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DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.010 Instrument Variable Name:
10-Aug-12
CASMHSP
QuestionnaireFileName:
DURING THE PAST 12 MONTHS, has [fill: S.C. name] stayed overnight in a hospital because of asthma?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to CWZMSWK]
Question ID:
Sample Child
CHS.100_00.030 Instrument Variable Name:
QuestionText:
CWZMSWK
QuestionnaireFileName:
DURING THE PAST 12 MONTHS, HOW MANY DAYS of [fill1: daycare or preschool/fill2: school/fill3: school or
work] did [fill: S.C. name] miss because of [fill: his/her] asthma?
*Enter '0' for none.
*Enter 995 if child home schooled.
*Enter 996 if child did not go to [fill1: daycare or preschool/fill2: school/fill3: school or work].
000-365
995
996
997
999
Sample Child
000-365 days
Child was home schooled
child did not go to day care, preschool, school, or work
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<0-100,995,996,R,D> [go to CASMPMED]
<101-365> [go to ERR1_CWZMSWK]
<366-994> [go to ERR2_CWZMSWK]
Page 2 of 8
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.060 Instrument Variable Name:
10-Aug-12
CASMPMED
QuestionnaireFileName:
Sample Child
Now I'm going to ask you about two different kinds of ASTHMA medicine. One prevents symptoms over the long term.
The other is for quick relief of symptoms during an attack or episode. This quick relief medicine is breathed in through
your mouth using a canister inhaler or a disk inhaler.
QuestionText:
DURING THE PAST 3 MONTHS, has [fill: S.C. name] used the kind of PRESCRIPTION asthma inhaler that gives
QUICK relief from asthma symptoms during an attack? Include only medications prescribed by a health care professional.
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1> [goto CASMTYP] <2,R,D> [go to CASMDTP2]
Question ID:
CHS.100_00.065 Instrument Variable Name:
QuestionText:
CASMTYP
QuestionnaireFileName:
Sample Child
When [fill: S.C. name] takes [his/her]rescue prescription asthma medication, would you say that [he/she] most often uses
an inhaler and/or disk, or does [he/she] most often use a nebulizer?
*Read if necessary: Both an inhaler or a disk inhaler are very portable canisters or devices used to inhale medication in
one or two breaths. A nebulizer is a machine that turns liquid medication into a mist that you inhale into the lungs over a
few minutes
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample child <18 who have used a quick relief prescription asthma inhaler in the past three months
SkipInstructions:
<1> [go to CASMCAN] <2,R,D> [go to CASMDTP2]
Page 3 of 8
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.070 Instrument Variable Name:
10-Aug-12
CASMCAN
QuestionnaireFileName:
Sample Child
DURING THE PAST 3 MONTHS did [fill: S.C. name] use more than three canisters or disks of this type of quick relief
inhaler?
QuestionText:
Yes
No
Refused
Don't Know
1
2
7
9
UniverseText:
Sample child <18 who have used a prescription asthma inhaler/disk most often in the past three months
SkipInstructions:
<1,2,R,D> [go to CASMDTP2]
Question ID:
CHS.100_00.090 Instrument Variable Name:
QuestionText:
CASMDTP2
QuestionnaireFileName:
Sample Child
The second kind of asthma medication is different from inhalers used for quick relief. It is the preventive kind that is used
to protect your lungs and keep you from having attacks. It can be either a pill or an inhaler.
Is [fill: S.C. name] NOW taking a preventive asthma medication every day or almost every day, less often, or never?
1
2
3
7
9
Every day or almost every day
Less often
Never
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1-3,R,D> [go to CASWMP]
Page 4 of 8
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.100 Instrument Variable Name:
10-Aug-12
CASWMP
QuestionnaireFileName:
Sample Child
An asthma action plan is a printed form with specific instructions based on [fill: S.C. name]'s asthma that tells when to
change the amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room.
Has a doctor or other health professional EVER given [fill: S.C. name] an asthma action plan?
QuestionText:
*Read if necessary: Include nurses and asthma educators.
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to CASCLASS]
Question ID:
CHS.100_00.110 Instrument Variable Name:
QuestionText:
CASCLASS
QuestionnaireFileName:
Has [fill: S.C. name] ever taken a course or class on how to manage [fill: his/her] asthma?
*Include adult(s) who took a course for the child's asthma.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to CAS_REC]
Sample Child
Page 5 of 8
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.116 Instrument Variable Name:
10-Aug-12
CAS_REC
QuestionnaireFileName:
Sample Child
Has a doctor or other health professional EVER taught [fill: S.C. name] or [fill: his/her] parent or guardian
QuestionText:
...how to recognize early signs or symptoms of an asthma episode?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to CAS_RES]
Question ID:
CHS.100_00.117 Instrument Variable Name:
QuestionText:
CAS_RES
QuestionnaireFileName:
*Read if necessary: Has a doctor or other health professional EVER taught [fill: S.C. name] or [fill: his/her] parent or
guardian
...how to respond to episodes of asthma?
1
2
7
9
Sample Child
Yes
No
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to CAS_MON]
Page 6 of 8
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.118 Instrument Variable Name:
10-Aug-12
CAS_MON
QuestionnaireFileName:
Sample Child
*Read if necessary: Has a doctor or other health professional EVER taught [fill: S.C. name] or [fill: his/her] parent or
guardian
QuestionText:
...how to monitor peak flow for daily therapy?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to CAPENVLN]
Question ID:
CHS.100_00.130 Instrument Variable Name:
QuestionText:
1
2
3
7
9
CAPENVLN
QuestionnaireFileName:
Sample Child
Has a doctor or other health professional EVER advised you to change things in [fill: S.C. name]'s home, school, or work
to improve [fill: his/her] asthma?
Yes
No
Was told no changes needed
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1-3,R,D> [go to CAROUTIN]
Page 7 of 8
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.135 Instrument Variable Name:
10-Aug-12
CAROUTIN
QuestionnaireFileName:
Sample Child
During the past 12 months how many times did [fill: S.C. name] see a doctor or other health professional for a routine
checkup for [fill: his/her] asthma? Please do not include emergency room visits, visits to urgent care centers, or other visits
for acute care for an asthma episode or attack.
QuestionText:
*Enter '0' for none.
None
001-365 times
Refused
Don't know
000
001-365
997
999
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<0> [if AGE LE 2 go to CCONDT1_1; else go to CCONDT_1]; <1-50,R,D> [go to CASYMPT] <51-365> [goto
ERR_CAROUTIN]
Question ID:
CHS.100_00.140 Instrument Variable Name:
QuestionText:
CASYMPT
QuestionnaireFileName:
Sample Child
At his/her last visit, did [fill: S.C. name]'s doctor or other health professional ask HOW OFTEN
….[fill: he/she] had asthma symptoms?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months and saw a
doctor/health professional about S.C.'s asthma in the past year
SkipInstructions:
<1,2,R,D> if CASMPMED=1 [go to CARESCUE]; else [goto CAACTLIM]
Page 8 of 8
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.145 Instrument Variable Name:
10-Aug-12
CARESCUE
QuestionnaireFileName:
Sample Child
At his/her last visit, did [fill: S.C. name]’s doctor or other health professional ask HOW OFTEN
QuestionText:
….[fill: he/she] used [fill: his/her] quick relief inhaler?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months and use a quick relief
inhaler and saw a doctor/health professional about S.C.'s asthma in the past year
SkipInstructions:
<1,2,R,D> [go to CAACTLIM]
Question ID:
CHS.100_00.150 Instrument Variable Name:
QuestionText:
CAACTLIM
QuestionnaireFileName:
Sample Child
At his/her last visit, did [fill: S.C. name]’s doctor or other health professional ask HOW OFTEN
…asthma symptoms limited [fill: his/her] daily activities?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months and saw a
doctor/health professional about S.C.'s asthma in the past year
SkipInstructions:
<1,2,R,D> [if AGE LE 2 go to CCONDT1_1; else go to CCONDT_1]
Page 1 of 10
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:
ACN.020_00.010 Instrument Variable Name:
10-Aug-12
HYPYR
Sample Adult
DURING THE PAST 12 MONTHS, have you had hypertension, also called high blood pressure?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample adults 18+ who were ever told they had hypertention
SkipInstructions:
<1,2,R,D> [goto CHLYR]
Question ID:
QuestionnaireFileName:
ACN.025_00.010 Instrument Variable Name:
CHLYR
QuestionnaireFileName:
Sample Adult
DURING THE PAST 12 MONTHS, have you had high cholesterol?
QuestionText:
*Enter '1' if respondent is taking medication to control his/her high cholesterol.
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample adults 18+
SkipInstructions:
<1,2,R,D> [goto CHDEV]
Question ID:
ACN.100_00.010 Instrument Variable Name:
QuestionText:
AASMHSP
QuestionnaireFileName:
DURING THE PAST 12 MONTHS, have you stayed overnight in a hospital because of asthma?
*If in hospital for asthma AND other reasons, enter '1'.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to AWZMSWK]
Sample Adult
Page 2 of 10
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:
ACN.100_00.030 Instrument Variable Name:
10-Aug-12
AWZMSWK
QuestionnaireFileName:
Sample Adult
DURING THE PAST 12 MONTHS, HOW MANY DAYS were you UNABLE to [fill1: work/get work done around the
house] because of your asthma?
QuestionText:
*Enter '0' for none.
*Enter '996' if respondent is unable to do this activity.
000-365 days
Unable to do this activity
Refused
Don't know
000-365
996
997
999
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<0-100,996,R,D> [go to AASMPMED]
<101-365> [go to ERR1_AWZMSWK]
<366-994> [go to ERR2_AWZMSWK]
Question ID:
ACN.100_00.060 Instrument Variable Name:
QuestionText:
AASMPMED
QuestionnaireFileName:
Sample Adult
Now I'm going to ask you about two different kinds of ASTHMA medicine. One prevents symptoms over the long term.
The other is for quick relief of symptoms during an attack or episode. This quick relief medicine is breathed in through
your mouth using a canister inhaler or a disk inhaler.
DURING THE PAST 3 MONTHS, have you used the kind of PRESCRIPTION asthma inhaler that gives QUICK relief
from asthma symptoms during an attack? Include only medications prescribed by a health care professional.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1> [goto AASMTYP] <2,R,D> [go to AASMDTP2]
Page 3 of 10
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:
ACN.100_00.065 Instrument Variable Name:
10-Aug-12
AASMTYP
QuestionnaireFileName:
Sample Adult
When you take your rescue prescription asthma medication, would you say that you most often use an inhaler and/or disk,
or do you most often use a nebulizer?
QuestionText:
*Read if necessary: Both an inhaler or a disk inhaler are very portable canisters or devices used to inhale medication in
one or two breaths. A nebulizer is a machine that turns liquid medication into a mist that you inhale into the lungs over a
few minutes
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample adults 18+ who have used a quick relief prescription asthma inhaler in the past three months
SkipInstructions:
<1> [go to AASMCAN] <2,R,D> [go to AASMDTP2]
Question ID:
ACN.100_00.070 Instrument Variable Name:
QuestionText:
1
2
7
9
AASMCAN
QuestionnaireFileName:
Sample Adult
DURING THE PAST 3 MONTHS did you use more than three canisters or disks of this type of quick relief inhaler?
Yes
No
Refused
Don't know
UniverseText:
Sample adults 18+ who have used a prescription asthma inhaler/disk most often in the past three months
SkipInstructions:
<1,2,R,D> [go to AASMDTP2]
Page 4 of 10
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:
ACN.100_00.090 Instrument Variable Name:
10-Aug-12
AASMDTP2
QuestionnaireFileName:
Sample Adult
The second kind of asthma medication is different from inhalers used for quick relief. It is the preventive kind that is used
to protect your lungs and keep you from having attacks. It can be either a pill or an inhaler.
QuestionText:
Are you NOW taking a preventive asthma medication every day or almost every day, less often, or never?
Every day or almost every day
Less often
Never
Refused
Don't know
1
2
3
7
9
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1-3,R,D> [go to AASWMP]
Question ID:
ACN.100_00.100 Instrument Variable Name:
QuestionText:
AASWMP
QuestionnaireFileName:
An asthma action plan is a printed form with specific instructions based on your asthma that tells when to change the
amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room.
Has a doctor or other health professional EVER given you an asthma action plan?
*Read if necessary: Include nurses and asthma educators.
1
2
7
9
Sample Adult
Yes
No
Refused
Don't know
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to AASCLASS]
Page 5 of 10
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:
ACN.100_00.110 Instrument Variable Name:
10-Aug-12
AASCLASS
QuestionnaireFileName:
Have you ever taken a course or class on how to manage asthma yourself?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to AAS_REC]
Question ID:
Sample Adult
ACN.105_00.110 Instrument Variable Name:
AAS_REC
QuestionnaireFileName:
Sample Adult
Has a doctor or other health professional EVER taught you
QuestionText:
...how to recognize early signs or symptoms of an asthma episode?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to AAS_RES]
Question ID:
ACN.105_02.020 Instrument Variable Name:
QuestionText:
AAS_RES
QuestionnaireFileName:
*Read if necessary: Has a doctor or other health professional EVER taught you
...how to respond to episodes of asthma?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to AAS_MON]
Sample Adult
Page 6 of 10
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:
ACN.105_03.030 Instrument Variable Name:
10-Aug-12
AAS_MON
QuestionnaireFileName:
Sample Adult
*Read if necessary: Has a doctor or other health professional EVER taught you
QuestionText:
...how to monitor peak flow for daily therapy?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to AAPENVLN]
Question ID:
ACN.107_00.010 Instrument Variable Name:
QuestionText:
1
2
3
7
9
AAPENVLN
QuestionnaireFileName:
Sample Adult
Has a doctor or other health professional EVER advised you to change things in your home, school, or work to improve
your asthma?
Yes
No
Was told no changes needed
Refused
Don't know
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1-3,R,D> [go to AAROUTIN]
Page 7 of 10
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:
ACN.107_00.020 Instrument Variable Name:
10-Aug-12
AAROUTIN
QuestionnaireFileName:
Sample Adult
During the past 12 months how many times did you see a doctor or other health professional for a routine checkup for
your asthma? Please do not include emergency room visits, visits to urgent care centers, or other visits for acute care for an
asthma episode or attack.
QuestionText:
*Enter '0' for none.
None
001-365 times
Refused
Don't know
000
001-365
997
999
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<0> [goto ULCEV]; <1-50,R,D> [go to AASYMPT] <51-365> [goto ERR_AAROUTIN]
Question ID:
ACN.107_00.030 Instrument Variable Name:
QuestionText:
AASYMPT
QuestionnaireFileName:
Sample Adult
At your last visit, did your doctor or other health professional ask HOW OFTEN
….you had asthma symptoms ?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months and saw a
doctor/health professional about their asthma in the past year
SkipInstructions:
<1,2,R,D> if AASMPMED=1 [go to AARESCUE]; else [goto AAACTLIM]
Page 8 of 10
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:
ACN.107_00.040 Instrument Variable Name:
10-Aug-12
AARESCUE
QuestionnaireFileName:
Sample Adult
At your last visit, did your doctor or other health professional ask HOW OFTEN
QuestionText:
….you used your quick relief inhaler?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months and who use a quick
relief inhaler and saw a doctor/health professional about their asthma in the past year
SkipInstructions:
<1,2,R,D> [go to AAACTLIM]
Question ID:
ACN.107_00.050 Instrument Variable Name:
AAACTLIM
QuestionnaireFileName:
Sample Adult
At your last visit, did your doctor or other health professional ask HOW OFTEN
QuestionText:
…your asthma symptoms limited your daily activities?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months and saw a
doctor/health professional about their asthma in the past year
SkipInstructions:
<1,2,R,D> [goto ULCEV]
Question ID:
ACN.192_00.010 Instrument Variable Name:
QuestionText:
1
2
7
9
EPILEP1
QuestionnaireFileName:
Sample Adult
Have you ever been told by a doctor or other health professional that you have a seizure disorder or epilepsy?
