Family Core - line 2

2013Q4:

Attachment 3a Family Core (23 minutes)
Page 1 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:

FID.100_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HHCHANGE

QuestionnaireFileName:

I have recorded that [your name is {fill fullname}, you are /fill ALIAS is] [fill sex], [fill age] years old, born on [fill
birthdate]. [His/Her] national origin is [fill Hispanic origin], and [his/her] race is [fill race]:
Is this information correct?

1

Yes, this information is correct
No, correction(s) needed/more corrections needed

2

UniverseText:

All nondeleted family members

SkipInstructions:

<1> if no additional PX remain
if SCREENIN = 0 and I_SCRN_STATUS = S [goto EXIT(HHC)]
else [goto FIDCC13]
<2> [goto CWHAT2]

Question ID:

Family

FID.110_00.000 Instrument Variable Name:

QuestionText:

CWHAT2

QuestionnaireFileName:

* Change(s) needed for [ALIAS].
* Enter each number that applies. If a wrong choice, type that choice again.

1
2
3

4
5

Name
Age or DOB
Sex
National origin
Race

UniverseText:

HHCHANGE = 2 (No, not correct)

SkipInstructions:

<1> [goto CHG_NAME_FNAME]
<2> [goto CHG_AGEDOB_1]
<3> [goto CHG_SEX]
<4> [goto CHG_NATOR]
<5> [goto CHG_RACE]

Family

Page 2 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:

FID.245_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HHCHANGE_1

QuestionnaireFileName:

Family

I have recorded that {your name is/ALIAS is} {fill full name}, age is {fill age}, date of birth is {fill birthdate}, {his/her}
national origin is {fill Hispanic origin}, and {his/her} {fill race} is:
Is this information correct?

1

Yes, this information is correct
No, correction(s) needed/more corrections needed

2

UniverseText:

All nondeleted family members with a change made to their demographic information

SkipInstructions:

<1> if no additional PX remain
if SCREENIN = 0 and I_SCRN_STATUS = S, GOTO EXIT(HHC)
else GOTO FIDCC13
<2> GOTO ERR_HHCHANGE_1

Hard Edit:

ERR_HHCHANGE_1
* Press enter to go back to change some demographic information or arrow down and press enter to change your
answer.
Default Goto should be CWHAT2

Question ID:

FID.250_00.000 Instrument Variable Name:

QuestionText:

MARITAL

QuestionnaireFileName:

Family

* ASK OR VERIFY
[fill: Are you/Is ALIAS] now married, widowed, divorced, separated, never married, or living with a partner?

1
2
3
4

5
6
7
9

Married
Widowed
Divorced
Separated
Never Married
Living with partner
Refused
Don't know

UniverseText:

All persons, 14 and older, who don't have a marital status yet

SkipInstructions:

<1> [goto SPFLAG]
<2-5, R, D> [goto FIDCCI3]
<6> if LINTAL[FAMINT] = 1 [goto FIDCCI4]
else [goto COHAB1]

Page 3 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:

FID.260_00.000 Instrument Variable Name:

QuestionText:

SPOUS

* ASK OR VERIFY
Is [fill: your/ALIAS's] spouse living in the household?

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

A potential spouse lives in the unit.

SkipInstructions:

<1> If SPOUS2[PX] = null [goto SPOUS2]
else [goto FIDCCI3]
<2,R,D> [goto FIDCCI3]

20-Aug-13

QuestionnaireFileName:

Family

Page 4 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:

FID.270_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

SPOUS2

QuestionnaireFileName:

Family

* Probe as necessary and enter the line number of the spouse.
[Display all possible spouse candidates]

01-25

Person # of spouse

UniverseText:

Person has an unidentified spouse in the household.

SkipInstructions:

Do not allow line number of the subject to be entered. If so [goto ERR_SPOUS2]
<1-25,R,D> [goto FIDCCI3]

Hard Edit:

ERR1_SPOUS2
*Person can't be his or her own spouse.
*Please correct.

Soft Edit:

ERR2_SPOUS2
*If [ALIAS (SPOUS2(PX)] is [ALIAS (PX)]’s spouse, [ALIAS (SPOUS2(PX))]’s RPREL value should be ‘02’.
*Correct relationship code at RPREL or change answer at SPOUS2.
*First GOTO is to change Relationship code of [ALIAS (SPOUS2(PX))]
*Second GOTO is to choose different spouse at SPOUS2
Questions involved
RPREL: Relationship to Ref Person
SPOUS2

Value
RPREL(SPOUS2(PX))
ALIAS (SPOUS2(PX))

ERR3_SPOUS2
*Do not read this message to the respondent.
*The married couple [ALIAS (SPOUS2(PX))] and [ALIAS (PX)] are both [SEX(PX)].
*Suppress message if correct.
*Otherwise, correct SEX of either person or choose different spouse.
*First GOTO is to choose different spouse at SPOUS2
*Second GOTO is to change SEX of spouse [ALIAS (SPOUS2(PX))]
*Third GOTO is to change SEX of [ALIAS(PX)]
Questions involved
SPOUS2
SEX
SEX

Value
ALIAS (SPOUS2(PX))
SEX (SPOUS2(PX))
SEX (PX)

ERR4_SPOUS2
*Age difference between spouses is greater than or equal to 30 years.
I have recorded [ALIAS (PX)] is [AGE(PX)] years old and [fill: his/her] spouse [ALIAS(SPOUS2(PX))] is
[AGE(SPOUS2(PX))] years old. Are these ages and relationships correct?
*First GOTO is to choose different spouse at SPOUS2
*Second GOTO is to change AGE of spouse [ALIAS (SPOUS2(PX))]
*Third GOTO is to change AGE of [ALIAS(PX)]
Questions involved
SPOUS2
AGE
AGE

Value
ALIAS (SPOUS2(PX))
AGE (SPOUS2(PX))
AGE (PX)

Page 5 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:

FID.280_00.000 Instrument Variable Name:

QuestionText:

COHAB1

QuestionnaireFileName:

Family

QuestionnaireFileName:

Family

[fill: Have you/Has ALIAS] ever been married?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Marital status is "living with a partner."

SkipInstructions:

<1> [goto COHAB2]
<2,R,D> if COHAB3[PX] = null [goto COHAB3]
else [goto FIDCCI3]

Question ID:

20-Aug-13

FID.290_00.000 Instrument Variable Name:

QuestionText:
1
2
3

4
7
9

COHAB2

What is [fill: your/ALIAS's] current legal marital status?
Married
Widowed
Divorced
Separated
Refused
Don't know

UniverseText:

Person is currently cohabiting and has been married.

SkipInstructions:

<1-4,R,D> If COHAB3[PX] = null [goto COHAB3]
else [goto FIDCCI3]

Page 6 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:

FID.300_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

COHAB3

QuestionnaireFileName:

Family

* Probe as necessary and enter the line number of the cohabiting partner.
[Display all possible cohabitation candidates]

01-25

Person number

UniverseText:

Cohabiting partner has yet to be identified.

SkipInstructions:

If line number of the subject is entered [goto ERR_COHAB3]
<1-25,R,D> [goto FIDCCI3]

Hard Edit:

ERR1_COHAB3
* Person can't be his or her own partner.
* Please correct.

Soft Edit:

ERR2_COHAB3
*If [ALIAS (COHAB3(PX))] is [ALIAS (PX)]’s cohabiting partner, [ALIAS (COHAB3(PX))]’s RPREL value
should be ‘03’.
*Correct relationship code at RPREL or change answer at COHAB3.
*First GOTO is to change Relationship code of [ALIAS (COHAB3(PX))]
*Second GOTO is to choose different cohabiting partner at COHAB3
Questions involved
RPREL: Relationship to Ref Person
COHAB3

Value
RPREL(COHAB3 (PX))
ALIAS (COHAB3 (PX))

ERR3_COHAB3
*If [ALIAS (COHAB3(PX))] and [ALIAS (PX)] are cohabiting partners, it is not possible for both to have RPREL
codes equal to ‘04’ for ‘Child’. One of their RPREL codes should equal ‘12’ for ‘Other relative’.
*Correct relationship code at RPREL or change answer at COHAB3.
*First GOTO is to change Relationship code of [ALIAS (COHAB3(PX))]
*Second GOTO is to change Relationship code of [ALIAS (PX)]
*Third GOTO is to choose different cohabiting partner at COHAB3
Questions involved
RPREL: Relationship to Ref Person
RPREL: Relationship to Ref Person
COHAB3

Value
Child
Child
ALIAS (COHAB3 (PX))

ERR4_ COHAB3
*Age difference between cohabiting partners is greater than or equal to 20 years.
I have recorded [ALIAS (PX)] is [AGE(PX)] years old and [fill: his/her] cohabiting partner
[ALIAS(COHAB3(PX))] is [AGE(COHAB3(PX))] years old. Are these ages and relationships correct?
*First GOTO is to choose different cohabiting partner at COHAB3
*Second GOTO is to change AGE of cohabiting partner [ALIAS (COHAB3(PX))]
*Third GOTO is to change AGE of [ALIAS(PX)]
Questions involved
COHAB3
AGE
AGE

Value
ALIAS (COHAB3 (PX))
AGE (COHAB3 (PX))
AGE (PX)

Page 7 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:
QuestionText:

1
2
3
4

5
7
9

FID.322_00.000 Instrument Variable Name:

DEGREE4

20-Aug-13

QuestionnaireFileName:

Family

I noted that [father's fullname] is the father of [child's fullname]. Is [child's fullname] his biological, adoptive, step, foster,
or [fill: son/daughter] in law?

Biological
Adoptive
Step
Foster
-in-law
Refused
Don't know

Page 8 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

20-Aug-13

UniverseText:

When the reference person is the person in question's parent.

SkipInstructions:

<1> if AGEDIFF <12 [goto ERR_DEGREE4]
if ERR_DEGREE4 = 1 [goto FIDCCI4B]
else reset DEGREE4 [goto DEGREE4] endif
else [goto FIDCCI4B]
<2-5,R,D> [goto FIDCCI4B]

Hard Edit:

ERR2_DEGREE4
*Age difference between father and child is [AGEDIFF] years.
I have recorded [ALIAS (X2)] is [AGE(X2)] years old and his child [ALIAS(PX)] is [AGE(PX)] years old.
Are these ages and relationships correct?
* Please correct relationship code or age.
*First GOTO is to change Relationship code of [ALIAS(X2)]
*Second GOTO is to change Relationship code of [ALIAS(PX)]
*Third GOTO is to change AGE of father [ALIAS(X2)]
*Fourth GOTO is to change AGE of child [ALIAS(PX)]
Questions involved
RPREL: Relationship to Ref Person
RPREL: Relationship to Ref Person
AGE
AGE

Soft Edit:

Value
Spouse (husband) or Unmarried Partner
Child or Child of Partner
AGE (X2)
AGE(PX)

ERR1_DEGREE4
*Age difference between father and child is only [AGEDIFF] years.
I have recorded [ALIAS (X2)] is [AGE(X2)] years old and his child [ALIAS(PX)] is [AGE(PX)] years old. Are
these ages and relationships correct?
*First GOTO is to change Relationship code of [ALIAS(X2)]
*Second GOTO is to change Relationship code of [ALIAS(PX)]
*Third GOTO is to change AGE of father [ALIAS(X2)]
*Fourth GOTO is to change AGE of child [ALIAS(PX)]
Questions involved
RPREL: Relationship to Ref Person
RPREL: Relationship to Ref Person
AGE
AGE

Value
Spouse (husband) or Unmarried Partner
Child or Child of Partner
AGE (X2)
AGE(PX)

If suppressed and additional persons remain, GOTO FIDCCI4
else GOTO FIDCCI4B, endif
ERR3_DEGREE4
*Age difference between father and child is greater than or equal to 50 years.
I have recorded [ALIAS (X2)] is [AGE(X2)] years old and his child [ALIAS(PX)] is [AGE(PX)] years old. Are
these ages and relationships correct?
*First GOTO is to change Relationship code of [ALIAS(X2)]
*Second GOTO is to change Relationship code of [ALIAS(PX)]
*Third GOTO is to change AGE of father [ALIAS(X2)]
*Fourth GOTO is to change AGE of child [ALIAS(PX)]
Questions involved
RPREL: Relationship to Ref Person
RPREL: Relationship to Ref Person
AGE
AGE

Value
Spouse (husband) or Unmarried Partner
Child or Child of Partner
AGE (X2)
AGE(PX)

Page 9 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

20-Aug-13

If suppressed and additional persons remain, GOTO FIDCCI4
else GOTO FIDCCI4B, endif

Page 10 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:
QuestionText:

1
2
3
4

5
7
9

FID.324_00.000 Instrument Variable Name:

DEGREE5

20-Aug-13

QuestionnaireFileName:

Family

I noted that [mother's fullname] is the mother of [child's fullname]. Is [child's fullname] her biological, adoptive, step,
foster, or [fill: son/daughter] in law?

Biological
Adoptive
Step
Foster
-in-law
Refused
Don't know

Page 11 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

20-Aug-13

UniverseText:

When the reference person is the person in question's parent.

SkipInstructions:

<1> if AGEDIFF <12 [goto ERR_DEGREE5]
if yes, continue the interview [goto FIDCCI4B]
else, reset DEGREE5 [goto DEGREE5] endif
else [goto FIDCCI4B]
<2-5,R,D> [goto FIDCCI4B]

Hard Edit:

ERR2_DEGREE5
*Age difference between mother and child is [AGEDIFF] years.
I have recorded [ALIAS (X2)] is [AGE(X2)] years old and her child [ALIAS(PX)] is [AGE(PX)] years old.
Are these ages and relationships correct?
* Please correct relationship code or age.
*First GOTO is to change Relationship code of [ALIAS(X2)]
*Second GOTO is to change Relationship code of [ALIAS(PX)]
*Third GOTO is to change AGE of mother [ALIAS(X2)]
*Fourth GOTO is to change AGE of child [ALIAS(PX)]
Questions involved
RPREL: Relationship to Ref Person
RPREL: Relationship to Ref Person
AGE
AGE

Soft Edit:

Value
Spouse (wife) or Unmarried Partner
Child or Child of Partner
AGE (X2)
AGE(PX)

ERR1_DEGREE5
*Age difference between mother and child is only [AGEDIFF] years.
I have recorded [ALIAS (X2)] is [AGE(X2)] years old and her child [ALIAS(PX)] is [AGE(PX)] years old. Are
these ages and relationships correct?
*First GOTO is to change Relationship code of [ALIAS(X2)]
*Second GOTO is to change Relationship code of [ALIAS(PX)]
*Third GOTO is to change AGE of mother [ALIAS(X2)]
*Fourth GOTO is to change AGE of child [ALIAS(PX)]
Questions involved
RPREL: Relationship to Ref Person
RPREL: Relationship to Ref Person
AGE
AGE

Value
Spouse (wife) or Unmarried Partner
Child or Child of Partner
AGE (X2)
AGE(PX)

If suppressed and additional persons remain, GOTO FIDCCI4
else GOTO FIDCCI4B, endif
ERR3_DEGREE5
*Age difference between mother and child is greater than or equal to 50 years.
I have recorded [ALIAS (X2)] is [AGE(X2)] years old and her child [ALIAS(PX)] is [AGE(PX)] years old. Are
these ages and relationships correct?
*First GOTO is to change Relationship code of [ALIAS(X2)]
*Second GOTO is to change Relationship code of [ALIAS(PX)]
*Third GOTO is to change AGE of mother [ALIAS(X2)]
*Fourth GOTO is to change AGE of child [ALIAS(PX)]
Questions involved
RPREL: Relationship to Ref Person
RPREL: Relationship to Ref Person
AGE
AGE

Value
Spouse (wife) or Unmarried Partner
Child or Child of Partner
AGE (X2)
AGE(PX)

Page 12 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

20-Aug-13

If suppressed and additional persons remain, GOTO FIDCCI4
else GOTO FIDCCI4B, endif
Question ID:

FID.326_00.000 Instrument Variable Name:

QuestionText:

MOTHER

* Choose mother over mother-in-law if both are present.
00

97
99

Family

* Ask or verify
Is [fill: your/ALIAS's] mother a household member? (Include biological (natural), adoptive, step, or foster mother or
mother-in-law)
* Enter the line number of the mother or mother-in-law.
If the mother or mother-in-law is not a household member, enter "0".

01-25

QuestionnaireFileName:

Mother not a household member
Person number of mother
Refused
Don't know

UniverseText:

Potential mother in the Family, mother not already identified

SkipInstructions:

<01-25> [goto MOTHERCK_A]
<0,R,D> [goto FIDCCI5]

Page 13 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:
QuestionText:

1
2
3
4

5
7
9

FID.330_01.000 Instrument Variable Name:

20-Aug-13

MOTHERCK_A

QuestionnaireFileName:

Family

[fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster mother or mother-in-law?

Biological mother
Adoptive mother
Step mother
Foster mother
Mother-in-law
Refused
Don't know

Page 14 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

20-Aug-13

UniverseText:

Mother is in the immediate family.

SkipInstructions:

<1> If AGEDIFF <12 [goto ERR_MOTHERCK_A]
if <1> [goto FIDCCI5]
elseif <2> [goto MOTHER]
elseif <3>, reset MOTHERCK_A [goto MOTHERCK_A]
else [goto FIDCCI5]
<2-5,R,D> [goto FIDCCI5]

Hard Edit:

ERR2_MOTHERCK_A
*Age difference between mother and child is [AGEDIFF] years.
I have recorded [ALIAS (LNMOM[PX])] is [AGE(LNMOM[PX])] years old and her child [ALIAS(PX)] is
[AGE(PX)] years old. Are these ages and relationships correct?
* Please correct relationship code or age.
*First GOTO is to change code at MOTHER
*Second GOTO is to change AGE of mother [ALIAS (LNMOM[PX])]
*Third GOTO is to change AGE of child [ALIAS(PX)]
Questions involved
MOTHER
AGE
AGE

Soft Edit:

Value
ALIAS (MOTHER [PX])
AGE(LNMOM[PX])
AGE(PX)

ERR1_MOTHERCK_A
*Age difference between mother and child is only [AGEDIFF] years.
I have recorded [ALIAS (LNMOM[PX])] is [AGE(LNMOM[PX])] years old and her child [ALIAS(PX)] is
[AGE(PX)] years old. Are these ages and relationships correct?
*First GOTO is to change code at MOTHER
*Second GOTO is to change AGE of mother [ALIAS (LNMOM[PX])]
*Third GOTO is to change AGE of child [ALIAS(PX)]
Questions involved
MOTHER
AGE
AGE

Value
ALIAS (MOTHER [PX])
AGE(LNMOM[PX])
AGE(PX)

if suppressed goto FIDCCI5
ERR3_MOTHERCK_A
*Age difference between mother and child is greater than or equal to 50 years.
I have recorded [ALIAS (LNMOM[PX])] is [AGE(LNMOM[PX])] years old and her child [ALIAS(PX)] is
[AGE(PX)] years old. Are these ages and relationships correct?
*First GOTO is to change code at MOTHER
*Second GOTO is to change AGE of mother [ALIAS (LNMOM[PX])]
*Third GOTO is to change AGE of child [ALIAS(PX)]
Questions involved
MOTHER
AGE
AGE
if suppressed goto FIDCCI5

Value
ALIAS (MOTHER [PX])
AGE(LNMOM[PX])
AGE(PX)

Page 15 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:

FID.330_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MOM_CKFG

Family

[fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster mother or mother-in-law?

UniverseText:

Mother is in the immediate family.

SkipInstructions:

<1> If AGEDIFF <12 [goto ERR_MOTHERCK_A]
if <1> [goto FIDCCI5]
elseif <2> [goto MOTHER]
elseif <3>, reset MOTHERCK_A [goto MOTHERCK_A]
else [goto FIDCCI5]
<2-5,R,D> [goto FIDCCI5]

Question ID:

QuestionnaireFileName:

FID.340_00.000 Instrument Variable Name:

QuestionText:

FATHER

QuestionnaireFileName:

Family

* Ask or verify
Is [fill: your/ALIAS's] father a household member? (Include biological (natural), adoptive, step, or foster father or fatherin-law).
* Enter the line number of the father or father-in-law.
* If the father is not a household member, enter '0'.
* Choose father over father-in-law if both are present.

00
01-25
97

99

Father not in household
Person # of father
Refused
Don't know

UniverseText:

Potential Father in Family, not already identified

SkipInstructions:

<1-25> [goto FATHERCK_A]
<0,R,D> [goto FIDCCI4]

Page 16 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:
QuestionText:

1
2
3
4

5
7
9

FID.350_01.000 Instrument Variable Name:

20-Aug-13

FATHERCK_A

QuestionnaireFileName:

Family

[fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster father or father-in-law?

Biological father
Adoptive father
Step father
Foster father
Father-in-law
Refused
Don’t know

Page 17 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

20-Aug-13

UniverseText:

Father is in the immediate family.

SkipInstructions:

<1> If AGEDIFF <12 [goto ERR_FATHERCK_A]
if ERRFATHERCK_A = <1> [goto FIDCCI4]
elseif <2> [goto FATHER]
elseif <3> reset FATHERCK_A
[goto FATHERCK_A] endif
else [goto FIDCCI4]
<2-5,R,D> [goto FIDCCI4]

Hard Edit:

ERR2_FATHERCK_A
*Age difference between father and child is [AGEDIFF] years.
I have recorded [ALIAS(LNDAD[PX])] is [AGE(LNDAD[PX])] years old and his child [ALIAS(PX)] is
[AGE(PX)] years old.
Are these ages and relationships correct?
* Please correct relationship code or age.
*First GOTO is to change code at FATHER
*Second GOTO is to change AGE of father [ALIAS (LNDAD[PX])]
*Third GOTO is to change AGE of child [ALIAS(PX)]
Questions involved
FATHER
AGE
AGE

Soft Edit:

Value
ALIAS(FATHER [PX])
AGE(LNDAD[PX])
AGE(PX)

ERR1_FATHERCK_A
*Age difference between father and child is only [AGEDIFF] years.
I have recorded [ALIAS(LNDAD[PX])] is [AGE (LNDAD[PX])] years old and his child [ALIAS(PX)] is
[AGE(PX)] years old. Are these ages and relationships correct?
*First GOTO is to change code at FATHER
*Second GOTO is to change AGE of father [ALIAS (LNDAD[PX])]
*Third GOTO is to change AGE of child [ALIAS(PX)]
Questions involved
FATHER
AGE
AGE

Value
ALIAS(FATHER [PX])
AGE(LNDAD[PX])
AGE(PX)

if suppressed goto FIDCCI4
ERR3_FATHERCK_A
*Age difference between father and child is greater than or equal to 50 years.
I have recorded [ALIAS(LNDAD[PX])] is [AGE (LNDAD[PX])] years old and his child [ALIAS(PX)] is
[AGE(PX)] years old. Are these ages and relationships correct?
*First GOTO is to change code at FATHER
*Second GOTO is to change AGE of father [ALIAS (LNDAD[PX])]
*Third GOTO is to change AGE of child [ALIAS(PX)]
Questions involved
FATHER
AGE
AGE
if suppressed goto FIDCCI4

Value
ALIAS(FATHER [PX])
AGE(LNDAD[PX])
AGE(PX)

Page 18 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:

FID.350_02.000 Instrument Variable Name:

QuestionText:

DAD_CKFG

QuestionnaireFileName:

Family

[fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster father or father-in-law?

UniverseText:

Father has been identified

SkipInstructions:

<1> If AGEDIFF <12 [goto ERR_FATHERCK_A]
if ERRFATHERCK_A = <1> [goto FIDCCI4]
elseif <2> [goto FATHER]
elseif <3> reset FATHERCK_A
[goto FATHERCK_A] endif
else [goto FIDCCI4]
<2-5,R,D> [goto FIDCCI4]

Question ID:

20-Aug-13

FID.361_00.000 Instrument Variable Name:

QuestionText:
1
2
7

9

LGGUARD1

QuestionnaireFileName:

Family

[fill: Do you/Does ALIAS] have a legal guardian?
Yes
No
Refused
Don't know

UniverseText:

(Person is ward of reference person OR both mother and father are not present in the household) AND person is
less than 18 AND person is not deleted

SkipInstructions:

<1> [goto LGGUARD2]
<2,R,D> if additional persons remain, GOTO FIDCCI4
else GOTO ROSTERCK

Page 19 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:

FID.362_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LGGUARD2

QuestionnaireFileName:

Family

QuestionnaireFileName:

Family

*Ask or verify.
Is [fill ALIAS’S] legal guardian a household member?
*Enter the line number of the legal guardian.
*If the legal guardian is not a household member, enter '0'.

00

Guardian not a household member
Person # of guardian
Refused
Don't know

01-25
97
99

UniverseText:

Person less than 18 has legal guardian

SkipInstructions:

<0-25, D, R> if additional persons remain, GOTO FIDCCI4
else GOTO ROSTERCK

Question ID:

FID.380_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

KNOW2

* Verify or ask
Who in the family would you say knows about the health of all the family members?
[Display all family members who not deleted and > 17 or emancipated minors.]
* Mark all that apply, separate with commas.
Yes, knows family members' health
No, does not know family member's health
Refused
Don't know

UniverseText:

More than one adult

SkipInstructions:

<1-25,R,D>
if SCSEL = 0 [goto FINTRO2]
else [goto KNOWSC2]

Page 20 of 20

DRAFT 2013 NHIS Questionnaire - Family
Family Identification
Document Version Date:

Question ID:

FID.390_03.000 Instrument Variable Name:

QuestionText:

FINTRO2

QuestionnaireFileName:

Family

* Enter line number(s) of family members listed that are currently present. Enter up to 10 numbers, separate with commas.
[Display all family members who are not deleted and >17 or emancipated minors]
* If any persons listed are not present, say:
We would like to have all adult family members who are at home take part in the interview. Are (READ NAMES) at
home now?
* If yes, ask: Could they join us?
* If nobody is presently available, enter "96" to proceed to a callback screen.

1

Present
Not present

2

UniverseText:

All nondeleted persons >17 or emancipated minors

SkipInstructions:

<96> [goto FCALLBK1]
if only one PX selected [goto HLTH_BEG]
else [goto FAMRESP]

Question ID:

20-Aug-13

FID.390_04.000 Instrument Variable Name:

QuestionText:

01-25

FAMRESP

QuestionnaireFileName:

Family

* Ask if necessary: With whom am I speaking?
* Enter the line number of the person you consider to be the main respondent for this family's health questions.
Person # of Family Respondent

UniverseText:

More than 1 adult present.

SkipInstructions:

goto HLTH_BEG

Page 1 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.005_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FLAPLYLM

QuestionnaireFileName:

Family

? [F1]
[fill1: Are/Is]
* Read names
(fill roster of persons age 0-4)
limited in the kind or amount of play activities [fill2: they/he/she] can do because of a physical, mental, or emotional
problem?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All families with one or more persons less than 5 years of age

SkipInstructions:

<1> [if only one child less than 5 years of age, store the person number in PLAPLYLM and goto PLAPLYUN;
else, goto PLAPLYLM]
<2,R,D> [goto FSPEDEIS]

Question ID:

FHS.010_00.000 Instrument Variable Name:

QuestionText:

PLAPLYLM

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons less than five years of age and at least one is limited in play activities

SkipInstructions:

goto PLAPLYUN
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 2 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.020_00.000 Instrument Variable Name:

20-Aug-13

PLAPLYUN

QuestionnaireFileName:

Is [fill: ALIAS] able to take part AT ALL in the usual kinds of play activities done by most children [fill: ALIAS]’s age?

QuestionText:

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All persons less than 5 years of age who are limited in play activities

SkipInstructions:

repeat this question for all persons listed at PLAPLYLM, then goto FSPEDEIS

Question ID:

Family

FHS.050_00.000 Instrument Variable Name:

QuestionText:

FSPEDEIS

QuestionnaireFileName:

Family

? [F1]
[fill: Do you/Does/Do any of these family members,
* Read names
(fill roster of persons less than age 18)]
receive Special Educational or Early Intervention Services?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with one or more persons less than 18 years of age

SkipInstructions:

<1> [if only one person less than 18 years of age, store the person number in PSPEDEIS and goto PSPEDEM;
else, goto PSPEDEIS]
<2,R,D> [goto FLAADL]

Page 3 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.060_00.000 Instrument Variable Name:

QuestionText:

PSPEDEIS

20-Aug-13

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

All families with two or more persons less than 18 years of age and at least one receives Special Educational or
Early Intervention Services

SkipInstructions:

goto PSPEDEM
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FHS.065_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

PSPEDEM

QuestionnaireFileName:

Family

[fill: Do you/Does ALIAS] receive these services because of an emotional
or behavioral problem?
Yes
No
Refused
Don't know

UniverseText:

All persons less than 18 years of age who receive Special Educational or Early Intervention Services

SkipInstructions:

repeat this question for all persons listed at PSPEDEIS, then goto FLAADL

Page 4 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.070_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FLAADL

QuestionnaireFileName:

Family

? [F1]
Because of a physical, mental, or emotional problem, [fill1: do you/does anyone in the family] need the help of other
persons with PERSONAL CARE NEEDS, such as eating, bathing, dressing, or getting around inside this home?
[fill2: Do not include family members age 2 and under.]

