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pdfAttachment 3i NHIS 2013 Flashcard Booklet
54HIS-501(C) (2013)
NATIONAL
HEALTH
INTERVIEW
SURVEY
U.S. Department
of Commerce
BUREAU OF THE
CENSUS
Field
Representative’s
Flashcard and
Information
Booklet (CAPI)
CARD H1
You may choose more than one.
1.
Puerto Rican
2.
Cuban/Cuban American
3.
Dominican (Republic)
4.
Mexican
5.
Mexican American
6.
Central or South American
7.
Other Latin American
8.
Other Hispanic/Latino/Spanish
CARD H2
You may choose more than one.
1.
White
2.
Black/African American
3.
Indian (American)
4.
Alaska Native
5.
Native Hawaiian
6.
Guamanian or Chamorro
7.
Samoan
8.
Other Pacific Islander
9.
Asian Indian
10. Chinese
11. Filipino
12. Japanese
13. Korean
14. Vietnamese
15. Other Asian
CARD H3
2.
Spouse (husband/wife)
3.
Unmarried Partner
4.
Child (biological/adoptive/in-law/
step/foster)
5.
Child of Partner
6.
Grandchild
7.
Parent (biological/adoptive/in-law/
step/foster)
8.
Brother/Sister (biological/adoptive/in-law/
step/foster)
9.
Grandparent (Grandmother/Grandfather)
10. Aunt/Uncle
11. Niece/Nephew
12. Other relative
13. Housemate/Roommate
14. Roomer/Boarder
15. Other non-relative
16. Legal Guardian
17. Ward
CARD F1
You may choose more than one.
1.
Vision/problem seeing
2.
Hearing problem
3.
Speech problem
4.
Asthma/breathing problem
5.
Birth defect
6.
Injury
7.
Intellectual disability, also known as mental
retardation
8.
Other developmental problem
(for example, cerebral palsy)
9.
Other mental, emotional, or behavioral
problem
10. Bone, joint, or muscle problem
11. Epilepsy or seizures
12. Learning disability
13. Attention Deficit/Hyperactivity
Disorder (ADD/ADHD)
Other impairment/problem
CARD F2
You may choose more than one.
1.
Vision/problem seeing
2.
Hearing problem
3.
Arthritis/rheumatism
4.
Back or neck problem
5.
Fracture or bone/joint injury
6.
Other injury
7.
Heart problem
8.
Stroke problem
9.
Hypertension/high blood pressure
10. Diabetes
11. Lung/breathing problem (for example, asthma
and emphysema)
12. Cancer
13. Birth defect
14. Intellectual disability, also known as mental
retardation
15. Other developmental problem (for example, cerebral
palsy)
16. Senility
17. Depression/anxiety/emotional problem
18. Weight problem
Other impairment/problem
CARD F3
Beginning
1
2
3
8
9
10
4
5
6
7
11
12
13
14
18
19
20
Middle
Middle
Middle
15
16
17
21
End
22
23
24
29
30
31
25
26
27
28
CARD F4
You may choose up to four.
Insert drawing of injured body parts here
Insert drawing of face here.
CARD F5
You may choose up to two.
1.
Broken bone or fracture
2.
Sprain, strain, or twist
3.
Cut
4.
Scrape
5.
Bruise
6.
Burn
7.
Insect bite
8.
Animal bite
9.
Other (specify)
CARD F6
1.
2.
3.
4.
5.
6.
7.
8.
9.
Passenger car
Passenger truck, such as a pickup truck, van, or
SUV
Bus
Large commercial truck, such as a semi-truck, big
rig, or 18-wheeler
Motorcycle (including mopeds, minibikes)
All terrain vehicle or ski/snow-mobile
Farm equipment (such as a tractor)
Industrial or construction vehicle
Other
CARD F7
You may choose up to two.
On, down, from, or into:
1.
Stairs, steps, or escalator
2.
Floor or level ground
3.
Curb (including sidewalk)
4.
Ladder or scaffolding
5.
Playground equipment
6.
Sports field, court, or rink
7.
Building or other structure
8.
Chair, bed, sofa, or other furniture
9.
Bathtub, shower, toilet, or commode
10. Hole or other opening
11. Other
CARD F8
1.
Slipping or tripping
2.
Jumping or diving
3.
Bumping into an object or another person
4.
Being shoved or pushed by another person
5.
Losing balance or having dizziness (becoming faint
or having a seizure)
6.
Other
CARD F9
1.
Swallowing a drug or medical substance mistakenly
or in overdose
2.
Swallowing or touching a harmful solid or liquid
substance
3.