Yes
No
Refused
Don't know
UniverseText:
Sample adults 18+
SkipInstructions:
<1> [goto EPILEP2]
<2,R,D> [goto AHAYFYR]
Page 9 of 10
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:
ACN.192_00.020 Instrument Variable Name:
EPILEP2
10-Aug-12
QuestionnaireFileName:
Are you currently taking any medicine to control your seizure disorder or epilepsy?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample adults 18+ who have ever been told they have epilepsy or a seizure disorder
SkipInstructions:
<1,2,R,D> [goto EPILEP3]
Question ID:
Sample Adult
ACN.192_00.030 Instrument Variable Name:
QuestionText:
EPILEP3
QuestionnaireFileName:
Sample Adult
Today is [fill: Current Date]. Think back to last year about the same time. About how many seizures of any type have you
had in the past year?
*Read if necessary: Some people may call it “convulsion,” “fit,” “falling out spell,” “episode,” “attack,” “drop attack,”
“staring spell,” or “out-of-touch.”.
*If the respondent mentions and counts “auras” as seizures accept the response. If a respondent indicates that he/she has
had nothing more than an aura and is unsure about counting the aura(s), do NOT count auras as seizures.
0
1
2
3
4
7
9
None
One
Two or three
Between four and ten
More than 10
Refused
Don't know
UniverseText:
Sample adults 18+ who have ever been told they have epilepsy or a seizure disorder
SkipInstructions:
<0-4,R,D> [goto EPILEP4]
Page 10 of 10
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:
ACN.192_00.040 Instrument Variable Name:
EPILEP4
10-Aug-12
QuestionnaireFileName:
In the past year have you seen a neurologist or epilepsy specialist for your epilepsy or seizure disorder?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample adults 18+ who have ever been told they have epilepsy or a seizure disorder
SkipInstructions:
<1,2,R,D> [goto EPILEP5]
Question ID:
Sample Adult
ACN.192_00.050 Instrument Variable Name:
QuestionText:
EPILEP5
QuestionnaireFileName:
DURING THE PAST 30 DAYS, to what extent has epilepsy or its treatment interfered with your normal activities like
working, school, or socializing with family or friends? Would you say…
*Read categories below.
1
2
3
4
5
7
9
Sample Adult
Not at all
Slightly
Moderately
Quite a bit
Extremely
Refused
Don't know
UniverseText:
Sample adults 18+ who have ever been told they have epilepsy or a seizure disorder
SkipInstructions:
<1-5,R,D> [goto AHAYFYR]
2013 NHIS Instrument Spec Report
Section name: Adult Immunosuppression
Module
49
Section Name
Adult Immunosuppression
Part
Question ID
AIS.010_00.010
Variable Name
AIMSUPEV
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text
Sample adults 18+
Question Text
Have you EVER been told by a doctor or other health professional that your immune
system is weakened?
*Read if necessary: A weakened immune system is also called immune compromised
or immune suppressed. It means that you are not able to fight infections and is usually
caused by an underlying illness or by various medical treatments or prescription
medications.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto AIMSPSTL]
<2,R,D> [goto next section]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 1 of 7
Module
49
Section Name
Adult Immunosuppression
Part
Question ID
AIS.010_00.020
Variable Name
AIMSPSTL
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and AIMSUPEV(e)='1'
Universe-text
Sample adults 18+ who have ever been told by a doctor/other health professional that
they had a weakened immune system
Question Text
Do you still have a weakened immune system?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto AIMSPMED]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 2 of 7
Module
49
Section Name
Adult Immunosuppression
Part
Question ID
AIS.010_00.030
Variable Name
AIMSPMED
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and AIMSUPEV(e)='1'
Universe-text
Sample adults 18+ who have ever been told by a doctor/other health professional that
they had a weakened immune system
Question Text
The next questions are about reasons a doctor or other health professional may have
told you that your immune system was weakened. Please say yes or no to each.
DURING THE PAST 6 MONTHS, have you taken prescription medication or had any
medical treatments that a doctor or other health professional told you would weaken
your immune system? Examples include steroid or corticosteroid pills, such as
prednisone, or other oral or injected medications for treating many types of autoimmune
conditions or certain cancers.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto AIMSPCHC]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 3 of 7
Module
49
Section Name
Adult Immunosuppression
Part
Question ID
AIS.010_00.040
Variable Name
AIMSPCHC
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and AIMSUPEV(e)='1'
Universe-text
Sample adults 18+ who have ever been told by a doctor/other health professional that
they had a weakened immune system
Question Text
Do you currently have a health condition that a doctor or other health professional told
you weakens the immune system, even without related medications or treatments?
Examples include certain kinds of leukemia, lymphoma, or HIV infection.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto AIMSPSHC]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 4 of 7
Module
49
Section Name
Adult Immunosuppression
Part
Question ID
AIS.010_00.050
Variable Name
AIMSPSHC
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and AIMSUPEV(e)='1'
Universe-text
Sample adults 18+ who have ever been told by a doctor/other health professional that
they had a weakened immune system
Question Text
Has a doctor or other health professional EVER told you that your immune system is
weakened because you have kidney disease, lung disease, liver disease, diabetes,
poor nutrition, or general frailty?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> if CANKIND_1=1-30 or CANKIND_2=1-30 or CANKIND_3=1-30 or
CANKIND_4=96 [goto AIMSPCAN]; else [goto AIMSPCLD]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 5 of 7
Module
49
Section Name
Adult Immunosuppression
Part
Question ID
AIS.010_00.060
Variable Name
AIMSPCAN
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and AIMSUPEV(e)='1'
and ((01<=CANKIND_1(e)<=30) or (01<=CANKIND_2(e)<=30) or
(01<=CANKIND_3(e)<=30) or CANKIND_4(e)='96)
Universe-text
Sample adults 18+ who have ever been told by a doctor/other health professional that
they had a weakened immune system and have one or more kinds of cancer
Question Text
Earlier you said you had {fill1: type of cancer from CANKIND_1, CANKIND_2,
CANKIND_3, CANKIND_4 cancer}. Did a doctor or other health professional EVER tell
you that your immune system is weakened because of {fill2: this cancer/these cancers}?
*Read if necessary: Please only respond yes if a doctor or health care professional told
you the cancer weakens the immune system, even if you are not now having
treatments or taking prescription medicines that weaken the immune system.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Fill1: Fill cancer(s) from CANKIND_1, CANKIND_2, CANKIND_3, CANKIND_4:
bladder cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 1
blood cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 2
bone cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 3
brain cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 4
breast cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 5
cervical cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 6
colon cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 7
esophageal cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 8
gallbladder cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 9
kidney cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 10
larynx-windpipe cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 11
leukemia if CANKIND_1 or CANKIND_2 or CANKIND_3 = 12
liver cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 13
lung cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 14
lymphoma if CANKIND_1 or CANKIND_2 or CANKIND_3 = 15
melanoma if CANKIND_1 or CANKIND_2 or CANKIND_3 = 16
mouth/tongue/lip cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 17
ovarian cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 18
pancreatic cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 19
prostate cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 20
rectal cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 21
skin (non-melanoma) cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 22
skin (don't know what kind) cancer CANKIND_1 or CANKIND_2 or CANKIND_3 = 23
soft tissue (muscle or fat) cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 24
Wednesday, August 08, 2012
Page 6 of 7
stomach cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 25
testicular cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 26
throat/pharynx cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 27
thyroid cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 28
uterine cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 29
cancer if CANKIND_1 or CANKIND_2 or CANKIND_3 = 30 or CANKIND_4=96 (more
than three kinds)
Refused
Don't know
Fill2: If CANKIND_1 not=blank and CANKIND_2, CANKIND_2,
CANKIND_4=blank,then fill “this cancer”; else fill “these cancers”
Special Instructions
Skip Instructions
<1,2,R,D> [goto AIMSPCLD]
Hard Edits
Soft Edits
AssocHelp
Module
49
Section Name
Adult Immunosuppression
Part
Question ID
AIS.010_00.070
Variable Name
AIMSPCLD
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and AIMSUPEV(e)='1'
Universe-text
Sample adults 18+ who have ever been told by a doctor/other health professional that
they had a weakened immune system
Question Text
Has a doctor or other health professional EVER told you that your immune system is
weakened because you seem to get many infections and colds or that you can’t seem
to get over them?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto next section]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 7 of 7
Page 1 of 3
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:
Question ID:
AAU.126_01.010 Instrument Variable Name:
QuestionnaireFileName:
Sample Adult
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample adults 18+
SkipInstructions:
<1> [goto ARX12_1]
<2,R,D> [goto ARX12_5]
AAU.365_00.010 Instrument Variable Name:
AHEPBTST
QuestionnaireFileName:
Sample Adult
AHEPCTST
QuestionnaireFileName:
Sample Adult
Have you ever had a blood test for hepatitis B?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample adults 18+
SkipInstructions:
<1,2,R,D> [goto SHTHEPB]
Question ID:
ARX12MO
DURING THE PAST 12 MONTHS, were you prescribed medication by a doctor or other health professional?
QuestionText:
Question ID:
10-Aug-12
AAU.405_00.010 Instrument Variable Name:
QuestionText:
1
2
7
9
Have you ever had a blood test for hepatitis C?
Yes
No
Refused
Don't know
UniverseText:
Sample adults 18+
SkipInstructions:
<1> [goto AHEPCRES] <2,R,D> if AGE GE 50 goto SHINGLES
elseif AGE LT 50 goto SHTTD
Page 2 of 3
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:
Question ID:
AAU.405_00.020 Instrument Variable Name:
10-Aug-12
AHEPCRES
QuestionnaireFileName:
Sample Adult
What is the MAIN reason you were tested for hepatitis C? Was it because...
QuestionText:
*Read answer categories below.
You or your doctor thought you were at risk for hepatitis C
You were born from 1945 to1965
You were at risk due to exposure of blood on your job, injection drug use or receipt of transfusion before 1992
Some other reason
Refused
Don't know
1
2
3
4
7
9
UniverseText:
Sample adults 18+ who have had a blood test for hepatitis C
SkipInstructions:
<1-4,R,D> if AGE GE 50 [goto SHINGLES]; elseif AGE LT 50 goto SHTTD
Question ID:
AAU.448_00.010 Instrument Variable Name:
QuestionText:
08-64
7
9
AHPVAGE
How old were you when you received your first HPV shot?
8 to 64 years
Refused
Don't know
UniverseText:
Sample adults age LE 64 who have had an HPV shot
SkipInstructions:
<8-64,R,D> [goto LIVEV]
QuestionnaireFileName:
Sample Adult
Page 3 of 3
DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access and Utilization
Document Version Date:
Question ID:
AAU.705_00.000 Instrument Variable Name:
10-Aug-12
WHYTST
Sample Adult
(book) A11
I am going to show you a list of reasons why some people have not been tested for HIV (the virus that causes AIDS).
Which one of these would you say is the MAIN reason why you have not been tested?
QuestionText:
It's unlikely you've been exposed to HIV
You were afraid to find out if you were HIV positive (that you had HIV)
You didn't want to think about HIV or about being HIV positive
You were worried your name would be reported to the government if you tested positive
You didn't know where to get tested
You don't like needles
You were afraid of losing job, insurance, housing, friends, family, if people knew you were positive for AIDS infection
Some other reason
No particular reason
Refused
Don't know
01
02
03
04
05
06
07
08
09
97
99
UniverseText:
Sample adults 18+ who have not been tested for HIV
SkipInstructions:
<1-7,9,R,D> [goto next section]
<8> [goto WHYSPEC]
Question ID:
QuestionnaireFileName:
AAU.706_00.000 Instrument Variable Name:
QuestionText:
Verbatim
7
9
WHYSPEC
What was the main reason why you have not been tested?
Verbatim response
Refused
Don't know
UniverseText:
Sample adults 18+ with some other reason for no HIV test
SkipInstructions:
<75 char long> [goto next section]
QuestionnaireFileName:
Sample Adult
2013 Instrument Spec Report
Section name: Cancer Screening
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.032_00.000
Variable Name
SNONCE
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text
Sample adults 18+
Question Text
DURING THE PAST 12 MONTHS, have you used an indoor tanning device such as a
sunlamp, sunbed, or tanning booth EVEN ONE TIME? Do NOT include times you have
gotten a spray-on tan.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto SNNUM1] <2,R,D> if SEX=2 and if APSPAP=1 [goto RPAP1_M1]; else if
SEX=2 and APSPAP ne 1 [goto PAPHAD1]; else if SEX=1 and AGE GE 40 [goto
PSAREC]; else [goto next section]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 1 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.033_00.000
Variable Name
SNNUM1
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and (SNONCE(e)='1')
Universe-text
Sample adults 18+ who have used indoor tanning device in past year
Question Text
DURING THE PAST 12 MONTHS, how many times have you used an indoor tanning
device such as a sunlamp, sunbed or tanning booth? Do NOT include times you have
gotten a spray-on tan.
Answer Codes
(Allow 1-365,R,D)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-365,R,D> if SEX=2 and if APSPAP=1 [goto RPAP1_M1]; else if SEX=2 and
APSPAP ne 1 [goto PAPHAD1]; else if SEX=1 and AGE GE 40 [goto PSAREC]; else
[goto next section]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 2 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.130_00.000
Variable Name
PAPHAD1
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and SEX='2' and
APSPAP(e) IN('2','7','9')
Universe-text
Female sample adults 18+ who have not had a Pap test in the past 12 months
Question Text
Have you EVER HAD a Pap smear or Pap test?
*Read if necessary.
A Pap smear or Pap test is a routine test for women in which the doctor examines the
cervix, takes a cell sample from the cervix with a small stick or brush, and sends it to
the lab.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions If APSPAP=1 fill '1' here and don't ask question
Skip Instructions
<1> [goto RPAP1_MT] <2> [goto MDRECP1] [goto HYST]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 3 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.150_01.000
Variable Name
RPAP1_M1
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and SEX='2' and
PAPHAD1(e)='1'
Universe-text
Female sample adults 18+ who have ever had a Pap smear
Question Text
1 of 2
[Fill1: Earlier you said you had a Pap test.]
When did you have your MOST RECENT Pap test?
*Enter month of last Pap test.
*Enter '96' to go to number and time period format.
Answer Codes
Question Type
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
96. Time period format
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
If APSPAP=1 then fill: Earlier you said you had a Pap test.
Special Instructions if RPAP1_M1 = store 'R' in RPAP1_Y1
if RPAP1_M1 = <96> store '9996' in RPAP1_Y1
Skip Instructions
<1-12,D> [goto RPAP1_Y1] store 'R' in RPAP1_Y1 [goto RPAP21] <96> store
'9996' in RPAP1_Y1 [goto RPAP1N1]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 4 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.150_02.000
Variable Name
RPAP1_Y1
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and SEX='2' and
PAPHAD1(e)='1' and ('01' <= RPAP1_M1(e) <= '12' or RPAP1_M1(e)='99')
Universe-text
Female sample adults age 18+ who answered month of last Pap smear test or didn't
know month of last Pap smear test
Question Text
2 of 2
*Enter year of last Pap test.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions Allow 4 character numeric field – must enter 4 numbers
Skip Instructions
if RPAP1_Y1 gt current year or (RPAP1_Y1=current year and RPAP1_M1
gt current month)
goto ERR1_ RPAP1_Y1 (future date)
elseif RPAP1_Y1 lt DOBY or (RPAP1_Y1=DOBY and RPAP1_M1 lt DOBM)
goto ERR2_ RPAP1_Y1 (prior to birth date)
elseif RPAP1_M1=D
goto RPAP21
elseif RPAP1_M1=1-12
goto PAPREA1
goto RPAP21
Hard Edits
ERR1_ RPAP1_Y1
* Future date invalid. Please correct.
ERR2_ RPAP1_Y1
* Date before birth. Please correct.