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with one or more persons 3 years of age or older

SkipInstructions:

<1> [if a single-person family, store the person number in PLAADL and goto LABATH; else, goto PLAADL]
<2,R,D> [goto FLAIADL]

Question ID:

FHS.080_00.000 Instrument Variable Name:

QuestionText:

PLAADL

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons 3 years of age or older and at least one needs the help of other persons with
personal care needs

SkipInstructions:

goto LABATH
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 5 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.090_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LABATH

QuestionnaireFileName:

Family

[fill: Do you/Does ALIAS] need the help of other persons with...
Bathing or showering?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All persons 3 years of age or older who need help with personal care needs

SkipInstructions:

goto LADRESS

Question ID:

FHS.090_02.000 Instrument Variable Name:

QuestionText:

LADRESS

QuestionnaireFileName:

* Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Dressing?

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All persons 3 years of age or older who need help with personal care needs

SkipInstructions:

goto LAEAT

Family

Page 6 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.090_03.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LAEAT

QuestionnaireFileName:

Family

* Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Eating?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All persons 3 years of age or older who need help with personal care needs

SkipInstructions:

goto LABED

Question ID:

FHS.090_04.000 Instrument Variable Name:

QuestionText:

LABED

QuestionnaireFileName:

* Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Getting in or out of bed or chairs?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All persons 3 years of age or older who need help with personal care needs

SkipInstructions:

goto LATOILT

Family

Page 7 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.090_05.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LATOILT

QuestionnaireFileName:

Family

* Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Using the toilet, including getting to the toilet?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All persons 3 years of age or older who need help with personal care needs

SkipInstructions:

goto LAHOME

Question ID:

FHS.090_06.000 Instrument Variable Name:

QuestionText:

LAHOME

QuestionnaireFileName:

* Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Getting around inside the home?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All persons 3 years of age or older who need help with personal care needs

SkipInstructions:

goto LABATH for the next persons listed at PLAADL; else, goto FLAIADL

Family

Page 8 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.150_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FLAIADL

QuestionnaireFileName:

Family

? [F1]
Because of a physical, mental, or emotional problem, do [fill: you/any of these family members
* Read names
(fill roster of persons age 18 or older)]
need the help of other persons in handling ROUTINE NEEDS, such as everyday household chores, doing necessary
business, shopping, or getting around for other purposes?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All families with one or more persons 18 years of age or older

SkipInstructions:

<1> [if only one person 18 years of age or older, store the person number in PLAIADL and goto FLAWKNOW;
else, goto PLAIADL]
<2,R,D> [goto FLAWKNOW]

Question ID:

FHS.160_00.000 Instrument Variable Name:

QuestionText:

PLAIADL

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons 18 years of age or older and at least one needs the help of other persons in
handling routine needs

SkipInstructions:

goto FLAWKNOW
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 9 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.170_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FLAWKNOW

QuestionnaireFileName:

Family

? [F1]
Does a physical, mental, or emotional problem NOW keep [fill: you/any of these family members
* Read names
(fill roster of persons age 18 or older)]
from working at a job or business?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with one or more persons 18 years of age or older

SkipInstructions:

<1> [if only one person 18 years of age or older, store the person number in PLAWKNOW and goto FLAWALK;
else, goto PLAWKNOW]
<2,R,D> [goto FLAWKLIM]

Question ID:

FHS.180_00.000 Instrument Variable Name:

QuestionText:

PLAWKNOW

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons 18 years of age or older and at least one is unable to work due to a physical,
mental, or emotional problem

SkipInstructions:

all persons selected goto FLAWALK; else, goto FLAWKLIM
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 10 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.190_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FLAWKLIM

QuestionnaireFileName:

Family

? [F1]
[fill: Are you limited in the kind OR amount of work you/ Is ALIAS limited in the kind OR amount of work he/she/ Are
any of these family members,
* Read names
(fill roster of persons age 18 or older)]
limited in the kind OR amount of work they] can do because of a physical, mental or emotional problem?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All families with one or more persons 18 years of age or older not listed as being unable to work due to a physical,
mental, or emotional problem

SkipInstructions:

<1> [if only one person 18 years of age or older not selected at PLAWKNOW, store person number in
PLAWKLIM and goto FLAWALK; else, goto PLAWKLIM]
<2,R,D> [goto FLAWALK]

Question ID:

FHS.200_00.000 Instrument Variable Name:

QuestionText:

PLAWKLIM

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)

0
1
2
7
9

Unable to work
Limited in work
Not limited in work
Refused
Don't know

UniverseText:

All families with two or more persons 18 years of age or older able to work and at least one is limited in the kind
or amount of work he/she can do

SkipInstructions:

goto FLAWALK
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 11 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.210_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FLAWALK

QuestionnaireFileName:

Family

? [F1]
Because of a health problem, [fill: do you/does anyone in the family]
have difficulty walking without using any special equipment?

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PLAWALK and goto FLAREMEM; else, goto
PLAWALK]
<2,R,D> [goto FLAREMEM]

Question ID:

FHS.220_00.000 Instrument Variable Name:

QuestionText:

PLAWALK

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one has difficulty walking without using special equipment

SkipInstructions:

goto FLAREMEM
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 12 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.230_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FLAREMEM

QuestionnaireFileName:

Family

? [F1]
[fill1: Are you/Is anyone in the family] LIMITED IN ANY WAY because of difficulty remembering or because
[fill2: you/they] experience periods of confusion?

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store person number in PLAREMEM and goto LAHCC; else, goto PLAREMEM]
<2,R,D> [goto FLIMANY]

Question ID:

FHS.240_00.000 Instrument Variable Name:

QuestionText:

PLAREMEM

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one is limited due to difficulty remembering or periods of
confusion

SkipInstructions:

goto FLIMANY
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 13 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.250_00.000 Instrument Variable Name:

QuestionText:

FLIMANY

20-Aug-13

QuestionnaireFileName:

Family

? [F1]
[fill: Are you/ Is ALIAS/ Are any family members
* Read names
(fill roster of applicable persons)]
LIMITED IN ANY WAY in any activities because of physical, mental or emotional problems?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families – please see note on PLIMANY

SkipInstructions:

<1> [if a one-person family or the respondent is the only person NOT previously mentioned as having a limitation,
store person number in PLIMANY and goto LAHCC; else goto PLIMANY]
<2,R,D> [goto LAHCC]

Question ID:

FHS.260_00.000 Instrument Variable Name:

QuestionText:

PLIMANY

* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)

0
1

2
7
9

QuestionnaireFileName:

Limitation previously mentioned
Yes, limited in some other way
Not limited in any way
Refused
Don't know

UniverseText:

All families – please see note on PLIMANY

SkipInstructions:

goto LAHCC

Family

Page 14 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.270_00.000 Instrument Variable Name:

QuestionText:

(book) F1

20-Aug-13

LAHCC

QuestionnaireFileName:

Family

? [F1]

What conditions or health problems cause [fill: ALIAS]’s limitations?
* Enter all that apply, separate with commas.
* Do not probe except to clarify answer.
01
02
03
04
05
06

07
08
09
10
11

12
13
90
91
97
99

Vision/problem seeing
Hearing problem
Speech problem
Asthma/breathing problem
Birth defect
Injury
Intellectual disability, also known as mental retardation
Other developmental problem (for example, cerebral palsy)
Other mental, emotional or behavioral problem
Bone, joint, or muscle problem
Epilepsy or seizures
Learning disability
Attention Deficit/Hyperactivity Disorder (ADD/ADHD)
Other impairment/problem (Specify one)
Other impairment/problem (Specify one)
Refused
Don't know/not sure

UniverseText:

All persons less than 18 years of age who have at least one reported limitation

SkipInstructions:

<1-4,6-13> [goto appropriate follow-up questions: LHCL01N - LHCL04N, LHCL06N - LHCL13N]
<5> [fill "96" in LHCL05N and fill "6" in LHCL05T]
<90> [goto LAHCC_S1]
<91> [goto LAHCC_S2]
[repeat this question for the next person less than 18 years of age with a reported limitation; if no more
persons less than 18 years of age with a reported limitation, goto LAHCA]
NOTE: This question and all appropriate follow-up questions are asked, in sequence, for each person less than 18
years of age with a reported limitation. The instrument then proceeds to LAHCA.

Page 15 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.271_90.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LAHCC_S1

QuestionnaireFileName:

Family

* Read if necessary.
What is the other impairment or problem?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All persons less than 18 years of age who have a limitation due to at least one condition not listed at LAHCC

SkipInstructions:

goto LHCL90N

Question ID:

FHS.271_91.000 Instrument Variable Name:

QuestionText:

LAHCC_S2

QuestionnaireFileName:

Family

* Read if necessary.
What is the other impairment or problem?

Verbatim
7
9

Verbatim response
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to at least one condition not listed at LAHCC

SkipInstructions:

goto LHCL91N

Page 16 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.280_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL01N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a vision problem or problem seeing?
* Enter number for time with a vision problem or problem seeing.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to a vision problem or problem seeing

SkipInstructions:

<1-95,D> [goto LHCL01T]
<96> [fill "6" in LHCL01T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL01T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 17 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.280_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL01T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with vision problem or problem seeing.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to a vision problem or problem seeing and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL01T]
if (LHCL01T = 4 and LHCL01N > AGE) or (LHCL01T = 3 and LHCL01N > AGE in months) or (LHCL01T = 2
and LHCL01N > AGE in weeks), goto ERR1_LHCL01T

Hard Edit:

ERR1_LHCL01T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL01T
* "6" not selectable.

Page 18 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.282_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL02N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a hearing problem?
* Enter number for time with a hearing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to a hearing problem

SkipInstructions:

<1-95,D> [goto LHCL02T]
<96> [fill "6" in LHCL02T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL02T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 19 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.282_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL02T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with hearing problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to a hearing problem and 1-95, D was entered for
the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL02T]
if (LHCL02T = 4 and LHCL02N > AGE) or (LHCL02T = 3 and LHCL02N > AGE in months) or (LHCL02T = 2
and LHCL02N > AGE in weeks), goto ERR1_LHCL02T

Hard Edit:

ERR1_LHCL02T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL02T
* "6" not selectable.

Page 20 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.284_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL03N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a speech problem?
* Enter number for time with a speech problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to a speech problem

SkipInstructions:

<1-95,D> [goto LHCL03T]
<96> [fill "6" in LHCL03T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL03T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 21 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.284_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL03T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with speech problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to a speech problem and 1-95, D was entered for
the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL03T]
if (LHCL03T = 4 and LHCL03N > AGE) or (LHCL03T = 3 and LHCL03N > AGE in months) or (LHCL03T = 2
and LHCL03N > AGE in weeks), goto ERR1_LHCL03T

Hard Edit:

ERR1_LHCL03T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL03T
* "6" not selectable.

Page 22 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.286_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL04N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had asthma or a breathing problem?
* Enter number for time with an asthma or breathing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to asthma/breathing problem

SkipInstructions:

<1-95,D> [goto LHCL04T]
<96> [fill "6" in LHCL04T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL04T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 23 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.286_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL04T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with asthma or a breathing problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to asthma/breathing problem and 1-95, D was
entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL04T]
if (LHCL04T = 4 and LHCL04N > AGE) or (LHCL04T = 3 and LHCL04N > AGE in months) or (LHCL04T = 2
and LHCL04N > AGE in weeks), goto ERR1_LHCL04T

Hard Edit:

ERR1_LHCL04T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL04T
* "6" not selectable.

Page 24 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.288_01.000 Instrument Variable Name:

QuestionText:

LHCL06N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill1: have you/has ALIAS] had the injury that caused [fill2:your/his/her] limitation?
* Enter number for time with the injury.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to an injury

SkipInstructions:

<1-95,D> [goto LHCL06T]
<96> [fill "6" in LHCL06T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL06T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 25 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.288_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL06T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with the injury that caused [fill: your/his/her] limitation.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to an injury and 1-95, D was entered for the
"number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL06T]
if (LHCL06T = 4 and LHCL06N > AGE) or (LHCL06T = 3 and LHCL06N > AGE in months) or (LHCL06T = 2
and LHCL06N > AGE in weeks), goto ERR1_LHCL06T

Hard Edit:

ERR1_LHCL06T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL06T
* "6" not selectable.

Page 26 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.290_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL07N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had intellectual disability, also known as mental retardation?
* Enter number for time with intellectual disability/mental retardation.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to intellectual disability/mental retardation

SkipInstructions:

<1-95,D> [goto LHCL07T]
<96> [fill "6" in LHCL07T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL07T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 27 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.290_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL07T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with intellectual disability/mental retardation.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to intellectual disability/mental retardation and 195, D was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL07T]
if (LHCL07T = 4 and LHCL07N > AGE) or (LHCL07T = 3 and LHCL07N > AGE in months) or (LHCL07T = 2
and LHCL07N > AGE in weeks), goto ERR1_LHCL07T

Hard Edit:

ERR1_LHCL07T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL07T
* "6" not selectable.

Page 28 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.292_01.000 Instrument Variable Name:

QuestionText:

LHCL08N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a developmental problem (e.g. cerebral palsy)?
* Enter number for time with a developmental problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to some other developmental problem

SkipInstructions:

<1-95,D> [goto LHCL08T]
<96> [fill "6" in LHCL08T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL08T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 29 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.292_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL08T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with developmental problem (e.g. cerebral palsy).

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to some other developmental problem and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL08T]
if (LHCL08T = 4 and LHCL08N > AGE) or (LHCL08T = 3 and LHCL08N > AGE in months) or (LHCL08T = 2
and LHCL08N > AGE in weeks), goto ERR1_LHCL08T

Hard Edit:

ERR1_LHCL08T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL08T
* "6" not selectable.

Page 30 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.294_01.000 Instrument Variable Name:

QuestionText:

LHCL09N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a mental, emotional, or behavioral problem?
* Enter number for time with a mental, emotional, or behavioral problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to a mental, emotional, or behavioral problem

SkipInstructions:

<1-95,D> [goto LHCL09T]
<96> [fill "6" in LHCL09T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL09T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 31 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.294_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL09T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with mental, emotional, or behavioral problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to a mental, emotional, or behavioral problem and
1-95, D was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL09T]
if (LHCL09T = 4 and LHCL09N > AGE) or (LHCL09T = 3 and LHCL09N > AGE in months) or (LHCL09T = 2
and LHCL09N > AGE in weeks), goto ERR1_LHCL09T

Hard Edit:

ERR1_LHCL09T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL09T
* "6" not selectable.

Page 32 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.296_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL10N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a bone, joint, or muscle problem?
* Enter number for time with a bone, joint, or muscle problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to a bone, joint, or muscle problem

SkipInstructions:

<1-95,D> [goto LHCL10T]
<96> [fill "6" in LHCL10T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL10T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 33 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.296_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL10T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with bone, joint, or muscle problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to a bone, joint, or muscle problem and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL10T]
if (LHCL10T = 4 and LHCL10N > AGE) or (LHCL10T = 3 and LHCL10N > AGE in months) or (LHCL10T = 2
and LHCL10N > AGE in weeks), goto ERR1_LHCL10T

Hard Edit:

ERR1_LHCL10T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL10T
* "6" not selectable.

Page 34 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.298_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL11N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had epilepsy or seizures?
* Enter number for time with epilepsy or seizures.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to epilepsy or seizures

SkipInstructions:

<1-95,D> [goto LHCL11T]
<96> [fill "6" in LHCL11T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL11T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 35 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.298_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL11T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with epilepsy or seizures.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to epilepsy or seizures and 1-95, D was entered for
the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL11T]
if (LHCL11T = 4 and LHCL11N > AGE) or (LHCL11T = 3 and LHCL11N > AGE in months) or (LHCL11T = 2
and LHCL11N > AGE in weeks), goto ERR1_LHCL11T

Hard Edit:

ERR1_LHCL11T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL11T
* "6" not selectable.

Page 36 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.300_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL12N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a learning disability?
* Enter number for time with a learning disability.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to a learning disability

SkipInstructions:

<1-95,D> [goto LHCL12T]
<96> [fill "6" in LHCL12T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL12T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 37 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.300_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL12T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with learning disability.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to a learning disability and 1-95, D was entered for
the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL12T]
if (LHCL12T = 4 and LHCL12N > AGE) or (LHCL12T = 3 and LHCL12N > AGE in months) or (LHCL12T = 2
and LHCL12N > AGE in weeks), goto ERR1_LHCL12T

Hard Edit:

ERR1_LHCL12T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL12T
* "6" not selectable.

Page 38 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.302_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL13N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had attention deficit/hyperactivity disorder?
* Enter number for time with attention deficit/hyperactivity disorder.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to Attention Deficit/Hyperactivity Disorder

SkipInstructions:

<1-95,D> [goto LHCL13T]
<96> [fill "6" in LHCL13T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL13T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 39 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.302_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL13T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with attention deficit/hyperactivity disorder.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to Attention Deficit/Hyperactivity Disorder and 195, D was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL13T]
if (LHCL13T = 4 and LHCL13N > AGE) or (LHCL13T = 3 and LHCL13N > AGE in months) or (LHCL13T = 2
and LHCL13N > AGE in weeks), goto ERR1_LHCL13T

Hard Edit:

ERR1_LHCL13T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL13T
* "6" not selectable.

Page 40 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.304_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL90N

QuestionnaireFileName:

Family

1 of 2
How long [fill1: have you/has ALIAS] had [fill2: problem in LAHCC_S1]?
* Enter number for time with [fill1: problem in LAHCC_S1]?
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to the problem entered at LAHCC_S1

SkipInstructions:

<1-95,D> [goto LHCL90T]
<96> [fill "6" in LHCL90T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL90T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 41 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.304_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL90T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with [fill: problem in LAHCC_S1].

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to the problem entered at LAHCC_S1 and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL90T]
if (LHCL90T = 4 and LHCL90N > AGE) or (LHCL90T = 3 and LHCL90N > AGE in months) or (LHCL90T = 2
and LHCL90N > AGE in weeks), goto ERR1_LHCL90T

Hard Edit:

ERR1_LHCL90T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL90T
* "6" not selectable.

Page 42 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.306_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL91N

QuestionnaireFileName:

Family

1 of 2
How long [fill1: have you/has ALIAS] had [fill2: problem in LAHCC_S2]?
* Enter number for time with [fill1: problem in LAHCC_S2].
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to the problem entered at LAHCC_S2

SkipInstructions:

<1-95,D> [goto LHCL91T]
<96> [fill "6" in LHCL91T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]
[store "R" in LHCL91T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more persons,
goto LAHCA]

Page 43 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.306_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHCL91T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with [fill: problem in LAHCC_S2].

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to the problem entered at LAHCC_S2 and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto LAHCC
for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL91T]
if (LHCL91T = 4 and LHCL91N > AGE) or (LHCL91T = 3 and LHCL91N > AGE in months) or (LHCL91T = 2
and LHCL91N > AGE in weeks), goto ERR1_LHCL91T

Hard Edit:

ERR1_LHCL91T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL91T
* "6" not selectable.

Page 44 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:
QuestionText:

FHS.350_00.000 Instrument Variable Name:

20-Aug-13

LAHCA

QuestionnaireFileName:

(book) F2
What conditions or health problems cause [fill: your/ALIAS’s] limitations?
* Enter all that apply, separate with commas.
* Do not probe except to clarify answer.

01
02
03
04
05
06

07
08
09
10
11

12
13
14
15
16
17

18
19
20
21
22
23

24
25
26
27
28

29
30
31
32
33
34

35
90
91
97
99

Vision/problem seeing
Hearing problem
Arthritis/rheumatism
Back or neck problem
Fracture, bone/joint injury
Other injury
Heart problem
Stroke problem
Hypertension/high blood pressure
Diabetes
Lung/breathing problem(for example, asthma and emphysema)
Cancer
Birth defect
Intellectual disability, also known as mental retardation
Other developmental problem (for example cerebral palsy)
Senility
Depression/anxiety/emotional problem
Weight problem
Missing limbs (fingers, toes or digits), amputee
Kidney, bladder or renal problems
Circulation problems (including blood clots)
Benign tumors, cysts
Fibromyalgia, lupus
Osteoporosis, tendinitis
Epilepsy, seizures
Multiple Sclerosis (MS), Muscular Dystrophy (MD)
Polio(myelitis), paralysis, para/quadriplegia
Parkinson's disease, other tremors
Other nerve damage, including carpal tunnel syndrome
Hernia
Ulcer
Varicose veins, hemorrhoids
Thyroid problems, Grave's disease, gout
Knee problems (not arthritis (03), not joint injury(05))
Migraine headaches (not just headaches)
Other impairment/problem (Specify one)
Other impairment/problem (Specify one)
Refused
Don't know/not sure

Family

Page 45 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

20-Aug-13

UniverseText:

All persons 18 years of age or older who have at least one reported limitation

SkipInstructions:

<1-12,14-35> [goto appropriate follow-up questions: LHAL01N - LHAL12N, LHAL14N - LHAL35N]
<13> [fill "96" in LHAL13N and fill "6" in LHAL13T]
<90> [goto LAHCA_S1]
<91> [goto LAHCA_S2]
[repeat this question for the next person 18 years of age or older with a reported limitation; if no more
persons 18 years of age or older with a reported limitation, goto PHSTAT]
NOTE: This question and all appropriate follow-up questions are asked, in sequence, for each person 18 years of
age or older with a reported limitation. The instrument then proceeds to PHSTAT.

Question ID:

FHS.351_90.000 Instrument Variable Name:

QuestionText:

LAHCA_S1

QuestionnaireFileName:

Family

* Read if necessary.
What is the other impairment or problem?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All persons less than 18 years of age who have a limitation due to at least one condition not listed at LAHCC

SkipInstructions:

goto LHAL90N

Question ID:

FHS.351_91.000 Instrument Variable Name:

QuestionText:

LAHCA_S2

QuestionnaireFileName:

Family

* Read if necessary.
What is the other impairment or problem?

Verbatim

7
9

Verbatim response
Refused
Don't know

UniverseText:

All persons less than 18 years of age who have a limitation due to at least one condition not listed at LAHCC

SkipInstructions:

goto LHAL91N

Page 46 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.360_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL01N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a vision problem or problem seeing?
* Enter number for time with a vision problem or problem seeing.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a vision problem or problem seeing

SkipInstructions:

<1-95,D> [goto LHAL01T]
<96> [fill "6" in LHAL01T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL01T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 47 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.360_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL01T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with vision problem or problem seeing.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a vision problem or problem seeing and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL01T]
if LHAL01T = 4 and LHAL01N > AGE, goto ERR1_LHAL01T

Hard Edit:

ERR1_LHAL01T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL01T
* "6" not selectable.

Page 48 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.362_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL02N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a hearing problem?
* Enter number for time with a hearing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a hearing problem

SkipInstructions:

<1-95,D> [goto LHAL02T]
<96> [fill "6" in LHAL02T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL02T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 49 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.362_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL02T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with hearing problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a hearing problem and 1-95, D was entered for
the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL02T]
if LHAL02T = 4 and LHAL02N > AGE, goto ERR1_LHAL02T

Hard Edit:

ERR1_LHAL02T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL02T
* "6" not selectable.

Page 50 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.364_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL03N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had arthritis or rheumatism?
* Enter number for time with arthritis or rheumatism.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to arthritis/rheumatism

SkipInstructions:

<1-95,D> [goto LHAL03T]
<96> [fill "6" in LHAL03T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL03T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 51 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.364_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL03T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with arthritis or rheumatism.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since Birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to arthritis/rheumatism and 1-95, D was entered for
the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL03T]
if LHAL03T = 4 and LHAL03N > AGE, goto ERR1_LHAL03T

Hard Edit:

ERR1_LHAL03T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL03T
* "6" not selectable.

Page 52 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.366_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL04N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a back or neck problem?
* Enter number for time with a back or neck problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a back or neck problem

SkipInstructions:

<1-95,D> [goto LHAL04T]
<96> [fill "6" in LHAL04T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL04T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 53 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.366_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL04T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with back or neck problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a back or neck problem and 1-95, D was entered
for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL04T]
if LHAL04T = 4 and LHAL04N > AGE, goto ERR1_LHAL04T

Hard Edit:

ERR1_LHAL04T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL04T
* "6" not selectable.

Page 54 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.368_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL05N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a fracture, bone, or joint injury?
* Enter number for time with a fracture, bone or joint injury.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a fracture or bone/joint injury

SkipInstructions:

<1-95,D> [goto LHAL05T]
<96> [fill "6" in LHAL05T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL05T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 55 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.368_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL05T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with fracture, bone, or joint injury.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a fracture or bone/joint injury and 1-95, D was
entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL05T]
if LHAL05T = 4 and LHAL05N > AGE, goto ERR1_LHAL05T

Hard Edit:

ERR1_LHAL05T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL05T
* "6" not selectable.

Page 56 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.370_01.000 Instrument Variable Name:

QuestionText:

LHAL06N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill1: have you/has ALIAS] had the other injury that caused [fill2: your/his/her] limitation?
* Enter number for time with the injury.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to some "other" injury

SkipInstructions:

<1-95,D> [goto LHAL06T]
<96> [fill "6" in LHAL06T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL06T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 57 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.370_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL06T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with other injury that caused [fill: your/his/her] limitation.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to some "other" injury and 1-95, D was entered for
the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL06T]
if LHAL06T = 4 and LHAL06N > AGE, goto ERR1_LHAL06T

Hard Edit:

ERR1_LHAL06T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL06T
* "6" not selectable.

Page 58 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.372_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL07N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a heart problem?
* Enter number for time with a heart problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a heart problem

SkipInstructions:

<1-95,D> [goto LHAL07T]
<96> [fill "6" in LHAL07T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL07T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 59 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.372_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL07T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with heart problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a heart problem and 1-95, D was entered for the
"number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL07T]
if LHAL07T = 4 and LHAL07N > AGE, goto ERR1_LHAL07T

Hard Edit:

ERR1_LHAL07T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL07T
* "6" not selectable.

Page 60 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.374_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL08N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a stroke problem?
* Enter number for time with a stroke problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a stroke problem

SkipInstructions:

<1-95,D> [goto LHAL08T]
<96> [fill "6" in LHAL08T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL08T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 61 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.374_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL08T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with stroke problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a stroke problem and 1-95, D was entered for the
"number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL08T]
if LHAL08T = 4 and LHAL08N > AGE, goto ERR1_LHAL08T

Hard Edit:

ERR1_LHAL08T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL08T
* "6" not selectable.

Page 62 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.376_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL09N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had hypertension or high blood pressure?
* Enter number for time with hypertension or high blood pressure.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to hypertension/high blood pressure

SkipInstructions:

<1-95,D> [goto LHAL09T]
<96> [fill "6" in LHAL09T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL09T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 63 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.376_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL09T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with hypertension or high blood pressure.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to hypertension/high blood pressure and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL09T]
if LHAL09T = 4 and LHAL09N > AGE, goto ERR1_LHAL09T

Hard Edit:

ERR1_LHAL09T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL09T
* "6" not selectable.

Page 64 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.378_01.000 Instrument Variable Name:

QuestionText:

LHAL10N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had diabetes?
* Enter number for time with diabetes.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to diabetes

SkipInstructions:

<1-95,D> [goto LHAL10T]
<96> [fill "6" in LHAL10T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL10T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 65 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.378_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL10T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with diabetes.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to diabetes and 1-95, D was entered for the
"number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL10T]
if LHAL10T = 4 and LHAL10N > AGE, goto ERR1_LHAL10T

Hard Edit:

ERR1_LHAL10T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL10T
* "6" not selectable.

Page 66 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.380_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL11N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a lung problem or breathing problem (e.g., asthma and emphysema)?
* Enter number for time with a lung problem or breathing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a lung/breathing problem

SkipInstructions:

<1-95,D> [goto LHAL11T]
<96> [fill "6" in LHAL11T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL11T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 67 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.380_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL11T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with lung problem or breathing problem (e.g., asthma and emphysema).

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a lung/breathing problem and 1-95, D was
entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL11T]
if LHAL11T = 4 and LHAL11N > AGE, goto ERR1_LHAL11T

Hard Edit:

ERR1_LHAL11T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL11T
* "6" not selectable.

Page 68 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.382_01.000 Instrument Variable Name:

QuestionText:

LHAL12N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had cancer?
* Enter number for time with cancer.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to cancer

SkipInstructions:

<1-95,D> [goto LHAL12T]
<96> [fill "6" in LHAL12T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL12T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 69 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.382_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL12T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with cancer.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to cancer and 1-95, D was entered for the "number"
part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL12T]
if LHAL12T = 4 and LHAL12N > AGE, goto ERR1_LHAL12T

Hard Edit:

ERR1_LHAL12T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL12T
* "6" not selectable.

Page 70 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.384_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL14N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had intellectual disability, also known as mental retardation?
* Enter number for time with intellectual disability/mental retardation.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to intellectual disability/mental retardation

SkipInstructions:

<1-95,D> [goto LHAL14T]
<96> [fill "6" in LHAL14T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL14T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 71 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.384_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL14T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with intellectual disability/mental retardation.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to intellectual disability/mental retardation and 195, D was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL14T]
if LHAL14T = 4 and LHAL14N > AGE, goto ERR1_LHAL14T

Hard Edit:

ERR1_LHAL14T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL14T
* "6" not selectable.

Page 72 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.386_01.000 Instrument Variable Name:

QuestionText:

LHAL15N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a developmental problem (e.g. cerebral palsy)?
* Enter number for time with a developmental problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to some other developmental problem

SkipInstructions:

<1-95,D> [goto LHAL15T]
<96> [fill "6" in LHAL15T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL15T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 73 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.386_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL15T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with developmental problem (e.g. cerebral palsy).