Inhaling harmful gases or vapors
4.
Eating a poisonous plant or other substance
mistaken for food
5.
Being bitten by a poisonous animal
6.
Other (specify)
CARD F10
You may choose up to two.
1.
Driving or riding in a motor vehicle
2.
Working at a paid job
3.
Working around the house or yard
4.
Attending school
5.
Unpaid work (such as volunteer work)
6.
Sports and exercise
7.
Leisure activity (excluding sports)
8.
Sleeping, resting, eating, or drinking
9.
Cooking
10. Being cared for (hands-on care from other person)
11. Other (specify)
CARD F11
You may choose up to two.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Home (inside)
Home (outside)
School (not residential)
Child care center or preschool
Residential institution (excluding hospital)
Health care facility (including hospital)
Street or highway
Sidewalk
Parking lot
Sport facility, athletic field, or playground
Shopping center, restaurant, store, bank, gas
station, or other place of business
Farm
Park or recreation area (including bike or jog path)
River, lake, stream, or ocean
Industrial or construction area
Other public building
Other
CARD F12
You may choose more than one.
1.
Private health insurance*
2.
Medicare
3.
Medi-Gap
4.
Medicaid
5.
SCHIP (CHIP/Children’s Health
Insurance Program)
6.
Military health care
(TRICARE/VA/CHAMP-VA)
7.
Indian Health Service
8.
State-sponsored health plan
9.
Other government program
10. Single service plan (e.g., dental, vision,
prescriptions)
11. No coverage of any type
*EXCLUDE private plans that only provide
extra cash while hospitalized.
CARD F13
Insert picture of Medicare card here.
CARD F14
STATE NAMES FOR MEDICAID, CHIP, STATE-/LOCALSPONSORED, AND OTHER HEALTH INSURANCE PROGRAMS
***FORTHCOMING***
CARD F15
You may choose more than one.
1.
Accidents
2.
AIDS care
3.
Cancer treatment
4.
Catastrophic care
5.
Dental care
6.
Disability insurance (cash payments
when unable to work for health reasons)
7.
Hospice care
8.
Hospitalization only
9.
Long-term care (nursing home care)
10. Prescriptions
11. Vision care
12. Other (specify)
CARD F16
1. Through employer
2. Through union
3. Through workplace, but don’t know if
employer or union
4. Through workplace, self-employed or
professional association
5. Purchased directly
6. Through a state/local government or
community program
7. Other (specify)
CARD F17
1.
6 months or less
2.
More than 6 months, but not more than
1 year ago
3.
More than 1 year, but not more than 3
years ago
4.
More than 3 years
5.
Never
CARD F18
You may choose up to five.
1.
Person in family with health insurance
lost job or changed employers
2.
Got divorced or separated/death
of spouse or parent
3.
Became ineligible because of
age/left school
4.
Employer does not offer coverage/
or not eligible for coverage
5.
Cost is too high
6.
Insurance company refused
coverage
7.
Medicaid/Medical plan stopped
after pregnancy
8.
Lost Medicaid/Medical plan
because of new job or increase
in income
9.
Lost Medicaid (Other reason for losing Medicaid)
10. Other (specify)
CARD F19
0.
Zero
1.
Less than $500
2.
$500 - $1,999
3.
$2,000 - $2,999
4.
$3,000 - $4,999
5.
$5,000 or more
CARD F20
1.
Yes, born in one of the 50 United
States, or the District of Columbia
2.
Yes, born in Puerto Rico, Guam,
American Virgin Islands, or other U.S.
territory
3.
Yes, born abroad to American parent(s)
4.
Yes, U.S. citizen by naturalization
5.
No, not a citizen of the United States
CARD F21
0.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Never attended/kindergarten only
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade, no diploma
GED or equivalent
HIGH SCHOOL GRADUATE
Some college, no degree
Associate’s degree: occupational,
technical, or vocational program
Associate’s degree: academic program
Bachelor’s degree (Example: BA, AB, BS, BBA)
Master’s degree (Example: MA, MS, MEng, MEd,
MBA)
Professional School degree (Example: MD, DDS,
DVM, JD)
Doctoral degree (Example: Phd, EdD)
CARD F22
1.
2.
3.
4.
Working for pay at a job or business
With a job or business but not at work
Looking for work
Working, but not for pay, at a family-owned job or
business
5. Not working at a job or business and not looking for
work
CARD C1
1. Parent (Biological, adoptive or step)
2. Grandparent
3. Aunt/Uncle
4. Brother/Sister
5. Other relative
6. Legal Guardian
7. Foster parent
8. Other non-relative
CARD C2
You may choose more than one.
