEE FEEDBACK. RESPONSE “1. ENGLISH”, “8. OTHER” AND INTERVIEW LANGUAGE WILL ALWAYS BE DISPLAYED.
HMLANGOTH
83A. Other – specify: __________
[ASK ONLY IF MODE = CAPI]
PHONE
What type of telephone service does your household have?
PLEASE READ ALL
MARK ALL THAT APPLY
1. Cell phone
2. Regular phone
3. No phone service
77. DON'T KNOW
99. REFUSED
DAILY_INTRO
These next questions are about your daily life.
HOME
84. Do you own or rent your home?
INTERVIEWER NOTE: “OTHER ARRANGEMENT” MAY INCLUDE GROUP HOME OR STAYING WITH FRIENDS OR FAMILY WITHOUT PAYING RENT.
PLEASE READ:
1. Own
2. Rent
3. Other arrangement [GO TO MEALS]
77. DON’T KNOW [GO TO MEALS]
99. REFUSE [GO TO MEALS]
HOUSING
85. How often in the past 12 months would you say you were worried or stressed about having enough money to pay your [IF HOME=1, FILL "MORTGAGE". ELSE IF HOME=2, FILL "RENT".]? Would you say you were worried or stressed---
1.
Always
2. Usually
3. Sometimes
4.
Rarely
5. Never
6. NOT APPLICABLE
77. DON’T
KNOW
99. REFUSED
MEALS
86. How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or stressed---
1.
Always
2. Usually
3. Sometimes
4. Rarely
5. Never
6. NOT APPLICABLE
77. DON’T
KNOW
99. REFUSED
CHCGROCER_MIN
How
long does it take you to get to your usual grocery store?
MINUTES |___|___|___|
777. DON’T KNOW
999. REFUSE
MINUTES RANGE 0-600, 777, 999
INTERVIEWER: ENTER RESPONSE AS GIVEN BY THE R. IF THEY RESPOND IN MINUTES (SUCH AS 90 MINUTES) ENTER 90 MINUTES, NOT 1 HOUR AND 30 MINUTES.
CHCGROCER_HRS
HOURS |___|___|
77. DON’T KNOW
99. REFUSE
HOURS RANGE 0-10, 77, 99
IF (CHCGROCER_HRS > 3 except 77 and 99) OR (CHCGROCER_MIN > 180 except 777 and 999) OR (CHCGROCER_HRS=3 AND CHCGROCER_MIN>0) GO TO CHCGROCER_CONF
CHCGROCER_CONF
Just to confirm that I entered it correctly, I have [CHCGROCER_HRS] hours / [CHCGROCER_MIN] minutes. Is that correct?
1. YES
2. NO
CHCFRTVEG
In your neighborhood, how often can you easily find a variety of good quality, affordable, fresh fruits and vegetables that you want? Would you say…
1. Always
2. Often
3. Sometimes
4. Seldom
5. Never
77.
DON’T KNOW
99. REFUSED
CHCQUALITY
How would you rate the quality of the fresh fruits and vegetables where you shop-very high quality, somewhat high quality, not of high quality or would you say that fresh fruits and vegetables are not available?
1. Very High
2. Somewhat High
3. Not High Quality
4. Not Available
77.
DON’T KNOW
99. REFUSED
CHCFASTFD
How often do you eat any food, including meals and snacks, from a fast food restaurant, like McDonald's, Taco Bell, Kentucky Fried Chicken or another similar type of place-4 or more times per week, 1-3 times per week, less than once a week but more than once a month, less than once a month or never?
1. 4+ times per week
2. 1-3 times per week
3. Less than once a week/More than once a month
4. Less than once a month
5. Never
77.
DON’T KNOW
99. REFUSED
INCOME
87. Is your annual household income from all sources. . .
VARIABLE INCOME2 WILL BE CODED BASED ON CASCADE.
INCOMEA
87A. (Is your annual household income from all sources. . .?)
Less
than $25,000?
1.
YES [GO TO INCOMEB]
2. NO [GO TO INCOMEE]
77. DON’T
KNOW [CODE INCOME2 77, GO TO HEARDPROG]
99. REFUSED [CODE
INCOME2 99, GO TO HEARDPROG]
INCOMEB
87B. (Is your annual household income from all sources. . .?)
Less
than $20,000?
1.
YES [GO TO INCOMEC]
2. NO [CODE INCOME2 04, GO TO
HEARDPROG]
77. DON’T KNOW [CODE INCOME2 10, GO TO
HEARDPROG]
99. REFUSED [CODE INCOME2 10, GO TO HEARDPROG]
INCOMEC
87C. (Is your annual household income from all sources. . .?)
Less
than $15,000?
1.
