Att 9C_Youth_CaregiverSurvey_ItemSources_2013_0618

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

#

Item Name
in CAPI

Item Text in CAPI

Data Source

Original Text in Source

1

INTRO_1_cy

ASK IF NEEDED OF EITHER ADULT CAREGIVER OR CHILD: What is
your/the child's age?

RTI Developed

N/A

N/A

2

INTRO_2_cy

ASK IF NEEDED OF EITHER ADULT CAREGIVER OR CHILD: What is
your/the child's name?

RTI Developed

N/A

N/A

3

INTRO_3_cy ASK IF NEEDED OF THE ADULT CAREGIVER: What is your name?

RTI Developed

N/A

N/A

4

INTRO_5_cy IF S.C. >11, SKIP TO INTRO_7_cy. “How are you related to {S.C}?”

RTI Developed

N/A

N/A

5

INTRO_6_cy

[ASK IF {S.C.}AGE<12, ELSE SKIP TO INTRO_7_cy] Are you {S.C}’s legal
RTI Developed
guardian?

N/A

N/A

6

INTRO_7_cy

What grade [TEXTFILL IF {S.C.} AGE<11, is {S.C} ELSE “are you”]
RTI Developed
enrolled in or will be enrolled in during the 2013-2014 school year?

N/A

N/A

The next questions exclude the work and
NHANES 2012:
Let’s begin by talking about the biking and walking that [TEXTFILL IF
transportation activities that you have already
PA_INTRO_c
Physical Activity and
7
{S.C} AGE<12 “{S.C} did with or without you,” ELSE “you did”] this
mentioned. Now I would like to ask you about
y
Physical Fitness
past week either for transportation or leisure.
sports, fitness and recreational activities.
Section

8

PA_01_cy

[ASK ONLY IF {S.C} AGE>5, ELSE SKIP] During the past week, on how
many days did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] walk or
bicycle [TEXTFILL IF {S.C} AGE<12”, with or without you,”] for at
least 10 minutes continuously to get to and from places?

NHANES 2012:
In a typical week {do you/does SP} walk or use a
Physical Activity and
bicycle for at least 10 minutes continuously to get
Physical Fitness
to and from places?
Section

Page 1 of 23

Divergence?

Yes

No

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

9

Item Name
in CAPI

PA_04_cy

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

[ASK ONLY IF {S.C} AGE>5, ELSE SKIP] Thinking about the past week,
not counting any walking that you already mentioned, on how many
days did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] walk or bike
for at least 10 minutes continuously for leisure?
IPAQ

10

11

12

PA_02_cy

PA_03_cy

PA_05_cy

Divergence?

Not counting any walking you have already
mentioned, during the last 7 days, on how many
days did you walk for at least 10 minutes at a
time in your leisure time?

Yes

NHANES 2012:
In a typical week, on how many days {do
Physical Activity and
you/does SP} walk or bicycle for at least 10
Physical Fitness
minutes continuously to get to and from places?
Section

Yes

IF NEEDED, SAY: (Think about only the walking that [TEXTFILL IF {S.C}
AGE<12 “{S.C}” ELSE “you”] did for at least 10 minutes at a time.)
Thinking about the last five week days, on a typical week day how
much time did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend
walking or bicycling for travel? For example, to go to a friend’s
house or school.

Original Text in Source

IF NEEDED, PROBE SAYING: How much time did [TEXTFILL IF {S.C}
AGE<12 “{S.C}” ELSE “you”] spend walking or biking for travel on
Wednesday?”)
Thinking about a typical day over the past weekend, how much time
did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend walking or
bicycling for travel? (For example, to go to a friend’s house or
NHANES 2012:
In a typical week, on how many days {do
school.)
Physical Activity and
you/does SP} walk or bicycle for at least 10
Physical Fitness
minutes continuously to get to and from places?
IF NEEDED, PROBE SAYING: (“How much time in total did [TEXTFILL Section
IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend walking or biking for
travel on Saturday?”)
Thinking about the past week,) on a typical weekday, how much
time did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend walking
or biking for leisure?
IPAQ
IF NEEDED, PROBE SAYING: (“How much time in total did you spend
walking on Wednesday?”)

Page 2 of 23

How much time did you usually spend on one of
those days walking in your leisure time?

Yes

Yes

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

13

14

15

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

PA_20_cy

[ASK ONLY IF {S.C} AGE<6, ELSE SKIP] During the past week, how
many days did {S.C.} play with other children [TEXTFILL IF
VERIFY_3_cy=1 "his" IF VERIFY_3_cy=2 "her"] age?

NSCH 2011

During the past week, how many days did [S.C.]
play with other children [his/her] age?

No

PA_07_cy

[ASK ONLY IF {S.C} AGE<6, ELSE SKIP] During the past week, how
many days did you or any family member take {S.C.} on any kind of
outing, such as to the park, library, zoo, shopping, church,
restaurants, or family gatherings?

NSCH 2011

During the past week, how many days did you or
any family member take [S.C.] on any kind of
outing, such as to the park, library, zoo,
shopping, church, restaurants, or family
gatherings?

Yes

PA_08_ cy

[ASK ONLY IF {S.C} AGE>5, ELSE SKIP] During the past week, on how
many days did [TEXTFILL IF {S.C.} AGE>6 “{S.C.}, ELSE “you”]
exercise, play a sport, or participate in physical activity for at least
20 minutes that made [TEXTFILL IF him/her AGE>6 “{S.C.}, ELSE
“you”] sweat and breath hard?

Divergence?

