Multi-mode Study--Line 8

National Health Interview Survey

Att 4 NHIS Oct 2013_Full NHCIS Questionnaire

Multi-mode Study--Line 8

OMB: 0920-0214

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0214 can be found here:

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Revised 8/6/13

Attachment 4. Full NHCIS Questionnaire

National Health Care Interview Survey (NHCIS) Survey Instrument Specifications

The questions in Section 1 are for CATI purposes only and should be treated on the ‘dashboard’ as a separate form. The CATI interviewer must complete this form and Section 2 before the other form is available to them.

OMB No. 0920-0214

Approval Expires 03/31/2016

The following public burden estimate statement must available as a CATI and Web screen.

Only display on the Main Menu screen.

Assurance of Confidentiality (NOTICE): The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347). If any federal employee, contractor, or agent knowingly shares identifiable information collected under this pledge of confidentiality with a person not entitled to have it, he or she can be fined up to $250,000, and/or imprisoned for up to 5 years.

Public reporting burden of this collection of information is estimated to average about 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports, Clearance Officer; Paperwork Reduction Project (0920-0214), 1600 Clifton Rd., MS D-74, Atlanta, GA 30333.

Section 1

Hello, my name is _________________. I’m calling on behalf of the CDC's National Center for Health

Statistics.

May I please speak to [ (fill ALIAS_SA)?

What is your date of birth?

---

--_----_---

ENTER MONTH ENTER DAY ENTER YEAR

Don’t know
Refused

What is your AGE?

---

ENTER AGE

Don’t know
Refused

Are you male or female?

Male
Female
Don’t know
Refused

Are you speaking on a landline or cell phone?

Landline
Cell phone
Don’t know
Refused

Are you currently driving a car or other motorized vehicle?

EVEN IF THE RESPONDENT IS USING A HANDS-FREE DEVICE WHILE DRIVING, YOU MUST END THE CALL

No
Yes
Prefers different number
Wrong time zone

I will call you back at another time. What day and time is convenient for you?

Agrees to a call back – RECORD THE CALL BACK DATE, TIME, AND PHONE NUMBER IN WebCATI
Refuses call back
Asks if web survey is available

We are interviewing only private residences. Thank you very much.

[(ALIAS_SA)/(HE/SHE)] has been selected to participate in a health survey. What difficulty does [(ALIAS_SA)/(HE/SHE)] have that prevents [HIM/HER] from speaking on the phone?

Hearing difficulty
Speech difficulty
Cognitive barrier
Physical barrier
Don’t know
Refused

Is an adult available who knows about [(ALIAS_SA)’s/(HIS/HER)] health and healthcare who can answer questions on [HIS/HER] behalf?

Yes, currently on phone
Not currently available
Don’t know
Refused

Because [(ALIAS_SA)/(HE/SHE)] cannot be interviewed and you are knowledgeable about [HIS/HER] health and healthcare, the CDC would like to interview you on [HIS/HER] behalf. If the question text states “you”, it is referring to [(ALIAS_SA)/(HIM/HER)].

Agrees to continue
Not currently available
Refused

We have a web-based survey available. [Would you like to/Can (he/she)] complete the survey using the web?

We can email or mail a letter to you with directions on completing the survey via web. Which would you prefer?

Email letter
Mail letter

What is [your/his/her] email address?

_____________________________________________ ENTER VERBATIM RESPONSE

Refused to give information

What is [your/his/her] mailing address?

Street1: ___________________

Street2: ___________________

City: ______________________

State: _____________________

Zip: _______________________

Refused

[You/He/She] will be receiving [an email in the next day or two/the letter in the next week or two]. It will contain information about our web survey. It also contains a toll free number that [you/he/she] may call at any time with any questions [you/he/she] may have. Thank you for your time. Have a nice day.