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to some other developmental problem and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL15T]
if LHAL15T = 4 and LHAL15N > AGE, goto ERR1_LHAL15T

Hard Edit:

ERR1_LHAL15T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL15T
* "6" not selectable.

Page 74 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.388_01.000 Instrument Variable Name:

QuestionText:

LHAL16N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had senility?
* Enter number for time with senility.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to senility

SkipInstructions:

<1-95,D> [goto LHAL16T]
<96> [fill "6" in LHAL16T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL16T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 75 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.388_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL16T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with senility.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to senility and 1-95, D was entered for the
"number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL16T]
if LHAL16T = 4 and LHAL16N > AGE, goto ERR1_LHAL16T

Hard Edit:

ERR1_LHAL16T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL16T
* "6" not selectable.

Page 76 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.390_01.000 Instrument Variable Name:

QuestionText:

LHAL17N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had depression, anxiety, or an emotional problem?
* Enter number for time with depression, anxiety or an emotional problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to depression/anxiety/emotional problem

SkipInstructions:

<1-95,D> [goto LHAL17T]
<96> [fill "6" in LHAL17T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL17T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 77 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.390_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL17T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with depression, anxiety, or an emotional problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to depression/anxiety/emotional problem and 1-95,
D was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL17T]
if LHAL17T = 4 and LHAL17N > AGE, goto ERR1_LHAL17T

Hard Edit:

ERR1_LHAL17T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL17T
* "6" not selectable.

Page 78 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.392_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL18N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a weight problem?
* Enter number for time with a weight problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a weight problem

SkipInstructions:

<1-95,D> [goto LHAL18T]
<96> [fill "6" in LHAL18T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL18T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 79 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.392_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL18T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with weight problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a weight problem and 1-95, D was entered for the
"number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL18T]
if LHAL18T = 4 and LHAL18N > AGE, goto ERR1_LHAL18T

Hard Edit:

ERR1_LHAL18T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL18T
* "6" not selectable.

Page 80 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.394_01.000 Instrument Variable Name:

QuestionText:

LHAL19N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a missing limb (finger, toe, or digit)?
* Enter number for time with a missing limb.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to missing limbs

SkipInstructions:

<1-95,D> [goto LHAL19T]
<96> [fill "6" in LHAL19T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL19T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 81 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.394_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL19T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with missing limb (finger, toe, or digit).

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to missing limbs and 1-95, D was entered for the
"number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL19T]
if LHAL19T = 4 and LHAL19N > AGE, goto ERR1_LHAL19T

Hard Edit:

ERR1_LHAL19T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL19T
* "6" not selectable.

Page 82 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.396_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL20N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a kidney, bladder or renal problem?
* Enter number for time with a kidney, bladder or renal problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a kidney, bladder, or renal problem

SkipInstructions:

<1-95,D> [goto LHAL20T]
<96> [fill "6" in LHAL20T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL20T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 83 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.396_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL20T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with kidney, bladder or renal problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a kidney, bladder, or renal problem and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL20T]
if LHAL20T = 4 and LHAL20N > AGE, goto ERR1_LHAL20T

Hard Edit:

ERR1_LHAL20T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL20T
* "6" not selectable.

Page 84 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.398_01.000 Instrument Variable Name:

QuestionText:

LHAL21N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a circulation problem (including blood clots)?
* Enter number for time with a circulation problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to circulation problems

SkipInstructions:

<1-95,D> [goto LHAL21T]
<96> [fill "6" in LHAL21T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL21T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 85 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.398_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL21T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with circulation problem (including blood clots).

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to circulation problems and 1-95, D was entered for
the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL21T]
if LHAL21T = 4 and LHAL21N > AGE, goto ERR1_LHAL21T

Hard Edit:

ERR1_LHAL21T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL21T
* "6" not selectable.

Page 86 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.400_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL22N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had benign tumors or cysts?
* Enter number for time with benign tumors or cysts.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to benign tumors or cysts

SkipInstructions:

<1-95,D> [goto LHAL22T]
<96> [fill "6" in LHAL22T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL22T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 87 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.400_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL22T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with benign tumors or cysts.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to benign tumors or cysts and 1-95, D was entered
for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL22T]
if LHAL22T = 4 and LHAL22N > AGE, goto ERR1_LHAL22T

Hard Edit:

ERR1_LHAL22T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL22T
* "6" not selectable.

Page 88 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.402_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL23N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had fibromyalgia or lupus?
* Enter number for time with fibromyalgia or lupus.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to fibromyalgia or lupus

SkipInstructions:

<1-95,D> [goto LHAL23T]
<96> [fill "6" in LHAL23T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL23T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 89 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.402_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL23T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with fibromyalgia or lupus.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to fibromyalgia or lupus and 1-95, D was entered
for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL23T]
if LHAL23T = 4 and LHAL23N > AGE, goto ERR1_LHAL23T

Hard Edit:

ERR1_LHAL23T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL23T
* "6" not selectable.

Page 90 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.404_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL24N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had osteoporosis or tendinitis?
* Enter number for time with osteoporosis or tendinitis.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to osteoporosis or tendinitis

SkipInstructions:

<1-95,D> [goto LHAL24T]
<96> [fill "6" in LHAL24T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL24T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 91 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.404_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL24T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with osteoporosis or tendinitis.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to osteoporosis or tendinitis and 1-95, D was
entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL24T]
if LHAL24T = 4 and LHAL24N > AGE, goto ERR1_LHAL24T

Hard Edit:

ERR1_LHAL24T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL24T
* "6" not selectable.

Page 92 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.406_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL25N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had epilepsy or seizures?
* Enter number for time with epilepsy or seizures.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to epilepsy or seizures

SkipInstructions:

<1-95,D> [goto LHAL25T]
<96> [fill "6" in LHAL25T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL25T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 93 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.406_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL25T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with epilepsy or seizures.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to epilepsy or seizures and 1-95, D was entered for
the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL25T]
if LHAL25T = 4 and LHAL25N > AGE, goto ERR1_LHAL25T

Hard Edit:

ERR1_LHAL25T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL25T
* "6" not selectable.

Page 94 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.408_01.000 Instrument Variable Name:

QuestionText:

LHAL26N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had multiple sclerosis (MS) or muscular dystrophy (MD)?
* Enter number for time with multiple sclerosis (MS) or muscular dystrophy (MD)?
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to multiple sclerosis or muscular dystrophy

SkipInstructions:

<1-95,D> [goto LHAL26T]
<96> [fill "6" in LHAL26T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL26T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 95 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.408_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL26T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with multiple sclerosis (MS) or muscular dystrophy (MD).

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to multiple sclerosis or muscular dystrophy and 195, D was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL26T]
if LHAL26T = 4 and LHAL26N > AGE, goto ERR1_LHAL26T

Hard Edit:

ERR1_LHAL26T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL26T
* "6" not selectable.

Page 96 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.410_01.000 Instrument Variable Name:

QuestionText:

LHAL27N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had polio(myelitis), paralysis or para/quadriplegia?
* Enter number for time with polio (myelitis) paralysis or para/quadriplegia.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to polio, paralysis, or para/quadriplegia

SkipInstructions:

<1-95,D> [goto LHAL27T]
<96> [fill "6" in LHAL27T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL27T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 97 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.410_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL27T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with polio(myelitis), paralysis or para/quadriplegia.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to polio, paralysis, or para/quadriplegia and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL27T]
if LHAL27T = 4 and LHAL27N > AGE, goto ERR1_LHAL27T

Hard Edit:

ERR1_LHAL27T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL27T
* "6" not selectable.

Page 98 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.412_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL28N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had Parkinson’s disease or tremors?
* Enter number for time with Parkinson's disease or tremors.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to Parkinson's disease or other tremors

SkipInstructions:

<1-95,D> [goto LHAL28T]
<96> [fill "6" in LHAL28T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL28T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 99 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.412_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL28T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with Parkinson’s disease or tremors.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to Parkinson's disease or other tremors and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL28T]
if LHAL28T = 4 and LHAL28N > AGE, goto ERR1_LHAL28T

Hard Edit:

ERR1_LHAL28T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL28T
* "6" not selectable.

Page 100 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.414_01.000 Instrument Variable Name:

QuestionText:

LHAL29N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had nerve damage (including carpal tunnel syndrome)?
* Enter number for time with nerve damage.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to other nerve damage, including carpal tunnel
syndrome

SkipInstructions:

<1-95,D> [goto LHAL29T]
<96> [fill "6" in LHAL29T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL29T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 101 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.414_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL29T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with nerve damage (including carpal tunnel syndrome).

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to other nerve damage, including carpal tunnel
syndrome, and 1-95, D was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL29T]
if LHAL29T = 4 and LHAL29N > AGE, goto ERR1_LHAL29T

Hard Edit:

ERR1_LHAL29T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL29T
* "6" not selectable.

Page 102 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.416_01.000 Instrument Variable Name:

QuestionText:

LHAL30N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a hernia?
* Enter number for time with a hernia.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a hernia

SkipInstructions:

<1-95,D> [goto LHAL30T]
<96> [fill "6" in LHAL30T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL30T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 103 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.416_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL30T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with hernia.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to a hernia and 1-95, D was entered for the
"number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL30T]
if LHAL30T = 4 and LHAL30N > AGE, goto ERR1_LHAL30T

Hard Edit:

ERR1_LHAL30T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL30T
* "6" not selectable.

Page 104 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.418_01.000 Instrument Variable Name:

QuestionText:

LHAL31N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had an ulcer?
* Enter number for time with an ulcer.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to an ulcer

SkipInstructions:

<1-95,D> [goto LHAL31T]
<96> [fill "6" in LHAL31T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL31T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 105 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.418_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL31T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with ulcer.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to an ulcer and 1-95, D was entered for the
"number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL31T]
if LHAL31T = 4 and LHAL31N > AGE, goto ERR1_LHAL31T

Hard Edit:

ERR1_LHAL31T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL31T
* "6" not selectable.

Page 106 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.420_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL32N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had varicose veins or hemorrhoids?
* Enter number for time with varicose veins or hemorrhoids.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to varicose veins or hemorrhoids

SkipInstructions:

<1-95,D> [goto LHAL32T]
<96> [fill "6" in LHAL32T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL32T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 107 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.420_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL32T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with varicose veins or hemorrhoids.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to varicose veins or hemorrhoids and 1-95, D was
entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL32T]
if LHAL32T = 4 and LHAL32N > AGE, goto ERR1_LHAL32T

Hard Edit:

ERR1_LHAL32T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL32T
* "6" not selectable.

Page 108 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.422_01.000 Instrument Variable Name:

QuestionText:

LHAL33N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a thyroid problem, Grave’s disease or gout?
* Enter number for time with a thyroid problem, Grave's disease or gout.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to thyroid problems, Grave's disease, or gout

SkipInstructions:

<1-95,D> [goto LHAL33T]
<96> [fill "6" in LHAL33T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL33T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 109 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.422_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL33T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with thyroid problem, Grave’s disease or gout.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to thyroid problems, Grave's disease, or gout and 195, D was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL33T]
if LHAL33T = 4 and LHAL33N > AGE, goto ERR1_LHAL33T

Hard Edit:

ERR1_LHAL33T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL33T
* "6" not selectable.

Page 110 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.424_01.000 Instrument Variable Name:

QuestionText:

LHAL34N

20-Aug-13

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had a knee problem?
* Enter number for time with a knee problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

1-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to knee problems

SkipInstructions:

<1-95,D> [goto LHAL34T]
<96> [fill "6" in LHAL34T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL34T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 111 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.424_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL34T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with knee problem.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to knee problems and 1-95, D was entered for the
"number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL34T]
if LHAL34T = 4 and LHAL34N > AGE, goto ERR1_LHAL34T

Hard Edit:

ERR1_LHAL34T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL34T
* "6" not selectable.

Page 112 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.426_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL35N

QuestionnaireFileName:

Family

1 of 2
How long [fill: have you/has ALIAS] had migraine headaches?
* Enter number for time with migraine headaches.
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to migraine headaches

SkipInstructions:

<1-95,D> [goto LHAL35T]
<96> [fill "6" in LHAL35T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL35T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 113 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.426_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL35T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with migraine headaches.

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to migraine headaches and 1-95, D was entered for
the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL35T]
if LHAL35T = 4 and LHAL35N > AGE, goto ERR1_LHAL35T

Hard Edit:

ERR1_LHAL35T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL35T
* "6" not selectable.

Page 114 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.450_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL90N

QuestionnaireFileName:

Family

1 of 2
How long [fill1: have you/has ALIAS] had [fill2: LAHCA_S1]?
* Enter number for time with [fill1: LAHCA_S1].
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to the problem entered at LAHCA_S1

SkipInstructions:

<1-95,D> [goto LHAL90T]
<96> [fill "6" in LHAL90T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL90T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 115 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.450_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL90T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with [fill: LAHCA_S1].

1
2
3

4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to the problem entered at LAHCA_S1 and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL90T]
if LHAL90T = 4 and LHAL90N > AGE, goto ERR1_LHAL90T

Hard Edit:

ERR1_LHAL90T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL90T
* "6" not selectable.

Page 116 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.452_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL91N

QuestionnaireFileName:

Family

1 of 2
How long [fill1: have you/has ALIAS] had [fill2: LAHCA_S2]?
* Enter number for time with [fill1: LAHCA_S2].
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94
95
96
97
99

01-94
95+
Since birth
Refused
Don't know

UniverseText:

All persons 18 years of age or older who have a limitation due to the problem entered at LAHCA_S2

SkipInstructions:

<1-95,D> [goto LHAL91T]
<96> [fill "6" in LHAL91T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]
[store "R" in LHAL91T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more persons,
goto PHSTAT]

Page 117 of 117

DRAFT 2013 NHIS Questionnaire - Family
Family Health Status & Limitations
Document Version Date:

Question ID:

FHS.452_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LHAL91T

QuestionnaireFileName:

Family

2 of 2
* Enter time period for time with [fill: LAHCA_S2].

1

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

2
3

4
6
7
9

UniverseText:

All persons 18 years of age or older who have a limitation due to the problem entered at LAHCA_S2 and 1-95, D
was entered for the "number" part of this two-part question

SkipInstructions:

<1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto LAHCA
for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL91T]
if LHAL91T = 4 and LHAL91N > AGE, goto ERR1_LHAL91T
ERR1_LHAL91T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL91T
* "6" not selectable.

Hard Edit:

Question ID:

FHS.500_00.000 Instrument Variable Name:

QuestionText:
1
2
3
4
5
7

9

PHSTAT

QuestionnaireFileName:

Would you say [fill: your/ALIAS’s] health in general is excellent, very good, good, fair, or poor?
Excellent
Very good
Good
Fair
Poor
Refused
Don't know

UniverseText:

All persons

SkipInstructions:

repeat for all persons in the family, goto FINJ3M

Family

Page 1 of 6

DRAFT 2013 NHIS Questionnaire - Family
Family Food Security
Document Version Date:

Question ID:

FFS.010_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FSRUNOUT

QuestionnaireFileName:

Family

These next questions are about whether you were always able to afford the food you needed in the last 30 days. I'm going
to read you several statements that people have made about their food situation. For these statements, please tell me
whether the statement was often true, sometimes true, or never true for [fill 1: you/your family] in the last 30 days.
The first statement is "[fill 2: I/We] worried whether [fill 3: my/our] food would run out before [fill 4: I/we] got money to
buy more." Was that often true, sometimes true, or never true for [fill 1: you/your family] in the last 30 days?

1

Often true
Sometimes true
Never true
Refused
Don't know

2
3
7
9

UniverseText:

All families

SkipInstructions:

<1-3,R,D> goto FSLAST

Question ID:

FFS.020_00.000 Instrument Variable Name:

QuestionText:

1
2
3
7
9

FSLAST

QuestionnaireFileName:

Family

"The food that [fill 1: I/we] bought just didn't last, and [fill 1: I/we] didn't have money to get more." Was that often true,
sometimes true, or never true for [fill 2: you/your family] in the last 30 days?
Often true
Sometimes true
Never true
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1-3,R,D> goto FSBALANC

Page 2 of 6

DRAFT 2013 NHIS Questionnaire - Family
Family Food Security
Document Version Date:

Question ID:

FFS.030_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FSBALANC

QuestionnaireFileName:

"[fill 1: I/We] couldn't afford to eat balanced meals." Was that often true, sometimes true, or never true for [fill 2:
you/your family] in the last 30 days?

1

Often true
Sometimes true
Never true
Refused
Don't know

2
3
7

9

UniverseText:

All families

SkipInstructions:

<1,2> [goto FSSKIP]
<3,D,R> [if FSRUNOUT in(1,2) or FSLAST in(1,2), goto FSSKIP; else goto FINJ3M]

Question ID:

Family

FFS.040_00.000 Instrument Variable Name:

QuestionText:

1
2
7

9

FSSKIP

QuestionnaireFileName:

Family

In the last 30 days, did [fill 1: you/you or other adults in your family] ever cut the size of your meals or skip meals because
there wasn't enough money for food?
Yes
No
Refused
Don't know

UniverseText:

Families for whom it was often or sometimes true in the last 30 days that they worried that food would run out
before they got money to buy more, or that food that was bought didn't last and they didn't have money to get
more, or they couldn't afford to eat balanced meals

SkipInstructions:

<1> [goto FSSKDAYS]
<2,R,D> [if FFS_FLG=1, goto FSLESS1
else if FFS_FLG=2, goto FSLESS2]

Page 3 of 6

DRAFT 2013 NHIS Questionnaire - Family
Family Food Security
Document Version Date:

Question ID:

FFS.050_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FSSKDAYS

QuestionnaireFileName:

Family

In the last 30 days, how many days did this happen?

01-30

Days
Refused
Don't know

97
99

UniverseText:

Adults in the family cut the size of their meals or skipped meals in the last 30 days because there wasn't enough
money for food

SkipInstructions:

<1-30,R,D> [if FFS_FLG=1, goto FSLESS1
else if FFS_FLG=2, goto FSLESS2]

Question ID:

FFS.060_00.010 Instrument Variable Name:

QuestionText:

FSLESS1

QuestionnaireFileName:

Family

In the last 30 days, did you ever eat less than you felt you should because there
wasn't enough money for food?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Random number generator=1 and families for whom it was often or sometimes true in the last 30 days that they
worried that food would run out before they got money to buy more, or that food that was bought didn't last and
they didn't have money to get more, or they couldn't afford to eat balanced meals

SkipInstructions:

<1,2,R,D> [goto FSHUNGR1]

Question ID:

FFS.060_00.020 Instrument Variable Name:

QuestionText:

1
2
7
9

FSLESS2

QuestionnaireFileName:

Family

In the last 30 days, did [fill 1: you/you or other adults in your family] ever eat less than you felt you should because there
wasn't enough money for food?

Yes
No
Refused
Don't know

UniverseText:

Random number generator=2 and families for whom it was often or sometimes true in the last 30 days that
theyworried that food would run out before they got money to buy more, or that food that was bought didn't last
and they didn't have money to get more, or they couldn't
afford to eat balanced meals

SkipInstructions:

<1,2,R,D> [goto FSHUNGR2]

Page 4 of 6

DRAFT 2013 NHIS Questionnaire - Family
Family Food Security
Document Version Date:

Question ID:

FFS.070_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

FSHUNGR1

QuestionnaireFileName:

Family

In the last 30 days, were you ever hungry but didn't eat because there wasn't enough money for food?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Random number generator=1 and families for whom it was often or sometimes true in the last 30 days that they
worried that food would run out before they got money to buy more, or that food that was bought didn't last and
they didn't have money to get more, or they couldn't afford to eat balanced meals

SkipInstructions:

<1,2,R,D> [goto FSWEIGH1]

Question ID:

FFS.070_00.020 Instrument Variable Name:

QuestionText:

1
2
7

9

FSHUNGR2

QuestionnaireFileName:

Family

In the last 30 days, were [fill 1: you/you or other adults in your family] ever hungry but didn't eat because there wasn't
enough money for food?
Yes
No
Refused
Don't know

UniverseText:

Random number generator=2 and families for whom it was often or sometimes true in the last 30 days that they
worried that food would run out before they got money to buy more, or that food that was bought didn't last and
they didn't have money to get more, or they couldn't afford to eat balanced meals

SkipInstructions:

<1,2,R,D> [goto FSWEIGH2]

Page 5 of 6

DRAFT 2013 NHIS Questionnaire - Family
Family Food Security
Document Version Date:

Question ID:

FFS.080_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

FSWEIGH1

QuestionnaireFileName:

Family

In the last 30 days, did you lose weight because there wasn't enough money for food?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Random number generator=1 and families for whom it was often or sometimes true in the last 30 days that they
worried that food would run out before they got money to buy more, or that food that was bought didn't last and
they didn't have money to get more, or they couldn't afford to eat balanced meals

SkipInstructions:

<1> [goto FSNOTEAT]
<2,R,D> [if FSSKIP=1 or FSLESS1=1 or FSHUNGR1=1, goto FSNOTEAT; else goto FINJ3M]

Question ID:

FFS.080_00.020 Instrument Variable Name:

QuestionText:

1
2
7

9

FSWEIGH2

QuestionnaireFileName:

Family

In the last 30 days, did [fill 1: you/you or other adults in your family] lose weight because there wasn't enough money for
food?
Yes
No
Refused
Don't know

UniverseText:

Random number generator=2 and families for whom it was often or sometimes true in the last 30 days that they
worried that food would run out before they got money to buy more, or that food that was bought didn't last and
they didn't have money to get more, or they couldn't afford to eat balanced meals

SkipInstructions:

<1> [goto FSNOTEAT]
<2,R,D> [if FSSKIP=1 or FSLESS2=1 or FSHUNGR2=1, goto FSNOTEAT; else goto FINJ3M]

Page 6 of 6

DRAFT 2013 NHIS Questionnaire - Family
Family Food Security
Document Version Date:

Question ID:

FFS.090_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FSNOTEAT

QuestionnaireFileName:

Family

In the last 30 days, did [fill 1: you/you or other adults in your family] ever not eat for a whole day because there wasn't
enough money for food?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families where adult(s) cut the size of meals or meals were skipped, ate less than they felt they should, were
hungry but didn't eat, or lost weight in the last 30 days because there wasn't enough money for food

SkipInstructions:

<1> [goto FSNEDAYS]
<2,R,D> [goto FINJ3M]

Question ID:

FFS.100_00.000 Instrument Variable Name:

QuestionText:
01-30
97
99

FSNEDAYS

QuestionnaireFileName:

Family

In the last 30 days, how many days did this happen?
Days
Refused
Don't know

UniverseText:

All families where the adult(s) did not eat for a whole day, in the last 30 days, because there wasn't enough money
for food

SkipInstructions:

<1-30,R,D> [goto FINJ3M]

Page 1 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.010_00.000

QuestionText:

Instrument Variable Name:

FINJ3M

20-Aug-13

QuestionnaireFileName:

Family

? [F1]
The next set of questions is about INJURIES AND POISONINGS. People can be injured or poisoned unexpectedly,
accidentally or on purpose. They may have hurt themselves or others may have caused them to be hurt.
DURING THE PAST THREE MONTHS, that is since [fill1: (date 91 days before today's date)], [fill2: did you/did you or
anyone in your family] have an injury where any part of [fill3: your/the] body was hurt, for example, with a [fill4:
(random set of injury examples)]?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in WFINJ3M and goto TFINJ3M; else, goto WFINJ3M]
<2,R,D> [goto FPOI3M]

Question ID:

FIJ.012_00.000

QuestionText:

Instrument Variable Name:

WFINJ3M

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who was this?
(Anyone else?)

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one person was injured during the past 3 months

SkipInstructions:

[goto FPOI3M]
else, goto TFINJ3M
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 2 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.014_00.000

QuestionText:

Instrument Variable Name:

TFINJ3M

20-Aug-13

QuestionnaireFileName:

Family

? [F1]
DURING THE PAST THREE MONTHS, how many different times [fill: were you/was ALIAS] injured?

01-91

1-91 times
Refused
Don't know

97
99

UniverseText:

All persons injured during the past 3 months

SkipInstructions:

<1-10,D> [goto MFINJ3M]
[goto TFINJ3M for the next person with a reported injury episode; if no more persons with an injury episode,
goto FPOI3M]
<11-91> [goto ERR_TFINJ3M]

Soft Edit:

ERR_TFINJ3M
* ^TFINJ3M is unusually high. Please verify.
[goto MFINJ3M]
[reset TFINJ3M for new entry]
[reset TFINJ3M for new entry]

Question ID:

FIJ.016_00.000

QuestionText:

Instrument Variable Name:

MFINJ3M

QuestionnaireFileName:

Family

? [F1]
Did [fill1: you /ALIAS] talk to or see a medical professional about [fill2: any of these
injuries/this injury/your injury or injuries/his injury or injuries/her injury or injuries]?

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All persons with at least one or an unknown number of injury episodes during the past 3 months

SkipInstructions:

<1> [if TFINJ3M eq 1, fill "1" in MTFINJ3M and goto IPDATEM; else, goto MTFINJ3M]
<2,R,D> [goto TFINJ3M for the next person with a reported injury episode; if no more persons with an injury
episode, goto FPOI3M]

Page 3 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.018_00.000

QuestionText:

Instrument Variable Name:

20-Aug-13

MTFINJ3M

QuestionnaireFileName:

Family

? [F1]
Of [fill1: the ^TFINJ3M/all the] times that [fill2: you were/ALIAS was] injured, how many of
those times was the injury serious enough that a medical professional was consulted?

01-91
97

99

1-91 times
Refused
Don't know

UniverseText:

All persons who consulted a medical professional for their injury episode(s)

SkipInstructions:

<1-91> [If MTFINJ3M gt TFINJ3M, goto ERR1_MTFINJ3M; else, if MTFINJ3M gt 3 and TFINJ3M eq D, goto
ERR2_MTFINJ3M; else, goto IPDATEM]
[goto TFINJ3M for the next person with a reported injury episode; if no more persons with an injury
episode, goto FPOI3M]

Hard Edit:

ERR1_MTFINJ3M
[If (MTIFNJ3M gt TFINJ3M), display ERR1_MTFINJ3M]:
[^MTFINJ3M] is greater than the total number of times you said [you were/ALIAS was] injured, which is
[^TFINJ3M]. For this question, we are asking about the number of times [you were/ALIAS was] injured and a
medical professional was consulted. For example, if you were injured three different times but only sought
medical advice or treatment for one of those times, the answer would be one, even if you saw or talked to a trained
medical professional more than once about that injury event.
Goto
Close

Soft Edit:

ERR2_MTFINJ3M
[If (TFINJ3M = 99 and MTFINJ3M gt 3), display ERR2_MTFINJ3M]:
^MTFINJ3M is an unusually high number of injuries for which a medical professional was consulted. Please
verify.
*Read if necessary.
For this question, we are asking about the number of times [you were/ALIAS was] injured and a medical
professional was consulted. For example, if you were injured three different times, but only sought medical advice
or treatment for one of those times, the answer would be one, even if you saw or talked to a trained medical
professional more than once about that injury event.

Suppress
Goto
Close

Page 4 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.020_00.000

QuestionText:

Instrument Variable Name:

20-Aug-13

FPOI3M

QuestionnaireFileName:

Family

? [F1]
DURING THE PAST THREE MONTHS, that is since [fill1: (date 91 days before today's date)], [fill2: were you/ were
you or anyone in your family] poisoned by swallowing or breathing in a harmful substance such as bleach, carbon
monoxide, or too many pills or drugs? Do not include food poisoning, sun poisoning, or poison ivy rashes.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families

SkipInstructions:

<1> [if single-person family, store person number in WFPOI3M and goto TFPOI3M; else,
goto WFPOI3M]
<2,DK,R> [goto next section]

Question ID:

FIJ.022_00.000

QuestionText:

Instrument Variable Name:

WFPOI3M

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who was this?
(Anyone else?)

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one person was poisoned during the past 3 months

SkipInstructions:

<1-25> [All family members. Avoid duplicate; goto TFPOI3M]
[goto next section]

Page 5 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.024_00.000

QuestionText:

Instrument Variable Name:

20-Aug-13

TFPOI3M

QuestionnaireFileName:

Family

? [F1]
DURING THE PAST THREE MONTHS, how many different times [fill: were you/was ALIAS] poisoned? Do not
include food poisoning, sun poisoning, or poison ivy rashes.

01-91

1-91 times
Refused
Don't know

97

99

UniverseText:

All persons poisoned during the past 3 months

SkipInstructions:

<01-10, DK> [goto MFPOI3M]
[goto TFPOI3M for next person with reported poisoning; if
no more persons with a poisoning, goto next section]
<11-91> [goto ERR_TFPOI3M]

Soft Edit:

ERR_TFPOI3M
[If TFPOI3M gt 10, display ERR_TFPOI3M]
* ^TFPOI3M is unusually high. Please verify.
[goto MFPOI3M]
[goto TFPOI3M for new entry]
[goto TFPOI3M for new entry]

Question ID:

FIJ.026_00.000

QuestionText:

Instrument Variable Name:

MFPOI3M

QuestionnaireFileName:

Family

? [F1]
Did [fill1: you /ALIAS] talk to or see a medical professional about [fill2: any of these
poisonings/this poisoning/your poisoning or poisonings/his poisoning or poisonings/her poisoning or poisonings]?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All persons with at least one or an unknown number of poisoning episodes during the past 3 months

SkipInstructions:

<1> [if TFPOI3M eq 1, fill "1" in MTFPOI3M and goto IPDATEM; else goto MTFPOI3M]
<2,DK,R> [goto TFPOI3M for next person with reported poisoning; if no more persons with a poisoning, goto
next section]

Page 6 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.028_00.000

QuestionText:

Instrument Variable Name:

20-Aug-13

MTFPOI3M

QuestionnaireFileName:

Family

? [F1]
Of [fill1: the ^TFPOI3M/all the] times that [fill2: you were/ALIAS was] poisoned, how many of
those times was the poisoning serious enough that a medical professional was consulted?