During the past week, on how many days did
[S.C.] exercise, play a sport, or participate in
physical activity for at least 20 minutes that made
[him/her] sweat and breathe hard?
NSCH 2011

IF NEEDED, SAY: Include active sports such as baseball, softball
basketball, swimming, soccer, tennis, or football: riding a bike or
rollerskating; walking or jogging; jumping rope; gymnastics; or
active dance such as ballet.

READ IF NECESSARY: Include active sports such as
baseball, softball, basketball, swimming, soccer,
tennis, or football; riding a bike or rollerstkating;
walking or jogging; jumping rope; gymnastics;
and active dance such as ballet.

No

16

[ASK IF {S.C.} AGE >4, ELSE SKIP TO PA_14_cy]. (During the past
week,) on how many days did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE
PA_12_ cy
“you”] play active video games such as Wii Sports, Wii Fit, Xbox 360,
Xbox Kinect, Playstation 3, or Dance, Dance Revolution?

NHANES 2012:
Physical Activity and
Physical Fitness
Section

During the past 7 days, on how many days did
{you/SP} play active video games such as Wii
Sports, Wii Fit, Xbox 360, Xbox Kinect, Playstation
3, or Dance, Dance Revolution?

No

17

On average, for how long did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE
“you”] play these active video games on a typical day?
PA_13_ cy. IF NEEDED, PROBE SAYING: ("How much time in total did [TEXTFILL
IF {S.C} AGE<12 “{S.C}” ELSE “you”]spend playing active video games
on Wednesday?”)

NHANES 2012:
Physical Activity and On average, for how long did {you/SP} play these
Physical Fitness
active video games?
Section

Yes

Page 3 of 23

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

18

Item Name
in CAPI

PA_14_cy

19

PA_18_cy

20

PA_18a_cy

Item Text in CAPI

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey
Data Source

The following questions are about the total time [TEXTFILL IF {S.C}
AGE<12 “{S.C} spends” ELSE “you spend”] sitting anywhere, such as
at school, [TEXTFILL IF {S.C} AGE<6 “at day care,”] [TEXTFILL IF {S.C}
AGE>14 “at work,”] home, getting to and from places, or with
friends, including time spent sitting at a desk, traveling in a car or
NHANES 2012:
bus, reading, playing cards, watching television, or using a
Physical Activity and
computer. Do not include time spent sleeping.
Physical Fitness
Section
(Thinking about the past week,) on a typical day how much time
[TEXTFILL IF {S.C} AGE<12 “did {S.C}” ELSE “did you”] spend sitting?
IF NEEDED, PROBE SAYING: (“How much time in total [TEXTFILL IF
{S.C} AGE<12 “did {S.C}” ELSE “did you”] spend sitting on
Wednesday?”)

Original Text in Source

The following question is about sitting at work, at
home, getting to and from places, or with friends,
including time spent sitting at a desk, traveling in
a car or bus, reading, playing cards, watching
television, or using a computer. Do not include
time spent sleeping.

Divergence?

Yes

How much time {do you/does SP} usually spend
sitting on a typical day?

Now, I have a few questions about your
neighborhood and community. Please tell me if
the following places and things are available to
children in your neighborhood, even if [S.C.] does
not actually use them.

Yes

NSCH 2011

Sidewalks or walking paths?

No

NSCH 2011

A park or playground area?

No

NSCH 2011

A recreation center, community center, or boys’
or girls’ club?

No

Let’s talk now about your neighborhood and community. Please tell
me if the following places and things are available in your
NSCH 2011
neighborhood, even if [TEXTFILL IF {S.C} AGE<12 “{S.C} does” ELSE
“you do”] not actually use them.
Sidewalks or walking paths?
IF NEEDED, SAY: Do those exist in your neighborhood?
A park or playground area?

21

PA_18b_cy
IF NEEDED, SAY: Do those exist in your neighborhood?
A recreation center, community center, or boys’ or girls’ club?

22

PA_18c_cy
IF NEEDED, SAY: Do those exist in your neighborhood?

Page 4 of 23

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

23

Item Name
in CAPI

PA_19_cy

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI
How often do you feel [TEXTFILL IF {S.C} AGE<12 “{S.C} is”] safe in
your community or neighborhood? Would you say….
1. Always
2. Usually
3. Sometimes
4. Never

Data Source

Original Text in Source

NSCH 2011

How often do you feel [S.C.] is safe in your
community or neighborhood? Would you say
never, sometimes, usually, or always?

No

These questions are about the different kinds of
foods {you/SP} ate or drank during the past
month, that is, the past 30 days. When
answering, please include meals and snacks
eaten at home, at work or school, in restaurants,
and anyplace else.

Yes

NUTRITION
Now I have some questions about [TEXTFILL IF {S.C} AGE<12
“{S.C.’s}” ELSE “your”] eating habits.
These questions are about the different kinds of foods [TEXTFILL IF
{S.C} AGE<12 “{S.C}” ELSE “you”] ate or drank during the past
NHANES 2010:
N_INTRO_cy
24
month, that is, since [FILL IN WITH DAY 30 DAYS AGO]. When
Dietary Screener
.
answering, please include meals and snacks eaten [TEXTFILL IF {S.C} Section
AGE<12 “by {S.C}” ELSE “by you”] at home, at [TEXTFILL IF {S.C}
AGE>14 “at work,”] school, [TEXTFILL IF {S.C} AGE<6 “at day care,”]
in restaurants, and anyplace else. Keep in mind there are no right
or wrong answers. Your best guess is fine.

Page 5 of 23

Divergence?

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

NHANES 2010:
Dietary Screener
Section

(During the past month), how often did {you/SP}
have milk {either to drink or on cereal}? Do not
include soy milk or small amounts of milk in
coffee or tea. (You can tell me per day, per week
or per month.)