Section 2: Confirm Identity of Eligible Respondent

[RESPONDENT SELF-ADMINISTERED WEB INSTRUMENT (RS-AWI) BEGINS HERE]

The first screen that self respondents will come to depends upon whether or not we have a name for that case. The following instructions should be applied:

If ALIAS_SA=<blank> go to NAME_V

If ALIAS_SA ne <blank> go to VSANAME

Initialize SPV_CNTR = 0 when entering this section This counter variable will be used to determine if the respondent is a “match” with the Sample Adult demographic information. Also, determines if the interview continues or not.

English:

SELECT OR ENTER A RESPONSE AND CLICK ‘NEXT’ TO PROCEED.

We want to make sure our records are correct. Is your name [PRE-LOADED FIRST NAME, MIDDLE NAME/INITIAL, LAST NAME]?

First Name: NAME_FNA_SA

Middle Name: NAME_MNA_SA

Last Name: NAME_LNA_SA

Yes
Not exactly, make correction

Screen Name	VSANAME
Pre-loaded Data	NAME_FNA_SA NAME_MNA_SA NAME_LNA_SA
Question Wording	See sample image.
Response Options	Radio buttons: 1 Yes 2 Not exactly, make correction [ALLOW EDITS TO PRELOADED FIELDS] 3 No
Skip Pattern(s)	<1> increment SPV_CNTR by 1 & go to [DOB_V] <2> increment SPV_CNTR by 1 & go to [VSANAME2] <3> go to [NAME_V]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	Allow alpha characters and the following special characters: period (.), apostrophe (‘), quote (“) and dash (-). 50 characters max If FNAME_V= 1 or 2, then increment SPV_CNTR by 1. If <1, 2>, output NAME_FNA_SA, NAME_MNA_SA, and NAME_LNA_SA.

Section 3: INFORMED CONSENT

Last year you participated in the National Health Interview Survey. During that interview we mentioned that we might re-contact you. The Census Bureau is conducting this follow-up survey to help the CDC learn how the health care system is currently working for you.

Screen Name	INTRO_IC
Pre-loaded Data	None
Question Wording	See sample image.
Response Options
Skip Pattern(s)	Go to CONSENT
Help Text	None
Edits/Errors	None
Special Instructions	None

Your participation in this research is voluntary. You may choose not to answer any question you don't

wish to answer, or end the interview at any time with no impact on the benefits you may receive. On

average, the survey will take about 15 minutes to complete. We are required by Federal law to

develop and follow strict procedures to protect the confidentiality of your information and use your

answers only for statistical research. I can describe these laws if you wish.

If THANKYOU = 3, display, In appreciation for your time, we will send you $20 after you complete the interview.

If THANKYOU = 2, display, In appreciation for your time, we will send you $10 after you complete the interview.

If THANKYOU = 1, do NOT display any text.

In order to review my work, this call will be recorded and my supervisor may listen as I ask the

questions. I'd like to continue now unless you have any questions.

READ IF NECESSARY: The Public Health Service Act is Title 42 of the US Code, Section 242k. The collection of information in this survey is authorized by Section 306 of this Act. Through the National Center for Health Statistics, the confidentiality of your responses is assured by Section 308d of this Act and by the Confidential Information Protection and Statistical Efficiency Act. Would you like me to read the Confidential Information Protection provisions to you?

IF RESPONDENT WOULD LIKE TO HEAR PROVISIONS, READ: The information you provide will be used for statistical purposes only. In accordance with the Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107-347 and other applicable Federal laws, only those NCHS employees, our specially designated agents including the US Census Bureau, and our full research partners who must use your personal information for a specific reason can see your answers. Everyone else who uses this data can do so only after all information that could identify you and your family is removed. By law, every employee of the National Center for Health Statistics, the US Census Bureau, and their agents and contractors who work on this survey has taken an oath and is subject to a jail term of up to 5 years, a fine of up to $250,000, or both, if he or she willingly discloses ANY identifiable information about you or your household members.