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 5 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.160_01.000
Variable Name
RPAP1N1
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and SEX='2' and
PAPHAD1(e)='1' and RPAP1_M1(e)='96'
Universe-text
Female sample adults 18+ who selected number and time period format for most
recent Pap smear test from the initial month screen
Question Text
1 of 2
When did you have your MOST RECENT Pap test?
*Enter number for time since last Pap test.
*Enter '95' for 95 or more.
Answer Codes
(Allow 1-95,R,D)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions if RPAP1N1 = store 'R' in RPAP1T1
if RPAP1N1 = store 'D' in RPAP1T1
Skip Instructions
<1-95> [goto RPAP1T1] store 'R,D' in RPAP1T1 [goto RPAP21]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 6 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.160_02.000
Variable Name
RPAP1T1
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and SEX='2' and
PAPHAD1(e)='1' and RPAP1_M1(e)='96' and ('01' <= RPAP1N1(e) <= '95')
Universe-text
Female sample adults 18+ who answered 1-95 for number part of this 2 part question
Question Text
2 of 2
*Enter time period for time since most recent Pap test.
Answer Codes
Question Type
1. Days ago
2. Weeks ago
3. Months ago
4. Years ago
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions If RPAP1N1 gt 5 and RPAP1T1=4, store '5' in RPAP21.
If RPAP1N1=4 and RPAP1T1=4, store '4' in RPAP21.
Skip Instructions
<1-3> goto PAPREA1
<4> if RPAP1N1=4
set RPAP21=4
goto PAPREA1
elseif RPAP1N1 gt 5 and RPAP1N1 gt AGE
goto ERR_RPAP1T1 (greater than persons age)
elseif RPAP1N1 gt 5 and RPAP1N1 le AGE
set RPAP21=5
goto PAPREA1
elseif RPAP1N1=1,2,3,5
goto RPAP21
goto RPAP21
Hard Edits
ERR_RPAP1T1
* Time since last exam cannot be greater than age.
* Please correct.
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 7 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.165_00.000
Variable Name
RPAP21
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and SEX='2' and
PAPHAD1(e)='1' and (RPAP1_M1(e) IN ('97','98','99') or RPAP1_Y1(e) IN
('9997','9998','9999') or RPAP1N1(e) IN ('97','98','99') or RPAP1T1(e) IN ('7','8','9') or
(RPAP1T1(e) = '4' and RPAP1N1(e) IN ('1','2','3','5')))
Universe-text
Female sample adults 18+ who failed to give a complete date in either the month or
year format or failed to give a complete date in the number and time period format, or
entered years ago in the time period format (excluding those whose last Pap smear test
was over 5 years ago)
Question Text
Was it:
*Read answer categories.
Answer Codes
Question Type
1. A year ago or less
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. Over 5 years ago
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions Display answer categories 1-5 in BOLD BLACK text.
If RPAP1N1 gt 5 and RPAP1T1=4, store '5' in RPAP21 and don't ask question.
If RPAP1N1=4 and RPAP1T1=4, store '4' in RPAP21 and don't ask question.
Based upon prior answers:
if RPAP1N1 = 1 and RPAP1T1 = '4', gray out answer codes 3,4,5
if RPAP1N1 = 2 and RPAP1T1 = '4', gray out answer codes 1,4,5
if RPAP1N1 = 3 and RPAP1T1 = '4', gray out answer codes 1,2,5
if RPAP1N1 = 5 and RPAP1T1 = '4', gray out answer codes 1,2,3
Skip Instructions
<1-5,R,D> if answer code is grayed out [goto ERR_RPAP21] else [goto PAPREA1]
Hard Edits
ERR_RPAP21
*That is not a valid response.
*Please correct.
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 8 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.170_00.000
Variable Name
PAPREA1
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and SEX='2' and
PAPHAD1(e)='1'
Universe-text
Female sample adults 18+ who have ever had a Pap smear
Question Text
What was the MAIN reason you had this Pap test - was it part of a routine exam,
because of a problem, or some other reason?
Answer Codes
Question Type
1. Part of a routine exam
2. Because of a problem
3. Other reason
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-3,R,D> [goto MDRECP1]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 9 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.215_00.000
Variable Name
MDRECP1
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and SEX='2' and
PAPHAD1(e) not IN ('7','9')
Universe-text
Female sample adults 18+ who did not answer refused or don't know to initial Pap test
question
Question Text
Fill1: (IF PAPHAD1=1 and most recent screening exam LE 3 years from system date)
"Was your most recent Pap test recommended by a doctor or other health
professional?"
Else (IF PAPHAD1=2, or PAPHAD1=1 and GT 3 years from system date or
RPAP21=R,D)
"In the PAST 12 MONTHS, has a doctor or other health professional RECOMMENDED
that you have a PAP test?"
Answer Codes
Question Type
1. Yes
2. No
3. Did not see a doctor in the last 12 months
Refused
Don't Know
Pick One - answer pane list
Field Pane Description
Fill Instructions
[fill 1] if PAPHAD1 = '1' and ((RPAP21 = 1,2,3) or (RPAP1T1 = 1,2) or (RPAP1_Y1 =
(current year – 3) and RPAP1_M1 ge current month) or (RPAP1_Y1 gt (current year –
3)) or (RPAP1T1 = 3 and RPAP1N1 le 36)) fill "Was your most recent Pap test
recommended by a doctor or other health professional?"
else fill "In the PAST 12 MONTHS, has a doctor or other health professional
RECOMMENDED that you have a PAP test?"
Special Instructions
Skip Instructions
<1-3,R,D> if PAPHAD1=1 [goto PAPWHEN]; else [goto HYST]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 10 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.216_00.000
Variable Name
PAPWHEN
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and SEX='2' and
PAPHAD1(e)='1'
Universe-text
Female sample adults 18+ who have ever had a Pap smear
Question Text
When do you expect to have your next Pap smear or Pap test?
Answer Codes
Question Type
1. A year or less from now
2. More than 1 year to 3 years from now
3. More than 3 years to 5 years from now
4. More than 5 years from now
5. When doctor recommends it
6. Never, had HPV DNA test
7. Never, had HPV vaccine
8. Never, other reason
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-8,R,D> [goto HYST]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 11 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.220_00.000
Variable Name
HYST
Universe
HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and SEX='2'
Universe-text
Female sample adults 18+
Question Text
Have you had a hysterectomy?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't Know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> if AGE GE 30 [goto MAMHAD]; else [goto next section]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 12 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.230_00.000
Variable Name
MAMHAD
Universe
HHSTAT4='S' and (AGE GE '030' and AGE not IN ('997','999')) and SEX='2' and
APSMAM(e) IN('2','7','9')
Universe-text
Female sample adults 30+ who have not had a mammogram in the past 12 months
Question Text
Have you EVER HAD a mammogram?
*Read if necessary.
A mammogram is an x-ray taken only of the breast by a machine that presses against
the breast.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't Know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions Display the text " A mammogram is an x-ray taken only of the breast by a machine that
presses against the breast." in BOLD GRAY text; if APSMAM=1 fill '1' here and don't
ask question
Skip Instructions
<1> [goto RMAM1_MT] <2> [goto MDRECMAM] if AGE GE 40 [goto COLHAD];
else [goto next section]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 13 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.260_01.000
Variable Name
RMAM1_MT
Universe
HHSTAT4='S' and (AGE GE '030' and AGE not IN ('997','999')) and SEX='2' and
MAMHAD(e)='1'
Universe-text
Female sample adults 30+ who have ever had a mammogram
Question Text
1 of 2
[Fill1: Earlier you said you had a mammogram.]
When did you have your MOST RECENT mammogram?
*Enter month of last mammogram.
*Enter '96' to go to number and time period format.
Answer Codes
Question Type
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
96. Time period format
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
If APSMAM=1 then fill: Earlier you said you had a mammogram.
Special Instructions if RMAM1_MT = store 'R' in RMAM1_YR
if RMAM1_MT = <96> store '9996' in RMAM1_YR
Skip Instructions
<1-12,D> [goto RMAM1_YR] store 'R' in RMAM1_YR [goto RMAM2] <96> store
'9996' in RMAM1_YR [goto RMAM1N]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 14 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.260_02.000
Variable Name
RMAM1_YR
Universe
HHSTAT4='S' and (AGE GE '030' and AGE not IN ('997','999')) and SEX='2' and
MAMHAD(e)='1' and ('01' <= RMAM1_MT(e) <= '12' or RMAM1_MT(e)='99')
Universe-text
Female sample adults age 30+ who answered month of last mammogram or didn't
know month of last mammogram
Question Text
2 of 2
*Enter year of last mammogram.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions Allow 4 character numeric field – must enter 4 numbers
Skip Instructions
if RMAM1_YR gt current year or (RMAM1_YR=current year and
RMAM1_MT gt current month)
goto ERR1_ RMAM1_YR (future date)
elseif RMAM1_YR lt DOBY or (RMAM1_YR=DOBY and RMAM1_MT lt DOBM)
goto ERR2_ RMAM1_YR (prior to birth date)
elseif RMAM1_MT=D
goto RMAM2
elseif RMAM1_MT=1-12
goto MAMREAS
goto RMAM2
Hard Edits
ERR1_ RMAM1_YR
* Future date invalid. Please correct.
ERR2_ RMAM1_YR
* Date before birth. Please correct.
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 15 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.270_01.000
Variable Name
RMAM1N
Universe
HHSTAT4='S' and (AGE GE '030' and AGE not IN ('997','999')) and SEX='2' and
MAMHAD(e)='1' and RMAM1_M1(e)='96'
Universe-text
Female sample adults 30+ who selected number and time period format for most
recent mammogram from the initial month screen
Question Text
1 of 2
When did you have your MOST RECENT mammogram?
*Enter number for time since last mammogram.
*Enter '95' for 95 or more.
Answer Codes
(Allow 1-95,R,D)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions if RMAM1N = store 'R' in RMAM1T
if RMAM1N = store 'D' in RMAM1T
Skip Instructions
<1-95> [goto RMAM1T] store 'R,D' in RMAM1T [goto RMAM2]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 16 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.270_02.000
Variable Name
RMAM1T
Universe
HHSTAT4='S' and (AGE GE '030' and AGE not IN ('997','999')) and SEX='2' and
MAMHAD(e)='1' and RMAM1_MT(e)='96' and ('01' <= RMAM1N(e) <= '95')
Universe-text
Female sample adults 30+ who answered 1-95 for number part of this 2 part question
Question Text
2 of 2
*Enter time period for time since most recent mammogram.
Answer Codes
Question Type
1. Days ago
2. Weeks ago
3. Months ago
4. Years ago
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions if RMAM1N gt 5 and RMAM1T=4, store '5' in RMAM2.
if RMAM1N=4 and RMAM1T=4, store '4' in RMAM2.
Skip Instructions
<1-3> goto MAMREAS
<4> if RMAM1N=4
set RMAM2=4
goto MAMREAS
elseif RMAM1N gt 5 and RMAM1N gt AGE
goto ERR_RMAM1T (greater than persons age)
elseif RMAM1N gt 5 and RMAM1N le AGE
set RMAM2=5
goto MAMREAS
elseif RMAM1N=1,2,3,5
goto RMAM2
goto RMAM2
Hard Edits
ERR_RMAM1T
* Time since last exam cannot be greater than age.
* Please correct.
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 17 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.275_00.000
Variable Name
RMAM2
Universe
HHSTAT4='S' and (AGE GE '030' and AGE not IN ('997','999')) and SEX='2' and
MAMHAD(e)='1' and (RMAM1_MT(e) IN ('97','98','99') or RMAM1_YR(e) IN
('9997','9998','9999') or RMAM1N(e) IN ('97','98','99') or RMAM1T(e) IN ('7','8','9') or
(RMAM1T(e) = '4' and RMAM1N(e) IN ('1','2','3','5')))
Universe-text
Female sample adults 30+ who failed to give a complete date in either the month or
year format or failed to give a complete date in the number and time period format, or
entered years ago in the time period format (excluding those whose last mammogram
was over 5 years ago)
Question Text
Was it:
*Read answer categories.
Answer Codes
Question Type
1. A year ago or less
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. Over 5 years ago
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions Display answer categories 1-5 in BOLD BLACK text.
If RMAM1N gt 5 and RMAM1T=4, store '5' in RMAM2 and don't ask question.
If RMAM1N=4 and RMAM1T=4, store '4' in RMAM2 and don't ask question.
Based upon prior answers:
if RMAM1N = 1 and RMAM1T = '4', gray out answer codes 3,4,5
if RMAM1N = 2 and RMAM1T = '4', gray out answer codes 1,4,5
if RMAM1N = 3 and RMAM1T = '4', gray out answer codes 1,2,5
if RMAM1N = 5 and RMAM1T = '4', gray out answer codes 1,2,3
Skip Instructions
<1-5,R,D> if answer code is grayed out [goto ERR_RMAM2]
else [goto MAMREAS]
Hard Edits
ERR_RMAM2
*That is not a valid response.
*Please correct.
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 18 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.310_00.000
Variable Name
MAMREAS
Universe
HHSTAT4='S' and (AGE GE '030' and AGE not IN ('997','999')) and SEX='2' and
MAMHAD(e)='1'
Universe-text
Female sample adults 30+ who have ever had a mammogram
Question Text
What was the MAIN reason you had this mammogram -- was it part of a routine exam,
because of a problem, or some other reason?
Answer Codes
Question Type
1. Part of a routine exam
2. Because of a problem
3. Other reason
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-3,R,D> [goto MDRECMAM]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 19 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.370_00.000
Variable Name
MDRECMAM
Universe
HHSTAT4='S' and (AGE GE '030' and AGE not IN ('997','999')) and SEX='2' and
MAMHAD(e) not IN('7','9')
Universe-text
Female sample adults 30+ who did not answer refused or don't know to initial
mammogram question
Question Text
Fill1: (IF MAMHAD=1 and most recent screening exam LE 2 years from system date)
[Was your most recent mammogram recommended by a doctor or other health
professional?]
Else (IF MAMHAD=2, or MAMHAD GT 2 years from system date or RMAM2=R,D)
[In the PAST 12 MONTHS, has a doctor or other health professional RECOMMENDED
that you have a mammogram?]
Answer Codes
Question Type
1. Yes
2. No
3. Did not see a doctor in the last 12 months
Refused
Don't Know
Pick One - answer pane list
Field Pane Description
Fill Instructions
[fill 1] if MAMHAD = '1' and ((RMAM2 = 1,2) or (RMAM1T = 1,2) or (RMAM1_YR =
(current year – 2) and RMAM1_MT ge current month) or (RMAM1_YR gt (current year –
2)) or (RMAM1T = 3 and RMAM1N le 24))
fill " Was your most recent mammogram recommended by a doctor or other health
professional?"
else
fill "In the PAST 12 MONTHS, has a doctor or other health professional
RECOMMENDED that you have a mammogram?"
Special Instructions
Skip Instructions
<1-3,R,D> if AGE GE 40 [goto COLHAD]; else [goto next section]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 20 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.427_00.000
Variable Name
PSAREC
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SEX='1'
Universe-text
Male sample adults 40+
Question Text
Has a doctor EVER recommended that you have a PSA test?
*Read if necessary. A PSA test is a blood test to detect prostate cancer. It is also
called a prostate-specific antigen test.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't Know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions Display the text "A PSA test is a blood test to detect prostate cancer. It is also called a
prostate-specific antigen test. " in BOLD GRAY text.
Skip Instructions
<1,2,R,D> [goto PSAHAD]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 21 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.430_00.000
Variable Name
PSAHAD
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SEX='1'
Universe-text
Male sample adults 40+
Question Text
Have you EVER HAD a PSA test?
*Read if necessary. A PSA test is a blood test to detect prostate cancer. It is also
called a prostate-specific antigen test.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't Know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions Display the text "A PSA test is a blood test to detect prostate cancer. It is also called a
prostate-specific antigen test. " in BOLD GRAY text.
Skip Instructions
<1> [goto RPSA1_MT] <2,R,D> [goto COLHAD]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 22 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.440_00.000
Variable Name
RPSA1_MT
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SEX='1' and
PSAHAD(e)='1'
Universe-text
Male sample adults 40+ who have had a PSA test
Question Text
1 of 2
When did you have your MOST RECENT PSA test?