01-91
97

99

1-91 times
Refused
Don't know

UniverseText:

All persons who consulted a medical professional for their poisoning episode(s)

SkipInstructions:

<01-91> [If MTFPOI3M gt TFPOI3M, goto ERR1_MTFPOI3M; else, goto IPDATEM]
[goto TFPOI3M for next person with reported poisoning; if no more persons with a
poisoning, goto next section]
If ((MTFPOI3M gt TFPOI3M) or (TFPOI3M eq DK and MTFPOI3M gt 3)), display ERR_MTFPOI3M]:

Hard Edit:

ERR1_MTFPOI3M
[If (MTFPOI3M gt TFPOI3M), display ERR1_MTFPOI3M]:
[^MTFPOI3M] is greater than the total number of times you said [you were/ALIAS was] poisoned, which is
[^TFPOI3M]. For this question, we are asking about the number of times [you were/ALIAS was] poisoned and a
medical professional was consulted. For example, if you were poisoned three different times but only sought
medical advice or treatment for one of those times, the answer would be one, even if you saw or talked to a trained
medical professional more than once about that poisoning event.
[goto MTFPOI3M for new entry]
[goto TFPOI3M or MTFPOI3M for new entry]

Soft Edit:

ERR2_MTFPOI3M
[If TFPOI3M = 99 and MTFPOI3M gt 3), display ERR2_MTFINJ3M]:
* ^MTFINJ3M is an unusually high number.
For this question, we are asking about the number of times [you were/ALIAS was]
poisoned and a medical professional was consulted. For example, if you were poisoned three different times but
only sought medical advice or treatment for one of those times, the answer would be one, even if you saw or talked
to a trained medical professional more than once about that poisoning event.
Suppress
Goto
Close

Page 7 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.050_01.000

QuestionText:

Instrument Variable Name:

IPDATEM

20-Aug-13

QuestionnaireFileName:

Family

1 of 3
* Please hand the calendar card to the respondent.
{if only 1 injury/poisoning episode for the person}
When did [fill1: your/ALIAS’s] [fill2: injury/poisoning] happen for which a medical professional was consulted?
{first of multiple injury/poisoning episodes for the person}
Now I’m going to ask a few questions about the [fill3: ^MTFINJ3M/^MTFPOI3M] times [fill4: you were/ALIAS was]
[fill5: injured/poisoned] for which a medical professional was consulted. Starting with the most recent time, when did this
[fill2: injury/poisoning] happen?
{second plus of multiple injury/poisoning episodes for the person}
You just told me about [fill1: your/ALIAS’s] [fill6: (month, day of previous event)] [fill7:most recent/second most
recent/third most recent/fourth most recent][fill2: injury/poisoning]. What was the date of the [fill2: injury/poisoning]
before that for which a medical professional was consulted?
* Enter month.

01

02
03
04
05
06
07

08
09
10
11
12
97

99

January
February
March
April
May
June
July
August
September
October
November
December
Refused
Don't know

UniverseText:

All injury/poisoning episodes for which a medical professional was consulted

SkipInstructions:

<1-12> [goto IPDATED]
[goto IPHOW]
[goto IPDATENO]

Page 8 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.050_02.000

QuestionText:

Instrument Variable Name:

20-Aug-13

IPDATED

QuestionnaireFileName:

2 of 3
* Enter day.

01-31
97
99

1-31
Refused
Don't know

UniverseText:

All injury/poisoning episodes where a valid month of episode was entered

SkipInstructions:

<1-31> [goto IPDATEY]
[goto IPHOW]
[goto IPDATEMT]

Hard Edit:

ERR_IPDATED
[fill1: IPDATED] is not a valid day for [fill2: IPDATEM ].
[reset IPDATED for new entry]
[reset IPDATED for new entry]

Family

Page 9 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.050_03.000

QuestionText:

Instrument Variable Name:

IPDATEY

20-Aug-13

QuestionnaireFileName:

Family

3 of 3
* Enter year.

Year
9997
9999

Year
Refused
Don't know

UniverseText:

All injury/poisoning episodes where a valid day of episode was entered

SkipInstructions:

if IPDATEM, IPDATED and IPDATEY result in a future date; goto ERR_IPDATEY; else, if IPDATEM,
IPDATED and IPDATEY result in a date prior to the start date of the 91 day reference period, goto
ERR1_IPDATEY; else, goto IPHOW

Hard Edit:

ERR_IPDATEY
* Future date invalid.
* Please correct.
[reset IPDATED for new entry]
[reset IPDATED for new entry]

Soft Edit:

ERR1_IPDATEY
* The reported date, [^IPDATEM(text)^IPDATED(numeric)^IPDATEY(4-digit year)], falls outside the reference
period beginning [fill date used in FIJ.010].
*Please verify the date and make any corrections.
ERR2_IPDATEY
*The reported date, [^IPDATEM(text)^IPDATED(numeric)^IPDATEY(4-digit year)], falls outside the reference
period beginning [fill date used in FIJ.010]. NOTE: The start of the reference period falls in the
[beginning/middle/end] of [month used in FIJ.010].
*Please verify the date and make any corrections.
ERR3_IPDATEY
* The reported date, [^IPDATEM(text)^IPDATEY(4-digit year)], falls outside the reference period beginning [fill
date used in FIJ.010].
*Please verify the date and make any corrections.

Page 10 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.051_01.000

QuestionText:

Instrument Variable Name:

20-Aug-13

IPDATENO

QuestionnaireFileName:

Family

1 of 2
Can you tell me approximately how long ago [fill1: your/ALIAS’s] [fill2: injury/poisoning] happened?
*Enter number for time since event.

001-096

1-96
Refused
Don't know

997
999

UniverseText:

All injury/poisoning episodes where don't know was entered for month of episode

SkipInstructions:

<1-91> [goto IPDATETP]
[goto IPHOW]

Question ID:

FIJ.051_02.000

QuestionText:

Instrument Variable Name:

IPDATETP

QuestionnaireFileName:

Family

2 of 2
*Enter number for time period since event.
^IPDATENO…

1
2
3
7
9

Days
Weeks
Months
Refused
Don't know

UniverseText:

All injury/poisoning episodes where don't know was entered for month of episode and 1-91 was entered for the
"number" part of this two-part question

SkipInstructions:

goto IPHOW

Hard Edit:

If IPDATENO GT 91 days (1) or
IPDATENO GT 13 weeks (2) or
IPDATENO GT 4 months (3) then goto ERR_IPDATETP
ERR_IPDATETP
defaul blaise message for now "Out of range"

Soft Edit:

ERR1_IPDATETP
*The approximate date falls outside the reference period beginning [fill date used in FIJ.010].
*Please verify and make any corrections.

Page 11 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.052_00.000

QuestionText:

(book) F3

Instrument Variable Name:

20-Aug-13

IPDATEMT

QuestionnaireFileName:

Family

? [F1]

Was this in the beginning of [fill: ^IPDATEM (text)], the middle of [fill: ^IPDATEM (text)], or the end of [fill:
^IPDATEM (text)]?
1

Beginning
Middle
End
Refused
Don't know

2

3
7
9

UniverseText:

All injury/poisoning episodes where don't know was entered for day of episode

SkipInstructions:

goto IPHOW

Question ID:

FIJ.060_00.000

QuestionText:

Instrument Variable Name:

IPHOW

QuestionnaireFileName:

Family

? [F1]
[fill1: How did [fill2: your/ALIAS’s] [fill3: injury/poisoning] on [fill4: ^IPDATEM ^IPDATED (starting with most
recent if multiple)] happen?/How did this [fill3: injury/poisoning] happen?] Please describe fully the circumstances or
events leading to the [fill3: injury/poisoning], and any objects, substances, or other people involved.
* Enter the verbatim response, probing for as much detail as possible, including specifically what the person was doing at
the time and all circumstances surrounding the event. Record all volunteered information.

Verbatim
7

9

Verbatim response
Refused
Don't know

UniverseText:

All injury/poisoning episodes for which a medical professional was consulted

SkipInstructions:

[if an injury episode, goto ICAUS; else, if a poisoning episode, goto PPCC]
[if an injury episode, fill "R" in ICAUS and goto IJBODY; else, if a poisoning episode, goto PPCC]
[if an injury episode, fill "D" in ICAUS and goto IJBODY; else, if a poisoning episode, goto PPCC]

Page 12 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.065_00.000

QuestionText:

Instrument Variable Name:

ICAUS

20-Aug-13

QuestionnaireFileName:

Family

? [F1]
* Do not read.
* Enter the number which best describes the cause of the person’s injury from the list below.

01

02
03
04
05
06
07

97
99

In a motor vehicle
On a bike, scooter, skateboard, skates, skis, horse, etc.
Pedestrian who was struck by a vehicle such as a car or bicycle
In a boat, train, or plane
Fall
Burned or scalded by substances such as hot objects or liquids, fire, or chemicals
Other
Refused
Don't know

UniverseText:

All injury episodes for which a medical professional was consulted and don't know or refused was not entered at
IPHOW

SkipInstructions:

goto IJBODY

Page 13 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.070_00.000

QuestionText:

(book) F4

Instrument Variable Name:

20-Aug-13

IJBODY

QuestionnaireFileName:

* Enter up to 4 responses, separate with commas.
* Ask or verify.
In this injury, what parts of [fill: your/ALIAS’s] body were hurt?
01
02
03
04
05

06
07
08
09
10
11

12
13
14
15
16

17
18
19
20
21
22

23
24
25
26
27

28
29
97
99

Ankle
Back
Buttocks
Chest
Ear
Elbow
Eye
Face
Finger/thumb
Foot
Forearm
Groin
Hand
Head (not face)
Hip
Jaw
Knee
Lower leg
Mouth
Neck
Nose
Shoulder
Stomach
Teeth
Thigh
Toe
Upper arm
Wrist
Other, specify
Refused
Don't know

UniverseText:

All injury episodes for which a medical professional was consulted

SkipInstructions:

<1-28> [goto IJTYPE1]
<29> [goto IJBODYOS]
[goto IPEV]

Family

Page 14 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.071_00.000

QuestionText:

Instrument Variable Name:

20-Aug-13

IJBODYOS

QuestionnaireFileName:

Family

QuestionnaireFileName:

Family

*Read if necessary.
What other parts of the body were hurt?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All injury episodes where some "other" part of the body was hurt

SkipInstructions:

goto IJTYPE1

Question ID:

FIJ.072_00.000

QuestionText:

(book) F5

Instrument Variable Name:

IJTYPE1

*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill1: your/ALIAS’s] [fill2: first entry--^IJBODY (text) or ^IJBODYOS] hurt?
01

02
03
04
05
06

07
08
09
97
99

Broken bone or fracture
Sprain, strain, or twist
Cut
Scrape
Bruise
Burn
Insect bite
Animal bite
Other, specify
Refused
Don't know

UniverseText:

All injury episodes where at least one part of the body was hurt

SkipInstructions:

<1-8,D> [goto IJTYPE2 for next body part entered at IJBODY; if no more body parts, goto IPEV]
<9> [goto IJTYP1OS]
[goto IPEV]

Page 15 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.073_00.000

QuestionText:

Instrument Variable Name:

IJTYP1OS

20-Aug-13

QuestionnaireFileName:

Family

? [F1]
* Read if necessary.
How was [fill1: your/ALIAS’s] [fill2: first entry -- ^IJBODY (text) or ^IJBODYOS] hurt?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All injury episodes where the first body part was hurt in some "other" way

SkipInstructions:

goto IJTYPE2 for next body part; if no more body parts, goto IPEV

Question ID:

FIJ.074_00.000

QuestionText:

(book) F5

Instrument Variable Name:

IJTYPE2

QuestionnaireFileName:

Family

*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill1: your/ALIAS’s] [fill2: second entry--^IJBODY (text) or ^IJBODYOS] hurt?
01
02
03
04

05
06
07
08
09
97

99

Broken bone or fracture
Sprain, strain, or twist
Cut
Scrape
Bruise
Burn
Insect bite
Animal bite
Other, specify
Refused
Don't know

UniverseText:

All injury episodes where at least two body parts were hurt and the type of injury or don't know was entered for the
first body part at IJTYPE1

SkipInstructions:

<1-8,D> [goto IJTYPE3 for next body part entered at IJBODY; if no more body parts, goto IPEV]
<9> [goto IJTYP2OS]
[goto IPEV]

Page 16 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.075_00.000

QuestionText:

Instrument Variable Name:

IJTYP2OS

20-Aug-13

QuestionnaireFileName:

Family

* Read if necessary.
How else was [fill1: your/ALIAS’s] [fill2: second entry -- ^IJBODY (text) or ^IJBODYOS] hurt?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All injury episodes where the second body part was hurt in some "other" way

SkipInstructions:

goto IJTYPE3 for next body part; if no more body parts, goto IPEV

Question ID:

FIJ.076_00.000

QuestionText:

(book) F5

Instrument Variable Name:

IJTYPE3

QuestionnaireFileName:

Family

*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill1: your/ALIAS’s] [fill2: third entry--^IJBODY (text) or ^IJBODYOS] hurt?
01

02
03
04
05
06

07
08
09
97
99

Broken bone or fracture
Sprain, strain, or twist
Cut
Scrape
Bruise
Burn
Insect bite
Animal bite
Other, specify
Refused
Don't know

UniverseText:

All injury episodes where at least three body parts were hurt and type of injury or don't know was entered for the
second body part at IJTYPE2

SkipInstructions:

<1-8,D> [goto IJTYPE4 for next body part entered at IJBODY; if no more body parts, goto IPEV]
<9> [goto IJTYP3OS]
[goto IPEV]

Page 17 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.077_00.000

QuestionText:

Instrument Variable Name:

IJTYP3OS

20-Aug-13

QuestionnaireFileName:

Family

* Read if necessary.
How else was [fill1: your/ALIAS’s] [fill2: third entry -- ^IJBODY (text) or ^IJBODYOS] hurt?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All injury episodes where the third body part was hurt in some "other" way

SkipInstructions:

goto IJTYPE4 for next body part; if no more body parts, goto IPEV

Question ID:

FIJ.078_00.000

QuestionText:

(book) F5

Instrument Variable Name:

IJTYPE4

QuestionnaireFileName:

Family

*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill1: your/ALIAS’s] [fill2: fourth entry--^IJBODY (text) or ^IJBODYOS] hurt?
01

02
03
04
05
06

07
08
09
97
99

Broken bone or fracture
Sprain, strain, or twist
Cut
Scrape
Bruise
Burn
Insect bite
Animal bite
Other, specify
Refused
Don't know

UniverseText:

All injury episodes where four body parts were hurt and type of injury or don't know was entered for the third body
part at IJTYPE3

SkipInstructions:

<1-8,R,D> [goto IPEV]
<9> [goto IJTYP4OS]

Page 18 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.079_00.000

QuestionText:

Instrument Variable Name:

IJTYP4OS

20-Aug-13

QuestionnaireFileName:

Family

* Read if necessary.
How else was [fill1: your/ALIAS’s] [fill2: fourth entry -- ^IJBODY (text) or ^IJBODYOS] hurt?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All injury episodes where the fourth body part was hurt in some "other" way

SkipInstructions:

if a poisoning episode, goto PPCC; else, goto IPEV

Question ID:

FIJ.080_01.000

QuestionText:

Instrument Variable Name:

PPCC

QuestionnaireFileName:

Did [fill: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this poisoning from..
A phone call to a poison control center?

1
2
7
9

Family

Yes
No
Refused
Don't know

UniverseText:

All poisoning episodes for which a medical professional was consulted

SkipInstructions:

<1,2,D> [goto IPEV]
[goto IPHOSP]

Page 19 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.080_02.000

QuestionText:

Instrument Variable Name:

IPEV

20-Aug-13

QuestionnaireFileName:

Family

* Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
An emergency vehicle, such as an ambulance or fire truck

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All injury/poisoning episodes for which a medical professional was consulted

SkipInstructions:

<1,2,D> [goto IPER]
[goto IPHOSP]

Question ID:

FIJ.080_03.000

QuestionText:

Instrument Variable Name:

IPER

QuestionnaireFileName:

Family

* Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
A visit to an emergency room

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

All injury/poisoning episodes for which a medical professional was consulted

SkipInstructions:

<1,2,D> [goto IPDO]
[goto IPHOSP]

Page 20 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.080_04.000

QuestionText:

Instrument Variable Name:

20-Aug-13

IPDO

QuestionnaireFileName:

Family

? [F1]
* Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
A visit to a doctor’s office or other health clinic

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All injury/poisoning episodes for which a medical professional was consulted

SkipInstructions:

<1,2,D> [goto IPPCHCP]
[goto IPHOSP]

Question ID:

FIJ.080_05.000

QuestionText:

Instrument Variable Name:

IPPCHCP

QuestionnaireFileName:

Family

? [F1]
* Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
A phone call to a doctor, nurse, or other health care professional

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All injury/poisoning episodes for which a medical professional was consulted

SkipInstructions:

<1,2,D> [goto IPOTH]
[goto IPHOSP]

Page 21 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.080_06.000

QuestionText:

Instrument Variable Name:

IPOTH

20-Aug-13

QuestionnaireFileName:

Family

* Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
Any place else?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All injury/poisoning episodes for which a medical professional was consulted

SkipInstructions:

<1> [goto IPOTHOS]
if [MTFINJ3M= 01-91 and IPEV=2] goto IPVER
<2> [if poisoning and episode and PPCC eq 2 and IPEV eq 2 and IPER eq 2 and IPDO eq 2 and IPPCHCP eq 2,
goto IPVER; else if an injury episode and IPEV eq 2 and IPER eq 2 and IPDO eq 2 and IPPCHCP eq 2, goto
IPVER; else goto IPHOSP]
[goto IPHOSP]

Question ID:

FIJ.081_00.000

QuestionText:

Instrument Variable Name:

IPOTHOS

QuestionnaireFileName:

Family

* Read lead-in if necessary.
Where else did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?

Verbatim

7
9

Verbatim response
Refused
Don't know

UniverseText:

All injury/poisoning episodes where medical advice, treatment, or follow-up care was received from some "other"
place

SkipInstructions:

goto IPHOSP

Page 22 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.082_00.000

QuestionText:

Instrument Variable Name:

IPVER

20-Aug-13

QuestionnaireFileName:

Family

* Please verify.
[fill1: You/ALIAS] DID NOT receive any medical advice, treatment, or follow-up for this [fill2: injury/poisoning]. Is that
correct?

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

All injury/poisoning episodes for which a medical professional was consulted, but no source of medical advice,
treatment, or follow-up care was selected

SkipInstructions:

<1>[If the subject HAS more injury/poisoning episodes, then go to FIJ.050_1for that subject. If the subject DOES
NOT HAVE more injury/poisoning episodes, then go to FIJ.014/FIJ.024 for next person with an injury/poisoning.
If no more family members with an injury/poisoning, go to next section.]
<2> [if poisoning, goto PPCC for new entries; else if injury, goto IPEV for new entries]

Hard Edit:

ERR_IPVER

Question ID:

FIJ.090_00.000

QuestionText:

Instrument Variable Name:

IPHOSP

QuestionnaireFileName:

Family

? [F1]
[fill1: Were you/Was ALIAS] hospitalized for at least one night as a result of this [fill2: injury/poisoning]?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All injury/poisoning episodes for which a medical professional was consulted

SkipInstructions:

<1> [goto IPIHNO]
<2,R,D> [if an injury episode, goto IMTRAF; if a poisoning episode, goto PPOIS]

Page 23 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.091_00.000

QuestionText:

Instrument Variable Name:

20-Aug-13

IPIHNO

QuestionnaireFileName:

Family

? [F1]
How many nights [fill: were you/was ALIAS] in the hospital?
* If still in hospital, ask how many nights up to today.
* Enter '95' for 95 or more nights.

01-94

1-94 nights
95+ nights
Refused
Don't know

95
97
99

UniverseText:

All injury/poisoning episodes for which a medical professional was consulted and resulted in hospitalization

SkipInstructions:

<1-60,R,D> [if ICAUS eq 1-3, goto IMTRAF; else, if ICAUS eq 4-7,R,D, goto IPWHAT; else, if ICAUS eq 5,
goto IFALL; if a poisoning episode, goto PPOIS]
<61-95> [goto ERR_IPIHNO]

Soft Edit:

[if IPIHNO gt 60, display ERR_IPIHNO]
* ^IPIHNO is unusually high. Please verify.
Suppress
Goto
Close
[if ICAUS eq 01 or 02 or 03, goto IMTRAF]
if ICAUS eq 04 or 06 or 07 or 97, or 99, goto IPWHAT]
if ICAUS eq 05, goto IFALL]]
[reset IPIHNO for new entry]

Question ID:

FIJ.109_00.000

QuestionText:

Instrument Variable Name:

IMTRAF

QuestionnaireFileName:

Family

? [F1]
* Ask or verify.
Did this accident occur on a public highway, street, or road?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All medically-consulted injury episodes that occurred while in a motor vehicle; on a bike, scooter, skateboard,
skates, skis, horse, etc.; or as a pedestrian who was struck by a vehicle such as a car or bicycle

SkipInstructions:

goto IMVWHO

Page 24 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.110_00.000

QuestionText:

Instrument Variable Name:

IMVWHO

20-Aug-13

QuestionnaireFileName:

Family

*Read all categories.
* Ask or verify.
[fill: Were you/Was ALIAS] injured as:
* Read answer categories.

1
2
3
4
5

7
9

The driver of a motor vehicle
A passenger in a motor vehicle
A pedestrian
A bicycle rider or tricycle rider
The rider of a scooter, skateboard, skates, or other non-motorized vehicle
Refused
Don't know

UniverseText:

All medically-consulted injury episodes that occurred while in a motor vehicle; on a bike, scooter, skateboard,
skates, skis, horse, etc.; or as a pedestrian who was struck by a vehicle such as a car or bicycle

SkipInstructions:

<1,2> [goto IMVTYP]
<4,5> [goto IHELMT]
<3,R,D> [goto IPWHAT]

Page 25 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.111_00.000

QuestionText:

(book) F6

Instrument Variable Name:

20-Aug-13

IMVTYP

QuestionnaireFileName:

Family

? [F1]

* Ask or verify.
What type of vehicle [fill: were you/was ALIAS] in?
01

Passenger car
Passenger truck, such as a pickup truck, van, or SUV
Bus
Large commercial truck, such as a semi-truck, big rig, or 18 wheeler
Motorcycle (including mopeds and minibikes)
All terrain vehicle or ski/snow-mobile
Farm equipment (such as a tractor)
Industrial or construction vehicle
Other
Refused
Don't know

02
03
04
05
06
07

08
09
97
99

UniverseText:

All medically-consulted injury episodes that occurred while a driver or passenger of a vehicle

SkipInstructions:

<1,2,4> [goto ISBELT]
<5,6> [goto IHELMT]
<3,7,8,9,R,D> [goto IPWHAT]

Question ID:

FIJ.112_00.000

QuestionText:

Instrument Variable Name:

ISBELT

QuestionnaireFileName:

Family

? [F1]
* Ask or verify.
[fill: Were you/Was ALIAS] restrained at the time of the accident?

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

All medically-consulted injury episodes that occurred while a driver or passenger of a car or truck

SkipInstructions:

goto IPWHAT

Page 26 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.113_00.000

QuestionText:

Instrument Variable Name:

IHELMT

20-Aug-13

QuestionnaireFileName:

Family

? [F1]
* Ask or verify.
[fill: Were you/Was ALIAS] wearing a helmet at the time of the accident?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All medically-consulted injury episodes that occurred while riding a bicycle, tricycle, scooter, skateboard, skates,
or other nonmotorized vehicle; a motorcycle; or an all terrain vehicle or ski/snow-mobile

SkipInstructions:

goto IPWHAT

Question ID:

FIJ.130_00.000

QuestionText:

(book) F7

Instrument Variable Name:

IFALL

QuestionnaireFileName:

* Enter up to 2 responses, separate with a comma.
* Ask or verify.
How did [fill: you/ALIAS] fall? Anything else?
01
02
03

04
05
06
07
08
09

10
11
97
99

Stairs, steps, or escalator
Floor or level ground
Curb (including sidewalk)
Ladder or scaffolding
Playground equipment
Sports field, court, or rink
Building or other structure
Chair, bed, sofa, or other furniture
Bathtub, shower, toilet, or commode
Hole or other opening
Other
Refused
Don't know

UniverseText:

All medically-consulted injury episodes that occurred due to a fall

SkipInstructions:

goto IFALLWHY

Family

Page 27 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.131_00.000

QuestionText:

(book) F8

Instrument Variable Name:

20-Aug-13

IFALLWHY

QuestionnaireFileName:

Family

* Ask or verify.
What caused [fill: you/ALIAS] to fall?
1

Slipping or tripping
Jumping or diving
Bumping into an object or another person
Being shoved or pushed by another person
Losing balance or having dizziness (becoming faint or having a seizure)
Other
Refused
Don't know

2
3
4
5
6
7

9

UniverseText:

All medically-consulted injury episodes that occurred due to a fall

SkipInstructions:

goto IPWHAT

Question ID:

FIJ.140_00.000

QuestionText:

(book) F9

Instrument Variable Name:

PPOIS

QuestionnaireFileName:

? [F1]

* Ask or verify.
What did [fill: your/ALIAS’s] poisoning result from?
1

2
3
4
5
6
7

9

Swallowing a drug or medical substance mistakenly or in overdose
Swallowing or touching a harmful solid or liquid substance
Inhaling harmful gases or vapors
Eating a poisonous plant or other substance mistaken for food
Being bitten by a poisonous animal
Other, please specify
Refused
Don't know

UniverseText:

All poisoning episodes for which a medical professional was consulted

SkipInstructions:

<1-5,R,D> [goto IPWHAT]
<6> [goto PPOISOS]

Family

Page 28 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.141_00.000

QuestionText:

Instrument Variable Name:

PPOISOS

20-Aug-13

QuestionnaireFileName:

Family

* Read if necessary.
How did [fill: your/ALIAS’s] poisoning occur?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All medically-consulted poisoning episodes where the poisoning resulted from some "other" reason

SkipInstructions:

goto IPWHAT

Question ID:

FIJ.150_00.000

QuestionText:

(book) F10

Instrument Variable Name:

IPWHAT

QuestionnaireFileName:

? [F1]

* Enter up to 2 responses, separate with a comma.
* Ask or verify.
What activity [fill1: were you/was ALIAS] involved in at the time of the [fill2: injury/poisoning]?
01

02
03
04
05
06

07
08
09
10
11
97

99

Driving or riding in a motor vehicle
Working at a paid job
Working around the house or yard
Attending school
Unpaid work (such as volunteer work)
Sports and exercise
Leisure activity (excluding sports)
Sleeping, resting, eating, or drinking
Cooking
Being cared for (hands-on care from other person)
Other, please specify
Refused
Don't know

UniverseText:

All injury/poisoning episodes for which a medical professional was consulted

SkipInstructions:

<1-10,R,D> [goto IPWHER]
<11> [goto IPWHATOT]

Family

Page 29 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.151_00.000

QuestionText:

Instrument Variable Name:

20-Aug-13

IPWHATOT

QuestionnaireFileName:

Family

* Read if necessary.
What other activity [fill1: were you/was ALIAS] involved in at the time of the [fill2: injury/poisoning]?

Verbatim
7
9

Verbatim response
Refused
Don't know

UniverseText:

All medically-consulted injury/poisoning episodes that occurred in some "other" place

SkipInstructions:

goto IPWHER

Page 30 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.160_00.000

QuestionText:

(book) F11

Instrument Variable Name:

IPWHER

20-Aug-13

QuestionnaireFileName:

Family

? [F1]

* Enter up to 2 responses, separate with a comma.
* Ask or verify.
Where [fill1: were you/was ALIAS] when the [fill2: injury/poisoning] happened?
01
02
03
04
05

06
07
08
09
10
11

12
13
14
15
16

17
97
99

Home (inside)
Home (outside)
School (not residential)
Child care center or preschool
Residential institution (excluding hospital)
Health care facility (including hospital)
Street or highway
Sidewalk
Parking lot
Sport facility, athletic field, or playground
Shopping center, restaurant, store, bank, gas station, or other place of business
Farm
Park or recreation area (include bike or jog path)
River, lake, stream, or ocean
Industrial or construction area
Other public building
Other
Refused
Don't know

UniverseText:

All injury/poisoning episodes for which a medical professional was consulted

SkipInstructions:

<01-17,R,DK> [If AGE lt 5 and person HAS more injury/poisoning episodes, goto IPDATEM
for that person; else if AGE lt 5 and person DOES NOT HAVE more
injury/poisoning episodes, goto TFINJ3M/TFPOI3M for next person with an
injury/poisoning; else if AGE lt 5 and no more family members with an
injury/poisoning, go to FPOI3M/next section;
Else [if AGE ge 13, goto IPEMP; else if AGE ge 5 and AGE le 12, goto IPSTU]

Page 31 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.170_00.000

QuestionText:

Instrument Variable Name:

IPEMP

20-Aug-13

QuestionnaireFileName:

Family

? [F1]
At the time of this [fill1: injury/poisoning], [fill2: were you/was ALIAS] employed full-time, part-time, or not employed?