ACCEPT, CONTINUE TO SURVEY
DECLINE, EXIT SURVEY

Section 4: Financial Burden of Medical Care

The first question is about money that you or your family 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 you spend for medical care and dental care?

READ ANSWER CHOICES IF NECESSARY

Nothing
Less than $500
$500-$1,999
$2,000-$2,999
$3,000-$4,999
$5,000 or more
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ001
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 0 Nothing 1 Less than $500 2 $500-$1,999 3 $2,000-$2,999 4 $3,000-$4,999 5 $5,000 or more 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<0,1,2,3,4,5,7,9, BLANK> go to WFQ002
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	If interviewer accessed display “READ ANSWER CHOICES IF NECESSARY” in all CAPS and italics. 8^th Radio button (7):: If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’/ ‘Prefiere no responder’ (Spanish)/ ‘Prefiere no responder’ (Spanish) If ‘Nothing’ is selected, output 0.

IN THE PAST 12 MONTHS did you 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
Don’t know
if interviewer = Refused; if respondent = Prefer not to answer

Screen Name	WFQ002
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ003
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7):: If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Do you 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.

Yes
No
Don’t know
If interviewer = Refused; if respondent = Prefer not to answer

Screen Name	WFQ003
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	[<1,2,7,9, BLANK> and WFQ002=2] go to WFQ005; [<1,2,7,9, BLANK> and WFQ002= 1,7,9, BLANK] go to WFQ004
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7):: If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Do you currently have any medical bills that you are unable to pay at all?

Yes
No
Don’t know
if interviewer = Refused; if respondent = Prefer not to answer

Screen Name	WFQ004
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ005
Help Text	None
Edits/Errors	If left blank, display: (English) Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7):: If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

If you get sick or have an accident, how worried are you that you will be able to pay your medical bills? If interviewer, display: Would you say you are very worried, somewhat worried, or not at all worried?

Very worried
Somewhat worried
Not at all worried
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ005
Pre-loaded Data	None
Question Wording	See sample image
Response Options	English: Radio Buttons: 1 Very worried 2 Somewhat worried 3 Not at all worried 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,3,7,9, BLANK> go to WFQ006
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	Only display if interviewer: “Would you say you are very worried, somewhat worried, or not at all worried?” 5^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Section 5: Health Status

Would you say your health in general is… Only display if interviewer: excellent, very good, good, fair, or poor?

Excellent
Very good
Good
Fair
Poor
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ006
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,3,4,5,7,9, BLANK> go to WFQ007
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	Only display on screen if interviewer accessed: “excellent, very good, good, fair, or poor?” 7^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

About how long has it been since you last saw or talked to a doctor or other health care professional about your own health? Include doctors seen while a patient in a hospital.

READ ANSWER CHOICES IF NECESSARY

Never
6 months or less
More than 6 months, but not more than 1 year ago
More than 1 year, but not more than 2 years ago
More than 2 years, but not more than 5 years ago
More than 5 years ago
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ007
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 0 Never 1 6 months or less 2 More than 6 months, but not more than 1 year ago 3 More than 1 year, but not more than 2 years ago 4 More than 2 years, but not more than 5 years ago 5 More than 5 years ago 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<0,1,2,3,4,5,7,9, BLANK> go to WFQ008
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	8^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’ If ‘Never’ is selected, output 0.

About how long has it been since you last saw a dentist? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

READ ANSWER CHOICES IF NECESSARY

Never
6 months or less
More than 6 months, but not more than 1 year ago
More than 1 year, but not more than 2 years ago
More than 2 years, but not more than 5 years ago
More than 5 years ago
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ008
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 0 Never 1 6 months or less 2 More than 6 months, but not more than 1 year ago 3 More than 1 year, but not more than 2 years ago 4 More than 2 years, but not more than 5 years ago 5 More than 5 years ago 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<0,1,2,3,4,5,7,9, BLANK> go to WFQ009
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	8^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’/ ‘Prefiere no responder’ (Spanish) If ‘Never’ is selected, output 0.