* Enter month of last PSA test.
* Enter '96' to go to number and time period format.
Answer Codes
Question Type
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
96. Time period format
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions if RPSA1_MT = store 'R' in RPSA1_YR
if RPSA1_MT = <96> store '9996' in RPSA1_YR
Skip Instructions
<1-12,D> [goto RPSA1_YR] store 'R' in RPSA1_YR [goto RPSA2] <96> store
'9996' in RPSA1_YR [goto RPSA1N]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 23 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.440_01.000
Variable Name
RPSA1_YR
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SEX='1' and
PSAHAD(e)='1' and ('01' <= RPSA1_MT(e) <= '12' or RSPA1_MT(e)='99')
Universe-text
Male sample adults 40+ who answred month of last PSA test or didn't know month of
last PSA test
Question Text
2 of 2
* Enter year of last PSA test.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions Allow 4 character numeric field – must enter 4 numbers
Skip Instructions
if RPSA1_YR gt current year or (RPSA1_YR=current year and RPSA1_MT
gt current month)
goto ERR1_ RPSA1_YR (future date)
elseif RPSA1_YR lt DOBY or (RPSA1_YR=DOBY and RPSA1_MT lt DOBM)
goto ERR2_ RPSA1_YR (prior to birth date)
elseif RPSA1_MT=D
goto RPSA2
elseif RPSA1_MT=1-12
goto PSAREAS
goto RPSA2
Hard Edits
ERR1_ RPSA1_YR
* Future date invalid. Please correct.
ERR2_ RPSA1_YR
* Date before birth. Please correct.
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 24 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.440_02.000
Variable Name
RPSA1N
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SEX='1' and
PSAHAD(e)='1' and RPSA1_MT(e)='96'
Universe-text
Male sample adults 40+ who have selected number and time period format for most
recent PSA test from the initial month screen
Question Text
1 of 2
When did you have your MOST RECENT PSA test?
* Enter number for time since last PSA test.
* Enter '95' for 95 or more.
Answer Codes
(Allow 1-95,R,D)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions if RPSA1N = store 'R' in RPSA1T
if RPSA1N = store 'D' in RPSA1T
Skip Instructions
<1-95> [goto RPSA1T] store 'R,D' in RPSA1T [goto RPSA2]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 25 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.440_03.000
Variable Name
RPSA1T
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SEX='1' and
PSAHAD(e)='1' and RPSA1_MT(e)='96' and ('01' <= RPSA1N(e) <= '95')
Universe-text
Male sample adults 40+ who answered 1-95 for number part of this 2 part question
Question Text
2 of 2
* Enter time period for time since most recent PSA test.
Answer Codes
Question Type
1. Days ago
2. Weeks ago
3. Months ago
4. Years ago
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions If RPSA1N gt 5 and RPSA1T=4, store '5' in RPSA2.
If RPSA1N=4 and RPSA1T=4, store '4' in RPSA2.
Skip Instructions
<1-3> goto PSAREAS
<4> if RPSA1N=4
set RPSA2=4
goto PSAREAS
elseif RPSA1N gt 5 and RPSA1N gt AGE
goto ERR_RPSA1T (greater than persons age)
elseif RPSA1N gt 5 and RPSA1N le AGE
set RPSA2=5
goto PSAREAS
elseif RPSA1N=1,2,3,5
goto RPSA2
goto RPSA2
Hard Edits
ERR_RPSA1T
* Time since last exam cannot be greater than age.
* Please correct.
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 26 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.440_04.000
Variable Name
RPSA2
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SEX='1' and
PSAHAD(e)='1' and (RPSA1_MT(e) IN ('97','98','99') or RPSA1_YR(e) IN
('9997','9998','9999') or RPSA1N(e) IN ('97','98','99') or RPSA1T(e) IN ('7','8','9') or
(RPSA1T(e) = '4' and RPSA1N(e) IN ('1','2','3','5')))
Universe-text
Male sample adults 40+ who failed to give a complete date in either the month or year
format or failed to give a complete date in the number and time period format, or
entered years ago in the time period format (excluding those whose last PSA test was
over 5 years ago)
Question Text
Was it:
*Read answer categories.
Answer Codes
Question Type
1. A year ago or less
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. Over 5 years ago
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions Display answer categories 1-5 in BOLD BLACK text.
If RPSA1N gt 5 and RPSA1T=4, store '5' in RPSA2 and don't ask question.
If RPSA1N=4 and RPSA1T=4, store '4' in RPSA2 and don't ask question.
Based upon prior answers:
if RPSA1N = 1 and RPSA1T = '4', gray out answer codes 3,4,5
if RPSA1N = 2 and RPSA1T = '4', gray out answer codes 1,4,5
if RPSA1N = 3 and RPSA1T = '4', gray out answer codes 1,2,5
if RPSA1N = 5 and RPSA1T = '4', gray out answer codes 1,2,3
Skip Instructions
<1-5,R,D> if answer code is grayed out [goto ERR_RPSA2] else [goto PSAREAS]
Hard Edits
ERR_RPSA2
*That is not a valid response.
*Please correct.
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 27 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.441_00.000
Variable Name
PSAREAS
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SEX='1' and
PSAHAD(e)='1'
Universe-text
Male sample adults 40+ who have had a PSA test
Question Text
What was the MAIN reason you had this PSA test - was it part of a routine exam,
because of a problem, or some other reason?
Answer Codes
Question Type
1. Part of a routine exam
2. Because of a problem
3. Other reason
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-3,R,D> [goto COLHAD]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 28 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.540_00.000
Variable Name
COLHAD
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999'))
Universe-text
Sample adults 40+
Question Text
Colonoscopy (colon-OS-copy) and sigmoidoscopy (sigmoid-OS-copy) are exams in
which a doctor inserts a tube into the rectum to look for polyps or cancer. For a
colonoscopy, the doctor checks the entire colon, and you are given medication through
a needle in your arm to make you sleepy, and told to have someone drive you home.
For a sigmoidoscopy, the doctor checks only part of the colon and you are fully awake.
Have you EVER HAD a colonoscopy?
*Read if necessary:
A polyp is a small growth that develops on the inside of the colon or rectum.
Before these tests, you are asked to take a medication that causes diarrhea.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't Know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions Display the text "A polyp is a small growth that develops on the inside of the colon or
rectum." in BOLD GRAY text.
Display the text "Before these tests, you are asked to take a medication that causes
diarrhea." in BOLD GRAY text.
Skip Instructions
<1> [goto COL_MT] <2,R,D> [goto SIGHAD]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 29 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.560_01.000
Variable Name
COL_MT
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and COLHAD(e)='1'
Universe-text
Sample adults 40+ who have ever had a colonoscopy
Question Text
1 of 2
When did you have your MOST RECENT colonoscopy?
*Enter month of last exam.
*Enter '96' to go to number and time period format.
Answer Codes
Question Type
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
96. Time period format
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions if COL_MT = store 'R' in COL_YR
if COL_MT = <96> store '9996' in COL_YR
Skip Instructions
<1-12,D> [goto COL_YR] store 'R' in COL_YR [goto COL2] <96> store '9996' in
COL_YR [goto COLN]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 30 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.560_02.000
Variable Name
COL_YR
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and COLHAD(e)='1'
and ('01' <= COL_MT(e) <= '12' or COL_MT(e)='99')
Universe-text
Sample adults age 40+ who answered month of last colonoscopy or didn't know month
of last colonoscopy
Question Text
2 of 2
*Enter year of last colonoscopy.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions Allow 4 character numeric field – must enter 4 numbers
Skip Instructions
if COL_YR gt current year or (COL_YR=current year and COL_MT gt
current month)
goto ERR1_ COL_YR (future date)
elseif COL_YR lt DOBY or (COL_YR=DOBY and COL_MT lt DOBM)
goto ERR2_ COL_YR (prior to birth date)
elseif COL_MT=D
goto COL2
elseif COL_MT=1-12
goto COLREAS
goto COL2
Hard Edits
ERR1_ COL_YR
* Future date invalid. Please correct.
ERR2_ COL_YR
* Date before birth. Please correct.
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 31 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.570_01.000
Variable Name
COLN
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and COLHAD(e)='1'
and COL_MT(e)='96'
Universe-text
Sample adults 40+ who selected number and time period format for most recent
colonoscopy from the initial month screen
Question Text
1 of 2
When did you have your MOST RECENT colonoscopy?
*Enter number for time since last colonoscopy.
*Enter '95' for 95 or more.
Answer Codes
(Allow 1-95,R,D)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions if COLN = store 'R' in COLT
If COLN = store 'D' in COLT
Skip Instructions
<1-95> [goto COLT] store 'R,D' in COLT [goto COL2]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 32 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.570_02.000
Variable Name
COLT
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and COLHAD(e)='1'
and COL_MT(e)='96' and ('01' <= COLN(e) <= '95')
Universe-text
Sample adults 40+ who answered 1-95 for number part of this 2 part question
Question Text
2 of 2
*Enter time period for time since most recent colonoscopy.
Answer Codes
Question Type
1. Days ago
2. Weeks ago
3. Months ago
4. Years ago
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions If COLN gt 10 and COLT=4, store '6' in COL2.
If COLN=6,7,8,9 and COLT=4, store '5' in COL2.
If COLN=4 and COLT=4, store '4' in COL2.
Skip Instructions
<1-3> goto COLREAS
<4> if COLN=4
set COL2=4
goto COLREAS
elseif COLN=6,7,8,9
set COL2=5
goto COLREAS
elseif COLN gt 10 and COLN gt AGE
goto ERR_COLT (greater than persons age)
elseif COLN gt 10 and COLN le AGE
set COL2=6
goto COLREAS
elseif COLN=1,2,3,5,10
goto COL2
goto COL2
Hard Edits
ERR_COLT
* Time since last exam cannot be greater than age.
* Please correct.
Soft Edits
Wednesday, August 08, 2012
Page 33 of 53
AssocHelp
Wednesday, August 08, 2012
Page 34 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.575_00.000
Variable Name
COL2
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and COLHAD(e)='1'
and (COL_MT(e) IN ('97','98','99') or COL_YR(e) IN ('9997','9998','9999') or COLN(e)
IN ('97','98','99') or COLT(e) IN ('7','8','9') or (COLT(e)='4' and COLN(e) IN
('1','2','3','5','10')))
Universe-text
Sample adults 40+ who failed to give a complete date in either the month or year format
or failed to give a complete date in the number and time period format, or entered years
ago in the time period format (excluding those whose last colonoscopy was 6-9 or over
10 years ago)
Question Text
Was it:
*Read answer categories.
Answer Codes
Question Type
1. A year ago or less
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. More than 5 years but not more than 10 years
6. Over 10 years ago
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions Display answer categories 1-6 in BOLD BLACK text.
If COLN gt 10 and COLT=4, store '6' in COL2 and don't ask question.
If COLN=6,7,8,9 and COLT=4, store '5' in COL2 and don't ask question.
If COLN=4 and COLT=4, store '4' in COL2 and don't ask question.
Based upon prior answers:
if COLN = 1 and COLT = '4', gray out answer codes 3,4,5,6
if COLN = 2 and COLT = '4', gray out answer codes 1,4,5,6
if COLN = 3 and COLT = '4', gray out answer codes 1,2,5,6
if COLN = 5 and COLT = '4', gray out answer codes 1,2,3,6
if COLN = 10 and COLT = '4', gray out answer codes 1,2,3,4
Skip Instructions
<1-6,R,D> if answer code is grayed out [goto ERR_COL2] else [goto COLREAS]
Hard Edits
ERR_COL2
*That is not a valid response.
*Please correct.
Wednesday, August 08, 2012
Page 35 of 53
Soft Edits
AssocHelp
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.590_00.000
Variable Name
COLREAS
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and COLHAD(e)='1'
Universe-text
Sample adults 40+ who have had a colonoscopy
Question Text
What was the MAIN reason you had this colonoscopy - was it part of a routine exam,
because of a problem, as a follow-up test of an earlier test or screening exam, or some
other reason?
Answer Codes
Question Type
1. Part of a routine exam
2. Because of a problem
3. Follow-up test of an earlier test or screening exam
4. Other reason
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-4,R,D> [goto SIGHAD]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 36 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.591_00.000
Variable Name
SIGHAD
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999'))
Universe-text
Sample adults 40+
Question Text
Recall that a sigmoidoscopy is similar to a colonoscopy but the doctor checks only part
of the colon and you are fully awake. Have you EVER HAD a sigmoidoscopy?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't Know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto SIG_MT] <2,R,D> [goto HFOBHAD]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 37 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.592_01.000
Variable Name
SIG_MT
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SIGHAD(e)='1'
Universe-text
Sample adults 40+ who have ever had a sigmoidoscopy
Question Text
1 of 2
When did you have your MOST RECENT sigmoidoscopy?
*Enter month of last exam.
*Enter '96' to go to number and time period format.
Answer Codes
Question Type
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
96. Time period format
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions if SIG_MT = store 'R' in SIG_YR
if SIG_MT = <96> store '9996' in SIG_YR
Skip Instructions
<1-12,D> [goto SIG_YR] store 'R' in SIG_YR [goto SIG2] <96> store '9996' in
SIG_YR [goto SIGN]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 38 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.593_02.000
Variable Name
SIG_YR
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SIGHAD(e)='1' and
('01' <= SIG_MT(e) <= '12' or SIG_MT(e)='99')
Universe-text
Sample adults age 40+ who answered month of last sigmoidoscopy or didn't know
month of last sigmoidoscopy
Question Text
2 of 2
*Enter year of last sigmoidoscopy.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions Allow 4 character numeric field – must enter 4 numbers
Skip Instructions
if SIG_YR gt current year or (SIG_YR=current year and SIG_MT gt current
month)
goto ERR1_ SIG_YR (future date)
elseif SIG_YR lt DOBY or (SIG_YR=DOBY and SIG_MT lt DOBM)
goto ERR2_ SIG_YR (prior to birth date)
elseif SIG_MT=D
goto SIG2
elseif SIG_MT=1-12
goto SIGREAS
goto SIG2
Hard Edits
ERR1_ SIG_YR
* Future date invalid. Please correct.
ERR2_ SIG_YR
* Date before birth. Please correct.
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 39 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.594_01.000
Variable Name
SIGN
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SIGHAD(e)='1' and
SIG_MT(e)='96'
Universe-text
Sample adults 40+ who selected number and time period format for most recent
sigmoidoscopy from the initial month screen
Question Text
1 of 2
When did you have your MOST RECENT sigmoidoscopy?
*Enter number for time since last sigmoidoscopy.
*Enter '95' for 95 or more.
Answer Codes
(Allow 1-95,R,D)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions if SIGN = store 'R' in SIGT
If SIGN = store 'D' in SIGT
Skip Instructions
<1-95> [goto SIGT] store 'R,D' in SIGT [goto SIG2]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 40 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.595_02.000
Variable Name
SIGT
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SIGHAD(e)='1' and
SIG_MT(e)='96' and ('01' <= SIGN(e) <= '95')
Universe-text
Sample adults 40+ who answered 1-95 for number part of this 2 part question
Question Text
2 of 2
*Enter time period for time since most recent sigmoidoscopy.
Answer Codes
Question Type
1. Days ago
2. Weeks ago
3. Months ago
4. Years ago
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions If SIGN gt 10 and SIGT=4, store '6' in SIG2.
If SIGN=6,7,8,9 and SIGT=4, store '5' in SIG2.
If SIGN=4 and SIGT=4, store '4' in SIG2.
Skip Instructions
<1-3> goto SIGREAS
<4> if SIGN=4
set SIG2=4
goto SIGREAS
elseif SIGN=6,7,8,9
set SIG2=5
goto SIGREAS
elseif SIGN gt 10 and SIGN gt AGE
goto ERR_SIGT (greater than persons age)
elseif SIGN gt 10 and SIGN le AGE
set SIG2=6
goto SIGREAS
elseif SIGN=1,2,3,5,10
goto SIG2
goto SIG2
Hard Edits
ERR_SIGT
* Time since last exam cannot be greater than age.