(During the past month), since [FILL IN DATE 30 DAYS AGO) how
often did [TEXTFILL IF {S.C.} AGE<12 "{S.C.}" ELSE "you"] have milk
either to drink or on cereal? You can answer by telling me how
often you drank milk on an average day, average week, or for the
entire month.
25

N_03_cy

IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK:
“Was that per day, per week, or per month?”

Divergence?

Yes

YOU MAY READ EXAMPLES FROM THE LIST UPON REQUEST.
• (Include buttermilk, chocolate milk, lactose-free milk, low-fat milk,
no-fat milk, other flavored milks, skim milk, whole milk.)
• (Do not include cream.)
What type of milk was it?
IF RESPONDENT CANNOT PROVIDE USUAL TYPE, CODE ALL THAT
APPLY.
IF RESPONDENT INDICATES A FLAVORED MILK, SUCH AS
“CHOCOLATE MILK,” PROBE FOR A BEST GUESS THAT FITS ANSWER
OPTIONS BEFORE CODING AS OTHER
26

N_03a_cy

READ ANSWER OPTIONS ONLY IF NECESSARY:
1.
2.
3.
4.
5.
6.
7.
8.

Whole milk
2% fat milk
1% fat milk
Skim, nonfat, or ½% fat milk
Soy milk
Rice milk
Raw, unpasteurized milk
Other

NHANES 2006: Food
Frequency
What kind of milk did you usually drink?
Questionnaire

Page 6 of 23

Yes

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

27

28

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

N_03b_cy

IF NEEDED SAY: (Was the milk [TEXTFILL IF {S.C} AGE<12 “{S.C}”
ELSE “you”] usually drank flavored?)

RTI Developed

NA

NA

N_04_cy

During the past month, how often did [TEXTFILL IF {S.C} AGE<12
“{S.C}” ELSE “you”] drink regular soda, or pop that contained sugar?
Do not include diet soda. (You can tell me per day, per week or per
month.)
IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK:
NHANES 2010:
“Was that per day, per week, or per month?”
Dietary Screener
Section
YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.
• (Include Manzanita, Penafiel sodas, Coke, and Pepsi)
• (Do not include diet fruit drinks, juices in cans, sugar-free fruit
drinks, tea in cans, Diet Coke, or Diet Pepsi.)

During the past month, how often did {you/SP}
drink regular soda or pop that contains sugar? Do
not include diet soda. You can tell me per day,
per week or per month.

No

(During the past month), how often did {you/SP}
drink 100% pure fruit juice such as orange,
mango, apple, grape and pineapple juices? Do
not include fruit-flavored drinks with added sugar
or fruit juice you made at home and added sugar
to. (You can tell me per day, per week or per
month.)

No

(During the past month), since (POPULATE WITH DATE 30 DAYS
AGO) how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”]
drink 100% pure fruit juice such as orange, mango, apple, grape and
pineapple juices? Do not include fruit-flavored drinks with added
sugar or fruit juice [TEXTFILL IF {S.C} AGE<12 “{S.C}/you” ELSE “you”]
made at home and added sugar to. (You can tell me per day, per
week or per month.)
29

N_05_cy

IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK:
“Was that per day, per week, or per month?”

NHANES 2010:
Dietary Screener
Section

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.
• (Include only 100% pure juices.)
• (Do not include fruit-flavored drinks with added sugar, cranberry
cocktail, Gatorade, Hi-C, Kook-Aid, lemonade, Sunndy Delight,
Tampico)

Page 7 of 23

Divergence?

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI
Now we are going to ask about fruit-flavored drinks with added
sugar. (During the past month), how often did [TEXTFILL IF {S.C}
AGE<12 “{S.C}” ELSE “you”] drink sweetened fruit drinks, sports or
energy drinks, such as Kool-aid, lemonade, Hi-C, cranberry drink,
Gatorade, Red Bull or Vitamin Water? Include fruit juices you made
at home and added sugar to. Do not include diet drinks or artificially
sweetened drinks. (You can tell me per day, per week or per
month.)

30

N_06_cy

IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK:
“Was that per day, per week, or per month?”

Data Source

Original Text in Source

NHANES 2010:
Dietary Screener
Section

(During the past month), how often did {you/SP}
drink sweetened fruit drinks, sports or energy
drinks, such as Kool-aid, lemonade, Hi-C,
cranberry drink, Gatorade, Red Bull or Vitamin
Water? Include fruit juices you made at home
and added sugar to. Do not include diet drinks or
artificially sweetened drinks. (You can tell me per
day, per week or per month.)

No

NHANES 2010:
Dietary Screener
Section

(During the past month), how often did {you/SP}
eat fruit? Include fresh, frozen or canned fruit. Do
not include juices. (You can tell me per day, per
week or per month.)

No

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.
• (Include drinks with added sugar, Tampico, Sunny Delight, and
Twister.)
• (Do not include, 100% fruit juices or soda, carbonated water, fruitflavored teas, soda, or yogurt drinks.)

Divergence?

(During the past month), how often did [TEXTFILL IF {S.C} AGE<12
“{S.C}” ELSE “you”] eat fruit? Include fresh, frozen or canned fruit.
Do not include juices. (You can tell me per day, per week or per
month.)

31

N_07_cy

IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK:
“Was that per day, per week, or per month?”
YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.
• (Include fruits such as apples, applesauce, bananas, berries, fruit
salad, grapes, mangos, melon, oranges, papayas.)
• (Do not include dried fruits.)

Page 8 of 23

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

Divergence?