DURING THE PAST 12 MONTHS, were you prescribed medication by a doctor or other health professional?

Yes
No
Don’t know
if interviewer = Refused; if respondent = Prefer not to answer

Screen Name	WFQ009
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ010
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Section 6: Access and Utilization of Health Care

Is there a place that you USUALLY go to when you are sick or need advice about your health?

READ ANSWER CHOICES IF NECESSARY

Yes
There is no place
There is more than one place
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ010
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 There is no place 3 There is more than one place 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,3> go to WFQ011; <2,7,9, BLANK> go to WFQ012
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	5^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

[If WFQ010=1: What kind of a place is it - a clinic, doctor’s office, emergency room, or some other place?]

[If WFQ010=3: What kind of place do you go to most often – a clinic, doctor’s office, emergency room, or some other place?]

READ ANSWER CHOICES IF NECESSARY

Clinic or health center
Doctor’s office or HMO
Hospital emergency room
Hospital outpatient department
Some other place
Doesn’t go to one place most often
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ011
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Clinic or health center 2 Doctor’s office or hmo 3 Hospital emergency room 4 Hospital outpatient department 5 Some other place 6 Doesn’t go to one place most often 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<6> go to WFQ012; <1,2,3,4,5,7,9, BLANK> go to WFQ013
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	8^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’ [If WFQ010=1: What kind of a place is it - a clinic, doctor’s office, emergency room, or some other place? [If WFQ010=3: What kind of place do you go to most often – a clinic, doctor’s office, emergency room, or some other place?

What is the main reason you do not have a usual source of medical care?

READ ANSWER CHOICES IF NECESSARY

[If interviewer accessed (CATI): Doesn’t need a doctor/haven’t had any problems; if respondent accessed (RS-AWI): Don’t need a doctor/haven’t had any problems]
[If interviewer accessed (CATI): Doesn’t like/trust/believe in doctors; if respondent accessed (RS-AWI): Don’t like/trust/believe in doctors]
[If interviewer accessed (CATI): Doesn’t know where to go; if respondent accessed (RS-AWI): Don’t know where to go]
Previous doctor is not available/ moved
Too expensive/no insurance/cost
Speak a different language
No care available/care too far away, not convenient
Put it off/ didn’t get around to it
Other
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ012
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 01 Doesn’t need a doctor/ haven’t had any problems 02 Doesn’t like/trust/believe in doctors 03 Doesn’t know where to go 04 Previous doctor is not available/moved 05 Too expensive/no insurance/cost 06 Speak a different language 07 No care available/care too far away, not convenient 08 Put it off/didn’t get around to it 09 Other 99 Don’t know 97 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<01-99> go to WFQ025
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	11^th Radio button (97): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’ If Don’t Know is selected, output 99. If Refused is selected, output 97.

IN THE PAST 12 MONTHS, did you visit your usual provider for a check-up or routine care?

Yes
No
Don’t know
if interviewer = Refused; if respondent = Prefer not to answer

Screen Name	WFQ013
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,7,9, BLANK> go to WFQ014 <2>, go to WFQ025
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE PAST 12 MONTHS, when you made an appointment for a check-up or routine care with your usual provider, how often did you get an appointment as soon as you needed? If interviewer display: Would you say never, sometimes, usually, or always?

Never
Sometimes
Usually
Always
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ014
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Never 2 Sometimes 3 Usually 4 Always 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,3,4,7,9, BLANK> go to WFQ015
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	6^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’/ ‘Prefiere no responder’ (Spanish)

IN THE PAST 12 MONTHS, how often did this provider explain things in a way that was easy to understand?