* Please correct.
Soft Edits
Wednesday, August 08, 2012
Page 41 of 53
AssocHelp
Wednesday, August 08, 2012
Page 42 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.596_00.000
Variable Name
SIG2
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SIGHAD(e)='1' and
(SIG_MT(e) IN ('97','98','99') or SIG_YR(e) IN ('9997','9998','9999') or SIGN(e) IN
('97','98','99') or SIGT(e) IN ('7','8','9') or (SIGT(e)='4' and SIGN(e) IN ('1','2','3','5','10')))
Universe-text
Sample adults 40+ who failed to give a complete date in either the month or year format
or failed to give a complete date in the number and time period format, or entered years
ago in the time period format (excluding those whose last sigmoidoscopy was 6-9 or
over 10 years ago)
Question Text
Was it:
*Read answer categories.
Answer Codes
Question Type
1. A year ago or less
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. More than 5 years but not more than 10 years
6. Over 10 years ago
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions Display answer categories 1-6 in BOLD BLACK text.
If SIGN gt 10 and SIGT=4, store '6' in SIG2 and don't ask question.
If SIGN=6,7,8,9 and SIGT=4, store '5' in SIG2 and don't ask question.
If SIGN=4 and SIGT=4, store '4' in SIG2 and don't ask question.
Based upon prior answers:
if SIGN = 1 and SIGT = '4', gray out answer codes 3,4,5,6
if SIGN = 2 and SIGT = '4', gray out answer codes 1,4,5,6
if SIGN = 3 and SIGT = '4', gray out answer codes 1,2,5,6
if SIGN = 5 and SIGT = '4', gray out answer codes 1,2,3,6
if SIGN = 10 and SIGT = '4', gray out answer codes 1,2,3,4
Skip Instructions
<1-6,R,D> if answer code is grayed out {goto ERR_SIG2] else [goto SIGREAS]
Hard Edits
ERR_SIG2
*That is not a valid response.
*Please correct.
Soft Edits
Wednesday, August 08, 2012
Page 43 of 53
AssocHelp
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.597_00.000
Variable Name
SIGREAS
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and SIGHAD(e)='1'
Universe-text
Sample adults 40+ who have had a sigmoidoscopy
Question Text
What was the MAIN reason you had this sigmoidoscopy - was it part of a routine exam,
because of a problem, as a follow-up test of an earlier test or screening exam, or some
other reason?
Answer Codes
Question Type
1. Part of a routine exam
2. Because of a problem
3. Follow-up test of an earlier test or screening exam
4. Other reason
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-4,R,D> [goto HFOBHAD]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 44 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.620_00.000
Variable Name
HFOBHAD
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999'))
Universe-text
Sample adults 40+
Question Text
The following questions are about the blood stool or occult blood test, a test to
determine whether you have blood in your stool or bowel movement. The blood stool
test can be done at home using a kit. You use a stick or brush to obtain a small
amount of stool at home and send it back to the doctor or lab.
Have you EVER HAD a blood stool test, using a HOME test kit?
*Read if necessary:
Do not include tests done at the doctor's office.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't Know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions Display the text "Do not include tests done at the doctor's office." In BOLD GRAY text.
Skip Instructions
<1> [goto RHFO1_MT] <2,R,D> [goto COLPROB]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 45 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.640_01.000
Variable Name
RHFO1_MT
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and HFOBHAD(e)='1'
Universe-text
Sample adults 40+ who have ever had a home blood stool test
Question Text
1 of 2
When did you have your MOST RECENT blood stool test using a kit at home?
*Enter month of last home blood stool test.
*Enter '96' to go to number and time period format.
Answer Codes
Question Type
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
96. Time period format
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions if RHFO1_MT = store 'R' in RHFO1_YR
if RHFO1_MT = <96> store '9996' in RHFO1_YR
Skip Instructions
<1-12,D> goto RHFO1_YR
store "R" in RHFO1_YR and goto RHFO2
<96> store "9996" in RHFO1_YR and goto RHFO1N
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 46 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.640_02.000
Variable Name
RHFO1_YR
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and HFOBHAD(e)='1'
and ('01' <= RHFO1_MT(e) <= '12' or RHFO1_MT(e)='99')
Universe-text
Sample adults age 40+ who answered month of last home blood stool test or didn't
know month of last test
Question Text
2 of 2
*Enter year of last home blood stool test.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions Allow 4 character numeric field – must enter 4 numbers
Skip Instructions
if RHFO1_YR gt current year or (RHFO1_YR=current year and
RHRO1_MT gt current month)
goto ERR1_RHFO1_YR (future date)
elseif RHFO1_YR lt DOBY or (RHFO1_YR=DOBY and RHFO1_MT lt
DOBM)
goto ERR2_RHFO1_YR (prior to birth date)
elseif RHFO1_MT=D
goto RHFO2
elseif RHFO1_MT=1-12
goto HFOBREA1
goto RHFO2
Hard Edits
ERR1_ RHFO1_YR
* Future date invalid. Please correct.
ERR2_ RHFO1_YR
* Date before birth. Please correct.
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 47 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.650_01.000
Variable Name
RHFO1N
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and HFOBHAD(e)='1'
and RHFO1_MT(e)='96'
Universe-text
Sample adults 40+ who selected number and time period format for most recent home
blood stool test from the initial month screen
Question Text
1 of 2
When did you have your MOST RECENT blood stool test using a kit at home?
*Enter number for time since last home blood stool test.
*Enter '95' for 95 or more.
Answer Codes
(Allow 1-95,R,D)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions if RHFO1N = store 'R' in RHFO1T
If RHFO1N = store 'D' in RHFO1T
Skip Instructions
<1-95> [goto RHFO1T] store 'R,D' in RHFO1T [goto RHFO2]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 48 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.650_02.000
Variable Name
RHFO1T
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and HFOBHAD(e)='1'
and RHFO1_MT(e)='96' and ('01' <= RHFO1N(e) <= '95')
Universe-text
Sample adults 40+ who answered 1-95 for number part of this 2 part question
Question Text
2 of 2
*Enter time period for time since most recent home blood stool test.
Answer Codes
Question Type
1. Days ago
2. Weeks ago
3. Months ago
4. Years ago
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions If RHFO1N gt 10 and RHFO1T=4, store '6' in RHFO2.
If RHFO1N=6,7,8,9 and RHFO1T=4, store '5' in RHFO2.
If RHFO1N=4 and RHFO1T=4, store '4' in RHFO2.
Skip Instructions
<1-3> goto HFOBREA1
<4> if RHFO1N=4
set RHFO2=4
goto HFOBREA1
elseif RHFO1N=6,7,8,9
set RHFO2=5
goto HFOBREA1
elseif RHFO1N gt 10 and RHFO1N gt AGE
goto ERR_RHFO1T (greater than persons age)
elseif RHFO1N gt 10 and RHFO1N le AGE
set RHFO2=6
goto HFOBREA1
elseif RHFO1N=1,2,3,5,10
goto RHFO2
goto RHFO2
Hard Edits
ERR_RHFO1T
* Time since last exam cannot be greater than age.
* Please correct.
Soft Edits
Wednesday, August 08, 2012
Page 49 of 53
AssocHelp
Wednesday, August 08, 2012
Page 50 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.655_00.000
Variable Name
RHFO2
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and HFOBHAD(e)='1'
and (RHFO1_MT(e) IN ('97','98','99') or RHFO1_YR(e) IN ('9997','9998','9999') or
RHFO1N(e) IN ('97','98','99') or RHFO1T(e) IN ('7','8','9') or (RHFO1T(e) = '4' and
RHFO1N(e) IN ('1','2','3','5','10')))
Universe-text
Sample adults 40+ who failed to give a complete date in either the month or year format
or failed to give a complete date in the number and time period format, or entered years
ago in the time period format (excluding those whose last home blood stool test was 69 or over 10 years ago)
Question Text
Was it:
*Read answer categories.
Answer Codes
Question Type
1. A year ago or less
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. More than 5 years but not more than 10 years
6. Over 10 years ago
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions Display answer categories 1-6 in BOLD BLACK text.
If RHFO1N gt 10 and RHFO1T=4, store '6' in RHFO2 and don't ask question.
If RHFO1N=6,7,8,9 and RHFO1T=4, store '5' in RHFO2 and don't ask question.
If RHFO1N=4 and RHFO1T=4, store '4' in RHFO2 and don't ask question.
Based upon prior answers:
if RHFO1N = 1 and RHFO1T = '4', gray out answer codes 3,4,5,6
if RHFO1N = 2 and RHFO1T = '4', gray out answer codes 1,4,5,6
if RHFO1N = 3 and RHFO1T = '4', gray out answer codes 1,2,5,6
if RHFO1N = 5 and RHFO1T = '4', gray out answer codes 1,2,3,6
if RHFO1N = 10 and RHFO1T = '4', gray out answer codes 1,2,3,4
Skip Instructions
<1-6,R,D> if answer code is grayed out [goto ERR_RHFO2] else [goto HFOBREA1]
Hard Edits
ERR_RHFO2
*That is not a valid response.
*Please correct.
Wednesday, August 08, 2012
Page 51 of 53
Soft Edits
AssocHelp
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.660_00.000
Variable Name
HFOBREA1
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999')) and HFOBHAD(e)='1'
Universe-text
Sample adults 40+ who have had a home blood stool test
Question Text
What was the MAIN reason you had this home blood stool test - was it part of a routine
exam, because of a problem, or some other reason?
Answer Codes
Question Type
1. Part of a routine exam
2. Because of a problem
3. Other reason
Refused
Don't know
Pick One - answer pane list
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-3,R,D> [goto COLPROB]
Hard Edits
Soft Edits
AssocHelp
Wednesday, August 08, 2012
Page 52 of 53
Module
30
Section Name
Cancer Screening
Part
Question ID
NAF.750_00.000
Variable Name
COLPROB
Universe
HHSTAT4='S' and (AGE GE '040' and AGE not IN ('997','999'))
Universe-text
Sample adults 40+
Question Text
In the PAST 12 MONTHS, did a doctor or other health professional RECOMMEND that
you be tested to look for problems in your colon or rectum?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't Know
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto next section]
Hard Edits
Soft Edits
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Wednesday, August 08, 2012
Page 53 of 53
2013 NHIS ACASI Instrument Spec Report
Section name: Adult ACASI Module
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.005_00.000
Variable Name
ACILANG
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
*You are about to enter the ACASI portion of the interview. Select '1' for English or '2'
for Spanish.
*Read if necessary: The next portion of the interview will be completed by you. Would
you prefer to complete these questions in English or Spanish?
Answer Codes
Question Type
1. English
2. Spanish
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not allow don't know or refused.
Skip Instructions
<1,2> goto ACASINTR
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Thursday, August 09, 2012
Page 1 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.010_00.000
Variable Name
ACASINTR
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
READ TO RESPONDENT: Now I will ask you to do an important part of this interview
on your own, using the computer and headphones. You will hear questions through the
headphones and see them on the computer screen.
*TURN COMPUTER AND HAND HEADPHONES TO RESPONDENT.
Before you start, you will go through a short practice session. Let me first show you the
keys you will use. The practice session that follows will go through what each key does
also.
*WHEN THE RESPONDENT IS READY, ASK THEM TO PRESS '1' TO CONTINUE.
Answer Codes
1. Enter 1 to Continue
Question Type
Continue
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1> if ACILANG=1 [goto ENGLISH ACIHEAD]
else if ACILANG=2 [goto SPANISH ACIHEAD]
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Thursday, August 09, 2012
Page 2 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.030_00.000
Variable Name
ACIHEAD
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
First I want to make sure you can hear me. I will ask you questions at this level. If you
want to change the level of my voice, use the knob that the interviewer showed you. If
you have difficulty, ask the interviewer for help. When you are comfortable with the
volume, press the Green Arrow Key once.
[Display Green Arrow Key]
Answer Codes
(Allow Enter)
Question Type
Other
Field Pane Description
Fill Instructions
Special Instructions Audio file(s):
ACIHEAD_Q
Skip Instructions
[goto ACIINTR1]
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Thursday, August 09, 2012
Page 3 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.040_00.000
Variable Name
ACIINTR1
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
We want you to be able to answer the remaining questions in complete privacy. The
first questions are for practice.
When you are ready to go to the next screen, press the Green Arrow Key.
[Display Green Arrow Key]
Answer Codes
(Allow Enter)
Question Type
Other
Field Pane Description
Fill Instructions
Special Instructions Audio file(s):
ACIINTR1_Q
Skip Instructions
[goto ACIINTR2]
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Thursday, August 09, 2012
Page 4 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.050_00.000
Variable Name
ACIINTR2
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
You can read the questions on the computer screen and hear them read through the
headphones. If you would like to just see the questions on the screen without sound,
you can turn off the voice using the knob on the cord. Now press the Green Arrow Key.
[Display Green Arrow Key]
Answer Codes
(Allow Enter)
Question Type
Other
Field Pane Description
Fill Instructions
Special Instructions Audio file(s):
ACIINTR2_Q
Skip Instructions
[goto ACITV]
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Thursday, August 09, 2012
Page 5 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.060_00.000
Variable Name
ACITV
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
After you hear or read this question, press the Red Circle Key until the circle is on the
answer you want, then press the Green Arrow Key.
Did you watch TV in the past 24 hours?
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Yes
2. No
Yes/No
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code (i.e., only Yes should appear, not 1. Yes)
Audio file(s):
ACITV_Q
YESNO_A
YES_A
NO_A
Skip Instructions
<1,2> [goto ACIDOAGN]
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Thursday, August 09, 2012
Page 6 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.080_00.000
Variable Name
ACIDOAGN
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
You can tell the computer to repeat a question by pressing The Red Circle Key until you
are at the question again. Try this now. Then press the Red Circle Key to pick your
answer, and then press the Green Arrow Key.
Do you own a bicycle?
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Yes
2. No
Yes/No
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code
Audio file(s):
ACIDOAGN_Q
YESNO_A
YES_A
NO_A
Skip Instructions
<1,2> [goto ACIBACK]
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Thursday, August 09, 2012
Page 7 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.090_00.000
Variable Name
ACIBACK
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
If you want to change or see your answer to a previous question, you can back up using
the Blue Arrow Key. Each time you press this key, the computer will go back one
question.
Press the Green Arrow Key to continue.
Pressing the Green Arrow Key will take you to the next question.
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
(Allow Enter)
Question Type
Other
Field Pane Description
Fill Instructions
Special Instructions Audio file(s):
ACIBACK_Q.1
Skip Instructions
[goto ACISTART]
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Thursday, August 09, 2012
Page 8 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.120_00.000
Variable Name
ACISTART
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
You have now completed the practice questions. For the remaining questions, if you
are unsure about your answer, please give us your best estimate.
If you have any questions, ask your interviewer now. If not, press the Green Arrow Key
to begin the questions.
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
(Allow Enter)
Question Type
Other
Field Pane Description
Fill Instructions
Special Instructions Audio file(s):
ACISTART_Q
Skip Instructions
[goto ACICPUSE]
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Thursday, August 09, 2012
Page 9 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.130_00.000
Variable Name
ACICPUSE
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
These questions are about you and your neighborhood.