(During the past month), how often did [TEXTFILL IF {S.C} AGE<12
“{S.C}” ELSE “you”] eat vegetables? Include salads, cooked beans,
and all types of potatoes, except for fried potatoes such as French
fried. (You can tell me per day, per week or per month.)
IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK:
“Was that per day, per week, or per month?”
32

N_08_cy

NHANES 2010:
YOU MAY READ EAMPLES FROM LIST UPON REQUEST.
Dietary Screener
• (Include black beans, black-eyed peas, bean sprouts, broccoli, cow
Section
peas, cabbage, carrots, collard greens, corn, garbanzo, green beans,
green leafy salad, kidney, lentils, lettuce salad, lima beans, pinto
beans, potatoes au gratin, scalloped potatoes, soybeans, spinach
salad, tomatoes.)
• (Do not include French fried, fried potatoes, hash brown potatoes,
home fries.)
• (Keep in mind there are no right or wrong answers. Your best
estimates are fine.)
During the past month, (that is since [FILL IN DATE 30 DAYS AGO],)
how many times per day, week or month, did [TEXTFILL IF {S.C}
AGE<12 “{S.C}” ELSE “you”] drink water? Include tap, bottled, and
unflavored sparkling water.

33

N_13_cy

IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK:
“Was that per day, per week, or per month?”

CPPW BRFSS

IF SAYS LESS THAN ONCE PER MONTH, SELECT NEVER.

Page 9 of 23

(During the past month), how often did {you/SP}
eat a green leafy or lettuce salad, with or without
other vegetables? (You can tell me per day, per
week or per month.)

No

During the past 7 days, how many times did you
drink an 8 ounce bottle or glass of plain water?
Count tap, bottled, and unflavored sparkling
water.

Yes

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

34

35

36

Item Name
in CAPI

Item Text in CAPI

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey
Data Source

Original Text in Source

Divergence?

N_14_cy

Now, let’s talk about what foods you keep at home. How often do
you have fruits available at home? This includes fresh, dried, canned
How often {does your family/do you} have fruits
and frozen fruits. Would you say . . . ?
NHANES 2010:
available at home? This includes fresh, dried,
1. Always
Consumer Behavior canned and frozen fruits. Would you say always,
2. Most of the time
Section
most of the time, sometimes, rarely, or never?
3. Sometimes
HAND CARD CBQ1
4. Rarely or
5. Never

No

N_15_cy

How often do you have any of these dark green vegetables available
How often {does your family/do you} have any of
at home? Broccoli; spinach and other greens like collard, mustard,
these dark green vegetables available at home?
and turnip greens; and dark green leafy lettuce like romaine. Would
This includes fresh, dried, canned, and frozen
you say . . . ?
NHANES 2010:
vegetables. [Would you say always, most of the
1. Always
Consumer Behavior
time, sometimes, rarely, or never?] HAND CARD
2. Most of the time
Section
CBQ2 and HAND CARD CBQ3. INTERVIEWER
3. Sometimes
INSTRUCTION: DO NOT INCLUDE ICEBERG,
4. Rarely or
BUTTERHEAD, BOSTON, AND MANOA LETTUCE
5. Never

Yes

N_16_cy

How often do you have fat-free or low-fat (1%) milk at home?
(Would you say . .. . ?)
1. Always
2. Most of the time
3. Sometimes
4. Rarely or
5. Never)

Yes

How often {does your family/do you} have 1%
NHANES 2010:
fat, skim or fat free milk available at home?
Consumer Behavior Please do not include 2% milk. [Would you say
Section
always, most of the time, sometimes, rarely, or
never?]

Page 10 of 23

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

37

Item Name
in CAPI

N_17_cy

38

N_20_cy

39

N_20a_cy

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

How often does your family/do you have soft drinks, fruit-flavored
drinks, or fruit punch available at home? Do not include diet drinks,
How often {does your family/do you} have soft
100 percent juice or sports drinks. (Would you say…?)
drinks, fruit-flavored drinks, or fruit punch
NHANES 2010:
1. Always
available at home? Please do not include diet
Consumer Behavior
2. Most of the time
drinks, 100 percent juice or sports drinks. [Would
Section
3. Sometimes
you say always, most of the time, sometimes,
4. Rarely or
rarely, or never?]
5. Never)
Our next question about food is about whole meals. By meal, I
mean breakfast, lunch and dinner. During the past 7 days, how
many meals did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat
that were prepared away from home in places such as restaurants,
fast food places, food stands, grocery stores, or from vending
machines? Please do not include meals provided as part of the
school lunch or school breakfast.

During the past 7 days, how many meals {did
you/did SP} get that were prepared away from
home in places such as restaurants, fast food
NHANES 2010: Diet places, food stands, grocery stores, or from
Behavior and
vending machines? {Please do not include meals
Nutrition Section
provided as part of the school lunch or school
breakfast./Please do not include meals provided
IF NEEDED, SAY: (Grocery store ready to eat foods include: salads,
as part of the community programs you reported
soups, chicken, sandwiches and cooked vegetables in salad bars and
earlier.}
deli counters.)

How many of those meals did you get from a fast-food or pizza
place?

NHANES 2010: Diet
How many of those meals did you get from a fastBehavior and
food or pizza place?
Nutrition Section

Page 11 of 23

Divergence?

No

No

No

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

40

Item Name
in CAPI

N_21_cy

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

What food or foods did [TEXTFILL IF {S.C.} AGE<12 "{S.C.}" ELSE
"you"] eat during [TEXTFILL IF {S.C.’s} AGE<12 “{S.C}’s” ELSE “your”]
last meal or snack? Please tell me all the food and drinks [TEXTFILL RTI Developed
IF {S.C} AGE<12 “{S.C} had” ELSE “you have had”] during [TEXTFILL IF
{S.C} AGE<12 “{S.C}’s” ELSE “your”] last meal or snack.