1

Full-time
Part-time
Not employed
Refused
Don't know

2
3

7
9

UniverseText:

All medically-consulted injury/poisoning episodes for persons 13 years of age or older

SkipInstructions:

<1,2> [goto IPWKLS]
<3,R,D> [goto IPSTU]

Question ID:

FIJ.171_00.000

QuestionText:
1
2

3
4
7
9

Instrument Variable Name:

IPWKLS

QuestionnaireFileName:

Family

As a result of this [fill1: injury/poisoning], how many days of work did [fill2: you/ALIAS] miss?
None
Less than one day
One to five days
Six or more days
Refused
Don't know

UniverseText:

All medically-consulted injury/poisoning episodes for persons 13 years of age or older who were employed at the
time of the episode

SkipInstructions:

goto IPSTU

Page 32 of 32

DRAFT 2013 NHIS Questionnaire - Family
Injuries & Poisoning
Document Version Date:

Question ID:

FIJ.180_00.000

QuestionText:

Instrument Variable Name:

IPSTU

20-Aug-13

QuestionnaireFileName:

Family

At the time of this [fill1: injury/poisoning], [fill2: were you/was ALIAS] a full-time student, part-time student or not a
student?

1

Full-time
Part-time
Not a student
Refused
Don't know

2
3
7

9

UniverseText:

All medically-consulted injury/poisoning episodes for persons 5 years of age or older

SkipInstructions:

<1,2> [goto IPSCLS]
<3,R,DK> [If person HAS more injury/poisoning episodes, goto IPDATEM for that person; else if person DOES
NOT HAVE more injury/poisoning episodes, goto TFINJ3M/TFPOI3M for next person with an injury/poisoning;
else if no more family members with an injury/poisoning, goto next section]

Question ID:

FIJ.181_00.000

QuestionText:
1

2
3
4
7
9

Instrument Variable Name:

IPSCLS

QuestionnaireFileName:

Family

As a result of this [fill1: injury/poisoning], how many days of school did [fill2: you/ALIAS] miss?
None
Less than one day
One to five days
Six or more days
Refused
Don't know

UniverseText:

All medically-consulted injury/poisoning episodes for persons 5 years of age or older who were students at the
time of the episode

SkipInstructions:

<1-4,R,DK>[If person HAS more injury/poisoning episodes, goto IPDATEM for that person; else
if person DOES NOT HAVE more injury/poisoning episodes, goto
TFINJ3M/TFPOI3M for next person with an injury/poisoning; else if no more family
members with an injury/poisoning, goto next section]

Page 1 of 10

DRAFT 2013 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:

Question ID:

FAU.010_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FDMED12M

QuestionnaireFileName:

Family

? [F1]
The following questions are about the use of health care. Do not include dental care.
DURING THE PAST 12 MONTHS, [fill: have you delayed seeking medical care/has medical care been delayed for
anyone in the family] because of worry about the cost?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PDMED12M and goto FNMED12M; else, goto
PDMED12M]
<2,R,D> [goto FNMED12M]

Question ID:

FAU.020_00.000 Instrument Variable Name:

QuestionText:

PDMED12M

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
For which family member was medical care delayed?
(Anyone else?)

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one had medical care delayed due to worry about the cost during
the past 12 months

SkipInstructions:

goto FNMED12M
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 2 of 10

DRAFT 2013 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:

Question ID:

FAU.030_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FNMED12M

QuestionnaireFileName:

Family

? [F1]
DURING THE PAST 12 MONTHS, was there any time when [fill1: you/someone in the family] needed medical care, but
did not get it because [fill2: you/the family] couldn't afford it?

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PNMED12M and goto FHOSPYR; else, goto
PNMED12M]
<2,R,D> [goto FHOSPYR]

Question ID:

FAU.040_00.000 Instrument Variable Name:

QuestionText:

PNMED12M

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who didn't get needed care?
(Anyone else?)

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one didn't get medical care due to cost during the past 12 months

SkipInstructions:

goto FHOSPYR
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 3 of 10

DRAFT 2013 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:

Question ID:

FAU.050_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FHOSPYR

QuestionnaireFileName:

Family

?[F1]
[fill1: were you/Including all infants born in a hospital, has anyone in the family] been hospitalized OVERNIGHT in the
past 12 months? Do not include an overnight stay in the emergency room.

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PHOSPYR and goto HOSPNO; else, goto PHOSPYR]
<2,R,D> [goto FHCHM2W]

Question ID:

FAU.060_00.000 Instrument Variable Name:

QuestionText:

PHOSPYR

QuestionnaireFileName:

Family

*Ask or verify. Enter applicable line number(s), separate with commas.
Who was in a hospital overnight?
(Anyone else?)

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one was a patient overnight during the past 12 months
(excluding ER)

SkipInstructions:

goto HOSPNO
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 4 of 10

DRAFT 2013 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:

Question ID:

FAU.070_00.000 Instrument Variable Name:

QuestionText:

HOSPNO

20-Aug-13

QuestionnaireFileName:

Family

? [F1]
How many different times did [fill: you/ALIAS] stay in any hospital overnight or longer DURING THE PAST 12
MONTHS?

001-365

1-365 times
Refused
Don't know

997

999

UniverseText:

All persons who had an overnight hospital stay during the past 12 months (excluding ER)

SkipInstructions:

<1-10> [goto HPNITE]
<11-365> [goto ERR_HOSPNO]
[goto HPNITE]

Soft Edit:

ERR_HOSPNO
* [fill: HOSPNO] is unusually high.
* Verify entry.
* Make corrections if necessary.

Question ID:

FAU.110_00.000 Instrument Variable Name:

QuestionText:

HPNITE

QuestionnaireFileName:

Family

? [F1]
Altogether how many nights [fill: were you/was ALIAS] in the hospital DURING THE PAST 12 MONTHS?

001-365
997
999

1-365 nights
Refused
Don't know

UniverseText:

All persons who had an overnight hospital stay during the past 12 months (excluding ER)

SkipInstructions:

<1-50,R,D> [goto next person selected at PHOSPYR; if no more persons, goto FHCM2W]
<51-365> [goto ERR1_HPNITE]
if HOSPNO gt HPNITE, goto ERR2_HPNITE

Soft Edit:

ERR1_HPNITE
* [fill: HPNITE] is unusually high.
* Verify entry.
* Make corrections if necessary.
ERR2_HPNITE
* Do not read.
* [fill: HPNITE] night(s) is less than the total number of times in the hospital overnight.
* Please verify.
Note: If edit suppressed, store S in HPNITE_FLG

Page 5 of 10

DRAFT 2013 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:

Question ID:

FAU.120_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FHCHM2W

QuestionnaireFileName:

Family

?[F1]
These next questions are about health care received DURING THE LAST 2 WEEKS. Include care from ALL types of
medical doctors, such as dermatologists, psychiatrists, ophthalmologists (AHF-thal-MOL-oh-jists), and general
practitioners. Also include care from OTHER health professionals such as nurses, physical therapists, and chiropractors.
Do not include dental care. Do not include care while an overnight patient in a hospital.
DURING THE LAST 2 WEEKS, did [fill: you/anyone in the family] receive care
AT HOME from a nurse or other health care professional?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PHCHM2W and goto PHCHMN2W; else, goto
PHCHM2W]
<2,R,D> [goto FHCPH2W]

Question ID:

FAU.130_00.000 Instrument Variable Name:

QuestionText:

PHCHM2W

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who received care at home?
(Anyone else?)

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one received care at home from a health care professional during
the past 2 weeks (excluding dental care)

SkipInstructions:

goto PHCHMN2W
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 6 of 10

DRAFT 2013 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:

Question ID:

FAU.140_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PHCHMN2W

QuestionnaireFileName:

Family

How many home visits did [fill: you/ Alias] receive DURING THE LAST 2 WEEKS?
* Enter '50' for 50 or more visits.

01-50

1-50 home visits
Refused
Don't know

97
99

UniverseText:

All persons who received care at home from a health care professional during the past 2 weeks (excluding dental
care)

SkipInstructions:

<1-14,R,D> [repeat for all eligible persons, then goto FHCPH2W]
<15-50> [goto ERR_PHCPHMN2W]

Soft Edit:

ERR_PHCHMN2W
* [fill: PHCHMN2W] is unusually high.
* Verify entry.
* DO NOT PROBE. Make corrections if necessary.

Question ID:

FAU.150_00.000 Instrument Variable Name:

QuestionText:

FHCPH2W

QuestionnaireFileName:

Family

DURING THE LAST 2 WEEKS, did [fill: you/anyone in the family] get any medical advice or test results over the
PHONE from a doctor, nurse, or other health care professional?
Do not include phone calls to make appointments, for billing questions or for prescription refills.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PHCPH2W and goto PHCPHN2W; else, goto
PHCPH2W]
<2,R,D> [goto FHCDV2W]

Page 7 of 10

DRAFT 2013 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:

Question ID:

FAU.160_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PHCPH2W

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who was the phone call about?
(Anyone else?)

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

All families with two or more persons and at least one received medical advice or test results over the phone
during the past 2 weeks (excluding calls for appointments, billing questions, or prescription medicines)

SkipInstructions:

goto PHCPHN2W
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FAU.170_00.000 Instrument Variable Name:

QuestionText:

PHCPHN2W

QuestionnaireFileName:

Family

DURING THE LAST 2 WEEKS, how many telephone calls
[fill1: did you make?]
[fill2: were made about [fill: Alias]?
* Enter '50' for 50 or more phone calls.

01-50
97

99

1-50 calls
Refused
Don't know

UniverseText:

All persons for whom medical advice or test results were received over the phone from a health care professional
during the past 2 weeks (excluding calls for appointments, billing questions, or prescription refills)

SkipInstructions:

<1-14,R,D> [repeat for all eligible persons, then goto FHCDV2W]
<15-50> [goto ERR_PHCPHN2W]

Soft Edit:

ERR_PHCPHN2W
* [fill: PHCPHN2W] is unusually high.
* Verify that all calls were within the two week period.
* Make corrections if necessary.

Page 8 of 10

DRAFT 2013 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:

Question ID:

FAU.180_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FHCDV2W

QuestionnaireFileName:

Family

DURING THE LAST 2 WEEKS, did [fill1: you/anyone in the family] see a doctor or other health care professional at a
doctor's OFFICE, a clinic, an emergency room, or some other place?
[fill2: Do not include times during an overnight hospital stay.]

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PHCDV2W and goto PHCDVN2W; else, goto
PHCDV2W]
<2,R,D> [goto F10DVYR]

Question ID:

FAU.190_00.000 Instrument Variable Name:

QuestionText:

PHCDV2W

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who received care?
(Anyone else?)

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one saw a health care professional in an office, clinic,
emergency room, or some other place during the past 2 weeks (excluding visits during overnight hospital stays)

SkipInstructions:

goto PHCDVN2W
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 9 of 10

DRAFT 2013 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:

Question ID:

FAU.200_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PHCDVN2W

QuestionnaireFileName:

Family

How many times did [fill: you/ Alias] visit a doctor or other health care professional DURING THE LAST 2 WEEKS?
* Enter '50' for 50 or more visits.

01-50

1-50 times
Refused
Don't know

97
99

UniverseText:

All persons who visited a health care professional during the past 2 weeks (excluding overnight hospital stays)

SkipInstructions:

<1-14,R,D> [repeat for all eligible persons, then goto F10DVYR]
<15-50> [goto ERR_PHCDVN2W]

Soft Edit:

ERR_PHCDVN2W
* [fill: PHCDVN2W] is unusually high.
* Verify that all visits were within the two week reference period.
* Make corrections if necessary.

Question ID:

FAU.210_00.000 Instrument Variable Name:

QuestionText:

1
2

7
9

F10DVYR

QuestionnaireFileName:

Family

DURING THE PAST 12 MONTHS, did [fill: you/any member of the family] receive care from doctors or other health
care professionals 10 or more times? Do not include telephone calls.
Yes
No
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in P10DVYR and goto FHICOV; else, goto P10DVYR]
<2,R,D> [goto FHICOV]

Page 10 of 10

DRAFT 2013 NHIS Questionnaire - Family
Family Access to Health Care & Utilization
Document Version Date:

Question ID:

FAU.220_00.000 Instrument Variable Name:

QuestionText:

P10DVYR

20-Aug-13

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who received care 10 or more times?
(Anyone else?)

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one received care 10 or more times from a health care
professional during the past 12 months (excluding telephone calls)

SkipInstructions:

goto FHICOV
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 1 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.050_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FHICOV

QuestionnaireFileName:

Family

(book) F12 and (book) F14
The next questions are about health insurance. Include health insurance obtained through employment or purchased
directly as well as government programs like Medicare and Medicaid that provide Medical care or help pay medical bills.
[fill: Are you/Is anyone in the family] covered by any kind of health insurance or some other kind of health care plan?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1,R,D> [goto HIKIND]
<2> [if AGE ge 65, goto MCAREPRB; else, goto MCAIDPRB]

Page 2 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.070_00.000 Instrument Variable Name:

QuestionText:

(book) F12 and (book) F14

20-Aug-13

HIKIND

QuestionnaireFileName:

Family

? [F1]

What kind of health insurance or health care coverage [fill: do you/does ALIAS] have? INCLUDE those that pay for only
one type of service (nursing home care, accidents, or dental care). EXCLUDE private plans that only provide extra cash
while hospitalized.
* Enter all that apply, separate with commas.
01

Private health insurance
Medicare
Medi-Gap
Medicaid
SCHIP (CHIP/Children's Health Insurance Program)
Military health care (TRICARE/VA/CHAMP-VA)
Indian Health Service
State-sponsored health plan
Other government program
Single service plan (e.g., dental, vision, prescriptions)
No coverage of any type
Refused
Don't know

02
03
04
05

06
07
08
09
10
11

97
99

UniverseText:

All persons in families where FHICOV= yes, don't know, or refused

SkipInstructions:

[goto HCSPFYR]
<1-10> [if AGE ge 65 and HIKIND ne 2, goto MCAREPRB; else, if HIKIND ne 10 goto SINCOV; else, goto
HICHANGE]
<11> [if HIKIND = 1-10, goto ERR_HIKIND; else, if AGE ge 65 goto MCAREPRB; else, goto MCAIDPRB]

Hard Edit:

ERR_HIKIND:
* Cannot mark "No coverage of any kind" and another type.
* Please correct.

Question ID:

FHI.072_00.000 Instrument Variable Name:

QuestionText:

1
2
7

9

MCAREPRB

QuestionnaireFileName:

Family

(book) F13
People covered by Medicare have a card that looks like this.
[fill: Are you/Is ALIAS] covered by Medicare?
Yes
No
Refused
Don't know

UniverseText:

All persons 65 years of age or older in families not covered by health insurance or Medicare was not selected for
those persons at HIKIND

SkipInstructions:

if HIKIND ne 10, goto SINCOV; else, goto HICHANGE

Page 3 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.073_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MCAIDPRB

QuestionnaireFileName:

Family

(book F14)
* Refer to flashcard F14 for state Medicaid names.
There is a program called Medicaid that pays for health care for persons in need. In this State it is also called (* fill State
name). [fill: Are you/Is ALIAS] covered by Medicaid?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All persons less than 65 years of age with no insurance coverage of any type

SkipInstructions:

goto SINCOV

Question ID:

FHI.074_00.000 Instrument Variable Name:

QuestionText:

1

2
7
9

SINCOV

QuestionnaireFileName:

Family

[fill: Do you/Does ALIAS] have any type of insurance that pays for only one type of service such as dental, vision, or
prescriptions?
Yes
No
Refused
Don't know

UniverseText:

All persons in families not covered by health insurance or single service plan was not selected for those persons at
HIKIND

SkipInstructions:

goto HICHANGE

Page 4 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.075_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HICHANGE

QuestionnaireFileName:

Family

QuestionnaireFileName:

Family

I have recorded [fill1: you are/ALIAS is] [fill 2: covered by:
fill3: ^HIKIND] / not covered by health insurance.]
Is this correct?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All persons

SkipInstructions:

<1,R,D> [repeat for all eligible persons, then goto MCPART]
<2> [goto ERR_HICHANGE]

Hard Edit:

ERR_HICHANGE
*Press enter to go back to HIKIND and update coverage.

Question ID:

FHI.090_00.000 Instrument Variable Name:

QuestionText:

MCPART

{if subject ne respondent}:
Earlier I recorded that ALIAS is covered by Medicare. May I please see ALIAS’s Medicare card to determine the type of
coverage?
{if subject eq respondent}:
* Read if necessary.
What type of Medicare coverage do you have? Is it Part A - hospital insurance, Part B - medical insurance, or both?
* Fill in appropriate coverage type below.

1
2
3
7

9

Part A - Hospital only
Part B - Medical only
Both Part A and Part B
Refused
Don't know

UniverseText:

All persons with Medicare

SkipInstructions:

<1-3> [goto MCCARD]
[prefill MCCARD with a "2" and goto MCCHOICE]

Page 5 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.092_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MCCARD

QuestionnaireFileName:

* Do not read. Was the type of coverage obtained from a Medicare card or some other form of documentation?

1

Yes
No

2

UniverseText:

All persons with Part A Medicare coverage, Part B Medicare coverage, or both

SkipInstructions:

if MCPART = 1, goto MCPARTD; else, goto MCCHOICE

Question ID:

Family

FHI.095_00.000 Instrument Variable Name:

QuestionText:

MCCHOICE

QuestionnaireFileName:

Family

? [F1]
Medicare Advantage is the new name for Medicare Plus Choice plans. [fill: Are you/Is ALIAS] enrolled in a Medicare
Advantage plan?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for Part
B coverage

SkipInstructions:

goto MCHMO

Page 6 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.100_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MCHMO

QuestionnaireFileName:

Family

? [F1]
[fill: Are you/Is ALIAS] under a Medicare managed care arrangement, such as an HMO, that is, a Health Maintenance
Organization? (With an HMO, you must generally receive care from HMO doctors, otherwise the expense is not covered
unless you were referred by the HMO or there was a medical emergency).

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for Part
B coverage

SkipInstructions:

<1> [goto MCANAME]
<2,R,D> [if MCCHOICE=1, goto MCANAME; else if MCCHOICE=2,R,D, goto MCREF]

Question ID:

FHI.112_00.000 Instrument Variable Name:

QuestionText:

MCANAME

QuestionnaireFileName:

? [F1]
What is the name of [fill 1: your/ALIAS’s] Medicare Advantage or Medicare HMO plan?
* Read if necessary: Do you have a health plan card or something with the plan name on it?

Verbatim
7
9

Verbatim response
Refused
Don't know

UniverseText:

All persons that had either a Medicare Advantage plan or a Medicare HMO plan

SkipInstructions:

goto MCPREM

Family

Page 7 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.113_00.000 Instrument Variable Name:

20-Aug-13

MCPREM

QuestionnaireFileName:

Besides [fill 1: your/ALIAS’s] Medicare Part B payment, [fill 2: are you/is ALIAS] paying a premium for [fill 3:
your/his/her] Medicare Advantage or Medicare HMO plan?

QuestionText:

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All persons that had either a Medicare Advantage plan or a Medicare HMO plan

SkipInstructions:

<1,2,R,D> goto MCREF

Question ID:

Family

FHI.114_00.000 Instrument Variable Name:

QuestionText:

MCREF

QuestionnaireFileName:

Family

? [F1]
Under [fill1: your/ALIAS's] Medicare plan, if [fill2: you need/he needs/she needs] to go to a different doctor or place for
special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for Part
B coverage

SkipInstructions:

<1,2,R,D> goto MCPARTD

Question ID:

FHI.118_00.000 Instrument Variable Name:

QuestionText:
1
2
7

9

MCPARTD

QuestionnaireFileName:

Family

[Fill 1: Are you/Is ALIAS] enrolled in Medicare Part D, also known as the Medicare Prescription Drug Plan?
Yes
No
Refused
Don't know

UniverseText:

All persons with Medicare

SkipInstructions:

<1,2,7,9> [goto MCPART for next person with Medicare; else goto MACHMD]

Page 8 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.120_00.000 Instrument Variable Name:

QuestionText:

(book F14)

20-Aug-13

MACHMD

QuestionnaireFileName:

Family

? [F1]

* Refer to flashcard F14 for state Medicaid names.
The next questions are about Medicaid coverage. In this State it is also called (* fill State Name). [fill1: You are/ALIAS
is] listed as having Medicaid coverage. Can [fill2: you/ALIAS] go to ANY doctor who will accept Medicaid or MUST
[fill3: you/he/she] choose from a book or list of doctors or is a doctor assigned?
1

Any doctor
Select from book/list
Doctor is assigned
Refused
Don't know

2
3
7
9

UniverseText:

All persons with Medicaid

SkipInstructions:

<1,R,D> [goto MAPCMD]
<2> [goto MACHMD1]
<3> [goto MACHMD2]

Question ID:

FHI.130_00.000 Instrument Variable Name:

QuestionText:

MACHMD1

QuestionnaireFileName:

* Ask or verify.
What is the name of the health plan that provided the book or list?
*Read if necessary: Do you have a health plan card or something with the plan name on it?

Verbatim

7
9

Verbatim response
Refused
Don't know

UniverseText:

All persons with Medicaid who must select a doctor from a book or list of doctors

SkipInstructions:

goto MANAM

Family

Page 9 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.131_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MACHMD2

QuestionnaireFileName:

Family

* Ask or verify.
What is the name of the health plan that assigned the doctor?
*Read if necessary: Do you have a health plan card or something with the plan name on it?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All persons with Medicaid for whom a doctor is assigned

SkipInstructions:

goto MANAM

Question ID:

FHI.132_00.000 Instrument Variable Name:

QuestionText:

MANAM

QuestionnaireFileName:

Family

? [F1]
* Do not read. Was the Health Plan name obtained from a Health Plan Card or something with the Health Plan name on
it?

1

Yes
No

2

UniverseText:

All persons with Medicaid who must select a doctor from a book or list or for whom a doctor is assigned

SkipInstructions:

goto MAPCMD

Question ID:

FHI.140_00.000 Instrument Variable Name:

QuestionText:

1
2
7

9

MAPCMD

QuestionnaireFileName:

Family

[fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which
[fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care from a
specialist [fill4: you were/he was/she was] referred to.
Yes
No
Refused
Don't know

UniverseText:

All persons with Medicaid

SkipInstructions:

goto MAREF

Page 10 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.150_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MAREF

QuestionnaireFileName:

Family

? [F1]
Under [fill1: your/ALIAS's] Medicaid plan, if [fill2: you need/he needs/she needs] to go to a different doctor or place for
special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

All persons with Medicaid

SkipInstructions:

goto MACHMD for the next person with Medicaid; else, goto SSTYPE2

Question ID:

FHI.156_00.000 Instrument Variable Name:

QuestionText:

SSTYPE2

QuestionnaireFileName:

Family

(book) F15
* Enter all that apply, separate with commas.
You mentioned that [fill1: you have/ALIAS has] a single-service plan - that is, an insurance plan that provides one
specific type of coverage. What type of service or care does [fill2: your/ALIAS's] single service plan or plans pay for?

01
02
03
04
05

06
07
08
09
10
11

12
97
99

Accidents
AIDS care
Cancer treatment
Catastrophic care
Dental care
Disability insurance
Hospice care
Hospitalization only
Long-term care
Prescriptions
Vision care
Other (specify)
Refused
Don't know

UniverseText:

All persons with single service plans

SkipInstructions:

<1-11,R,D> [repeat for all eligible persons, then goto FHICCI6]
<12> [goto SSOTHER]

Page 11 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.157_00.000 Instrument Variable Name:

QuestionText:

SSOTHER

20-Aug-13

QuestionnaireFileName:

* Other type of single-service plan

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All persons with an "other" single service plan

SkipInstructions:

goto SSTYPE2 for the next person with a single service plan; else, goto FHICCI6

Question ID:

Family

FHI.158_00.000 Instrument Variable Name:

QuestionText:

FHICCI6

QuestionnaireFileName:

Family

The next questions are about private health insurance plans [fill1: /including Medi-Gap]. These plans can be obtained
through work, purchased directly, or through a state or local government program or community program.
[fill2: We have the following persons listed as being covered by such plans:
* Read names.
(display roster of eligible persons)]
* Enter 1 to continue

1

Continue

UniverseText:

All families with at least one person covered by private health insurance

SkipInstructions:

goto HIPNAM1

Page 12 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.160_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HIPNAM1

QuestionnaireFileName:

Family

It is important that we record the complete and accurate name of each health insurance plan. What is the COMPLETE
name of the first plan?
Do NOT include plans that only provide extra cash while in the hospital or plans that pay for only one type of service,
such as nursing home care, accidents, or dental care.
* Read if necessary: Do you have your health plan card or something with the plan name on it?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All families with at least one person covered by private health insurance

SkipInstructions:

[goto PCARD1]
[prefill PCARD1 with a "2" and goto HIPNAM1B]

Question ID:

FHI.160_01.000 Instrument Variable Name:

QuestionText:
1

2

PCARD1

QuestionnaireFileName:

Family

* Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on it?
Yes
No

UniverseText:

All private health insurance plans where the plan name was entered at HIPNAM1

SkipInstructions:

goto HIPNAM1B

Page 13 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.170_00.000 Instrument Variable Name:

20-Aug-13

HIPNAM1B

QuestionnaireFileName:

Family

QuestionText:

* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by this plan?
* Indicate each family member covered by this plan.
1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with a private health insurance plan and the plan name, refused, or don't know was entered at
HIPNAM1

SkipInstructions:

[if HIPNAM1= R or D, goto STNAME]
goto MORPLAN
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FHI.171_00.000 Instrument Variable Name:

QuestionText:

MORPLAN

QuestionnaireFileName:

Family

* Ask if necessary
Are there any more private health insurance plans?

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

All families where a private health insurance plan name was entered at HIPNAM1 or a person number was entered
at HIPNAM1B

SkipInstructions:

<1> [goto HIPNAM2]
<2,R,D> [if no persons selected at HIPNAM1B, goto FHICCI8; else, if persons selected at HIPNAM1B, but not
all persons with HIKIND = 1 or 3 selected at HIPNAM1B, goto HIVER1]

Page 14 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.172_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HIPNAM2

QuestionnaireFileName:

Family

What is the name of the next plan?
*Read if necessary: Do you have a health plan card or something with the plan name on it?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All families with a second private health insurance plan

SkipInstructions:

[goto PCARD2]
[prefill PCARD2 with a "2" and goto HIPNAM2B]

Question ID:

FHI.172_01.000 Instrument Variable Name:

QuestionText:

1
2

PCARD2

QuestionnaireFileName:

Family

* Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on it?

Yes
No

UniverseText:

All private health insurance plans where the plan name was entered at HIPNAM2

SkipInstructions:

goto HIPNAM2B

Page 15 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.173_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HIPNAM2B

QuestionnaireFileName:

Family

* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by that plan?
* Indicate each family member covered by this plan.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with a second private health insurance plan and the plan name, refused, or don't know was entered at
HIPNAM2

SkipInstructions:

[if HIPNAM2 eq R or D and persons selected at HIPNAM1B, but not all persons with HIKIND eq 1 or 3
selected at HIPNAM1B, goto HIVER1; else, if HIPNAM2 eq R or D and persons selected at HIPNAM1B, and all
persons with HIKIND eq 1 or 3 selected at HIPNAM1B, goto FHICCI8; else, if HIPNAM2 eq R or D and persons
not selected at HIPNAM1B, goto FHICCI8; else, if a health plan name recorded in HIPNAM2, goto MORPLAN2]
goto MORPLAN2

Question ID:

FHI.174_00.000 Instrument Variable Name:

QuestionText:

MORPLAN2

QuestionnaireFileName:

Family

* Ask if necessary
Are there any more private health insurance plans?

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

All families where a private health insurance plan name was entered at HIPNAM2 or a person number was entered
at HIPNAM2B

SkipInstructions:

<1> [goto HIPNAM3]
<2,R,D> [if persons selected at HIPNAM2B or HIPNAM1B, but not all persons with HIKIND eq 1 or 3 selected
at HIPNAM2B or HIPNAM1B, goto HIVER1; else, goto FHICCI8]

Page 16 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.175_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HIPNAM3

QuestionnaireFileName:

Family

What is the name of the next plan?
*Read if necessary: Do you have a health plan card or something with the plan name on it?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All families with a third private health insurance plan

SkipInstructions:

[goto PCARD3]
[prefill PCARD3 with a "2" and goto HIPNAM3B]

Question ID:

FHI.175_01.000 Instrument Variable Name:

QuestionText:

1
2

PCARD3

QuestionnaireFileName:

Family

* Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on it?