How often do you use a computer?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Never or almost never
2. Some days
3. Most days
4. Every day
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACICPUSE_Q
ACICPUSE_A
ACICPUSE_A1
ACICPUSE_A2
ACICPUSE_A3
ACICPUSE_A4
Skip Instructions
<1-4> [goto ACISATHC]
[goto ACINOA1]
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Thursday, August 09, 2012
Page 10 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.135_00.000
Variable Name
ACINOA1
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACICPUSE=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACICPUSE
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACICPUSE]
<2,3> [goto ACISATHC]
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Thursday, August 09, 2012
Page 11 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.140_00.000
Variable Name
ACISATHC
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
In general, how satisfied are you with the health care you received in the past 12
months?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Very satisfied
2. Somewhat satisfied
3. Somewhat dissatisfied
4. Very dissatisfied
5. I haven’t had health care in the past 12 months
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACISATHC_Q
ACISATHC_A
ACISATHC_A1
ACISATHC_A2
ACISATHC_A3
ACISATHC_A4
ACISATHC_A5
Skip Instructions
<1-5> [goto ACITENUR]
[goto ACINOA2]
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Thursday, August 09, 2012
Page 12 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.145_00.000
Variable Name
ACINOA2
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACISATHC=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACISATHC
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISATHC]
<2,3> [goto ACITENUR]
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Thursday, August 09, 2012
Page 13 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.150_00.000
Variable Name
ACITENUR
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
About how long have you lived in your present neighborhood?
Answer Codes
Question Type
1. Less than 1 year
2. One to three years
3. Four to ten years
4. Eleven to twenty years
5. More than twenty years
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code
Audio file(s):
ACITENUR_Q
ACITENUR_A
ACITENUR_A1
ACITENUR_A2
ACITENUR_A3
ACITENUR_A4
ACITENUR_A5
Skip Instructions
<1-5> [goto ACINHELP]
[goto ACINOA3]
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Thursday, August 09, 2012
Page 14 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.155_00.000
Variable Name
ACINOA3
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACITENUR=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACITENUR
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACITENUR]
<2,3> [goto ACINHELP]
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Thursday, August 09, 2012
Page 15 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.160_00.000
Variable Name
ACINHELP
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
Please tell us how much you agree or disagree with the following statements about your
neighborhood. “People in this neighborhood help each other out.” Would you say:
Answer Codes
Question Type
1. Definitely agree
2. Somewhat agree
3. Somewhat disagree
4. Definitely disagree
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code
Audio file(s):
ACINHELP_Q
AGREEDISAGREE_A
AGREEDISAGREE_A1
AGREEDISAGREE_A2
AGREEDISAGREE_A3
AGREEDISAGREE_A4
Skip Instructions
<1-4> [goto ACINCNTO]
[goto ACINOA4]
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Thursday, August 09, 2012
Page 16 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.165_00.000
Variable Name
ACINOA4
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACINHELP=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACINHELP
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACINHELP]
<2,3> [goto ACINCNTO]
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Thursday, August 09, 2012
Page 17 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.170_00.000
Variable Name
ACINCNTO
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
“There are people I can count on in this neighborhood.” Would you say:
Answer Codes
Question Type
1. Definitely agree
2. Somewhat agree
3. Somewhat disagree
4. Definitely disagree
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code
Audio file(s):
ACINCNTO_Q
AGREEDISAGREE_A
AGREEDISAGREE_A1
AGREEDISAGREE_A2
AGREEDISAGREE_A3
AGREEDISAGREE_A4
Skip Instructions
<1-4> [goto ACINTRU]
[goto ACINOA5]
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Thursday, August 09, 2012
Page 18 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.175_00.000
Variable Name
ACINOA5
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACINCNTO=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACINCNTO
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACINCNTO]
<2,3> [goto ACINTRU]
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Thursday, August 09, 2012
Page 19 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.180_00.000
Variable Name
ACINTRU
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
“People in this neighborhood can be trusted.” Would you say:
Answer Codes
Question Type
1. Definitely agree
2. Somewhat agree
3. Somewhat disagree
4. Definitely disagree
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINTRU_Q
AGREEDISAGREE_A
AGREEDISAGREE_A1
AGREEDISAGREE_A2
AGREEDISAGREE_A3
AGREEDISAGREE_A4
Skip Instructions
<1-4> [goto ACINKNT]
[goto ACINOA6]
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Thursday, August 09, 2012
Page 20 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.185_00.000
Variable Name
ACINOA6
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACINTRU=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACINTRU
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACINTRU]
<2,3> [goto ACINKNT]
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Thursday, August 09, 2012
Page 21 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.190_00.000
Variable Name
ACINKNT
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
“This is a close-knit neighborhood.” Would you say:
Answer Codes
Question Type
1. Definitely agree
2. Somewhat agree
3. Somewhat disagree
4. Definitely disagree
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINKNT_Q
AGREEDISAGREE_A
AGREEDISAGREE_A1
AGREEDISAGREE_A2
AGREEDISAGREE_A3
AGREEDISAGREE_A4
Skip Instructions
<1-4> if SEX=1 [goto ACISIM];
else if SEX=2 [goto ACISIF]
[goto ACINOA7]
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Thursday, August 09, 2012
Page 22 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.195_00.000
Variable Name
ACINOA7
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACINKNT=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACINKNT
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACINKNT]
<2,3> if SEX=1 [goto ACISIM];
else if SEX=2 [goto ACISIF]
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Thursday, August 09, 2012
Page 23 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.220_00.000
Variable Name
ACISIM
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=1
Universe-text
Male sample adults 18+
Question Text
Do you think of yourself as:
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Gay
2. Straight, that is, not gay
3. Bisexual
4. Something else
5. I don't know the answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACISIM_Q
ACISIM_A
ACISIM_A1
ACISIM_A2
ACISIM_A3
ACISIM_A4
DONTKNOW_A
Skip Instructions
<1,2,3> [goto ACIRETR]
<4> [goto ACISMELS]
<5> [goto ACISIMDK];
[goto ACISIMEN]
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Thursday, August 09, 2012
Page 24 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.225_00.000
Variable Name
ACISIMEN
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=1 and ACISIM=' '
Universe-text
Male sample adults 18+ who did not enter an answer at ACISIM
Question Text
You did not enter an answer for the question. That is because you:
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISIM]
<2,3> [goto ACIRETR]
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Thursday, August 09, 2012
Page 25 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.230_00.000
Variable Name
ACISMELS
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=1 and ACISIM='4'
Universe-text
Male sample adults 18+ who think of themselves as as something else
Question Text
By something else [underline words something else], do you mean that…
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. You are not straight, but identify with another label such as queer, trisexual,
omnisexual or pansexual
2. You are transgender, transsexual or gender variant
3. You have not figured out or are in the process of figuring out your sexuality
4. You do not think of yourself as having sexuality
5. You do not use labels to identify yourself
6. You made a mistake and did not mean to pick this answer
7. You mean something else
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
ACISMELS_Q
ACISMELS_A
ACISMELS_A1
ACISMELS_A2
ACISMELS_A3
ACISMELS_A4
ACISMELS_A5
ACISMELS_A6
ACISMELS_A7
Skip Instructions
<1-5> [goto ACIRETR]
<6> [go back to ACISIM]
<7> [goto ACIMSESP]
[goto ACIMSEEN]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 26 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.232_00.000
Variable Name
ACIMSEEN
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=1 and ACISMELS=' '
Universe-text
Male sample adults 18+ who did not enter an answer at ACISMELS
Question Text
You did not enter an answer for the question. That is because you:
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISMELS]
<2,3> [goto ACIRETR]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 27 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.234_00.000
Variable Name
ACISIMDK
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=1 and ACISIM(e)='5'
Universe-text
Male sample adults 18+ who answered don't know at ACISIM
Question Text
By Don't Know (underline words Don't Know), do you mean that…
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. You don't understand the words
2. You understand the words, but you have not figured out or are in the process of
figuring out your sexuality
3. You made a mistake and did not mean to pick this answer
4. You mean something else
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
For display at the top of the screen, wrap text of last two categories (Something else
and Don't know) so that the first three categories are in the first column and these two
categories are in a second column to the right.
ACISIMDK_Q
ACISIMDK_A
ACISIMDK_A1
ACISIMDK_A2
ACISIMDK_A3
ACISIMDK_A4
Skip Instructions
<1,2> [goto ACIRETR]
<3> [go back to ACISIM]
<4> [goto ACIMSESP]
[goto ACIMDKEN]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 28 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.236_00.000
Variable Name
ACIMDKEN
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=1 and ACISIMDK=' '
Universe-text
Male sample adults 18+ who did not enter an answer at ACISIMDK
Question Text
You did not enter an answer for the question. That is because you:
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISIMDK]
<2,3> [goto ACIRETR]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 29 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.238_00.000
Variable Name
ACIMSESP
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=1 and (ACISMELS(e)='7' or ACISIMDK(e)='3')
Universe-text
Male sample adults 18+ who answered something else at ACISMELS or ACISIMDK
Question Text
What do you mean by something else?
Please type in your answer then press the Green Arrow Key.
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Allow 75, Enter without answering
Question Type
Text
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text;
For display at the top of the screen, wrap text of last two categories (Something else
and Don't know; Something else) so that the first three categories are in the first
column and these two categories are in a second column to the right.
Below display and question, add graphic with hands at a keyboard with the following
text to the left: Please type in your answer
Skip Instructions
[goto ACIRETR]
[goto ACIMSENA]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 30 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.239_00.000
Variable Name
ACIMSENA
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=1 and (ACISMELS(e)='7' or ACISIMDK(e)='3') and ACIMSESP=' '
Universe-text
Male sample adults 18+ who answered something else at ACISMELS or ACISIMDK
and didn't enter a response at ACIMSESP
Question Text
You did not enter an answer for the question. That is because you:
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key] Goes to the next question.
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [goto ACIMSESP]
<2,3> [goto ACIRETR]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 31 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.240_00.000
Variable Name
ACISIF
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=2
Universe-text
Female sample adults 18+
Question Text
Do you think of yourself as:
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Lesbian or gay
2. Straight, that is, not lesbian or gay
3. Bisexual
4. Something else
5. I don't know the answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACISIM_Q
ACISIM_A
ACISIM_A1
ACISIM_A2
ACISIM_A3
ACISIM_A4
DONTKNOW_A
Skip Instructions
<1,2,3> [goto ACIRETR]
<4> [goto ACISFELS]
<5> [goto ACISIFDK];
[goto ACISIFEN]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 32 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.245_00.000
Variable Name
ACISIFEN
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=2 and ACISIF=' '
Universe-text
Female sample adults 18+ who did not enter an answer at ACISIM
Question Text
You did not enter an answer for the question. That is because you:
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key] Goes to the next question.
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISIF]
<2,3> [goto ACIRETR]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 33 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.250_00.000
Variable Name
ACISFELS
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=2 and ACISIF(e)='4'
Universe-text
Female sample adults 18+ who think of themselves as as something else
Question Text
By something else [underline words something else], do you mean that…
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key] Goes to the next question.
Answer Codes
Question Type
1. You are not straight, but identify with another label such as queer, trisexual,
omnisexual or pansexual
2. You are transgender, transsexual or gender variant
3. You have not figured out or are in the process of figuring out your sexuality
4. You do not think of yourself as having sexuality
5. You do not use labels to identify yourself
6. You made a mistake and did not mean to pick this answer
7. You mean something else
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACISMELS_Q
ACISMELS_A
ACISMELS_A1
ACISMELS_A2
ACISMELS_A3
ACISMELS_A4
ACISMELS_A5
ACISMELS_A6
ACISMELS_A7
Skip Instructions
<1-5> [goto ACIRETR]
<6> [go back to ACISIF]
<7> [goto ACIFSESP]
[goto ACIFSEEN]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 34 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.252_00.000
Variable Name
ACIFSEEN
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=2 and ACISFELS=' '
Universe-text
Female sample adults 18+ who did not enter an answer at ACISMELS
Question Text
You did not enter an answer for the question. That is because you:
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key] Goes to the next question.
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISFELS] <2,3> [goto ACIRETR]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 35 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.254_00.000
Variable Name
ACISIFDK
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=2 and ACISIF(e)='5'
Universe-text
Female sample adults 18+ who answered don't know at ACISIM
Question Text
By Don't Know (underline words Don't Know), do you mean that...
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key] Goes to the next question.
Answer Codes
Question Type
1. You don't understand the words
2. You understand the words, but you have not figured out or are in the process of
figuring out your sexuality
3. You made a mistake and did not mean to pick this answer
4. You mean something else
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
For display at the top of the screen, wrap text of last two categories (Something else
and Don't know) so that the first three categories are in the first column and these two
categories are in a second column to the right.
Skip Instructions
<1,2> [goto ACIRETR]
<3> [go back to ACISIF]
<4> [goto ACIFSESP]
[goto ACIFDKEN]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 36 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.256_00.000
Variable Name
ACIFDKEN
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=2 and ACISIFDK=' '
Universe-text
Female sample adults 18+ who did not enter an answer at ACISIMDK
Question Text
You did not enter an answer for the question. That is because you:
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key] Goes to the next question.
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISIFDK] <2,3> [goto ACIRETR]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 37 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.258_00.000
Variable Name
ACIFSESP
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=2 and (ACISFELS(e)='7' or ACISIFDK(e)='3')
Universe-text
Female sample adults 18+ who answered something else at ACISMELS or ACISIMDK
Question Text
What do you mean by something else?
Please type in your answer then press the Green Arrow Key.
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Allow 75, Enter without answering
Question Type
Text
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text;
For display at the top of the screen, wrap text of last two categories (Something else
and Don't know; Something else) so that the first three categories are in the first
column and these two categories are in a second column to the right.
Below display and question, add graphic with hands at a keyboard with the following
text to the left: Please type in your answer
Skip Instructions
[goto ACIRETR]
[goto ACIFSENA]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 38 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.259_00.000
Variable Name
ACIFSENA
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
SEX=2 and (ACISFELS(e)='7' or ACISIFDK(e)='3') and ACIFSESP=' '
Universe-text
Female sample adults 18+ who answered something else at ACISFELS or ACISIFDK
and didn't enter a response at ACIFSESP
Question Text
You did not enter an answer for the question. That is because you:
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key] Goes to the next question.
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACIFSESP]
<2,3> [goto ACIRETR]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 39 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.260_00.000
Variable Name
ACIRETR
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
The next questions ask how worried you are right now about financial matters.
How worried are you right now about not having enough money for retirement? Are
you...