Original Text in Source

Divergence?

N/A

N/A

N/A

N/A

During the past 7 days, on how many days were
you in the same room with someone who was
smoking cigarettes?

No

Have you ever tried cigarette smoking, even one
or two puffs?

No

[TEXTFILL IF {S.C.} AGE<12 "Has your child" ELSE "Have you"] had
anything to eat or drink anything within the last 30 minutes?
41

N_22_cy

RTI Developed
1. Yes
2. No

42

During the past 7 days, on how many days [TEXTFILL IF {S.C} AGE<12
CG_01_cy "was your child" ELSE "were you"] in the same room with somebody NYTS 2009
who was smoking cigarettes?
[IF {S.C.} AGE<12, SKIP TO H_INTRO_cy, ELSE CONTINUE]

43

SHOW RESPONDENT SHOWCARD 1
Have you ever tried cigarette smoking, even one or two puffs?
Please just tell me the letter on the showcard that represents your
CG_02_cy answer.

YRBS 2011

1. A - YES
2. B - NO
-1 DON’T KNOW
-2 REFUSED

Page 12 of 23

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

Divergence?

YRBS 2011

During the past 30 days, on how many days did
you smoke cigars, cigarillos, or little cigars?

Yes

YRBS 2011

During the past 30 days, on how many days did
you smoke cigarettes?

No

NYTS 2009

During the past 30 days, on the days you smoked,
how many cigarettes did you smoke per day?

Yes

NYTS 2009

During the past 30 days, on the days you smoked,
how many cigarettes did you smoke per day?

Yes

SHOW RESPONDENT SHOWCARD 1B
In addition to what you just told me about cigarettes, do you
currently smoke cigarillos, cigars or pipes?
44

CG_03_cy

1.
2.
-1.
-.2

A - YES
B - NO
DON’T KNOW
REFUSED

SHOW RESPONDENT SHOWCARD 2

45

During the past 30 days, on how many days did you smoke
cigarettes?
READ ANSWER CATEGORIES ONLY IF NEEDED
1. A - 0 DAYS
CG_04_cy
2. B - 1 OR 2 DAYS
3. C - 3 TO 5 DAYS
4. D - 6 TO 9 DAYS
5. E - 10 TO 19 DAYS
6. F - 20 TO 29 DAYS
7. G - ALL 30 DAYS

46

SHOW RESPONDENT SHOWCARD 3A
Please read the question on this card and tell me a number.
CG_05_cy THINKING ABOUT [TEXTFILL IF [SKIP IF CG_02_cy=1 (0 DAYS)
“CIGARETTES”,] CIGARILLOS, CIGARS AND PIPES, PLEASE TELL ME
HOW MUCH YOU USUALLY SMOKE PER DAY?

47

CG_05a_cy

SHOW RESPONDENT SHOWCARD 3
OF CIGARETTES…(HOW MANY DO YOU USUALLY SMOKE PER DAY?)

Page 13 of 23

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

48

CG_05b_cy

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

NYTS 2009

During the past 30 days, on the days you smoked,
how many cigarettes did you smoke per day?

Yes

NYTS 2009

During the past 30 days, on the days you smoked,
how many cigarettes did you smoke per day?

Yes

NYTS 2009

During the past 30 days, on the days you smoked,
how many cigarettes did you smoke per day?

Yes

How long has it been since you last smoked a
cigarette, even one or two puffs?
0 1 Within the past month (less than 1 month
ago)
0 2 Within the past 3 months (1 month but less
than 3 months ago)
0 3 Within the past 6 months (3 months but less
than 6 months ago)
0 4 Within the past year (6 months but less than
1 year ago)
0 5 Within the past 5 years (1 year but less than 5
years ago)
0 6 Within the past 10 years (5 years but less
than 10 years ago)
0 7 10 years or more
7 7 Don‘t know / Not sure
9 9 Refused

Yes

SHOW RESPONDENT SHOWCARD 4
OF CIGARILLOS…(HOW MANY DO YOU USUALLY SMOKE PER DAY?)
SHOW RESPONDENT SHOWCARD 5
49

CG_05c_cy
OF CIGARS…(HOW MANY DO YOU USUALLY SMOKE PER DAY?)
SHOW RESPONDENT SHOWCARD 6

50

CG_05d_cy
OF PIPES…(HOW MANY DO YOU USUALLY SMOKE PER DAY?)

SHOW RESPONDENT SHOWCARD 7
51

CG_06_cy

HOW LONG HAS IT BEEN SINCE YOU LAST SMOKED A [TEXT FILL IF
BRFSS 2011
[CG_02_cy=1, “CIGARETTE,”] CIGARILLO, CIGAR OR PIPE, EVEN ONE
OR TWO PUFFS? YOU CAN TELL ME IN HOURS, DAYS OR MONTHS
AGO.

Page 14 of 23

Divergence?

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

Divergence?

YRBS 2011

During the past 30 days, how did you usually get
your own cigarettes? (Select only one response.)

No

YRBS 2011

During the past 12 months, did you ever try to
quit smoking cigarettes?

No

BRFSS 2011

When you quit smoking…The last time you tried
to quit smoking…did you use any of the following
medications: a nicotine patch, nicotine gum,
nicotine lozenges, nicotine nasal spray, a nicotine
inhaler, or pills such as Wellbutrin, Zyban,
buproprion, Chantix, or varenicline to help you
quit?