Yes
No

UniverseText:

All private health insurance plans where the plan name was entered at HIPNAM3

SkipInstructions:

goto HIPNAM3B

Page 17 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.176_00.000 Instrument Variable Name:

20-Aug-13

HIPNAM3B

QuestionnaireFileName:

Family

QuestionText:

* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by that plan?
* Indicate each family member covered by this plan.
1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with a third private health insurance plan and the plan name, refused, or don't know was entered at
HIPNAM3

SkipInstructions:

[if HIPNAM3 eq R or D and persons selected at HIPNAM1B or HIPNAM2B, but not all persons with
HIKIND eq 1 or 3 selected at HIPNAM1B or HIPNAM2B, goto HIVER1; else, if HIPNAM3 eq R or D and
persons selected at HIPNAM1B or HIPNAM2B, and all persons with HIKIND eq 1 or 3 selected at HIPNAM1B
or HIPNAM2B, goto FHICCI8; else, if HIPNAM3 eq R or D and persons not selected at HIPNAM1B and
HIPNAM2B, goto FHICCI8; else, if the health plan name was entered at HIPNAM3, goto MORPLAN3]
goto MORPLAN3

Question ID:

FHI.177_00.000 Instrument Variable Name:

QuestionText:

MORPLAN3

QuestionnaireFileName:

Family

* Ask if necessary
Are there any more private health insurance plans?

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families where a private health insurance plan name was entered at HIPNAM3 or a person number was entered
at HIPNAM3B

SkipInstructions:

<1> [goto HIPNAM4]
<2,R,D> [if persons selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, but not all persons with HIKIND eq
1 or 3 selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, goto HIVER1; else, goto FHICCI8]

Page 18 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.178_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HIPNAM4

QuestionnaireFileName:

Family

What is the name of the next plan?
*Read if necessary: Do you have a health plan card or something with the plan name on it?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All families with a fourth private health insurance plan

SkipInstructions:

[goto PCARD4]
[prefill PCARD4 with a "2" and goto HIPNAM4B]

Question ID:

FHI.178_01.000 Instrument Variable Name:

QuestionText:

1
2

PCARD4

QuestionnaireFileName:

Family

* Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on it?

Yes
No

UniverseText:

All private health insurance plans where the plan name was entered at HIPNAM4

SkipInstructions:

goto HIPNAM4B

Page 19 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.179_00.000 Instrument Variable Name:

20-Aug-13

HIPNAM4B

QuestionnaireFileName:

Family

QuestionText:

* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by that plan?
* Indicate each family member covered by this plan.
1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with a fourth private health insurance plan and the plan name, refused, or don't know was entered at
HIPNAM4

SkipInstructions:

[if HIPNAM4 eq R or D and persons selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, but not all
persons with HIKIND eq 1 or 3 selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, goto HIVER1; else, goto
FHICCI8]
goto FHICCI8

Question ID:

FHI.180_00.000 Instrument Variable Name:

QuestionText:

HIVER1

QuestionnaireFileName:

Family

? [F1]
[fill1: You are/ALIAS is] listed as having private insurance but [fill2: were/was] not mentioned as being covered by any
of the plans we just discussed. [fill3: Are you/Is ALIAS] covered by private insurance?

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

All persons who have private health insurance coverage, but were not mentioned as being covered by any of the
reported plans

SkipInstructions:

<1> [ goto HIVER2]
<2,R,D> [goto ERR_HIVER1]

Hard Edit:

ERR_HIVER1
*Press ENTER to go back to HIKIND to update health insurance coverage.

Page 20 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.190_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HIVER2

QuestionnaireFileName:

Family

? [F1]
* Enter all that apply, separate with commas.
Is [fill: your/ALIAS's] health insurance plan the same as one of those already mentioned?

1

1st plan mentioned (^HIPNAM1)
2nd plan mentioned (^HIPNAM2)
3rd plan mentioned (^HIPNAM3)
4th plan mentioned (^HIPNAM4)
Some other plan not already mentioned
Refused
Don't know

2
3
4
5
7
9

UniverseText:

All persons for whom it was verified they have private health insurance coverage, but were not mentioned as being
covered by any of the reported plans

SkipInstructions:

<1-4> [update responses for HIPNAM1B/HIPNAM2B/HIPNAM3B/HIPNAM4B and goto FHICCI8]
<5> [if 4 plans were reported, ignore this 5th plan and goto FHICCI8; else, goto HIPNAM2, or HIPNAM3, or
HIPNAM4 accordingly to enter information on this plan]
[goto FHICCI8]

Question ID:

FHI.195_01.000 Instrument Variable Name:

QuestionText:

FHICCI8

QuestionnaireFileName:

Family

[fill1: Now I am going to ask some questions about the [fill2: plan/plans] you just told me about [fill3: /,starting with
[fill4: ^HIPNAM1/Plan1]]./Next I would like to ask you about [fill5: ^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 2/Plan
3/Plan 4]].
* Enter 1 to continue.

1

Continue

UniverseText:

All families where a private health insurance plan was reported

SkipInstructions:

goto FHI200
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.

Page 21 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.200_01.000 Instrument Variable Name:

QuestionText:

FHI200

20-Aug-13

QuestionnaireFileName:

Family

? [F1]
Health insurance plans are usually obtained in one person's name even if other family members are covered. That person
is called the policyholder. In whose name is this plan?
* Enter line number of family member (from list below) in whose name this plan is held.
* Enter 0 if the policyholder is not on the family roster."

00

Policyholder not on family roster
Two-digit person number
Refused
Don't know

01-25
97
99

UniverseText:

All private health insurance plans

SkipInstructions:

if <00> [ goto PRPOLH]
<01 to 25> [go to PRCOOH]
[go to PLNWRK]

Question ID:

FHI.202_01.010 Instrument Variable Name:

QuestionText:

PRPOLH

QuestionnaireFileName:

Family

How [fill1:are you/is ALIAS] related to the policyholder for [fill2: plan1/plan2/plan3/plan4]?
*Read if Necessary…
[fill3:You are/ALIAS is} the policyholder’s…

1

2
3
4
7
9

Child (including stepchildren)
Spouse
Former spouse
Some other relationship
Refused
Don't know

UniverseText:

All persons on each plan where the policyholder is outside of the family roster

SkipInstructions:

<1-4,R,D> [goto PLNWRK]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.

Page 22 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.204_01.010 Instrument Variable Name:

QuestionText:

20-Aug-13

PRCOOH

QuestionnaireFileName:

Does this plan cover anyone who does not live here?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All private health insurance plans with policyholder on family roster

SkipInstructions:

<1> [goto PRCTOH]
<2,R,D> [goto PLNWRK]

Question ID:

Family

FHI.205_01.010 Instrument Variable Name:

QuestionText:

01-30
97
99

PRCTOH

QuestionnaireFileName:

Family

How many people does this plan cover who live somewhere else?

1-30 persons
Refused
Don't know

UniverseText:

All private health insurance plans with policyholder on family roster that cover someone outside the family roster

SkipInstructions:

<1-30 > [goto PRRELOH]
[goto PLNWRK]

Page 23 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.206_10.010 Instrument Variable Name:

QuestionText:

20-Aug-13

PRRELOH

QuestionnaireFileName:

Family

What [fill 1: is the relationship of this person/ are the relationships of these persons] to the policyholder?
*Read if Necessary: Children includes adult children.
*Enter all that apply, separate with commas.

1

Child (including stepchild)
Spouse
Former spouse
Some other relationship
Refused
Don't know

2
3
4
7
9

UniverseText:

All private health insurance plans with policyholder on family roster that cover someone outside the family roster

SkipInstructions:

<1 > [goto PRCNUM]
<2-4,R,D> [goto PLNWRK]

Question ID:

FHI.207_01.010 Instrument Variable Name:

QuestionText:

PRCNUM

QuestionnaireFileName:

Family

How many children of the policyholder are covered who live elsewhere?
*Read if Necessary: Children includes adult children.
*If more than 10 children, enter '10'.

01-10
97

99

1-10 children
Refused
Don’t know

UniverseText:

All private health insurance plans with policyholder on family roster that cover a child or children not on the roster

SkipInstructions:

<01-10> if [PRCNUM > PRCTOH goto ERR1_PRCNUM]
else goto PRAGEOH
[goto PLNWRK]

Hard Edit:

if PRCNUM > PRCTOH
*Number of children, [fill 1], exceeds the total number who live elsewhere, [fill 2].

Page 24 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.208_01.010 Instrument Variable Name:

QuestionText:

20-Aug-13

PRAGEOH

QuestionnaireFileName:

Family

How old is {fill1: this child/the first child/ the next child}?

000-100

0-100 years
Refused
Don't know

997
999

UniverseText:

All private health insurance plans with policyholder on family roster that cover one or more children not on the
roster

SkipInstructions:

<000-100,R,D>if [AGE >= 50 years goto ERR1_PRAGEOH]
else if PRCNUM GE 2 [goto PRAGEOH up to 9 more times]
else [goto PLNWRK]

Soft Edit:

If AGE >= 50 years
*Respondent said the child is [fill: PRAGEOH] years old. Please verify.

Question ID:

FHI.210_01.000 Instrument Variable Name:

QuestionText:

(book) F16

PLNWRK

QuestionnaireFileName:

Family

? [F1]

Which one of these categories best describes how this plan was obtained?
01

02
03
04
05
06
07

97
99

Through employer
Through union
Through workplace, but don't know if employer or union
Through workplace, self-employed or professional association
Purchased directly
Through a state/local government or community program
Other, specify
Refused
Don't know

UniverseText:

All private health insurance plans

SkipInstructions:

<1-6,R,D> [goto PLNPAY]
<7> [goto PLNWKSP]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.

Page 25 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.211_01.000 Instrument Variable Name:

QuestionText:

PLNWKSP

20-Aug-13

QuestionnaireFileName:

Family

*Read if necessary.
How was this plan obtained?

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All private health insurance plans where the plan was obtained through an "other" source

SkipInstructions:

goto PLNPAY
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.

Question ID:

FHI.220_10.000 Instrument Variable Name:

QuestionText:

PLNPAY

QuestionnaireFileName:

Family

? [F1]
* Enter all that apply, separate with commas.
Who pays for this health insurance plan?
* If government program is reported, probe for Medicare or Medicaid or SCHIP before entering code 7. If government is
the employer, enter code 2.

01
02
03

04
05
06
07
97
99

Self or family (living in the household)
Employer or union
Someone outside the household
Medicare
Medicaid
Children's Health Insurance Program (CHIP/SCHIP)
State or local government or community program
Refused
Don't know

UniverseText:

All private health insurance plans

SkipInstructions:

<1-7,R,D> if includes '1' goto PLNPRE
elseif includes '2' goto EMPPAY
else goto PLNMGD

Page 26 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.225_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PLNPRE

QuestionnaireFileName:

Is the premium paid for this plan based on income?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All private health insurance plans where self/family pays at least part of premium

SkipInstructions:

<1,2,R,D> [goto HICOSTN]

Question ID:

Family

FHI.230_11.000 Instrument Variable Name:

QuestionText:

1 of 2

HICOSTN

QuestionnaireFileName:

Family

? [F1]

How much [fill1: do you/does your family] currently spend for health insurance premiums for [fill2:
^HIPNAM1/^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4]? Please include payroll deductions for
premiums.
*Enter dollar amount for premium payments.
00001-99995

99997
99999

$1-$99,995
Refused
Don't know

UniverseText:

All private health insurance plans paid for by self or family

SkipInstructions:

if gt 9999, [goto ERR_HICOSTN]
<1-9999> [goto HICOSTT]
[store in HICOSTT, goto EMPPAY if PLNPAY=2; else goto PLNMGD]
[store in HICOSTT, goto EMPPAY if PLNPAY=2; else goto PLNMGD]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family.

Soft Edit:

ERR_HICOSTN
* [fill # from HICOSTN] is unusually high. Please verify.
Make corrections if necessary.

Page 27 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.230_12.000 Instrument Variable Name:

QuestionText:

2 of 2

20-Aug-13

HICOSTT

QuestionnaireFileName:

Family

? [F1]

* Enter time period for premium payments.
01

Once a week
Once every 2 weeks
Once a month
Twice a month
Every 2 months
Quarterly (every 3 months)
Once a year
Twice a year
Refused
Don't know

02
03

04
05
06
07
08

97
99

UniverseText:

All private health insurance plans with a valid response to HICOSTN

SkipInstructions:

<1-8,R,D> if PLNPAY=2 [goto EMPPAY]; else [goto PLNMGD]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family.

Question ID:

FHI.235_01.010 Instrument Variable Name:

QuestionText:
1
2

7
9

EMPPAY

QuestionnaireFileName:

Do you know how much the employer or union is paying for [fill1: plan1/plan2/plan3/plan4]?
Yes
No
Refused
Don’t know

UniverseText:

All private health insurance plans paid for by employer or union

SkipInstructions:

<1> [goto EMPCOSTN] <2,R,D> [goto PLNMGD]

Family

Page 28 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.237_01.010 Instrument Variable Name:

QuestionText:

20-Aug-13

EMPCOSTN

QuestionnaireFileName:

Family

1 of 2
How much does the employer or union currently pay for health insurance premiums for [fill1: Plan 1/Plan 2/Plan 3/Plan
4]?
*Enter dollar amount for premium payments.
*Enter ‘ZZ’ to go to percentage format.

00001-99995

$1-$99,995
Refused
Don't know

99997
99999

UniverseText:

All private health insurance plans where amount of premium employer/union pays is known

SkipInstructions:

<1-99995> [goto EMPCOSTT]
[store "R" in EMPCOSTT and goto PLNMGD] [store "D" in EMPCOSTT and goto PLNMGD]
[goto EMPCOSTP]

Soft Edit:

ERR_EMPCOSTN
* [fill # from EMPCOSTN] is unusually high. Please verify.
Make corrections if necessary.

Question ID:

FHI.237_02.020 Instrument Variable Name:

QuestionText:

01
02
03
04
05

06
07
08
97
99

EMPCOSTT

QuestionnaireFileName:

2 of 2
* Enter time period for premium payments.
Once a week
Once every 2 weeks
Once a month
Twice a month
Every 2 months
Quarterly (every 3 months)
Once a year
Twice a year
Refused
Don't know

UniverseText:

All private health insurance plans with a valid response to EMPCOSTN

SkipInstructions:

goto PLNMGD

Family

Page 29 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.237_02.030 Instrument Variable Name:

QuestionText:

20-Aug-13

EMPCOSTP

QuestionnaireFileName:

Family

What percent of the premiums does the employer or union pay for [fill1: Plan 1/Plan 2/Plan 3/Plan 4]?

001-100

1-100 percent
Refused
Don’t know

997
999

UniverseText:

All private health insurance plans paid for by employer or union where respondent wanted to report percentage of
premium paid

SkipInstructions:

<1-100,R,D> [goto PLNMGD]

Question ID:

FHI.240_01.000 Instrument Variable Name:

QuestionText:

PLNMGD

QuestionnaireFileName:

Family

? [F1]
Is [fill: ^HIPNAM1/^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4] an HMO (Health Maintenance
Organization), an IPA (Individual Practice Association), a PPO (Preferred Provider Organization), a POS (Point-OfService), fee-for-service, or indemnity or is it some other kind of plan?

1
2
3

4
5
7
9

HMO/IPA
PPO
POS
Fee-for-service/indemnity
Other
Refused
Don't know

UniverseText:

All private health insurance plans

SkipInstructions:

goto HDHP
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.

Page 30 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.241_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HDHP

QuestionnaireFileName:

Family

?[F1]
[If only one person covered by this plan:]
Is the annual deductible for medical care for this plan less than $1,250 or $1,250 or more? If there is a separate deductible
for prescription drugs, hospitalization, or out-of-network care, do not include those deductible amounts here.
[If two or more persons in the family are covered by this plan:]
Is the family annual deductible for medical care for this plan less than $2,500 or $2,500 or more? If there is a separate
deductible for prescription drugs, hospitalization, or out-of-network care, do not include those deductible amounts here.

1

Less than [$1,250/$2,500]
[$1,250/$2,500] or more
Refused
Don't know

2

7
9

UniverseText:

All private health insurance plans

SkipInstructions:

1,R,D [goto MGCHMD]
2 [goto HSAHRA]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.

Question ID:

FHI.242_01.000 Instrument Variable Name:

QuestionText:

HSAHRA

QuestionnaireFileName:

Family

?[F1]
With this plan, is there a special account or fund that can be used to pay for medical expenses? The accounts are
sometimes referred to as Health Savings Accounts (HSAs), Health Reimbursement Accounts (HRAs), Personal Care
accounts, Personal Medical funds, or Choice funds, and are different from Flexible Spending Accounts.

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

All high deductible private health plans

SkipInstructions:

1,2,R,D [goto MGCHMD]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.

Page 31 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.243_01.000 Instrument Variable Name:

QuestionText:

MGCHMD

20-Aug-13

QuestionnaireFileName:

Family

Under this plan, can [fill1:you/ALIAS/the family members with this plan] choose ANY doctor or MUST
[fill2:you/he/she/they] choose one from a specific group or list of doctors?

1

Any doctor
Select from group/list
Refused
Don't know

2
7
9

UniverseText:

All private health insurance plans

SkipInstructions:

<1> [goto MGPRMD]
<2> [goto MGPYMD]
[goto MGPREF]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.

Question ID:

FHI.244_01.000 Instrument Variable Name:

QuestionText:

1

2
7
9

MGPRMD

QuestionnaireFileName:

Family

[fill: Do you/Does ALIAS/Do the family members with this plan] have the option of choosing a doctor from a preferred or
select list at a lower cost?
Yes
No
Refused
Don't know

UniverseText:

All private health insurance plans where covered persons can choose any doctor

SkipInstructions:

goto MGPREF
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.

Page 32 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.246_01.000 Instrument Variable Name:

QuestionText:

MGPYMD

20-Aug-13

QuestionnaireFileName:

Family

If [fill1: you select/ALIAS selects/the family members with this plan select] a doctor who is not in the plan, will [fill2:
^HIPNAM1/^HIPNAM2/^HIPNAM3/^ HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4] pay for any or part of the cost?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All private health insurance plans where covered persons must select from a group or list of doctors

SkipInstructions:

goto MGPREF
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.

Question ID:

FHI.248_01.000 Instrument Variable Name:

QuestionText:

MGPREF

QuestionnaireFileName:

Family

? [F1]
When [fill1: you need/ALIAS needs/the family members with this plan need] to go to a different doctor or place for
special care, [fill2: do you/does ALIAS/do they] need approval or a referral? Do not include emergency care.

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All private health insurance plans

SkipInstructions:

goto PCPREQ

Page 33 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.248_05.000 Instrument Variable Name:

QuestionText:

PCPREQ

QuestionnaireFileName:

Family

Does this plan REQUIRE [fill1: you/ALIAS/the family members with this plan] to have a primary care doctor or group of
doctors for all routine care?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Asked of all private health insurance plans

SkipInstructions:

<1,2,R,D> [goto PRRXCOV]

Question ID:

20-Aug-13

FHI.249_01.010 Instrument Variable Name:

QuestionText:

PRRXCOV

QuestionnaireFileName:

Family

Does [fill1: ^HIPNAM1/^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4] pay for any of the costs for
medicines prescribed by a doctor?
* Read if necessary: Does this plan have a drug benefit?

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

All private health insurance plans

SkipInstructions:

goto PRDNCOV
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.

Page 34 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.249_02.010 Instrument Variable Name:

QuestionText:

20-Aug-13

PRDNCOV

QuestionnaireFileName:

Does [fill 1: ^HIPNAM1 or ^HIPNAM2, or ^HIPNAM3, or ^HIPNAM4 or Plan 1 or Plan 2 or Plan 3 or Plan 4] pay for
any of the costs for dental care?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All private health insurance plans

SkipInstructions:

goto FHICCI8 for the next private health insurance plan; else, goto FCOVCONF

Question ID:

Family

FHI.249_03.000 Instrument Variable Name:

QuestionText:

FCOVCONF

QuestionnaireFileName:

Family

If [fill1: you/your family] had to buy a health plan on [fill 2: your/its] own with no help from [fill 3: your/an] employer,
how confident are you that [fill 1: you/your family] would be able to obtain affordable coverage Would you say…
*Read categories below.

1
2
3

4
7
9

Very confident
Somewhat confident
Not too confident
Not confident at all
Refused
Don’t know

UniverseText:

All families with an employer-based health plan

SkipInstructions:

<1-4,R,D> goto STNAME1 or STNAME2 or STNAME3 or MILSPC or HILAST or HINOTYR

Page 35 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.250_00.000 Instrument Variable Name:

STNAME1

20-Aug-13

QuestionnaireFileName:

Family

Earlier I recorded that [fill: you are/ALIAS is] covered by the Children’s Health Insurance Program (CHIP/SCHIP). What
is the name of the plan?

QuestionText:

* Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim

Verbatim response
Refused
Don't know

7

9

UniverseText:

All persons with SCHIP

SkipInstructions:

goto STDOC1

Question ID:

FHI.251_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Family

Under the [fill1:^STNAME1/SCHIP plan] can [fill2: you/ALIAS] go to ANY doctor who will accept this plan or MUST
[fill3: you/he/she] choose from a book or list of doctors or is the doctor assigned?

1

Any doctor
Select from book/list
Doctor is assigned
Refused
Don't know

2
3
7

9

UniverseText:

All persons with SCHIP

SkipInstructions:

goto STPCMD1

Question ID:

STDOC1

FHI.252_00.000 Instrument Variable Name:

QuestionText:

1
2
7

9

STPCMD1

QuestionnaireFileName:

Family

[fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which
[fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care from a
specialist [fill4: you were/he was/she was] referred to.
Yes
No
Refused
Don't know

UniverseText:

All persons with SCHIP

SkipInstructions:

goto STREF1

Page 36 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.253_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

STREF1

QuestionnaireFileName:

Family

? [F1]
Under [fill1: ^STNAME1/this SCHIP plan], if [fill2: you need/ALIAS needs] to go to a different doctor or place for
special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

All persons with SCHIP

SkipInstructions:

goto STNAME1 for the next person with SCHIP; else, goto STNAME2

Question ID:

FHI.257_00.000 Instrument Variable Name:

QuestionText:

STNAME2

QuestionnaireFileName:

Family

Earlier I recorded that [fill: you are/ALIAS is] covered by a state sponsored health plan. What is the name of the plan?
* Read if necessary: Do you have a health plan card or something with the plan name on it?

Verbatim

Verbatim response
Refused
Don't know

7

9

UniverseText:

All persons covered by a state sponsored health plan

SkipInstructions:

goto STDOC2

Question ID:

FHI.258_00.000 Instrument Variable Name:

QuestionText:

1
2
3
7

9

STDOC2

QuestionnaireFileName:

Family

Under the [fill1:^STNAME2/state sponsored plan] can [fill2: you/ALIAS] go to ANY doctor who will accept this plan or
MUST [fill3: you/he/she] choose from a book or list of doctors or is the doctor assigned?

Any doctor
Select from book/list
Doctor is assigned
Refused
Don't know

UniverseText:

All persons covered by a state sponsored health plan

SkipInstructions:

goto STPCMD2

Page 37 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.259_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

STPCMD2

Family

[fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which
[fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care from a
specialist [fill4: you were/he was/she was] referred to.

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All persons covered by a state sponsored health plan

SkipInstructions:

goto STREF2

Question ID:

QuestionnaireFileName:

FHI.260_00.000 Instrument Variable Name:

QuestionText:

STREF2

QuestionnaireFileName:

Family

? [F1]
Under [fill1:^STNAME2/this state sponsored plan], if [fill2: you need/ALIAS needs] to go to a different doctor or place
for special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

All persons covered by a state sponsored health plan

SkipInstructions:

goto STNAME2 for the next person with a state sponsored health plan; else, goto STNAME3

Question ID:

FHI.264_00.000 Instrument Variable Name:

QuestionText:

STNAME3

QuestionnaireFileName:

Earlier I recorded that [fill: you are/ALIAS is] covered by an other government program. What is the name of the plan?
* Read if necessary: Do you have a health plan card or something with the plan name on it?

Verbatim
7

9

Family

Verbatim response
Refused
Don't know

UniverseText:

All persons covered by an "other" government plan

SkipInstructions:

goto STDOC3

Page 38 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.265_00.000 Instrument Variable Name:

QuestionText:

STDOC3

Family

Any doctor
Select from book/list
Doctor is assigned
Refused
Don't know

2
3
7

9

UniverseText:

All persons covered by an "other" government plan

SkipInstructions:

goto STPCMD3

FHI.266_00.000 Instrument Variable Name:

QuestionText:

STPCMD3

QuestionnaireFileName:

Family

[fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which
[fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care from a
specialist [fill4: you were/he was/she was] referred to.

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All persons covered by an "other" government plan

SkipInstructions:

goto STREF3

Question ID:

QuestionnaireFileName:

Under the [fill1:^STNAME3/other government plan] can [fill2: you/ALIAS] go to ANY doctor who will accept this plan
or MUST [fill3:you/he/she] choose from a book or list of doctors or is the doctor assigned?

1

Question ID:

20-Aug-13

FHI.267_00.000 Instrument Variable Name:

QuestionText:

STREF3

QuestionnaireFileName:

Family

? [F1]
Under [fill1:^ STNAME3/this other government plan], if [fill2: you need/ALIAS needs] to go to a different doctor or
place for special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

All persons covered by an "other" government plan

SkipInstructions:

goto STNAME3 for the next person with an "other" government plan; else, goto MILSPC

Page 39 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.270_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MILSPC

QuestionnaireFileName:

Family

? [F1]
* Enter all that apply, separate with commas.
Earlier I recorded that [fill1: you are/ALIAS is] covered by military health care. What types of military health care [fill2:
are you/is ALIAS] covered by?

1

TRICARE
VA
CHAMP-VA
Other military coverage (specify)
Refused
Don't know

2
3
4
7
9

UniverseText:

All persons with military health care

SkipInstructions:

<1> [goto MILMAN]
<2,3,R,D> [repeat question for next person with military health care; else, goto HILAST]
<4> [goto MILSPCOT]

Question ID:

FHI.271_00.000 Instrument Variable Name:

QuestionText:
Verbatim
7
9

MILSPCOT

QuestionnaireFileName:

Family

* Other military coverage
Verbatim response
Refused
Don't know

UniverseText:

All persons with "other" military coverage

SkipInstructions:

if MILSPC eq 1, goto MILMAN; else, goto MILSPC for the next person with military health care; else, goto
HILAST

Page 40 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.275_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MILMAN

QuestionnaireFileName:

Family

? [F1]
Is [fill: your/ALIAS's] TRICARE plan, TRICARE prime, TRICARE Extra, TRICARE Standard or TRICARE for Life?

1

TRICARE Prime
TRICARE Extra
TRICARE Standard
TRICARE for life
TRICARE other (specify)
Refused
Don't know

2
3

4
5
7
9

UniverseText:

All persons with TRICARE coverage

SkipInstructions:

<1-4,R,D> [goto MILSPC for the next person with military health care; else, goto HILAST]
<5> [goto MILMANOT]

Question ID:

FHI.276_00.000 Instrument Variable Name:

QuestionText:
Verbatim
7
9

MILMANOT

QuestionnaireFileName:

* Other type of TRICARE coverage
Verbatim response
Refused
Don't know

UniverseText:

All persons with "other" type of TRICARE coverage

SkipInstructions:

goto MILSPC for the next person with military health care; else, goto HILAST

Family

Page 41 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.280_00.000 Instrument Variable Name:

QuestionText:

(book) F17

20-Aug-13

HILAST

QuestionnaireFileName:

Family

? [F1]

Not including Single Service Plans, about how long has it been since [fill: you/ALIAS] last had health care coverage?
1

6 months or less
More than 6 months, but not more than 1 year ago
More than 1 year, but not more than 3 years ago
More than 3 years
Never
Refused
Don't know

2
3

4
5
7
9

UniverseText:

All persons without known health insurance or with only single service plans

SkipInstructions:

goto HISTOP

Question ID:

FHI.290_00.000 Instrument Variable Name:

QuestionText:

HISTOP

QuestionnaireFileName:

Family

(book) F18
[fill1: Which of these are reasons [fill2: you/ALIAS] stopped being covered?/Which of these are reasons [fill3:you
do/ALIAS does] not have health insurance?]
* Enter up to 5 reasons, separate with commas.

01
02
03

04
05
06
07
08
09

10
97
99

Person in family with health insurance lost job or changed employers
Got divorced or separated/death of spouse or parent
Became ineligible because of age/left school
Employer does not offer coverage/or not eligible for coverage
Cost is too high
Insurance company refused coverage
Medicaid/Medical plan stopped after pregnancy
Lost Medicaid/Medical plan because of new job or increase in income
Lost Medicaid (other)
Other (specify)
Refused
Don't know

UniverseText:

All persons without known health insurance or with only single service plans

SkipInstructions:

<1-9,R,D> [goto HCSPFYR]
<10> [goto HISTOPOT]

Page 42 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.291_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HISTOPOT

QuestionnaireFileName:

Family

? [F1]
* Other reason for not having coverage

Verbatim

Verbatim response
Refused
Don't know

7
9

UniverseText:

All persons without known health insurance and an "other" reason for stopping or not having coverage

SkipInstructions:

goto HISTOP for the next person without known health insurance coverage or only single service plans; else, goto
HCSPFYR

Question ID:

FHI.300_00.000 Instrument Variable Name:

QuestionText:

HINOTYR

QuestionnaireFileName:

In the PAST 12 MONTHS, was there any time when [fill: you/ALIAS] did NOT have ANY health insurance or coverage?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All persons with known health insurance coverage except single service plans

SkipInstructions:

<1> [goto HINOTMYR] <2,R,D> [goto FHICHNG]

Question ID:

Family

FHI.310_00.000 Instrument Variable Name:

QuestionText:

HINOTMYR

QuestionnaireFileName:

Family

In the PAST 12 MONTHS, about how many months [fill: were you/was ALIAS] without coverage?
* If less than 1 month, enter '1'.