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIRETR_Q
HOWWORRIED_A
VERYWORRIED_A1
MODWORRIED_A2
NOTTOOWORRIED_A3
NOTWORRIED_A4
Skip Instructions
<1-4> [goto ACIMEDC]
[goto ACINOA8]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 40 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.265_00.000
Variable Name
ACINOA8
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACIRETR=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACIRETR
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACIRETR]
<2,3> [goto ACIMEDC]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 41 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.270_00.000
Variable Name
ACIMEDC
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not being able to pay medical costs of a serious
illness or accident? Are you…
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIMEDC_Q
HOWWORRIED_A
VERYWORRIED_A1
MODWORRIED_A2
NOTTOOWORRIED_A3
NOTWORRIED_A4
Skip Instructions
<1-4> [goto ACISTLV]
[goto ACINOA9]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 42 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.275_00.000
Variable Name
ACINOA9
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACIMEDC=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACIMEDC
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACIMEDC]
<2,3> [goto ACISTLV]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 43 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.280_00.000
Variable Name
ACISTLV
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not being able to maintain the standard of living
you enjoy? Are you…
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACISTLV_Q
HOWWORRIED_A
VERYWORRIED_A1
MODWORRIED_A2
NOTTOOWORRIED_A3
NOTWORRIED_A4
Skip Instructions
<1-4> [goto ACICNHC]
[goto ACINOA10]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 44 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.285_00.000
Variable Name
ACINOA10
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACISTLV=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACISTLV
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISTLV]
<2,3> [goto ACICNHC]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 45 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.290_00.000
Variable Name
ACICNHC
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not being able to pay medical costs for normal
healthcare? Are you…
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACICNHC_Q
HOWWORRIED_A
VERYWORRIED_A1
MODWORRIED_A2
NOTTOOWORRIED_A3
NOTWORRIED_A4
Skip Instructions
<1-4> [goto ACICCOLL]
[goto ACINOA11]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 46 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.295_00.000
Variable Name
ACINOA11
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACICNHC=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACICNHC
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACICNHC]
<2,3> [goto ACICCOLL]
Hard Edits
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Thursday, August 09, 2012
Page 47 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.300_00.000
Variable Name
ACICCOLL
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not having enough money to pay for your
children's college? Are you…
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
5. This does not apply to me
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACICCOLL_Q
ACICCOLL_A
VERYWORRIED_A1
MODWORRIED_A2
NOTTOOWORRIED_A3
NOTWORRIED_A4
DOESNOTAPPLY_A5
Skip Instructions
<1-5> [goto ACINBILL]
[goto ACINOA12]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 48 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.305_00.000
Variable Name
ACINOA12
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACICCOLL=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACICCOLL
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACICCOLL]
<2,3> [goto ACINBILL]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 49 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.310_00.000
Variable Name
ACINBILL
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not having enough to pay your normal monthly
bills? Are you…
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINBILL_Q
HOWWORRIED_A
VERYWORRIED_A1
MODWORRIED_A2
NOTTOOWORRIED_A3
NOTWORRIED_A4
Skip Instructions
<1-4> [goto ACIHCST]
[goto ACINOA13]
Hard Edits
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Thursday, August 09, 2012
Page 50 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.315_00.000
Variable Name
ACINOA13
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACINBILL=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACINBILL
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACINBILL]
<2,3> [goto ACIHCST]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 51 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.320_00.000
Variable Name
ACIHCST
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not being able to pay your rent, mortgage, or other
housing costs? Are you…
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIHCST_Q
HOWWORRIED_A
VERYWORRIED_A1
MODWORRIED_A2
NOTTOOWORRIED_A3
NOTWORRIED_A4
Skip Instructions
<1-4> [goto ACICCMP]
[goto ACINOA14]
Hard Edits
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Thursday, August 09, 2012
Page 52 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.325_00.000
Variable Name
ACINOA14
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACIHCST=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACIHCST
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACIHCST]
<2,3> [goto ACICCMP]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 53 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.330_00.000
Variable Name
ACICCMP
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not being able to make the minimum payments on
your credit cards? Are you...
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
5. I don't have credit cards
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACICCMP_Q
ACICCMP_A
VERYWORRIED_A1
MODWORRIED_A2
NOTTOOWORRIED_A3
NOTWORRIED_A4
DONTHAVECARDS_A5
Skip Instructions
<1-5> [goto ACISLEEP]
[goto ACINOA15]
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AssocHelp
Thursday, August 09, 2012
Page 54 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.335_00.000
Variable Name
ACINOA15
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACICCMP=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACICCMP
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACICCMP]
<2,3> [goto ACISLEEP]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 55 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.340_00.000
Variable Name
ACISLEEP
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
On average, how many hours of sleep do you get in a 24-hour period?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Four hours or less
2. Five hours
3. Six hours
4. Seven hours
5. Eight hours
6. Nine hours
7. Ten or more hours
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACISLEEP_Q
ACISLEEP_A
ACISLEEP_A1
ACISLEEP_A2
ACISLEEP_A3
ACISLEEP_A4
ACISLEEP_A5
ACISLEEP_A6
ACISLEEP_A7
Skip Instructions
<1-7> [goto ACISLPFL]
[goto ACINOA16]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 56 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.345_00.000
Variable Name
ACINOA16
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACISLEEP=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACISLEEP
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISLEEP]
<2,3> [goto ACISLPFL]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 57 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.350_00.000
Variable Name
ACISLPFL
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
In the past week, how often did you have trouble falling asleep?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
0. I didn’t have trouble falling asleep in the past week
1. One time
2. Two times
3. Three times
4. Four times
5. Five times
6. Six times
7. Seven or more times
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACISLPFL_Q
ACISLPFL_A
ACISLPFL_A0
ONETIME_A1
TWOTIMES_A2
THREETIMES_A3
FOURTIMES_A4
FIVETIMES_A5
SIXTIMES_A6
SEVENORMORETIMES_A7
Skip Instructions
<0-7> [goto ACISLPST]
[goto ACINOA17]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 58 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.355_00.000
Variable Name
ACINOA17
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACISLPFL=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACISLPFL
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISLPFL]
<2,3> [goto ACISLPST]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 59 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.360_00.000
Variable Name
ACISLPST
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
In the past week, how many times did you have trouble staying asleep?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
0. I didn’t have trouble staying asleep in the past week
1. One time
2. Two times
3. Three times
4. Four times
5. Five times
6. Six times
7. Seven or more times
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACISLPST_Q
ACISLPST_A
ACISLPST_A0
ONETIME_A1
TWOTIMES_A2
THREETIMES_A3
FOURTIMES_A4
FIVETIMES_A5
SIXTIMES_A6
SEVENORMORETIMES_A7
Skip Instructions
<0-7> [goto ACISLPMD]
[goto ACINOA18]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 60 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.365_00.000
Variable Name
ACINOA18
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACISLPST=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACISLPST
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISLPST]
<2,3> [goto ACISLPMD]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 61 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.370_00.000
Variable Name
ACISLPMD
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
In the past week, how many times did you take medication to help you fall asleep or
stay asleep?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
0. I did not take medication to help me sleep in the past week
1. One time
2. Two times
3. Three times
4. Four times
5. Five times
6. Six times
7. Seven or more times
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACISLPMD_Q
ACISLPMD_A
ACISLPMD_A0
ONETIME_A1
TWOTIMES_A2
THREETIMES_A3
FOURTIMES_A4
FIVETIMES_A5
SIXTIMES_A6
SEVENORMORETIMES_A7
Skip Instructions
<0-7> [goto ACIREST]
[goto ACINOA19]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 62 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.375_00.000
Variable Name
ACINOA19
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACISLPMD=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACISLPMD
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISLPMD]
<2,3> [goto ACIREST]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 63 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.380_00.000
Variable Name
ACIREST
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
In the past week, on how many days did you wake up feeling well rested?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
0. I never felt rested
1. One time
2. Two times
3. Three times
4. Four times
5. Five times
6. Six times
7. Seven or more times
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIREST_Q
ACIREST_A
ACIREST_A0
ONETIME_A1
TWOTIMES_A2
THREETIMES_A3
FOURTIMES_A4
FIVETIMES_A5
SIXTIMES_A6
SEVENORMORETIMES_A7
Skip Instructions
<0-7> [goto ACISAD]
[goto ACINOA20]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 64 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.385_00.000
Variable Name
ACINOA20
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACIREST=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACIREST
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACIREST]
<2,3> [goto ACISAD]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 65 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.390_01.000
Variable Name
ACISAD
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
Now I am going to ask you some questions about feelings you may have experienced
over the past 30 days.
During the past 30 days, how often did you feel
...So sad that nothing could cheer you up?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACISAD_Q
HOWMUCHOFTIME_A
ALLOFTIME_A1
MOSTOFTIME_A2
SOMEOFTIME_A3
LITTLEOFTIME_A4
NONEOFTIME_A5
Skip Instructions
<1-5> [goto ACINERV]
[gotoACINOA21]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 66 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.390_01.010
Variable Name
ACINOA21
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACISAD=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACISAD
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACISAD]
<2,3> [goto ACINERV]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 67 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.390_02.000
Variable Name
ACINERV
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
During the past 30 days, how often did you feel
...Nervous?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINERV_Q
HOWMUCHOFTIME_A
ALLOFTIME_A1
MOSTOFTIME_A2
SOMEOFTIME_A3
LITTLEOFTIME_A4
NONEOFTIME_A5
Skip Instructions
<1-5> [goto ACIRSTLS]
[goto ACINOA22]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 68 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.390_02.010
Variable Name
ACINOA22
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACINERV=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACINERV
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACINERV]
<2,3> [goto ACIRSTLS]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 69 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.390_03.000
Variable Name
ACIRSTLS
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
During the past 30 days, how often did you feel
...Restless or fidgety?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIRSTLS_Q
HOWMUCHOFTIME_A
ALLOFTIME_A1
MOSTOFTIME_A2
SOMEOFTIME_A3
LITTLEOFTIME_A4
NONEOFTIME_A5
Skip Instructions
<1-5> [goto ACIHOPLS]
[goto ACINOA23]
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Thursday, August 09, 2012
Page 70 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.390_03.010
Variable Name
ACINOA23
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACIRSTLS=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACIRSTLS
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACIRSTLS]
<2,3> [goto ACIHOPLS]
Hard Edits
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Thursday, August 09, 2012
Page 71 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.390_04.000
Variable Name
ACIHOPLS
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
During the past 30 days, how often did you feel
...Hopeless?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIHOPLS_Q
HOWMUCHOFTIME_A
ALLOFTIME_A1
MOSTOFTIME_A2
SOMEOFTIME_A3
LITTLEOFTIME_A4
NONEOFTIME_A5
Skip Instructions
<1-5> [goto ACIEFFRT]
[goto ACINOA24]
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Thursday, August 09, 2012
Page 72 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.390_04.010
Variable Name
ACINOA24
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACIHOPLS=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACIHOPLS
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACIHOPLS]
<2,3> [goto ACIEFFRT]
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Thursday, August 09, 2012
Page 73 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.390_05.000
Variable Name
ACIEFFRT
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
During the past 30 days, how often did you feel
...That everything was an effort?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIEFFRT_Q
HOWMUCHOFTIME_A
ALLOFTIME_A1
MOSTOFTIME_A2
SOMEOFTIME_A3
LITTLEOFTIME_A4
NONEOFTIME_A5
Skip Instructions
<1-5> [goto ACIWTHLS]
[goto ACINOA25]
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Thursday, August 09, 2012
Page 74 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.390_05.010
Variable Name
ACINOA25
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACIEFFRT=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACIEFFRT
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACIEFFRT]
<2,3> [goto ACIWTHLS]
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Thursday, August 09, 2012
Page 75 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.390_06.000
Variable Name
ACIWTHLS
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
During the past 30 days, how often did you feel
...Worthless?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIWTHLS_Q
HOWMUCHOFTIME_A
ALLOFTIME_A1
MOSTOFTIME_A2
SOMEOFTIME_A3
LITTLEOFTIME_A4
NONEOFTIME_A5
Skip Instructions
<1-5> if ACISAD or ACINERV or ACIRSTLS or ACIHOPLS or ACIEFFRT or
ACIWTHLS=1-3 [goto ACIMUCH];
else if [goto ACINOA26];
else goto ACIHIVT
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Thursday, August 09, 2012
Page 76 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.390_06.010
Variable Name
ACINOA26
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACIWTHLS=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACIWTHLS
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACIWTHLS]
<2,3> if ACISAD or ACINERV or ACIRSTLS or ACIHOPLS or ACIEFFRT or
ACIWTHLS=1-3 [goto ACIMUCH];
else goto ACIHIVT
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Thursday, August 09, 2012
Page 77 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.400_00.000
Variable Name
ACIMUCH
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
(ACISAD(e) IN('1','2','3') or ACINERV(e) IN('1','2','3') or ACIRSTLS(e) IN('1','2','3') or
ACIHOPLS(e) IN('1','2','3') or ACIEFFRT (e) IN('1','2','3') or ACIWTHLS(e) IN('1','2','3'))
Universe-text
Sample adults 18+ who at least some of the time have felt sad, nervous, restless or
fidgety, hopeless, that everything was an effort, or worthless, in the past 30 days
Question Text
We just talked about a number of feelings you had during the past 30 days. Altogether,
how much did these feelings interfere with your life or activities?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. A lot
2. Some
3. A little
4. Not at all
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIMUCH_Q
ACIMUCH_A
ACIMUCH_A1
ACIMUCH_A2
ACIMUCH_A3
ACIMUCH_A4
Skip Instructions
<1-4> [goto ACIHIVT]
[goto ACINOA27]
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Thursday, August 09, 2012
Page 78 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.405_00.000
Variable Name
ACINOA27
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACIMUCH=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACIMUCH
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACIMUCH]
<2,3> goto ACIHIVT]
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Thursday, August 09, 2012
Page 79 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.410_00.000
Variable Name
ACIHIVT
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
The next question is about the test for HIV, the virus that causes AIDS. Except for tests
you may have had as part of blood donations, have you ever been tested for HIV?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Yes
2. No
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIHIVT_Q
YESNODONTKNOWDONTWANT_A
YES_A
NO_A
Skip Instructions
<1-2> [goto ACIRDQ1]
[goto ACINOA28]
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Thursday, August 09, 2012
Page 80 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.415_00.000
Variable Name
ACINOA28
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACIHIVT=' '
Universe-text
Sample adults 18+ who did not enter an answer at ACIHIVT
Question Text
You did not enter an answer for the question. That is because you:
Answer Codes
Question Type
1. Made a mistake and would like to have another chance
2. Are not sure how to answer
3. Do not want to answer
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACINOAN_Q
ACINOAN_A
ACINOAN_A1
ACINOAN_A2
ACINOAN_A3
Skip Instructions
<1> [go back to ACIHIVT]
<2,3> [goto ACIRDQ1]
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Thursday, August 09, 2012
Page 81 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.465_00.010
Variable Name
ACIRDQ1
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
Answering questions on your own using a recorded voice is one way we can collect
data. To help us improve this process, the next few questions ask about your
experience using this computer.
Did the interviewer explain how to use this computer?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Yes
2. No
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIRDQ1_Q
YESNODONTKNOWDONTWANT_A
YES_A
NO_A
Skip Instructions
<1-2> [goto ACIRDQ2]
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Thursday, August 09, 2012
Page 82 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.465_00.020
Variable Name
ACIRDQ2
Universe
Universe-text
Sample adults 18+
Question Text
Did you have any difficulty using the keys to choose your answers?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Yes
2. No
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIRDQ2_Q
YESNODONTKNOWDONTWANT_A
YES_A
NO_A
Skip Instructions
<1-2> [goto ACIRDQ3]
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Thursday, August 09, 2012
Page 83 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.465_00.030
Variable Name
ACIRDQ3
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
Including the practice questions, did you listen to the recorded voice for all of the
questions, some of the questions, or none of the questions?
Answer Codes
Question Type
1. All of the questions
2. Some of the questions
3. None of the questions
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIRDQ3_Q
ACIRDQ3_A
ACIRDQ3_A1
ACIRDQ3_A2
ACIRDQ3_A3
Skip Instructions
<1,2> [goto ACIRDQ4]
<3> [goto ACIRDQ8]
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Thursday, August 09, 2012
Page 84 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.465_00.040
Variable Name
ACIRDQ4
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACIRDQ3 IN('1','2')
Universe-text
Sample adults 18+ who listened to some or all of the questions
Question Text
Was the recorded voice too slow, too fast, or about the right speed?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Too slow
2. Too fast
3. About the right speed
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIRDQ4_Q
ACIRDQ4_A
ACIRDQ4_A1
ACIRDQ4_A2
ACIRDQ4_A3
Skip Instructions
<1-3> [goto ACIRDQ5]
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Thursday, August 09, 2012
Page 85 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.465_00.050
Variable Name
ACIRDQ5
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1' and
ACIRDQ3 IN('1','2')
Universe-text
Sample adults 18+ who listened to some or all of the questions
Question Text
Did you have any difficulty adjusting the volume?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Yes
2. No
3. Did not have to adjust the volume
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIRDQ5_Q
ACIRDQ5_A
ACIRDQ5_A1
ACIRDQ5_A2
ACIRDQ5_A3
Skip Instructions
<1-3> [goto ACIRDQ8]
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Thursday, August 09, 2012
Page 86 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.465_00.080
Variable Name
ACIRDQ8
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
Do you think it was important for this part of the interview to be private?
[Display Blue Arrow Key]
[Display Red Circle Key] Circles your answer.