Yes

SHOW RESPONDENT SHOWCARD 8
Please read the question on this card and tell me the letter that
matches your answer. DURING THE PAST 30 DAYS, HOW DID YOU
USUALLY GET YOUR OWN CIGARETTES?
IF NEEDED, PROBE FOR SINGLE BEST ANSWER THAT MATCHES
RESPONSE OPTIONS
52

CG_07_cy

1. A - I DID NOT SMOKE CIGARETTES DURING THE PAST 30 DAYS
2. B - I BOUGHT THEM IN A STORE SUCH AS A CONVENIENCE STORE,
SUPERMARKET, DISCOUNT STORE, OR GAS STATION
3. C - I BOUGHT THEM FROM A VENDING MACHINE
4. D - I GAVE SOMEONE ELSE MONEY TO BUY THEM FOR ME
5. E - I BORROWED (OR BUMMED) THEM FROM SOMEONE ELSE
6. F - A PERSON 18 YEARS OLD OR OLDER GAVE THEM TO ME
7. G - I TOOK THEM FROM A STORE OR FAMILY MEMBER
8. H - I GOT THEM SOME OTHER WAY
SHOW RESPONDENT SHOWCARD 9

53

CG_08_cy

DURING THE PAST 12 MONTHS, DID YOU EVER TRY TO QUIT
SMOKING CIGARETTES?

SHOW RESPONDENT SHOWCARD 9B
54

CG_09_cy ARE YOU CURRENTLY USING ANYTHING TO HELP YOU QUIT
SMOKING LIKE A NICOTINE PATCH, NICOTINE GUM, NASAL SPRAY
OR INHALER?

Page 15 of 23

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

Divergence?

RTI Developed

N/A

N/A

NYTS 2009

Have you ever used chewing tobacco, snuff, or
dip, such as Redman, Levi Garrett, Beechnut,
Skoal, Skoal Bandits, or Copenhagen?

Yes

RTI Developed

N/A

N/A

NHIS 2012

The next questions are about health care. Is there
a place that [fill1: alias] USUALLY goes when [fill2:
he/she] is sick or you need advice about [fill3:
his/her] health?

No

SHOW RESPONDENT SHOWCARD 10
55

CG_10_cy WHEN DID YOU LAST USE ANY OF THESE THINGS THAT ARE
DESIGNED TO HELP YOU QUIT SMOKING? YOU CAN TELL ME IN
HOURS, DAYS OR MONTHS AGO.
SHOW RESPONDENT SHOWCARD 11

56

Please read the question on this card and tell me the letter that
matches your answer. DO YOU CURRENTLY USE CHEWING
CG_11_cy TOBACCO, SNUFF, OR DIP SUCH AS REDMAN, SKOAL, OR
COPENHAGEN?
1. A - YES
2. B - NO
SHOW RESPONDENT SHOWCARD 12

57

58

CG_12_cy

H_01_cy

APPROXIMATELY HOW LONG AGO DID YOU LAST USE ANY OF
THOSE? YOU CAN TELL ME IN HOURS, DAYS OR MONTHS AGO.
To begin, is there a place that [TEXTFILL IF {S.C} AGE<12 “{S.C}
usually goes when he/she is” ELSE “you usually go when you are”]
sick or you need advice about [TEXTFILL IF {S.C} AGE<12 “his/her”
ELSE “your"] health?

Page 16 of 23

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

59

60

Item Name
in CAPI

H_01a_cy

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

{TEXT FILL IF H_01_cy=3, “What kind of place [TEXTFILL IF {S.C}
AGE<12 “does {S.C}” ELSE “do you”] go to most often” ELSE “What
kind of place is it”} - a clinic, doctor's office, emergency room, or
some other place?

Data Source

Original Text in Source

NHIS 2012

[fill1: What kind of place is it / What kind of place
does [fill2: alias] go to most often] - a clinic,
doctor's office, emergency room, or some other
place?
1 Clinic or health center
2 Doctor's office or HMO
3 Hospital emergency room
4 Hospital outpatient department
5 Some other place
6 Doesn't go to one place most often
7 Refused
9 Don't know

Yes

Is that [fill1: CPLKIND/CAU.030] the same place
[fill2: alias] USUALLY goes when [fill3: he/she]
needs routine or preventive care, such as a
physical examination or (well baby/child) checkup?
1 Yes
2 No
7 Refused
9 Don't know

Yes

Is that [TEXTFILL IF H_01a_cy=1,2,3,4 "{H_01a_cy}" IF H_01a_cy=5
"other place"] the same place [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE
“you”] usually [TEXTFILL IF {S.C} AGE<12 “goes” ELSE “go”] when
H_01b_cy
NHIS 2012
[TEXTFILL IF “he/she needs” AGE<12 “{S.C}” ELSE “you need”]
routine or preventive care, such as a physical examination or [IF
{S.C.} AGE>12, “(well baby/child)”] check up?

Page 17 of 23

Divergence?

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

NHIS 2012

What kind of place does [fill1: alias] USUALLY go
to when [fill2: he/she] needs routine or
preventive care, such as a physical examination
or (well baby/child) check-up?
0 Doesn't get preventive care anywhere
1 Clinic or health center
2 Doctor's office or HMO
3 Hospital emergency room
4 Hospital outpatient department
5 Some other place
6 Doesn't go to one place most often
7 Refused

What kind of place [TEXTFILL IF {S.C} AGE<12 “Does {S.C}” ELSE “Do
you”] usually go to when [TEXTFILL IF “he/she needs” AGE<12
“{S.C}” ELSE “you need”]routine or preventive care, such as a
physical examination or[IF {S.C.} AGE>12, “(well baby/child)”] checkup?
READ ANSWER OPTIONS ONLY IF NECESSARY:
61

H_01c_cy.
1 Doesn't get preventive care anywhere
2 Clinic or health center
3 Doctor's office or HMO
4 Hospital emergency room
5 Hospital outpatient department
6 SOME OTHER PLACE
7 DOESN'T GO TO ONE PLACE MOST OFTEN

Page 18 of 23

Divergence?