01-12
97
99

1-12 months
Refused
Don't know

UniverseText:

All persons with known health insurance coverage, but did not have health insurance for some period of time in
the past 12 months

SkipInstructions:

goto HINOTYR for the next person with known health insurance coverage, except single service plans; else, goto
HCSPFYR

Page 43 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.312_00.010 Instrument Variable Name:

QuestionText:

1
2
7
9

FHICHNG

20-Aug-13

QuestionnaireFileName:

Did [fill1: you/ALIAS] have [fill2: type of health insurance coverage] for the past 12 months?

Yes
No
Refused
Don't know

UniverseText:

All persons who are currently insured who were continuously covered in the past year

SkipInstructions:

<1,R,D> [goto HCSPFYR]
<2> [goto FHIKDB]

Family

Page 44 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.315_00.010 Instrument Variable Name:

QuestionText:

FHIKDB

20-Aug-13

QuestionnaireFileName:

Family

(book) F12 and (book) F14
If person is currently uninsured:
{Think about the last time [fill1: you/ALIAS] had health insurance or health care coverage. What type did [fill1:
you/ALIAS] have?}
If person had a period without coverage in the past year:
{I recorded that [fill1: you/ALIAS] had a period without health insurance in the past year. What type of health insurance
or coverage did [fill1: you/ALIAS] have before this period?}
If person had a change in coverage type in the past year:
{What other types of health insurance or health care coverage did [fill1: you/ALIAS] have?}
*Enter all that apply, separate with commas.

01
02

03
04
05
06
07
08

09
10
11
97
99

Private health insurance
Medicare
Medi-Gap
Medicaid
SCHIP (CHIP/Children's Health Insurance Program)
Military health care (TRICARE/VA/CHAMP-VA)
Indian Health Service
State-sponsored health plan
Other government program
Single service plan (e.g., dental, vision, prescriptions)
No coverage of any type
Refused
Don't know

UniverseText:

All persons except those with continuous coverage who are currently uninsured for more than 1 year with no
changes

SkipInstructions:

<1> [goto PWRKB]
<2-11,R,D> [goto HCSPFYR]

Page 45 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.316_00.010 Instrument Variable Name:

20-Aug-13

PWRKB

Family

Which one of these categories best describes how [fill1: your/ALIAS’s] private health insurance was obtained?

QuestionText:

01

Through employer
Through union
Through workplace, but don't know if employer or union
Through workplace, self-employed or professional association
Purchased directly
Through a state/local government or community program
Other, specify
Refused
Don’t know

02
03
04

05
06
07
97
99

UniverseText:

All persons who had private health insurance previously

SkipInstructions:

<1-6,R,D> [goto HCSPFYR] <7> [goto PWRKBSP]

Question ID:

QuestionnaireFileName:

FHI.317_00.010 Instrument Variable Name:

QuestionText:
7
9
Verbatim

PWRKBSP

QuestionnaireFileName:

*Enter how private health insurance was obtained.
Refused
Don't know
Verbatim response

UniverseText:

All persons who had private health insurance obtained from other source previously

SkipInstructions:

[goto HCSPFYR]

Family

Page 46 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.320_00.000 Instrument Variable Name:

QuestionText:

HCSPFYR

20-Aug-13

QuestionnaireFileName:

Family

(book) F19
The next question is about money that [fill1: you have/your family has] spent out of pocket on medical care. We do NOT
want you to count health insurance premiums, over the counter drugs, or costs that you will be reimbursed for. In the
PAST 12 MONTHS, about how much did [fill2: you/your family] spend for medical care and dental care?

0

Zero
Less than $500
$500 - $1,999
$2,000 - $2,999
$3,000 - $4,999
$5,000 or more
Refused
Don't know

1
2
3
4
5
7

9

UniverseText:

All families

SkipInstructions:

goto MEDBILL

Question ID:

FHI.325_00.010 Instrument Variable Name:

QuestionText:

1
2
7
9

MEDBILL

QuestionnaireFileName:

Family

In the past 12 months did [fill1: you/anyone in the family] have problems paying or were unable to pay any medical bills?
Include bills for doctors, dentists, hospitals, therapists, medication, equipment, nursing home or home care.
Yes
No
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1,2,7,9> [goto MEDBPAY]

Page 47 of 47

DRAFT 2013 NHIS Questionnaire - Family
Family Health Insurance
Document Version Date:

Question ID:

FHI.327_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

MEDBPAY

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All families

SkipInstructions:

<1,2,7,9> if MEDBILL=2 [goto FSA]; else [goto MEDBNOP]

FHI.327_00.020 Instrument Variable Name:

QuestionText:

MEDBNOP

QuestionnaireFileName:

Family

[fill 1: Do you/Does anyone in your family] currently have any medical bills that you are unable to pay at all?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families but those who said they don’t have problems paying their medical bills

SkipInstructions:

<1,2,7,9> [goto FSA]

Question ID:

Family

[fill 1: Do you/Does anyone in your family] currently have any medical bills that are being paid off over time? This could
include medical bills being paid off with a credit card, through personal loans, or bill paying arrangements with hospitals
or other providers. The bills can be from earlier years as well as this year.

1

Question ID:

QuestionnaireFileName:

FHI.330_00.000 Instrument Variable Name:

QuestionText:

1
2
7

9

FSA

QuestionnaireFileName:

Family

[fill 1: Do you/Does anyone in your family] have a Flexible Spending Account for health expenses? These accounts are
offered by some employers to allow employees to set aside pre-tax dollars of their own money for their use throughout the
year to reimburse themselves for their out-of-pocket expenses for health care. With this type of account, any money
remaining in the account at the end of the year, following a short grace period, is lost to the employee.
Yes
No
Refused
Don't know

UniverseText:

All Families

SkipInstructions:

goto PLBORN

Page 1 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:

FSD.001_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

PLBORN

[fill: Were you/Was ALIAS] born in the United States?

Yes
No
Refused
Don't know

UniverseText:

All persons

SkipInstructions:

<1> [store "1" in CITIZEN and goto PLBORN1]
<2> [goto PLBORN2]
[goto CITIZEN]

20-Aug-13

QuestionnaireFileName:

Family

Page 2 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:
QuestionText:

01
02
03
04

05
06
07
08
09

10
11
12
13
14
15

16
17
18
19
20
21

22
23
24
25
26

27
28
29
30
31
32

33
34
35
36
37

38
39
40
41
42
43

44
45
46

FSD.002_00.000 Instrument Variable Name:
In what state [fill: were you/was ALIAS] born?

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont

PLBORN1

20-Aug-13

QuestionnaireFileName:

Family

Page 3 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
47
48
49

50
51
57

Virginia
Washington
West Virginia
Wisconsin
Wyoming
United States (state unknown)

UniverseText:

All persons born in the United States

SkipInstructions:

<1-51,57> [goto HEADST]

20-Aug-13

Page 4 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:
QuestionText:

FSD.003_00.000 Instrument Variable Name:

20-Aug-13

PLBORN2

In what country [fill: were you/was ALIAS] born?
* Please record country of birth. If country not found, type "ZZ"

060
061
062

063
064
065
066
067

068
069
070
071
072
073

074
075
076
077
078
079

080
081
082
083
084

085
100
101
102
103
104

105
106
107
108
109

110
111
112
113
114
115

116
117
118

AMERICAN SAMOA
AM SAMOA
BAKER ISLAND
GUAM
HOWLAND ISLAND
JARVIS ISLAND
JOHNSTON ATOLL
KINGMAN REEF
MANUA ISLANDS
MIDWAY ISLANDS
NAVASSA ISLAND
NORTHERN MARIANAS
PALMYRA ATOLL
PUERTO RICO
ROTA
SAIPAN
SAND ISLAND
ST CROIX
ST JOHN
ST THOMAS
TINIAN
US OUTLYING AREA
US VIRGIN ISLANDS
USVI
VIRGIN ISLANDS
WAKE ISLAND
ABROAD
ABU DHABI
ADEN
AFGHANISTAN
AFRICA
ALBANIA
ALBERTA
ALGERIA
ALGIERS
ALSACE-LORRAINE
AMSTERDAM
ANEGADA
ANGOLA
ANGUILLA
ANGUILLA BWI
ANOJOUAN
ANTARCTICA
ANTIGUA
ANTIGUA & BARBUDA

QuestionnaireFileName:

Family

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Document Version Date:
119
120
121

122
123
124
125
126

127
128
129
130
131
132

133
134
135
136
137
138

139
140
141
142
143

144
145
146
147
148
149

150
151
152
153
154

155
156
157
158
159
160

161
162
163
164
165
166

167
168
169

ANTIGUA WI
ANTILLES
ARAB PALESTINE
ARABIA
ARGENTINA
ARMENIA
ARUBA
ARUBA DWI
ARUBA NETHERLANDS
ASCENSION ISLAND
ASIA
ASIA MINOR
ASSAM
AT SEA
AUSTRALIA
AUSTRIA
AUSTRIA-HUNGARY
AZERBAIJAN
AZORES ISLANDS
BAHAMAS
BAHAMAS UK
BAHRAIN
BAJA CAL
BAJA CAL SUR
BALBOA
BANGLADESH
BARBADOS
BARBUDA
BAVARIA
BELARUS
BELFAST
BELGIAN CONGO
BELGIUM
BELIZE
BENIN
BERLIN
BERMUDA
BESSARABIA
BHUTAN
BOHEMIA
BOLIVIA
BONAIRE
BORNEO
BOSNIA
BOSNIA & HERZEGOVINA
BOTSWANA
BRASIL
BRAZIL
BRAZZAVILLE
BREMEN
BRITAIN

20-Aug-13

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Document Version Date:
170
171
172

173
174
175
176
177

178
179
180
181
182
183

184
185
186
187
188
189

190
191
192
193
194

195
196
197
198
199
200

201
202
203
204
205

206
207
208
209
210
211

212
213
214
215
216
217

218
219
220

BRITISH COLUMBIA
BRITISH EAST AFRICA
BRITISH GUIANA
BRITISH GUYANA
BRITISH HONDURAS
BRITISH HONG KONG
BRITISH ISLES
BRITISH VI
BRITISH VIRGIN IS
BRITISH WEST INDIES
BRITISH WI
BRUNEI
BULGARIA
BURKINA FASO
BURMA
BURUNDI
BWI
BYELARUS
BYELORUSSIA
CAICOS ISLANDS
CAM PHA
CAM RANH
CAMBODIA
CAMEROON
CAN THO
CANADA
CANAL ZONE
CANARY ISLANDS
CANTON & ENDERBURY IS
CANTON ISLAND
CAPE VERDE
CARIBBEAN
CAYMAN ISLANDS
CENTRAL AFRICA
CENTRAL AFRICAN REP
CENTRAL AMERICA
CEYLON
CHAD
CHANNEL ISLANDS
CHIAPAS
CHIHUAHUA
CHILE
CHINA
CHINA HONG KONG
CHRISTMAS ISLAND
CHRISTMAS ISLAND, INDIAN OCEAN
COAHUILA
COLIMA
COLOMBIA
COMOROS
CONGO

20-Aug-13

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DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
221
222
223

224
225
226
227
228

229
230
231
232
233
234

235
236
237
238
239
240

241
242
243
244
245

246
247
248
249
250
251

252
253
254
255
256

257
258
259
260
261
262

263
264
265
266
267
268

269
270
271

COOK ISLANDS
CORAL SEA ISLANDS
CORK
CORSICA
COSTA RICA
COTE D'IVORIE
CRETE
CRIMEA
CRISTOBAL
CROATIA
CUBA
CURACAO
CYPRUS
CZ
CZECH REPUBLIC
CZECHOSLOVAKIA
DA LAT
DA NANG
DAKAR
DANZIG
DELHI
DEMO PEOPLE'S REP OF KOREA
DEMO REP OF CONGO
DENMARK
DISTRITO FEDERAL
DJIBOUTI
DOM REP
DOMINICA
DOMINICA BWI
DOMINICA WI
DOMINICAN REPUBLIC
DUBAI
DUBLIN
DURANGO
DUTCH EAST INDIES
DUTCH GUIANA
DUTCH INDONESIA
DUTCH NEW GUINEA
EAST PAKISTAN
EAST PRUSSIA
EASTER ISLAND
EASTERN AFRICA
ECUADOR
EGYPT
EIRE
EL SALVADOR
ENGLAND
EQUATORIAL GUINEA
ERITREA
ESPANA
ESTONIA

20-Aug-13

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DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
272
273
274

275
276
277
278
279

280
281
282
283
284
285

286
287
288
289
290
291

292
293
294
295
296

297
298
299
300
301
302

303
304
305
306
307

308
309
310
311
312
313

314
315
316
317
318
319

320
321
322

ETHIOPIA
EUROPA ISLAND
EUROPE
FALKLAND ISLANDS
FAROE ISLANDS
FEDERAL DISTRICT
FEDERAL REPUBLIC OF YUGOSLAVIA
FEDERATED STATES OF MICRONESIA
FIJI
FILIPINES
FINLAND
FOREIGN COUNTRY
FORMOSA
FRANCE
FRANKFURT
FRENCH GUIANA
FRENCH MOROCCO
FRENCH POLYNESIA
GABON
GALAPAGOS ISLANDS
GALWAY
GAMBIA
GAZA STRIP
GEORGIA
GERMANY
GHANA
GIA DINH
GIBRALTER
GLORIOSO ISLANDS
GOA
GRAND BAHAMA
GRAND CAYMAN
GRAND TURK
GREAT BRITAIN
GREAT COMORE
GREECE
GREENLAND
GRENADA
GUADALAJARA
GUADELOUPE
GUANAJUATO
GUATEMALA
GUERNSEY
GUERRERO
GUIANA
GUINEA
GUINEA-BISSAU
GUYANA
HA DONG
HAI PHONG
HAITI

20-Aug-13

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DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
323
324
325

326
327
328
329
330

331
332
333
334
335
336

337
338
339
340
341
342

343
344
345
346
347

348
349
350
351
352
353

354
355
356
357
358

359
360
361
362
363
364

365
366
367
368
369
370

371
372
373

HAMBURG
HANOI
HANOVER
HAVANA
HEARD & MCDONALD ISLANDS
HERZEGOVINA
HESSE
HIDALGO
HIGH SEAS
HOLLAND
HONDURAS
HONG KONG
HUNGARY
HYDERABAD
ICELAND
INDIA
INDONESIA
INTERNATIONAL WATERS
IRAN
IRAQ
IRELAND
IRIAN JAYA
IRISH REPUBLIC
ISLE OF MAN
ISRAEL
ITALY
IVORY COAST
JALISCO
JAMAICA
JAN MEYAN
JAPAN
JAVA
JERSEY
JIBUTI
JORDAN
JUAN DE NOVA ISLAND
JUGOSLAVIA
KALININGRAD
KAMPUCHEA
KASHMIR
KAZAKHSTAN
KENYA
KHANH HUNG
KINSHASA
KIRIBATI
KOREA
KORO ISLAND
KUWAIT
KWAJALEIN
KWANTUNG
KYRGYZSTAN

20-Aug-13

Page 10 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
374
375
376

377
378
379
380
381

382
383
384
385
386
387

388
389
390
391
392
393

394
395
396
397
398

399
400
401
402
403
404

405
406
407
408
409

410
411
412
413
414
415

416
417
418
419
420
421

422
423
424

LABRADOR
LABUAN
LAOS
LATAKIA
LATIN AMERICA
LATVIA
LEBANON
LEEWARD ISLANDS
LESOTHO
LIBERIA
LIBYA
LIECHTENSTEIN
LITHUANIA
LOAS
LONDONDERRY
LONG XUYEN
LORRAINE
LUBECK
LUXEMBOURG
MACAO
MACAU
MACEDONIA
MADAGASCAR
MADEIRA ISLANDS
MAINLAND CHINA
MAJORCA
MALAGASY REPUBLIC
MALAWI
MALAYSIA
MALDIVES
MALI
MALLORCA
MALTA
MACHURIA
MANICA
MANILA
MANITOBA
MARSHALL ISLANDS
MARTINIQUE
MAURITANIA
MAURITIUS
MAYOTTE ISLAND
MELANESIA
MEXICO
MICHOACAN
MICRONESIA
MIDDLE EAST
MOLDAVIA
MOLDOVA
MONACO
MONAGAS

20-Aug-13

Page 11 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
425
426
427

428
429
430
431
432

433
434
435
436
437
438

439
440
441
442
443
444

445
446
447
448
449

450
451
452
453
454
455

456
457
458
459
460

461
462
463
464
465
466

467
468
469
470
471
472

473
474
475

MONGOLIA
MONTENEGRO
MONTSERRAT
MORELOS
MOROCCO
MOZAMBIQUE
MY THO
N. IRELAND
NAM DINH
NAMIBIA
NAURU
NAYARIT
NEPAL
NETHERLANDS
NETH. ANTILLES
NETH. EAST INDIES
NEVIS ISLAND
NEW BRUNSWICK
NEW CALEDONIA
NEW GUINEA
NEW HEBRIDES
NEW SOUTH WALES
NEW ZEALAND
NEWFOUNDLAND
NHA TRANG
NICARAGUA
NIGER
NIGERIA
NIUE ISLAND
NORFOLK ISLAND
NORTH AFRICA
NORTH AMERICA
NORTH KOREA
NORTH VIETNAM
NORTHERN IRELAND
NORTHERN TERRITORY
NORWAY
NOVA SCOTIA
NUEVO LEON
OAXACA
OCEANIA
OKINAWA
OMAN
ONTARIO
OVERSEAS
PAKISTAN
PALAU
PALESTINE
PANAMA
PANAMA CANAL ZONE
PAPUA NEW GUINEA

20-Aug-13

Page 12 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
476
477
478

479
480
481
482
483

484
485
486
487
488
489

490
491
492
494
495
496

497
498
499
500
501

502
503
504
505
506
507

508
509
510
511
512

513
514
515
516
517
518

519
520
521
522
523
524

525
526
527

PARACEL ISLANDS
PARAGUAY
PELAGOSA
PEOPLE'S REP. OF CHINA
PEOPLE'S REP. OF CONGO
PERSIA
PERU
PHAN THIET
PHILIPPINES
PITCAIRN ISLAND
POLAND
POLYNESIA
PONAPE
PORTUGAL
PORTUGUESE INDIA
PRINCE EDWARD ISLAND
PRINCIPE ISLAND
PRUSSIA
PUEBLA
PUNJAB
PUNJAB, INDIA
PUNJAB, PAKISTAN
QATAR
QUANG LONG
QUEBEC
QUEENSLAND
QUERETARO
QUI NHON
RACH GIA
RAJASTHAN
RED CHINA
REPUBLIC OF CHINA
REPUBLIC OF CYPRUS
REPUBLIC OF IRELAND
REPUBLIC OF KOREA
REPUBLIC OF PANAMA
REP. OF PHILIPPINES
REP. OF SOUTH AFRICA
REPUBLICA DOMINICANA
REUNION ISLAND
RHODESIA
ROC
ROK
ROMANIA
ROTTERDAM
RUMANIA
RUSSIA
RUSSIAN FEDERATION
RWANDA
SAIGON
SALVADOR

20-Aug-13

Page 13 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
528
529
530

531
532
533
534
535

536
537
538
539
540
541

542
543
544
545
546
547

548
549
550
551
552

553
554
555
556
557
558

559
560
561
562
563

564
565
566
567
568
569

570
571
572
573
574
575

576
577
578

SAMOA
SAN ANDRES
SAN LUIS POTOSI
SAN MARINO
SAN SALVADOR
SAO TOME ISLAND
SAO TOME & PRINCIPE
SARAWAK
SASKATCHEWAN
SAUDI ARABIA
SAXONY
SCOTLAND
SENEGAL
SEOUL
SERBIA
SEYCHELLES
SHANGHAI
SHARJAH
SIBERIA
SICILY
SIERRA LEONE
SIKKIM
SINALOA
SINGAPORE
SLAVONIA
SLOVAK REPUBLIC
SLOVAKIA
SLOVENIA
SOLOMAN ISLANDS
SOMALIA
SONORA
SOUTH AFRICA
SOUTH AMERICA
SOUTH AUSTRALIA
SOUTH KOREA
SOUTH VIETNAM
SOUTH WALES
SOUTH YEMEN
SOUTHEAST ASIA
SOUTHERN AFRICA
SOUTHERN RHODESIA
SOVIET UNION
SPAIN
SPRATLEY ISLANDS
SRI LANKA
ST BARTHELEMY
ST BARTS
ST CHRISTOPHER
ST CHRISTOPHER-NEVIS
ST EUSTATIUS
ST HELENA

20-Aug-13

Page 14 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
579
580
581

582
583
584
585
586

587
588
589
590
591
592

593
594
595
596
597
598

599
600
601
602
603

604
605
606
607
608
609

610
611
612
613
614

615
616
617
618
619
620

621
622
623
624
625
626

627
628
629

ST KITTS
ST KITTS-NEVIS
ST LUCIA
ST MAARTEN
ST MARTIN
ST PIERRE & MIQUELON
ST VINCENT
ST VINCENT & THE GRENADINES
SUDAN
SUMATRA
SURINAM
SURINAME
SVALBARD
SWAZILAND
SWEDEN
SWITZERLAND
SYRIA
SYRIAN ARAB REP
TABASCO
TADZHIK
TAHITI
TAIWAN
TAIWAN ROC
TAJIKISTAN
TAMAULIPAS
TANGANYIKA
TANGIER
TANZANIA
TASMANIA
THAILAND
THANH HOA
THE GRENADINES
TIBET
TIJUANA
TLAXCALA
TOBAGO
TOGO
TOGOLAND
TOKELAU
TONGA
TORTOISE ISLANDS
TORTOLA
TRANSVAAL
TRANSYLVANIA
TRIESTE
TRINIDAD
TRINIDAD & TOBAGO
TRIPOLI
TROMELIN ISLAND
TRUK
TUNIS

20-Aug-13

Page 15 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
630
631
632

633
634
635
636
637

638
639
640
641
642
643

644
645
646
647
648
649

650
651
652
653
654

655
656
657
658
659
660

661
662
663
664
665

666
667
668
669
670
671

672
673
674
675
676
677

678
679
680

TUNISIA
TURKEY
TURKMENISTAN
TURKS & CAICOS IS
TURK ISLANDS
TUVALU
TUY HOA
UGANDA
UK
UKRAINE
UKRAINIA
UNION ISLANDS
UNION OF SOUTH AFRICA
UNION OF SOVIET SOCIALIST REPUBLICS
UNITED ARAB EMIRATES
UNITED KINGDOM
UPPER VOLTA
URUGUAY
USSR
USBEKISTAN
VANCOUVER
VANUATU
VATICAN CITY
VENEZUELA
VERACRUZ
VICTORIA
VIETNAM
VINH LONG
VUNG TAU
WALES
WALLIS & FUTUNA ISLANDS
WEST AFRICA
WEST BANK
WEST BENGAL
WEST INDIES
WEST PAKISTAN
WESTERN AUSTRALIA
WESTERN SAHARA
WESTERN SAMOA
WHITE RUSSIA
WINDWARD ISLANDS
WINNIPEG
WURZBERG
YAP
YAR
YEMEN
YEMEN ARAB REPUBLIC
YEREVAN
YUCATAN
YUGOSLAVIA
YUKON TERRITORY

20-Aug-13

Page 16 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
681

999

ZACATECAS
ZADAR
ZAIRE
ZAMBIA
ZANZIBAR
ZIMBABWE
ZURICH
ANDORRA
BRITISH INDIAN OCEAN TERRITORY
DEUTSCHLAND
FRENCH SOUTHERN AND ANTARCTIC LANDS
GRENADINES, THE
KOSOVO
MYANMAR
NORTHWEST TERRITORY
NUNAVUT TERRITORY
Country not listed
Refused
Don't know

UniverseText:

All persons not born in the United States

SkipInstructions:

<60-85> [store "2" in CITIZEN and goto USYR]
<100-696,996,R,D> [goto USYR]

682
683

684
685
686
687
688

689
690
691
692
693
694

695
696
996
997

20-Aug-13

Page 17 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:

FSD.004_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

USYR

QuestionnaireFileName:

Family

* Read if necessary.
Earlier I recorded [fill1: your/ALIAS's] date of birth as [fill2: AGEDOB@3(text version) AGEDOB@4, AGEDOB@5].
In what year did [fill3: you/ALIAS] come to the United States to stay?

1880-Current
Year
9997

1880-Current Year
Refused
Don't know

9999

UniverseText:

All persons not born in the United States

SkipInstructions:

<1880-Current Year> [if USYR lt AGEDOB@5, goto ERR2_USYR; else, goto CITIZEN]
[goto USLONG]
NOTE: The "*Read if necessary…Earlier I recorded…" portion of this question is included for persons with
complete date of birth information.
ERR1_USYR

Hard Edit:

*Future year invalid: [fill: USYR]. Please correct.

ERR2_USYR: * [fill year from USYR] is prior to the person's birth year.
*Please correct.

Question ID:

FSD.005_00.000 Instrument Variable Name:

QuestionText:

USLONG

QuestionnaireFileName:

About how long [fill1: have you/has ALIAS] been in the United States?
* Read if necessary: Earlier I recorded that [fill2: you are/ALIAS is] [fill3: AGE] years old.
*Enter '95' for 95 or more years.
*If less than 1 year given as a response, code the answer as '0'.

00-94
95
97
99

00-94 years
95+ years
Refused
Don't know

UniverseText:

All persons not born in the United States and refused or don't know was reported for USYR

SkipInstructions:

<0-95> [if USLONG gt AGE, goto ERR_USLONG; else, goto CITIZEN]
[goto CITIZEN]

Hard Edit:

ERR_LONG: * In US longer than alive!
* Please correct.

Family

Page 18 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:

FSD.006_00.000 Instrument Variable Name:

QuestionText:

(book) F20

20-Aug-13

CITIZEN

QuestionnaireFileName:

Family

?[F1]

[fill: Are you/Is ALIAS] a CITIZEN of the United States?
1

Yes, born in one of the 50 United States or the District of Columbia
Yes, born in Puerto Rico, Guam, American Virgin Islands, or other U.S. territory
Yes, born abroad to American parent(s)
Yes, U.S. citizen by naturalization
No, not a citizen of the United States
Refused
Don't know

2
3

4
5
7
9

UniverseText:

All persons not born in the United States or a United States territory

SkipInstructions:

<1> [if PLBORN eq 2, goto ERR1_CITIZEN; else, if PLBORN eq R, goto ERR3_CITIZEN; else, goto HEADST]
<2> [if (PLBORN eq 2 or PLBORN eq R), goto ERR2_CITIZEN; else, goto HEADST]
[goto HEADST]

Hard Edit:

ERR1_CITIZEN
*Already indicated birth outside the United States.
*Please correct.
ERR2_CITIZEN
*Already indicated birth outside United States territory.
*Please correct.
ERR3_CITIZEN: Refused
Previously, you refused to say if [you/ALIAS] were/was born in the United States.
Would you like to change your answer to the question?

Soft Edit:

ERR4_CITIZEN: Don't Know
Previously, you didn't know if [you/ALIAS] were/was born in the United States.
Would you like to change your answer to the question?
Question ID:

FSD.007_00.000 Instrument Variable Name:

QuestionText:

HEADST

QuestionnaireFileName:

Family

?[F1]
Is [fill: ALIAS] now attending Head Start?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All persons less than 7 years of age

SkipInstructions:

<1> [if no more persons less than 7 years of age, goto EDUC; else, repeat this question for the next eligible person]
<2,R,D> [ goto HEADSTEV]

Page 19 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:

FSD.008_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

20-Aug-13

HEADSTEV

QuestionnaireFileName:

Family

Has [fill: ALIAS] ever attended Head Start?

Yes
No
Refused
Don't know

UniverseText:

All persons less than 18 years of age and not currently enrolled in Head Start

SkipInstructions:

if no more persons less than 7 years of age, goto EDUC; else, goto HEADST for the next eligible person

Page 20 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:

FSD.010_00.000 Instrument Variable Name:

QuestionText:

(book) F21

20-Aug-13

EDUC

QuestionnaireFileName:

Family

?[F1]

What is the HIGHEST level of school [fill: you have/ALIAS has] completed or the highest degree [fill: you have/ALIAS
has] received? Please tell me the number from the card.
* Enter highest level of school completed.
00
01
02
03
04
05

06
07
08
09
10

11
12
13
14
15
16

17
18
19
20
21
96

97
99

Never attended/kindergarten only
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade, no diploma
GED or equivalent
High School Graduate
Some college, no degree
Associate degree: occupational, technical, or vocational program
Associate degree: academic program
Bachelor's degree (Example: BA, AB, BS, BBA)
Master's degree (Example: MA, MS, MEng, MEd, MBA)
Professional School degree (Example: MD, DDS, DVM, JD)
Doctoral degree (Example: PhD, EdD)
Child under 5 years old
Refused
Don't know

UniverseText:

All persons 5 years of age or older

SkipInstructions:

repeat for all eligible persons, then goto ARMFVER

Page 21 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:

FSD.020_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ARMFVER

QuestionnaireFileName:

Family

Earlier [fill1: you said/it was said] [fill2: you/alias] [fill3: were/was] on full-time active duty with the Armed Forces. Is
this correct?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with a person age 18 or older who were said to be on active duty in the armed forces in the HHC
section

SkipInstructions:

<1> [goto ARMFFC] <2,R,D> [goto ARMFEV]

Question ID:

FSD.021_00.000 Instrument Variable Name:

QuestionText:

ARMFEV

QuestionnaireFileName:

Family

[fill1: Have you/Has alias] ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?
*Read if necessary. Active duty does not include training for the Reserves or National Guard, but DOES include
activation, for example, for service in the US or in a foreign country, in support of military or humanitarian operations.