READ ANSWER CHOICES IF NECESSARY

Never
Sometimes
Usually
Always
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ015
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Never 2 Sometimes 3 Usually 4 Always 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,3,4,7,9, BLANK> go to WFQ016
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	6^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE PAST 12 MONTHS, how often did this provider listen carefully to you?

READ ANSWER CHOICES IF NECESSARY

Never
Sometimes
Usually
Always
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ016
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Never 2 Sometimes 3 Usually 4 Always 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,3,4,7,9, BLANK> go to WFQ017
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	6^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE PAST 12 MONTHS, how often did this provider seem to know the important information about your medical history?

READ ANSWER CHOICES IF NECESSARY

Never
Sometimes
Usually
Always
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ017
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Never 2 Sometimes 3 Usually 4 Always 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,3,4,7,9, BLANK> go to WFQ018
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	6^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE PAST 12 MONTHS, how often did this provider show respect for what you had to say?

READ ANSWER CHOICES IF NECESSARY

Never
Sometimes
Usually
Always
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ018
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Never 2 Sometimes 3 Usually 4 Always 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,3,4,7,9, BLANK> go to WFQ019
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	6^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE PAST 12 MONTHS, how often did this provider spend enough time with you?

READ ANSWER CHOICES IF NECESSARY

Never
Sometimes
Usually
Always
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ019
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Never 2 Sometimes 3 Usually 4 Always 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,3,4,7,9, BLANK> go to WFQ020
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	6^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’/ ‘Prefiere no responder’ (Spanish)
IN THE PAST 12 MONTHS, did this provider order a blood test, X-ray, or other test for you? Yes No Don’t know If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’ <Previous> <Next>

Screen Name	WFQ020
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1> go to WFQ021: <2,7,9, BLANK> go to WFQ022
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE PAST 12 MONTHS, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you the results?

Never
Sometimes
Usually
Always
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ021
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Never 2 Sometimes 3 Usually 4 Always 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,3,4,7,9, BLANK> go to WFQ022
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer
Special Instructions	6^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Health care providers may ask during routine checkups about health-related behaviors like alcohol use. At your last routine checkup with this provider, did a doctor or other health professional ask you in person or on a form if you drank alcohol?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ022
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ023
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

At your last routine checkup, were you asked in person or on a form how much you drink?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

creen Name	WFQ023
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ024
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

At your last routine checkup, were you offered advice about what level of drinking is harmful or risky to your health?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ024
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ025
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

These next questions ask about which types of doctors you may have seen in the past year.

DURING THE PAST 12 MONTHS, have you seen or talked to a general doctor who treats a variety of illnesses (a doctor in general practice, family medicine, or internal medicine)?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ025
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	If (SEX_V = 2) or (SEX_V=<blank> and SEX_C = 2) go to [WFQ026]; If (SEX_V = <7, 9, BLANK> or (SEX_V =<BLANK> and SEX_C = <7, 9, BLANK>))and SEX_SA=2), go to [WFQ026]; Else go to [WFQ027]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, have you seen or talked to a doctor who specializes in women’s health (an obstetrician/gynecologist)?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ026
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ027
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, have you seen or talked to an optometrist, opthalmologist (AHF-thal-MOL-oh-jist), or eye doctor (someone who prescribes eyeglasses)?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ027
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ028
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, have you seen or talked to a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ028
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ029
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, have you seen or talked to a medical doctor who specializes in a particular medical disease or problem (other than obstetrician/gynecologist, psychiatrist, or ophthalmologist )?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ029
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ030
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they would not accept you as a new patient?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ030
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ031
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they did not accept your health care coverage?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ031
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ032
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, have you DELAYED seeking medical care because of worry about the cost?

Please do not include dental care in your answer.

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ032
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ033
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, was there any time when you needed medical care but didn’t get it because you couldn’t afford it?

Please do not include dental care in your answer.

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ033
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ034
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, was there any time when you needed dental care but didn’t get it because you couldn’t afford it? Yes No Don’t know If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’ <Previous> <Next>
Screen Name	WFQ034
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ035
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, was there any time you needed to see a specialist for care but didn’t get the care because you couldn’t afford it?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ035
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ036
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

The next questions are about prescription medicine.