Yes

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

NHIS 2012

Why doesn’t [fill: alias] have a usual source of
medical care?
*Enter all that apply, separate with commas.
01 Doesn't need a doctor/Haven't had any
problems
02 Doesn't like/trust/believe in doctors
03 Doesn't know where to go
04 Previous doctor is not available/moved
05 Too expensive/no insurance/cost
06 Speak a different language
07 No care available/Care too far away, not
convenient
08 Put it off/Didn't get around to it
09 Other
97 Refused

Yes

Yes

No

Why [IF {S.C.} AGE> 12, “doesn’t {S.C.}” ELSE “don’t you”] have a
usual source of medical care? [IF {S.C.} AGE<11, “(My parents
and/or I feel….”]
CHOOSE ALL THAT APPLY
ACCEPT ALL ANSWER AND PROBE UNTIL R INDICATES NO OTHERS
APPLY: Any others?
62

H_01d_cy

READ ANSWER OPTIONS ONLY IF NECESSARY:
1 Doesn't need a doctor/haven't had any problems
2 Doesn't like/trust/believe in doctors
3 Doesn't know where to go
4 Previous doctor is not available/moved
5 Too expensive/no insurance/cost
6 Speak a different language
7 No care available/care too far away, not convenient
8 Put it off/didn't get around to it
9 OTHER

63

64

H_02_cy

During the past 12 months did [TEXTFILL IF {S.C} AGE<12 “{S.C}”
ELSE “you”] see a doctor, nurse, or other health care professional
for any kind of medical care, including sick-child care, well-child
check-ups, physical exams, and hospitalizations?

NSCH 2011

[During the past 12 months/Since [his/her] birth],
did [S.C.] see a doctor, nurse, or other health care
professional for any kind of medical care,
including sick-child care, well-child check-ups,
physical exams, and hospitalizations?

H_03_cy

During the past 12 months how many times did [TEXTFILL IF {S.C}
AGE<12 “{S.C}” ELSE “you”] see a doctor, nurse, or other health care
NSCH 2011
provider for preventive medical care such as a physical exam or wellchild checkup?

[During the past 12 months/Since [his/her] birth],
how many times did [S.C.] see a doctor, nurse, or
other health care provider for preventive medical
care such as a physical exam or well-child
checkup?

Page 19 of 23

Divergence?

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

65

66

67

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

H_04_cy

[TEXTFILL IF {S.C} AGE<12 “Has {S.C}” ELSE “Have you”] had any
colds, flus or other illnesses in the last two weeks?

NHIS 2012

Did [fill: SC name] have a head cold or chest cold
that started during the last 2 weeks?

Yes

H_05_cy.

Mental health professionals include psychiatrists, psychologists,
psychiatric nurses, and clinical social workers. During the past 12
months, [TEXTFILL IF {S.C} AGE<12 “has {S.C}” ELSE “have you”]
received any treatment or counseling from a mental health
professional in or outside of [IF AGE>12, “day-care or”] school?

NSCH 2011

Mental health professionals include psychiatrists,
psychologists, psychiatric nurses, and clinical
social workers. During the past 12 months, has
[S.C.] received any treatment or counseling from
a mental health professional?

Yes

H_06_cy

Now I am going to read you a list of health problems, concerns or
conditions [TEXTFILL IF {S.C.} AGE>12, “that may affect {S.C.’s}
behavior, learning, or growth”]. For each condition, please tell me if
a doctor or other health care provider ever told you [TEXTFILL IF
NSCH 2011
AGE<11, “or your parents”] that [TEXTFILL IF {S.C} AGE<12 “{S.C}”
ELSE “you”] had the condition, even if [TEXTFILL IF {S.C} AGE<12
“he/she doesn’t” ELSE “you don’t"] have the condition now.

Now I am going to read you a list of conditions.
For each condition, please tell me if a doctor or
other health care provider ever told you that
[S.C.] had the condition, even if [he/she] does not
have the condition now.

Yes

Depression?
HELP SCREEN: Depression is an illness that
involves the body, mood, and thoughts. It is
marked by persistent sadness or an anxious or
empty mood. It affects how a person feels, and
the way a person eats, sleeps, and functions.

Yes

Has a doctor or other health care provider ever told you [TEXTFILL IF
AGE<11, “or your parents”] that [TEXTFILL IF {S.C} AGE<12 “{S.C}”
ELSE “you”] had depression?
68

H_06a_cy.

IF NEEDED, SAY: (Depression is an illness that involves the body,
mood, and thoughts. It is marked by persistent sadness or an
anxious or empty mood. It affects how a person feels, and the way a
person eats, sleeps, and functions.)

NSCH 2011

Page 20 of 23

Divergence?

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

NSCH 2011

Anxiety problems?
HELP SCREEN: Anxiety is a feeling of constant
worrying. Children with severe anxiety problems
may be diagnosed as having anxiety disorders.
Anxiety disorders include panic disorder,
obsessive-compulsive disorder, post-traumatic
stress disorder, and phobias.

Yes

NSCH 2011

Diabetes?
HELP SCREEN: Diabetes is a disease in which the
body does not properly make or use insulin.