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

All families with a person age 18 or older who is not currently on active duty or said R,D to active duty question

SkipInstructions:

<1> [goto ARMFFC] <2,R,D> [goto DOINGLW]

Page 22 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:

FSD.022_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ARMFFC

QuestionnaireFileName:

Family

Did [fill1: you/alias] ever serve in a foreign country during a time of armed conflict or on a humanitarian or peacekeeping mission?
*Read if necessary. This would include National Guard or reserve or active duty monitoring or conducting peace keeping
operations in Bosnia Kosovo, in the Sinai between Egypt and Israel, or in response to the 2004 tsunami, or Haiti in 2010.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with a person age 18 or older who has ever served in the armed forces

SkipInstructions:

<1,2,R,D> [goto ARMFTMP]

Question ID:

FSD.023_00.000 Instrument Variable Name:

QuestionText:

ARMFTMP

QuestionnaireFileName:

Family

When did [fill1: you/alias] serve on ACTIVE DUTY in the U.S. Armed Forces?
*Enter all that apply, separate with commas.
*Enter all periods in which this person served. Enter the item even if the person served for just part of that period.

01
02
03
04
05

06
07
08
97
99

Sept 2001 or later
August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)
January 1947 to June 1950
December 1946 or earlier
Refused
Don’t know

UniverseText:

All families with a person age 18 or older who has ever served in the armed forces

SkipInstructions:

<1,3-8,R,D> [goto DOINGLW] <2> [goto ARMFDS]

Hard Edit:

If gray answer code is selected please display:
That selection is not valid at this time.
Please correct.

Page 23 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:

FSD.024_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ARMFDS

QuestionnaireFileName:

Did [fill1: you/alias] serve in the Persian Gulf during Operation Desert Shield or Operation Desert Storm between August
1990 and April 1991?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with a person age 18 or older who served from August 1990 to August 2001

SkipInstructions:

<1,2,R,D> [goto DOINGLW]

Question ID:

Family

FSD.050_00.000 Instrument Variable Name:

QuestionText:

(book) F22

DOINGLW

QuestionnaireFileName:

? [F1]

The next few questions are about employment status.
Which of the following [fill: were you/was ALIAS] doing last week?
* Read answer categories.
1
2
3
4
5
7

9

Working for pay at a job or business
With a job or business but not at work
Looking for work
Working, but not for pay, at a family-owned job or business
Not working at a job or business and not looking for work
Refused
Don't know

UniverseText:

All persons 18 years of age or older

SkipInstructions:

<1,4> [goto WRKHRS]
<2,5> [goto WHYNOWRK]
<3,R,D> [goto WRKLYR]
NOTE: A flashcard was added to this question in quarter 3 of 2005.

Family

Page 24 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:

FSD.060_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

WHYNOWRK

QuestionnaireFileName:

Family

?[F1]
What is the main reason [fill1: you/ALIAS] did not [fill2: work last week/have a job or business last week]?

01

Taking care of house or family
Going to school
Retired
On a planned vacation from work
On family or maternity leave
Temporarily unable to work for health reasons
Have job/contract and off-season
On layoff
Disabled
Other
Refused
Don't know

02
03

04
05
06
07
08

09
10
97
99

UniverseText:

All persons 18 years of age or older who were either with a job or business but not at work, or not working at a job
or business and not looking for work

SkipInstructions:

<1-3,8-10,R,D> [goto WRKLYR]
<4-7> [goto WRKHRS]

Question ID:

FSD.070_00.000 Instrument Variable Name:

QuestionText:

WRKHRS1

QuestionnaireFileName:

Family

?[F1]
How many hours [fill: did you work LAST WEEK at ALL jobs or businesses/did ALIAS work LAST WEEK at ALL jobs
or businesses/do you USUALLY work at ALL jobs or businesses/does ALIAS USUALLY work at ALL jobs or
businesses]?

001-168
997
999

1-168 hours
Refused
Don't know

UniverseText:

All persons 18 years of age or older who were working for pay at a job or business, or working, but not for pay, at
a job or business last week, or on a planned vacation from work, or on family or maternity leave, or temporarily
unable to work for health reasons, or have a job/contract and off-season

SkipInstructions:

<1-34,R,D> [goto WRKFTALL]
<35-94> [goto WRKLYR]
<95-168> [goto ERR1_WRKHRS]

Soft Edit:

* [Fill: WRKHRS] is an unusually high number.
* Please verify.

Page 25 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:

FSD.080_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

WRKFTALL

QuestionnaireFileName:

Family

?[F1]
[fill: Do you/Does ALIAS] USUALLY work 35 hours or more per week in total at ALL jobs or businesses?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All persons 18 years of age or older who worked less than 35 hours last week or did not know/refused to answer
how many hours they worked last week

SkipInstructions:

[goto WRKLYR]
NOTE ON QUESTIONNAIRE FLOW: The instrument cycles through the appropriate questions from DOINGLW
to WRKFTALL for each eligible person, then proceeds to WRKLYR.

Question ID:

FSD.100_00.000 Instrument Variable Name:

QuestionText:

WRKLYR

QuestionnaireFileName:

?[F1]
Did [fill1: you/ALIAS] work for pay at any time in [fill2: last calendar year in 4-digit format]?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All persons 18 years of age or older

SkipInstructions:

<1> [goto WRKMYR]
<2,R,D> [goto HIEMPOF]

Family

Page 26 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:

FSD.110_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

WRKMYR

QuestionnaireFileName:

Family

How many months in [fill1: last calendar year in 4-digit format] did [fill2: you/ALIAS] have at least one job or business?
* If less than one month, enter '1'.

01

1 month or less
2-12 months
Refused
Don't know

02-12
97

99

UniverseText:

All persons 18 years of age or older who worked last year

SkipInstructions:

goto ERNYR

Question ID:

FSD.120_00.000 Instrument Variable Name:

QuestionText:

ERNYR

QuestionnaireFileName:

Family

?[F1]
What is your best estimate of [fill1: your/ALIAS's] earnings before taxes and deductions from ALL jobs and businesses in
[fill2: last calendar year in 4-digit format]?
Include hourly wages, salaries, tips and commissions.
* Enter '999,995' if the reported income is greater than $999,995.

000001- 999994
999995
999997
999999

$1-$999,994
$999,995+
Refused
Don't know

UniverseText:

All persons 18 years of age or older who worked last year

SkipInstructions:

goto HIEMPOF

Page 27 of 27

DRAFT 2013 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:

Question ID:

FSD.130_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

HIEMPOF

20-Aug-13

QuestionnaireFileName:

Family

Regarding [fill1: your/ALIAS's] job or work last week, was health insurance offered to [fill2: you/ALIAS] through [fill1:
your/ALIAS's] workplace?

Yes
No
Refused
Don't know

UniverseText:

All persons 18 years of age or older who were working for pay at a job or business, or with a job or business, but
not at work, or working, but not for pay, at a family-owned job or business

SkipInstructions:

goto INTROINC
NOTE ON QUESTIONNAIRE FLOW: The instrument cycles through the appropriate questions from WRKLYR
to HIEMPOF for each eligible person, then proceeds to INTROINC.

Page 1 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.010_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FINCINT

QuestionnaireFileName:

Family

* Read the following.
The next questions are about [fill1: your total/your total family] income in [fill2: last calendar year in 4-digit format]
BEFORE TAXES.
Income is important in analyzing the health information we collect. For example, with this information, we can learn
whether persons in one income group use certain types of medical services more or less often than those in another group.
Please be assured that, like all other information you have provided, these answers will be kept strictly confidential.

1

Enter 1 to continue

UniverseText:

All families

SkipInstructions:

goto FSAL

Question ID:

FIN.030_00.000 Instrument Variable Name:

QuestionText:

FSAL

QuestionnaireFileName:

Family

? [F1]
[fill1: Did you receive income in [fill2: last calendar year in 4-digit format] from wages and salaries?]
[fill3: When answering these questions, please remember that by "combined family income," I mean your income PLUS
the income of all family members living in this household (including cohabiting partners, and armed forces members
living at home).
Did any family members 18 and older, that is * Read names
(fill roster of people ge 18 years of age)
receive income in [fill2: last calendar year in 4-digit format] from...wages and salaries?]

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with one or more persons 18 years of age or older

SkipInstructions:

<1> [if a single-person family, store the person number in PSAL and goto FSEINC; else, goto PSAL]
<2,R,D> [goto FSEINC]

Page 2 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.040_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PSAL

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with two or more persons 18 years of age or older and at least one received income from wages and
salaries in the last calendar year

SkipInstructions:

goto FSEINC
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FIN.050_00.000 Instrument Variable Name:

QuestionText:

FSEINC

QuestionnaireFileName:

Family

[fill1: Did you receive income in [fill2: last calendar year in 4-digit format] from self-employment including business and
farm income?/ Did ALIAS receive income in [fill2: last calendar year in 4-digit format] from self-employment including
business and farm income?/Did any family members 18 and older, that is
*Read names
(fill roster of people ge 18 years of age)
receive income in [fill2: last calendar year in 4-digit format] from...self-employment including business and farm income?]

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with one or more persons 18 years of age or older

SkipInstructions:

<1> [if a single-person family, store the person number in PSEINC and goto FSSRR; else, goto PSEINC]
<2,R,D> [goto FSSRR]

Page 3 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.060_00.000 Instrument Variable Name:

QuestionText:

PSEINC

20-Aug-13

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with two or more persons 18 years of age or older and at least one received income from selfemployment in the last calendar year

SkipInstructions:

goto FSSRR
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FIN.070_00.000 Instrument Variable Name:

QuestionText:

FSSRR

QuestionnaireFileName:

Family

? [F1]
Did [fill1: you/any family members living here] receive income in [fill2: last calendar year in 4-digit format] from Social
Security or Railroad Retirement?
* Read if necessary: Social Security checks are either automatically deposited in the bank or mailed to arrive on the third
of every month.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PSSRR and goto FSSRRD; else, goto PSSRR]
<2,R,D> [goto FPENS]

Page 4 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.080_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PSSRR

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with two or more persons and at least one received income from Social Security or Railroad
Retirement in the last calendar year

SkipInstructions:

goto FSSRRD
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data.

Question ID:

FIN.082_00.000 Instrument Variable Name:

QuestionText:

FSSRRD

QuestionnaireFileName:

Family

Was [fill: your/any family member's *Read names
(fill roster of all persons selected at PSSRR and AGE LE 64)]
Social Security or Railroad Retirement income received as a disability benefit?

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with persons less than 65 years of age who received Social Security or Railroad Retirement income in
the last calendar year

SkipInstructions:

<1> [if only one person less than 65 years of age received Social Security or Railroad Retirement income, fill the
person number in PSSRRDB and goto PSSRRD; else, goto PSSRRDB]
<2,R,D> [goto FPENS]

Page 5 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.084_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PSSRRDB

QuestionnaireFileName:

Family

*Ask or verify. Enter applicable line number(s), separate with commas.
Was {person's} Social Security or Railroad Retirement income received as a disability benefit?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All families with two or more persons less than 65 years of age who received income from Social Security or
Railroad Retirement in the last calendar year and at least one received the income as a disability benefit

SkipInstructions:

goto PSSRRD
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FIN.086_00.000 Instrument Variable Name:

QuestionText:
1

2
7
9

PSSRRD

QuestionnaireFileName:

Family

Did [fill1: you/ALIAS] receive this benefit because [fill2: you are/he is/she is] disabled?
Yes
No
Refused
Don't know

UniverseText:

All persons less than 65 years of age who received Social Security or Railroad Retirement income as a disability
benefit in the last calendar year

SkipInstructions:

repeat for all eligible persons, then goto FPENS

Page 6 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.090_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FPENS

QuestionnaireFileName:

Family

Did [fill1: you/any family members living here] receive income in [fill2: last calendar year in 4-digit format] from any
disability pension [fill3: other than Social Security or Railroad Retirement]?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PPENS and goto FOPENS; else, goto PPENS]
<2,R,D> [goto FOPENS]

Question ID:

FIN.100_00.000 Instrument Variable Name:

QuestionText:

PPENS

QuestionnaireFileName:

Family

*Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
*Indicate each family member with this income.

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one received income from a disability pension (other than Social
Security or Railroad Retirement) in the last calendar year

SkipInstructions:

goto FOPENS
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 7 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.102_00.000 Instrument Variable Name:

QuestionText:

FOPENS

20-Aug-13

QuestionnaireFileName:

Family

Did [fill1: you/any family members living here] receive income from any retirement or survivor pension other [fill2: than
Social Security or Railroad Retirement/than a disability pension/than Social Security, Railroad Retirement, or a disability
pension]?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in POPENS and goto FSSI; else, goto POPENS]
<2,R,D> [goto FSSI]

Question ID:

FIN.104_00.000 Instrument Variable Name:

QuestionText:

POPENS

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one received income from a retirement or survivor pension in
the last calendar year

SkipInstructions:

goto FSSI
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 8 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.110_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FSSI

QuestionnaireFileName:

Family

? [F1]
Did [fill: you/any family members] receive Supplemental Security Income (SSI)?
* Read if necessary: Federal SSI checks are either automatically deposited in the bank or mailed to arrive on the first of
every month.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, fill the person number in PSSI and goto PSSID; else, goto PSSI]
<2,R,D> [goto FTANF]

Question ID:

FIN.120_00.000 Instrument Variable Name:

QuestionText:

PSSI

QuestionnaireFileName:

Family

*Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family received this?
(Anyone else?)
*Indicate each family member with this income.

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one received Supplemental Security Income (SSI) in the last
calendar year

SkipInstructions:

goto PSSID
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 9 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.122_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PSSID

Family

Did [fill1: you/ALIAS] receive SSI because [fill2: you have/he has/she has] a disability?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All persons who received SSI in the last calendar year

SkipInstructions:

repeat for all eligible persons, then goto FTANF

Question ID:

QuestionnaireFileName:

FIN.150_00.000 Instrument Variable Name:

QuestionText:

FTANF

QuestionnaireFileName:

Family

? [F1]
At any time during [fill1: last calendar year in 4-digit format], even for one month, did [fill2: you/any family members
living here] receive any CASH assistance from a state or county welfare program, such as (* fill specific program name)?
* Please do not include food stamps, SSI, energy assistance, or medical assistance payments.

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PTANF and goto FOWBEN; else, goto PTANF]
<2,R,D> [goto FOWBEN]

Page 10 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.160_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PTANF

QuestionnaireFileName:

Family

*Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family received this?
(Anyone else?)
*Indicate each family member with this income.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with two or more persons and at least one received cash assistance from a state or county welfare
program in the last calendar year

SkipInstructions:

goto FOWBEN
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FIN.164_00.000 Instrument Variable Name:

QuestionText:

1
2
7

9

FOWBEN

QuestionnaireFileName:

Family

At any time during [fill1: last calendar year in 4-digit format], did [fill2: you/any family members living here] receive any
OTHER kind of welfare assistance such as help with getting a job, placement in education or job training programs, or
help with transportation or child care?
Yes
No
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in POWBEN and goto FINTRST; else, goto POWBEN]
<2,R,D> [goto FINTRST]

Page 11 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.166_00.000 Instrument Variable Name:

QuestionText:

POWBEN

20-Aug-13

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with two or more persons and at least one received income from some "other" kind of welfare
assistance in the last calendar year

SkipInstructions:

goto FINTRST
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FIN.170_00.000 Instrument Variable Name:

QuestionText:

FINTRST

QuestionnaireFileName:

Family

Did [fill: you/any family members living here] receive income from interest bearing checking accounts, savings accounts,
IRAs or certificates of deposit, money market funds, treasury notes, bonds, or any other investments that earn interest?
* Do not include dividends

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PINTRST and goto FDIVD; else, goto PINTRST]
<2,R,D> [goto FDIVD]

Page 12 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.180_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PINTRST

QuestionnaireFileName:

Family

*Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with two or more persons and at least one received interest income in the last calendar year

SkipInstructions:

goto FDIVD
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FIN.190_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

FDIVD

QuestionnaireFileName:

Family

Did [fill: you/any family members living here] receive income from dividends from stocks or mutual funds, or net rental
income from property, royalties, estates or trusts?
Yes
No
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PDIVD and goto FCHLDSP; else, goto PDIVD]
<2,R,D> [goto FCHLDSP]

Page 13 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.200_00.000 Instrument Variable Name:

QuestionText:

PDIVD

20-Aug-13

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s). Separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with two or more persons and at least one received dividend or net rental income in the last calendar
year

SkipInstructions:

goto FCHLDSP
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FIN.210_00.000 Instrument Variable Name:

QuestionText:

FCHLDSP

QuestionnaireFileName:

Family

? [F1]
Did [fill: you/any family members living here] receive income from child support?

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PCHLDSP and goto FINCOT; else, goto PCHLDSP]
<2,R,D> [goto FINCOT]

Page 14 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.220_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PCHLDSP

QuestionnaireFileName:

Family

*Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate which child in the family this is for. If that child is no longer residing with this family, enter line number of
custodial parent.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with two or more persons and at least one received income from child support in the last calendar year

SkipInstructions:

goto FINCOT
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FIN.230_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

FINCOT

QuestionnaireFileName:

Family

Did [fill: you/any family members living here] receive income from any other source such as alimony, contributions from
family/others, VA payments, Worker’s Compensation, or unemployment compensation?
Yes
No
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PINCOT and goto FINCTOT; else, goto PINCOT]
<2,R,D> [goto FINCTOT]

Page 15 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.240_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PINCOT

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

All families with two or more persons and at least one received some "other" source of income in the last calendar
year

SkipInstructions:

goto FINCTOT
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FIN.250_00.000 Instrument Variable Name:

QuestionText:

FINCTOT

QuestionnaireFileName:

Family

[fill1: When answering this next question, please remember to include your income PLUS the income of all family
members living in this household.]
What is your best estimate of [fill2: your total income/the total income of all family members] from all sources, before
taxes, in [fill3: last calendar year in 4 digit format]?
* Enter ‘999,995’ if the reported income is greater than $999,995.

000000-999994
999995
999997
999999

$0-$999,994
$999,995+
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<0-999> goto ERR1_FINCTOT
<250001-999995> goto ERR2_FINCTOT
<1000-250000> goto HOUSEOWN
goto FINC50

Soft Edit:

ERR1_FINCTOT:
* Do not read to the respondent.
* $[fill: FINCTOT] is unusually low. Make corrections if necessary.
ERR2_FINCTOT:
* Do not read to the respondent.
* $[fill: FINCTOT] is unusually high. Make corrections if necessary.

Page 16 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.255_00.000 Instrument Variable Name:

QuestionText:

FINC50

QuestionnaireFileName:

Family

Was your total [fill: family] income from all sources less than $50,000 or $50,000 or more?

1

Less than $50,000
$50,000 or more
Refused
Don't know

2
7
9

UniverseText:

Respondents who don't know or refuse their income

SkipInstructions:

<1> [goto FINC35]
<2> [goto FINC100]
[HOUSEOWN]

Question ID:

20-Aug-13

FIN.260_00.000 Instrument Variable Name:

QuestionText:
1
2
7

9

FINC35

QuestionnaireFileName:

Was your total [fill: family] income from all sources less than $35,000 or $35,000 or more?
Less than $35,000
$35,000 or more
Refused
Don't know

UniverseText:

The respondent answered less than $50,000 in FINC50

SkipInstructions:

<1> if PCNT <= '5', goto FINCPOV;
else goto HOUSEOWN
<2> if PCNT = '8', goto FINCPOV;
else goto HOUSEOWN
goto HOUSEOWN

Family

Page 17 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.265_00.000 Instrument Variable Name:

QuestionText:

FINCPOV

20-Aug-13

QuestionnaireFileName:

Family

Was your total [fill1: family] income from all sources less than [fill2: fill based on poverty threshold] or [fill2: fill based
on poverty threshold] or more?

1

Less than [$11,500/$12,000/$14,000/$16,000/$18,500/$24,000/$28,500/$41,000]
[$11,500/$12,000/$14,000/$16,000/$18,500/$24,000/$28,500/$41,000] or more
Refused
Don't know

2
7
9

UniverseText:

The respondent answered Less than $35,000 and there were 5 or fewer persons in the family or the respondent
answered $35,000 or More and there were 8 persons in the family

SkipInstructions:

<1,R,D> goto HOUSEOWN
<2> if PCNT='1' or PCNT ='2' and AGE ge '66' for at least one person [goto F200POV]
elseif PCNT = ‘2’ and AGE lt '66' for both persons or PCNT ge '3' [goto HOUSEOWN]

Question ID:

FIN.268_00.000 Instrument Variable Name:

QuestionText:

1
2

7
9

F200POV

QuestionnaireFileName:

Family

Was your total [fill1: family/] income from all sources less than [fill2: fill based on 200% poverty threshold] or
[fill2: fill based on 200% poverty threshold] or more?
Less than [$23,000/$24,000/$28,000]
[$23,000/$24,000/$28,000] or more
Refused
Don't know

UniverseText:

The respondent answered More than poverty threshold and there is 1 person in the family or 2 persons in the
family, and the age of one or more of the persons is 66 or greater

SkipInstructions:

<1,2,R,D> [goto HOUSEOWN]

Page 18 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.270_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FINC100

Family

Was your total [fill: family] income from all sources less than $100,000 or $100,000 or more?

1

Less than $100,000
$100,000 or more
Refused
Don't know

2
7
9

UniverseText:

The respondent answered more than $50,000 in FINC50

SkipInstructions:

<1> [goto FINC75]
<2> [goto FINC150]
[goto HOUSEOWN]

Question ID:

QuestionnaireFileName:

FIN.272_00.000 Instrument Variable Name:

QuestionText:
1
2
7

9

FINC150

QuestionnaireFileName:

Was your total [fill: family] income from all sources less than $150,000 or $150,000 or more?
Less than $150,000
$150,000 or more
Refused
Don't know

UniverseText:

The respondent answered $100,000 or more in FINC100

SkipInstructions:

<1,2,R,D> [goto HOUSEOWN]

Family

Page 19 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.275_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FINC75

Family

Was your total [fill: family] income from all sources less than $75,000 or $75,000 or more?

1

Less than $75,000
$75,000 or more
Refused
Don't know

2
7
9

UniverseText:

The respondent answered less than $100,000 in FINC100

SkipInstructions:

<1> if PCNT = ‘5’or '6', goto F200PV75;
else goto HOUSEOWN
<2> if PCNT = '8', goto F200PV75;
else goto HOUSEOWN
goto HOUSEOWN

Question ID:

QuestionnaireFileName:

FIN.276_00.000 Instrument Variable Name:

QuestionText:

1
2

7
9

F200PV75

QuestionnaireFileName:

Family

Was your total family income from all sources less than [fill1: fill based on 200% poverty threshold] or [fill1: fill based on
200% poverty threshold] or more?
Less than [$57,000/$64,000/$82,000]
[$57,000/$64,000/$82,000] or more
Refused
Don't know

UniverseText:

The respondent answered less than $75,000 and there are 5 or 6 persons in the family OR The respondent
answered $75,000 or More and there are 8 persons in the family

SkipInstructions:

<1,2,R,D> [goto HOUSEOWN]

Page 20 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.280_00.000 Instrument Variable Name:

QuestionText:

HOUSEOWN

QuestionnaireFileName:

Family

Is this house/apartment owned or being bought, rented, or occupied by some other arrangement by you [fill: /or someone
in your family]?

1

9

Owned or being bought
Rented
Other arrangement
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1,3,R,D> [goto FSSAPL]
<2> [goto FGAH]

2
3
7

Question ID:

20-Aug-13

FIN.282_00.000 Instrument Variable Name:

QuestionText:

FGAH

QuestionnaireFileName:

Family

? [F1]
[fill: Are you/Is anyone in your family] paying lower rent because the Federal, State, or local government is paying part of
the cost?

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families that rent their house/apartment

SkipInstructions:

goto FSSAPL

Page 21 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.300_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FSSAPL

QuestionnaireFileName:

Family

[fill: Have you EVER applied for Supplemental Security Income or SSI, even if the claim was denied?/Have any family
members living here EVER applied for Supplemental Security Income (SSI)? This includes people who applied for
benefits, even if the claim was denied.]

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All families

SkipInstructions:

<1> [if a single-person family, store the person number in PSSAPL and goto FSDAPL; else, goto PSSAPL]
<2,R,D> [goto FSDAPL]

Question ID:

FIN.310_00.000 Instrument Variable Name:

QuestionText:

PSSAPL

QuestionnaireFileName:

Family

*Ask or verify. Enter applicable line number(s), separate with a comma.
Who in the family applied for it?
(Anyone else?)
* Indicate each family member who applied for SSI benefits.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one applied for SSI

SkipInstructions:

goto FSDAPL
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 22 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.330_00.000 Instrument Variable Name:

QuestionText:

FSDAPL

20-Aug-13

QuestionnaireFileName:

Family

[fill: Have you EVER APPLIED for disability benefits from Social Security even if the claim was denied?/Have any
family members living here EVER applied for disability benefits from Social Security? This includes people who applied
for benefits, even if the claim was denied.]

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

All Families

SkipInstructions:

<1> [if a single-person family, store the person number in PSDAPL and goto TANFMYR; else, goto PSDAPL]
<2,R,D> [goto TANFMYR]

Question ID:

FIN.340_00.000 Instrument Variable Name:

QuestionText:

PSDAPL

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family applied for it?
(Anyone else?)
* Indicate each family member who applied for Social Security Disability benefits.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons and at least one applied for Social Security Disability benefits

SkipInstructions:

goto TANFMYR
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 23 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.350_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

TANFMYR

QuestionnaireFileName:

Family

? [F1]
Earlier I recorded that [fill1: you/ALIAS] received cash assistance from programs such as welfare or public assistance in
[fill2: last calendar year in 4-digit format]. During [fill2: last calendar year in 4-digit format], about how many months
did [fill1: you/ALIAS] receive this assistance?
*Enter '1' if less than one month.

01-12

1-12 months
Refused
Don't know

97
99

UniverseText:

All persons who received cash assistance from public assistance programs in the last calendar year

SkipInstructions:

repeat for all eligible persons, then goto FSNAP

Question ID:

FIN.360_00.000 Instrument Variable Name:

QuestionText:

FSNAP

QuestionnaireFileName:

Family

?[F1]
At any time during [fill 1: last calendar year in 4-digit format], did [fill 2: you/any family members living here] receive
[fill 3: food stamp benefits/SNAPNAME or food stamp benefits]?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1> [goto FSNAPMYR]
<2, D, R> [Goto FINWIC to see if family falls into the universe for this question.]

Page 24 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.380_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FSNAPMYR

QuestionnaireFileName:

Family

?[F1]
During [fill 1: last year in 4 digit format], about how many months were [fill 2: food stamp benefits/SNAPNAME or food
stamp benefits] received?
* Enter "1" if less than 1 month

01-12

Months
Refused
Don't know

97
99

UniverseText:

Family received food stamp/SNAP benefits in previous calendar year

SkipInstructions:

Goto FINWIC to see if family fits into universe for this question.

Question ID:

FIN.384_00.000 Instrument Variable Name:

QuestionText:

FINWIC

QuestionnaireFileName:

Family

? [F1]
At any time during [fill1: last calendar year in 4-digit format] did [fill2: you/anyone in your family] receive benefits from
the WIC program, that is, the Women, Infants and Children program?

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with females 12-55 years of age or children 0-5 years of age

SkipInstructions:

<1> [if a single-person family, store the person number in PWIC and goto FMSSN; else, goto PWIC]
<2,R,D> [goto FMSSN]

Page 25 of 25

DRAFT 2013 NHIS Questionnaire - Family
Family Income
Document Version Date:

Question ID:

FIN.385_00.000 Instrument Variable Name:

QuestionText:

PWIC

20-Aug-13

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family received this?
(Anyone else?)
* Indicate family members who were authorized to receive WIC benefits.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with two or more persons who are female and between the ages of 12-55 or children between the ages
of 0-5, and at least one received WIC benefits in the last calendar year

SkipInstructions:

goto FMSSN
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Page 1 of 1

DRAFT 2013 NHIS Questionnaire - Family
Language of Interview
Document Version Date:

Question ID:

FLG.010_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4

7
9

20-Aug-13

ENGLANG

How well [fill: do you/does ALIAS] speak English? Would you say...
*Read categories below.

Very well
Well
Not well
Not at all
Refused
Don't know

UniverseText:

All persons age 5 or over

SkipInstructions:

<1-4,R,D> [goto next section]

QuestionnaireFileName:

Family