DURING THE PAST 12 MONTHS, was there any time when you needed prescription medicines but didn’t get them because you couldn’t afford them?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ036
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ037
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, are any of the following true for you?

You skipped medication doses to save money.

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ037
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ038
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

You took less medicine to save money.

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ038
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ039
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

You delayed filling a prescription to save money.

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ039
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ040
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

You asked your doctor for a lower cost medication to save money.

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ040
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ041
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

You bought prescription drugs from another country to save money.

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ041
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ042
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

You used alternative therapies to save money.

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ042
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ043
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Section 7: Health Insurance

English:

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.

What kinds of health insurance or health care coverage do you 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.

If respondent= PLEASE SELECT ALL THAT APPLY.

If interviewer= I will read you a list, please tell me all that apply.

READ ALL ANSWER CHOICES

Private health insurance
Medicare
Medi-Gap
Medicaid
Military health care (TRICARE/VA/CHAMPVA)
Indian Health Service
Other type of health plan
Single service plan (e.g., dental, vision, prescriptions)
No coverage of any type
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ043
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: WFQ043A 01 Private health insurance WFQ043B 02 Medicare WFQ043C 03 Medi-Gap WFQ043D 04 Medicaid WFQ043E 05 Military health care (Tricare/VA/CHAMPVA) WFQ043F 06 Indian Health Service WFQ043G 07 Other type of health plan WFQ043H 08 Single service plan (e.g., dental, vision, prescriptions) WFQ043I 09 No coverage of any type WFQ043J 99 Don’t know WFQ043K 97 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	if WFQ043G=1 go to [WFQ044]; if WFQ043A=1 or WFQ043C=1 go to [WFQ045]; If WFQ043I=1 go to [WFQ047] else go to [WQF046]
	None
Edits/Errors	If blank, display If left blank, display: (English) Please select the response option that best describes your answer. (Spanish) Por favor seleccione la opción que mejor corresponde a su respuesta.
Special Instructions	Allow for multiple responses to be selected 11^th Radio button (97): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’/ ‘Prefiere no responder’ (Spanish) Do not allow 09, 99, and 97 to be selected with any other answer category. If Don’t Know is selected, output 99. If Refused is selected, output 97.

What is the name of your plan?

Name of plan:

Screen Name	WFQ044
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	50 character text box: Name of plan: __________________
Skip Pattern(s)	If WFQ043A=1 or WFQ043C=1 go to [WFQ045] else goto WFQ046
Help Text	None
Edits/Errors	If blank, display: “Please enter the response option that best describes your answer.”
Special Instructions	None

Which one of these categories best describes how your [private health insurance plan/ Medi-Gap] was obtained?

If interviewer display: I will read you a list, please tell me which answer applies.

READ ALL ANSWER CHOICES

Through employer, union, or professional association
Purchased directly
Through school
Through a parent
Through a state/local government or community program
Other
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ045
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Through employer, union, or professional association 2 Purchased directly 3 Through school 4 Through a parent 5 Through a state/local government or community program 6 Other 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ046
Help Text	None
Edits/Errors	If blank, display If left blank, display: Please select the response option that best describes your answer.
Special Instructions	If WFQ043A=1, fill ‘private health insurance plan’/ If WFQ043C=1, fill ‘Medi-gap’ If WFQ043A=1, fill ’seguro privado’ If WFQ043C=1, fill ‘Medi-gap’ 8^th Radio button (97): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE PAST 12 MONTHS, was there any time when you did NOT have ANY health insurance or

coverage?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ046
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	If <1> go to [WFQ047]; If <2,7,9, BLANK> go to [WFQ048]
Help Text	None
Edits/Errors	If blank, display If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE PAST 12 MONTHS, about how many months were you without coverage?