Yes

Has a doctor or other health care provider ever told you [TEXTFILL IF
AGE<11, “or your parents”] that [TEXTFILL IF {S.C} AGE<12 “{S.C}”
ELSE “you”] had anxiety problems?
69

70

H_06b_cy

H_06c_cy

IF NEEDED, SAY: (Anxiety is a feeling of constant worrying. Children
with severe anxiety problems may be diagnosed as having anxiety
disorders. Anxiety disorders include panic disorder, obsessivecompulsive disorder, post-traumatic stress disorder, and phobias.)
Has a doctor or other health care provider ever told you [TEXTFILL IF
AGE<11, “or your parents”] that[TEXTFILL IF {S.C} AGE<12 “{S.C}
has” ELSE “you had”] diabetes?
IF NEEDED, SAY: (Diabetes is a disease in which the body does not
properly make or use insulin.)

71

Has a doctor or other health care provider ever told you [TEXTFILL IF NHANES 2010:
Has a doctor or other health professional ever
H_06d_cy AGE<11, “or your parents”] that [TEXTFILL IF {S.C} AGE<12 “{S.C}
Medical Conditions told {you/SP} that {you were/s/he/SP was}
was” ELSE “you were”] overweight?
Section
overweight?

72

H_06e_cy

[TEXTFILL IF {S.C} AGE<12 “Does {S.C}” ELSE “Do you”] have an
impairment or health problem that limits [TEXTFILL IF {S.C} AGE<12
NHIS 2012
{IF VERIFY_3_cy=1 "his" IF VERIFY_3_cy=2 "her" ELSE “your"] ability
to walk, run, or play?

73

H_06f_cy

[TEXTFILL IF {S.C} AGE<12 “Is {S.C}” ELSE “Are you”] limited in any
way in any activity because of a physical, mental or emotional
problem?

Does [fill1: SC name] have an impairment or
health problem that limits [fill2: his/her] ability to
(crawl), walk, run, or play?

NHANES 2010:
{Are you/Is SP} limited in any way in any activity
Physical Functioning because of a physical, mental or emotional
Section
problem?

Page 21 of 23

Divergence?

Yes

No

No

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

74

75

Item Name
in CAPI

D_01_cy

D_02_cy

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

[TEXTFILL IF {S.C} AGE<12 “Is {S.C}” ELSE “Are you”] Hispanic or
Latino?

Adapted from
American
Community Survey
(ACS) to align with Is Person 1 of Hispanic, Latino, or Spanish origin?
the HHS Policy for
Improving Race and
Ethnicity Data

What is Person 1’s race?
White
American Indian or Alaska Native — Print name
What [TEXTFILL, IF {S.C.} AGE>12, “do you consider to be {SP’s}”
of enrolled or principal tribe.
ELSE “do you consider to be your”] race? I am going to read a list.
Black, African Am., or Negro
You can select one or more options from the list.
Asian Indian
Chinese
RECORD ALL ANSWERS GIVEN BY RESPONDENT, BUT DO NOT PROBE
Filipino
FURTHER. OPTION #6, "OTHER" MAY BE USED AS A RECORDING
Adapted from
Other Asian – Print race,
OPTION FOR NON-CONFORMING RESPONSES. OPTION #6 SHOULD American
for example, Hmong,
NOT BE PRESENTED AS A RESPONSE OPTION.
Community Survey
Laotian, Thai, Pakistani,
(ACS) to align with
Cambodian, and so on.
{ONE OR MORE CATEGORIES MAY BE SELECTED}
the HHS Policy for
Japanese
Improving Race and
Korean
1. White
Ethnicity Data
Vietnamese
2. Black or African American
Native Hawaiian
3. American Indian or Alaskan Native
Guamanian or Chamorro
4. Asian
Samoan
5. Pacific Islander
Other Pacific Islander –
6. OTHER
Print race, for example,
Fijian, Tongan, and
so on.
Some other race

Page 22 of 23

Divergence?

Yes

Yes

Youth/Caregiver Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
IPAQ = International Physical Activity Questionnaire (Sallis, 2002)

#

Item Name
in CAPI

NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NSCH = National Survey of Children's Health
NYTS = National Youth Tobacco Survey
YRBS = Youth Risk Behavior Survey

Item Text in CAPI

Data Source

Original Text in Source

Divergence?

(In the last question), I asked you to [TEXTFILL IF {S.C} AGE<12
“identify {S.C.’s}” ELSE “self-identify your”] race. Now, I want to find
out how other people usually classify [TEXTFILL IF {S.C} AGE<12
“{S.C.}” ELSE “you”] in this country.
Would you say (other people this country usually classify [TEXTFILL
IF {S.C} AGE<12 “{S.C.}” ELSE “you”]as): White, Black or African
American, Hispanic or Latino, Asian, Native Hawaiian or Other
Pacific Islander, American Indian or Alaska Native, or some other
group?
76

D_03-ad.

IF NEEDED, SAY: We want to know how other people usually classify
BRFSS 2012
[TEXTFILL IF {S.C} AGE<12 “{S.C.}” ELSE “you”] in this country, which
might be different from how you classify [TEXTFILL IF {S.C} AGE<12
“{S.C.}” ELSE “yourself”].
ONLY ONE SELECTION ALLOWED.
1 WHITE
2 BLACK OR AFRICAN AMERICAN
3 HISPANIC OR LATINO
4 ASIAN
5 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
6 AMERICAN INDIAN OR ALASKA NATIVE
7 SOME OTHER GROUP

Page 23 of 23

Earlier I asked you to self-identify your race. Now
I will ask you how other people identify you and
treat you.
How do other people usually classify you in this
country? Would you say: White, Black or African
American, Hispanic or Latino, Asian, Native
Hawaiian or Other Pacific Islander, American
Indian or Alaska Native, or some other group?
INTERVIEWER NOTE: If the respondent requests
clarification of this question, say: “We want to
know how OTHER people usually classify you in
this country, which might be different from how
you classify yourself.”

Yes