[Display Green Arrow Key]
Answer Codes
Question Type
1. Yes
2. No
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Do not display numeric part of answer code; make instructions appear in different
font/color to differentiate from question text
Audio file(s):
ACIRDQ8_Q
YESNODONTKNOWDONTWANT_A
YES_A
NO_A
Skip Instructions
<1-2> [goto ACI_EXIT]
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Thursday, August 09, 2012
Page 87 of 88
Module
51
Section Name
Adult ACASI Module
Part
Question ID
ACI.470_00.000
Variable Name
ACI_EXIT
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='1'
Universe-text
Sample adults 18+
Question Text
You have now completed these questions. Once you leave this screen, you will no
longer be able to change your answers or go back. Your responses will be locked away
to maintain your privacy.
Press the Green Arrow Key to EXIT and return the laptop to your interviewer.
[Display Blue Arrow Key]
[Display Green Arrow Key]
Answer Codes
(Allow Enter)
Question Type
Other
Field Pane Description
Fill Instructions
Special Instructions Audio file(s):
ACI_EXIT_Q
Skip Instructions
[goto next module]
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Thursday, August 09, 2012
Page 88 of 88
2013 NHIS Instrument Spec Report
Section name: Adult SEXUALITY Module
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.005_00.000
Variable Name
ASIINTRO
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
*You are about to enter the Sexual Identity and Lifestyle questions section. This
section includes questions on computer use, the respondent’s neighborhood, sexual
identity, financial worries, mental health, and HIV testing.
*Enter 1 to Continue.
Answer Codes
1. Enter 1 to Continue
Question Type
Enter 1 to Continue
Field Pane Description
Fill Instructions
Special Instructions Do not allow don't know or refused for this screen.
Skip Instructions
<1> goto ACICPUSE
Hard Edits
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Thursday, August 09, 2012
Page 1 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.130_00.000
Variable Name
ACICPUSE
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
These questions are about you and your neighborhood.
How often do you use a computer?
*Read answer categories.
Answer Codes
Question Type
1. Never or almost never
2. Some days
3. Most days
4. Every day
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Display the answer codes in the answer pane in bold black.
Skip Instructions
<1-4,R,D> [goto ACISATHC]
Hard Edits
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Thursday, August 09, 2012
Page 2 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.140_00.000
Variable Name
ACISATHC
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
In general, how satisfied are you with the health care you received in the past 12
months?
*Read answer categories.
Answer Codes
Question Type
1. Very satisfied
2. Somewhat satisfied
3. Somewhat dissatisfied
4. Very dissatisfied
5. You haven’t had health care in the past 12 months
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Display the answer codes in the answer pane in bold black.
Skip Instructions
<1-5,R,D> [goto ACITENUR]
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Thursday, August 09, 2012
Page 3 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.150_00.000
Variable Name
ACITENUR
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
About how long have you lived in your present neighborhood?
Answer Codes
Question Type
1. Less than 1 year
2. 1-3 years
3. 4-10 years
4. 11-20 years
5. More than 20 years
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-5,R,D> [goto ACINHELP]
Hard Edits
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Thursday, August 09, 2012
Page 4 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.160_00.000
Variable Name
ACINHELP
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
How much do you agree or disagree with the following statements about your
neighborhood?
People in this neighborhood help each other out.
Would you say…
*Read answer categories.
Answer Codes
Question Type
1. Definitely agree
2. Somewhat agree
3. Somewhat disagree
4. Definitely disagree
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Display the answer codes in the answer pane in bold black.
Skip Instructions
<1-4,R,D> [goto ACINCNTO]
Hard Edits
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Thursday, August 09, 2012
Page 5 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.170_00.000
Variable Name
ACINCNTO
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
*Read if necessary.
How much do you agree or disagree with the following statements about your
neighborhood?
There are people I can count on in this neighborhood.
Would you say…
*Read answer categories if necessary.
Answer Codes
Question Type
1. Definitely agree
2. Somewhat agree
3. Somewhat disagree
4. Definitely disagree
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-4,R,D> [goto ACINTRU]
Hard Edits
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Thursday, August 09, 2012
Page 6 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.180_00.000
Variable Name
ACINTRU
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
*Read if necessary.
How much do you agree or disagree with the following statements about your
neighborhood?
People in this neighborhood can be trusted.
Would you say…
*Read answer categories if necessary.
Answer Codes
Question Type
1. Definitely agree
2. Somewhat agree
3. Somewhat disagree
4. Definitely disagree
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-4,R,D> [goto ACINKNT]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 7 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.190_00.000
Variable Name
ACINKNT
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
*Read if necessary.
How much do you agree or disagree with the following statements about your
neighborhood?
This is a close-knit neighborhood.
Would you say…
*Read answer categories if necessary.
Answer Codes
Question Type
1. Definitely agree
2. Somewhat agree
3. Somewhat disagree
4. Definitely disagree
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-4,R,D> [if SEX=1, goto ACISIM; elseif SEX=2, goto ACISIF]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 8 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.220_00.000
Variable Name
ACISIM
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2' and
SEX=1
Universe-text
Male sample adults 18+
Question Text
(book) ASI1
Which of the following best represents how you think of yourself?
Answer Codes
Question Type
1. Gay
2. Straight, that is, not gay
3. Bisexual
4. Something else
5. I don't know the answer
Refused
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-3,R> [goto ACIRETR]
<4> [goto ACISMELS]
<5> [goto ACISIMDK]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 9 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.230_00.000
Variable Name
ACISMELS
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2' and
SEX=1 and ACISIM(e)='4'
Universe-text
Male sample adults 18+ who think of themselves as something else
Question Text
(book) ASI3
What do you mean by something else?
Answer Codes
Question Type
1. You are not straight, but identify with another label such as queer, trisexual,
omnisexual or pansexual
2. You are transgender, transsexual or gender variant
3. You have not figured out or are in the process of figuring out your sexuality
4. You do not think of yourself as having sexuality
5. You do not use labels to identify yourself
6. You mean something else
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-5,R,D> [goto ACIRETR]
<6> [goto ACIMSESP]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 10 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.234_00.000
Variable Name
ACISIMDK
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2' and
SEX=1 and ACISIM(e)='5'
Universe-text
Male sample adults 18+ who answered don't know at ACISIM
Question Text
(book) ASI4
What do you mean by don't know?
Answer Codes
Question Type
1. You don't understand the words
2. You understand the words, but you have not figured out or are in the process of
figuring out your sexuality
3. You mean something else
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto ACIRETR]
<3> [goto ACIMSESP]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 11 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.238_00.000
Variable Name
ACIMSESP
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2' and
SEX=1 and (ACISMELS(e)='6' or ACISIMDK(e)='3')
Universe-text
Male sample adults 18+ who answered something else at ACISMELS or ACISIMDK
Question Text
What do you mean by something else?
Answer Codes
Question Type
Allow 75
Refused
Don't know
Text
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
[goto ACIRETR]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 12 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.240_00.000
Variable Name
ACISIF
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2' and
SEX=2
Universe-text
Female sample adults 18+
Question Text
(book) ASI2
Which of the following best represents how you think of yourself?
Answer Codes
Question Type
1. Lesbian or gay
2. Straight, that is, not lesbian or gay
3. Bisexual
4. Something else
5. I don't know the answer
Refused
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-3,R> [goto ACIRETR]
<4> [goto ACISFELS]
<5> [goto ACISIFDK]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 13 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.250_00.000
Variable Name
ACISFELS
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2' and
SEX=2 and ACISIF(e)='4'
Universe-text
Female sample adults 18+ who think of themselves as as something else
Question Text
(book) ASI3
What do you mean by something else?
Answer Codes
Question Type
1. You are not straight, but identify with another label such as queer, trisexual,
omnisexual or pansexual
2. You are transgender, transsexual or gender variant
3. You have not figured out or are in the process of figuring out your sexuality
4. You do not think of yourself as having sexuality
5. You do not use labels to identify yourself
6. You mean something else
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-5,R,D> [goto ACIRETR]
<6> [goto ACIFSESP]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 14 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.254_00.000
Variable Name
ACISIFDK
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2' and
SEX=2 and ACISIF(e)='5'
Universe-text
Female sample adults 18+ who answered don't know at ACISIM
Question Text
(book) ASI4
What do you mean by don't know?
Answer Codes
Question Type
1. You don't understand the words
2. You understand the words, but you have not figured out or are in the process of
figuring out your sexuality
3. You mean something else
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto ACIRETR]
<3> [goto ACIFSESP]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 15 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.258_00.000
Variable Name
ACIFSESP
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2' and
SEX=2 and (ACISFELS(e)='6' or ACISIFDK(e)='3')
Universe-text
Female sample adults 18+ who answered something else at ACISMELS or ACISIMDK
Question Text
What do you mean by something else?
Answer Codes
Question Type
Allow 75
Refused
Don't know
Text
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
[goto ACIRETR]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 16 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.260_00.000
Variable Name
ACIRETR
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
The next questions ask how worried you are right now about financial matters.
How worried are you right now about not having enough money for retirement? Are
you…
*Read answer categories.
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions Display the answer codes in the answer pane in bold black.
Skip Instructions
<1-4,R,D> [goto ACIMEDC]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 17 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.270_00.000
Variable Name
ACIMEDC
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not being able to pay medical costs of a serious
illness or accident? Are you…
*Read answer categories if necessary.
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-4,R,D> [goto ACISTLV]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 18 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.280_00.000
Variable Name
ACISTLV
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not being able to maintain the standard of living
you enjoy? Are you…
*Read answer categories if necessary.
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-4,R,D> [goto ACICNHC]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 19 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.290_00.000
Variable Name
ACICNHC
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not being able to pay medical costs for normal
healthcare? Are you…
*Read answer categories if necessary.
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-4,R,D> [goto ACICCOLL]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 20 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.300_00.000
Variable Name
ACICCOLL
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not having enough money to pay for your
children's college? Are you…
*Read answer categories if necessary.
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
5. This does not apply to me
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-5,R,D> [goto ACINBILL]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 21 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.310_00.000
Variable Name
ACINBILL
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not having enough to pay your normal monthly
bills? Are you…
*Read answer categories if necessary.
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-4,R,D> [goto ACIHCST]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 22 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.320_00.000
Variable Name
ACIHCST
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not being able to pay your rent, mortgage, or other
housing costs? Are you…
*Read answer categories if necessary.
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-4,R,D> [goto ACICCMP]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 23 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.330_00.000
Variable Name
ACICCMP
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
How worried are you right now about not being able to make the minimum payments on
your credit cards? Are you…
*Read answer categories if necessary.
Answer Codes
Question Type
1. Very worried
2. Moderately worried
3. Not too worried
4. Not worried at all
5. I don't have credit cards
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-5,R,D> [goto ACISLEEP]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 24 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.340_00.000
Variable Name
ACISLEEP
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
On average, how many hours of sleep do you get in a 24-hour period?
*Enter hours of sleep in whole numbers, rounding 30 minutes (1/2 hour) or more UP to
the next whole hour and dropping 29 or fewer minutes.
Answer Codes
Allow 1-24, R, D
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-5>[goto ERR_SLEEP];
<1-24, R,D>[goto ACISLPFL]
Hard Edits
Soft Edits
ERR_SLEEP
*Average number of hours of sleep is [ACISLEEP].
* Please verify.
AssocHelp
Thursday, August 09, 2012
Page 25 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.350_00.000
Variable Name
ACISLPFL
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
In the past week, how many times did you have trouble falling asleep?
*Enter '0' if respondent did not have trouble falling asleep in the past week.
*Enter '7' for 7 or more times.
Answer Codes
Allow 0-7, R, D
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<0-7,R,D> [goto ACISLPST]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 26 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.360_00.000
Variable Name
ACISLPST
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
In the past week, how many times did you have trouble staying asleep?
*Enter '0' if respondent did not have trouble staying asleep in the past week.
*Enter '7' for 7 or more times.
Answer Codes
Allow 0-7, R, D
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<0-7,R,D> [goto ACISLPMD]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 27 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.370_00.000
Variable Name
ACISLPMD
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
In the past week, how many times did you take medication to help you fall asleep or
stay asleep?
*Enter '0' if respondent did not take medication to help sleep in the past week.
*Enter '7' for 7 or more times.
Answer Codes
Allow 0-7, R, D
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<0-7,R,D> [goto ACIREST]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 28 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.380_00.000
Variable Name
ACIREST
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
In the past week, on how many days did you wake up feeling well rested?
*Enter '0' if respondent never felt well rested in the past week.
Answer Codes
Allow 0-7, R, D
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<0-7,R,D> [goto MHSAD_CK]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 29 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.390_00.000
Variable Name
MHSAD_CK
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
Now I am going to ask you some questions about feelings you may have experienced
over the PAST 30 DAYS.
Answer Codes
1. Enter 1 to Continue
Question Type
Enter 1 to Continue
Field Pane Description
Continue
Fill Instructions
Special Instructions Do not allow Don't know or Refused.
Skip Instructions
<1> [goto ACISAD]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 30 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.390_01.000
Variable Name
ACISAD
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
(book) ASI5
DURING THE PAST 30 DAYS, how often did you feel
...So sad that nothing could cheer you up?
Answer Codes
Question Type
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-5,R,D> [goto ACINERV]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 31 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.390_02.000
Variable Name
ACINERV
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
(book) ASI5
* Read if necessary:
During the PAST 30 DAYS, how often did you feel
...Nervous?
Answer Codes
Question Type
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-5,R,D> [goto ACIRSTLS]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 32 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.390_03.000
Variable Name
ACIRSTLS
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
(book) ASI5
* Read if necessary:
During the PAST 30 DAYS, how often did you feel
...Restless or fidgety?
Answer Codes
Question Type
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-5,R,D> [goto ACIHOPLS]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 33 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.390_04.000
Variable Name
ACIHOPLS
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
(book) ASI5
* Read if necessary:
During the PAST 30 DAYS, how often did you feel
...Hopeless?
Answer Codes
Question Type
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-5,R,D> [goto ACIEFFRT]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 34 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.390_05.000
Variable Name
ACIEFFRT
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
(book) ASI5
* Read if necessary:
During the PAST 30 DAYS, how often did you feel
...That everything was an effort?
Answer Codes
Question Type
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-5,R,D> [goto ACIWTHLS]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 35 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.390_06.000
Variable Name
ACIWTHLS
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
(book) ASI5
* Read if necessary:
During the PAST 30 DAYS, how often did you feel
...Worthless?
Answer Codes
Question Type
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-5,R,D> if ACISAD or ACINERV or ACIRSTLS or ACIHOPLS or ACIEFFRT or
ACIWTHLS=1-3 [goto ACIMUCH];
else [goto ACIHIVT]
Hard Edits
Soft Edits
AssocHelp
Thursday, August 09, 2012
Page 36 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.400_00.000
Variable Name
ACIMUCH
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2' and
(ACISAD(e) IN('1','2','3') or ACINERV(e) IN('1','2','3') or ACIRSTLS(e) IN('1','2','3') or
ACIHOPLS(e) IN('1','2','3') or ACIEFFRT (e) IN('1','2','3') or ACIWTHLS(e) IN('1','2','3'))
Universe-text
Sample adults 18+ who at least some of the time have felt sad, nervous, restless or
fidgety, hopeless, that everything was an effort, or worthless, in the past 30 days
Question Text
We just talked about a number of feelings you had during the PAST 30 DAYS.
Altogether, how MUCH did these feelings interfere with your life or activities: a lot,
some, a little, or not at all?
Answer Codes
Question Type
1. A lot
2. Some
3. A little
4. Not at all
Refused
Don't Know
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Thursday, August 09, 2012
Page 37 of 38
Module
52
Section Name
Adult SEXUALITY Module
Part
Question ID
ASI.410_00.000
Variable Name
ACIHIVT
Universe
HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and QTYPE='2'
Universe-text
Sample adults 18+
Question Text
The next question is about the test for HIV, the virus that causes AIDS. Except for tests
you may have had as part of blood donations, have you ever been tested for HIV?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto next section]
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Thursday, August 09, 2012
Page 38 of 38
| File Type | application/pdf |
| File Modified | 2012-09-06 |
| File Created | 2012-08-28 |