YES [GO TO INCOMED]
2. NO [CODE INCOME2 03, GO TO
HEARDPROG]
77. DON’T KNOW [CODE INCOME2 11, GO TO
HEARDPROG]
99. REFUSED [CODE INCOME2 11, GO TO HEARDPROG]
INCOMED
87D. (Is your annual household income from all sources. . .?)
Less
than $10,000?
1.
YES [CODE INCOME2 01, GO TO HEARDPROG]
2. NO [CODE
INCOME2 02, GO TO HEARDPROG]
77. DON’T KNOW [CODE INCOME2
11, GO TO HEARDPROG]
99. REFUSED [CODE INCOME2 11, GO TO
HEARDPROG]
INCOMEE
87E. (Is your annual household income from all sources. . .?)
Less
than $35,000?
1.
YES [CODE INCOME2 05, GO TO HEARDPROG]
2. NO [GO TO
INCOMEF]
77. DON’T KNOW [CODE INCOME2 12, GO TO
HEARDPROG]
99. REFUSED [CODE INCOME2 12, GO TO HEARDPROG]
INCOMEF
87F. (Is your annual household income from all sources. . .?)
Less
than $50,000?
1.
YES [CODE INCOME2 06, GO TO HEARDPROG]
2. NO [GO TO
INCOMEG]
77. DON’T KNOW [CODE INCOME2 13, GO TO
HEARDPROG]
99. REFUSED [CODE INCOME2 13, GO TO HEARDPROG]
INCOMEG
87G. (Is your annual household income from all sources. . .?)
Less
than $75,000?
1.
YES [CODE INCOME2 07, GO TO HEARDPROG]
2. NO [CODE
INCOME2 08, GO TO HEARDPROG]
77. DON’T KNOW [CODE
INCOME2 14, GO TO HEARDPROG]
99. REFUSED [CODE INCOME2 14, GO
TO HEARDPROG]
INCOME2
CALCULATE VARIABLE INCOME2 BASED ON RESPONSES TO INCOME SERIES.
1. Less than $10,000
2. $10,000 to less than $15,000
3. $15,000 to less than $20,000
4. $20,000 to less than $25,000
5. $25,000 to less than $35,000
6. $35,000 to less than $50,000
7. $50,000 to less than $75,000
8. $75,000 or more
9. Less than 25,000
10. Less than 20,000
11. Less than 15,000
12. More than 25,000
13. More than 35,000
14. More than 50,000
77. Don't know
99. Refused
HEARDPROG
88. Have you ever heard of a program in your area called [PROGRAM NAME]?
1. YES
2. NO
77. NOT SURE
99. REFUSED
GO TO AC_INCENT IF (INCENTIVE_GRP >0 OR <> NULL AND IF ALL ELIGIBLE MEMBERS HAVE COMPLETED THE QUESTIONNAIRES
ELSE GO TO CLOSING OR CLOSING_HHM AS APPROPRIATE.
CLOSING STATEMENT:
READ IF THERE ARE MULTIPLE HH MEMBERS AND NOT ALL ARE COMPLETE.
CLOSING_HHM
Those
are all the questions I have for you. There is another person in your
household eligible for this survey that I’d like to speak with
in a moment, but first I’d like to thank you on behalf of the
Centers for Disease Control and Prevention for the time and effort
you’ve spent answering these questions.
If you have
any questions about this survey, you may call my supervisor toll-free
at 1- 877-375-5964.
[IF COMMUNITY <>28 DISPLAY "If you would like more
information about health behaviors in your area call [INSERT GRANTEE
CONTACT INFORMATION]."] If you want to know more about your
rights as a study participant you may call the NORC Institutional
Review Board Administrator, toll free, at 866-309-0542.
Thanks
again.
1. Continue with roster [RETURN TO ROSTER TABLE
]
EXIT [GO TO UE]
CLOSING
Those
are all the questions I have. I'd like to thank you on behalf of the
Centers for Disease Control and Prevention for the time and effort
you’ve spent answering these questions. [IF INCENT_GRP <>
?? AND INCENT_GRP>0, FILL We will send you $[INCENT_GRP] as a
token of our appreciation.]
If you have any questions
about this survey, you may call my supervisor toll-free at 1-
877-375-5964.
If you would like more information about health behaviors in your
area call [INSERT GRANTEE CONTACT INFORMATION]. If you want to know
more about your rights as a study participant you may call the NORC
Institutional Review Board Administrator, toll free, at
866-309-0542.
Thanks again.
NORC REACH U.S. Final
Data User’s Manual and Methodology Report: Phase 2
File Type | application/msword |
Author | Julie Gasparac |
Last Modified By | CDC User |
File Modified | 2012-01-12 |
File Created | 2012-01-12 |