1. Down syndrome
2. Cerebral palsy
3. Muscular dystrophy
4. Cystic fibrosis
5. Sickle cell anemia
6. Autism/Autism spectrum disorder
7. Diabetes
8. Arthritis
9. Congenital heart disease
10. Other heart condition
CARD C3
0. Not true
1. Sometimes true
2. Often true
CARD C4
0. Never
1. 6 months or less
2. More than 6 months, but not more than 1 year ago
3. More than 1 year, but not more than 2 years ago
4. More than 2 years, but not more than 5 years ago
5. More than 5 years ago
CARD C5
0. None
1. 1
2. 2 - 3
3. 4 - 5
4. 6 - 7
5. 8 - 9
6. 10 - 12
7. 13 - 15
8. 16 or more
CARD C6
1. 1
2. 2 - 3
3. 4 - 5
4. 6 - 7
5. 8 - 9
6. 10 - 12
7. 13 - 15
8. 16 or more
CARD C7
1.
Not true
2.
Somewhat true
3.
Certainly true
CARD C8
Overall, do you think that this child has difficulties in any
of the following areas: emotions, concentration,
behavior, or being able to get along with other people?
1. No
2. Yes, minor difficulties
3. Yes, definite difficulties
4. Yes, severe difficulties
CARD C9
1. Pediatrician or family doctor
2. Psychiatrist, psychologist, clinical social worker or
psychiatric nurse
3. Speech, occupational or physical therapist
4. Religious or spiritual counselor or advisor
5. Probation or juvenile corrections officer or court
counselor
6. Other
CARD A1
1.
2.
3.
4.
Working for pay at a job or business
With a job or business but not at work
Looking for work
Working, but not for pay, at a family-owned job or
business
5. Not working at a job or business and not looking for
work
CARD A2
1. An employee of a PRIVATE company,
business, or individual for wages,
salary, or commission
2. A FEDERAL government employee
3. A STATE government employee
4. A LOCAL government employee
5. Self-employed in OWN business,
professional practice or farm
6. Working WITHOUT PAY in
family-owned business or farm
CARD A3
1. 1-9 employees
2. 10-24 employees
3. 25-49 employees
4. 50-99 employees
5. 100-249 employees
6. 250-499 employees
7. 500-999 employees
8. 1000 employees or more
Card A4
You may choose more than one.
Place drawing of joints here.
CARD A5
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
CARD A6
0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
CARD A7
You may choose more than one.
1. Vision/problem seeing
2. Hearing problem
3. Arthritis/rheumatism
4. Back or neck problem
5. Fracture or bone/joint injury
6. Other injury
7. Heart problem
8. Stroke problem
9. Hypertension/high blood pressure
10. Diabetes
11. Lung/breathing problem (for example, asthma and
emphysema)
12. Cancer
13. Birth defect
14. Intellectual disability, also known as mental retardation
15. Other developmental problem (for example, cerebral
palsy)
16. Senility
17. Depression/anxiety/emotional
problem
18. Weight problem
Other impairment/problem
CARD A8
0. Never
1. 6 months or less
2. More than 6 months, but not more than 1 year
ago.
3. More than 1 year, but not more than 2 years ago
4. More than 2 years, but not more than 5 years ago
5. More than 5 years ago
CARD A9
0. None
1. 1
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10-12
7. 13-15
8. 16 or more
CARD A10
1. 1
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10-12
7. 13-15
8. 16 or more
CARD A11
1.
It’s unlikely you’ve been exposed to HIV
2.
You were afraid to find out if you were HIV
positive (that you had HIV)
3.
You didn’t want to think about HIV or about
being HIV positive
4.
You were worried your name would be
reported to the government if you tested
positive
5.
You didn’t know where to get tested
6.
You don’t like needles
7.
You were afraid of losing job, insurance,
housing, friends, family, if people knew you
were positive for AIDS infection
8.
Some other reason (specify)
9.
No particular reason
CARD ASI1
1. Gay
2. Straight, that is, not gay
3. Bisexual
4. Something else
5. I don't know the answer
CARD ASI2
1. Lesbian or gay
2. Straight, that is, not lesbian or gay
3. Bisexual
4. Something else
5. I don't know the answer
CARD ASI3
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
CARD ASI4
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
CARD ASI5
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
| File Type | application/pdf |
| File Title | 54HIS-501(C) (2004) |
| Author | bft8 |
| File Modified | 2012-10-01 |
| File Created | 2012-10-01 |