---

(Drop down: 00,01, 02, 03, 04,05, 06, 07, 08, 09, 10, 11, 12)

Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ047
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Drop down AND Radio Buttons: (Drop down with the following options 00, 01, 02, 03, 04,05, 06, 07, 08, 09, 10, 11, 12) Radio Buttons (WFQ047_DR): 99 Don’t know 97 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ0048
Help Text	None
Edits/Errors	If blank, display “Please select your answer from the drop-down list
Special Instructions	2^nd Radio button (97): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’/ ‘Prefiere no responder’ (Spanish) IF drop down selected, clear Don’t know and Refused radio buttons. If Don’t know or Refused selected, clear drop down. If 00 is selected from the drop-down, output 00. If Don’t Know is selected, output 99. If Refused is selected, output 97.

In regard to your health insurance or health care coverage, how does it compare to a year ago?

If interviewer, display: Is it better, worse, or about the same?

Better
Worse
About the same
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ048
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Better 2 Worse 3 About the same 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ049
Help Text	None
Edits/Errors	If blank, display If left blank, display: Please select the response option that best describes your answer
Special Instructions	5^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

If you or anyone in your family had to buy a health plan on your own with no help from your

employer, how confident are you that you would be able to obtain affordable coverage?

If interviewer display : Would you say very confident, somewhat confident, not too confident, not confident at all?

Very confident
Somewhat confident
Not too confident
Not confident at all
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ049
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Very confident 2 Somewhat confident 3 Not too confident 4 Not confident at all 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ050A
Help Text	None
Edits/Errors	If blank, display If left blank, display: Please select the response option that best describes your answer
Special Instructions	6^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’/ ‘Prefiere no responder’ (Spanish)

A health insurance premium is…

If respondent= PLEASE SELECT ALL THAT APPLY.

If interviewer= I will read you a list, please tell me all that apply.

What a person pays when they go to a medical appointment
What a person pays after insurance pays for part of the cost of medical services
What a person pays each month to have health insurance
The best insurance a health insurance company offers
Not sure
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ050A
Pre-loaded Data
Question Wording	See sample image.
Response Options	Select all that apply: WFQ050A_1 What a person pays when they go to a medical appointment WFQ050A_2 What a person pays after insurance pays for part of the cost of medical services WFQ050A_3 What a person pays each month to have health insurance WFQ050A_4 The best insurance a health insurance company offers WFQ050A_5 Not sure WFQ050A_6 Don’t know WFQ050A_7 If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ050B
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	Allow for multiple responses to be selected. 7th Radio button (WFQ050A_7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’ If Don’t know or Refused selected, clear answer choices 1-5. If WFQ050A_6 Don’t Know is selected, output 9. If WFQ050A_7 Refused is selected, output 7.

If a health insurance premium is subsidized based on income, that means that…

If respondent= PLEASE SELECT ALL THAT APPLY.

If interviewer= I will read you a list, please tell me all that apply.

The premium amount depends on the type ofmedical services received
The premium amount depends on the family’s income, that is, the income of everyone in the family that uses the insurance
The premium amount depends on how healthy the family is
The premium amount depends on what type of insurance plan I buy
The premium amount depends on the income of the health insurance company
Not sure
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ050B
Pre-loaded Data
Question Wording	See sample image.
Response Options	Select all that apply: WFQ050B_1 The premium amount depends on the type of medical services received WFQ050B_2 The premium amount depends on the family’s income, that is, the income of everyone in the family that uses the insurance WFQ050B_3 The premium amount depends on how healthy the family is WFQ050B_4 The premium amount depends on what type of insurance plan I buy WFQ050B_5 The premium amount depends on the income of the health insurance company WFQ050B_6 Not sure WFQ050B_7 Don’t know WFQ050B_8 If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ050C
Help Text	None
Edits/Errors	If left blank, display: (English) Please select the response option that best describes your answer. (Spanish) Por favor seleccione la opción que mejor corresponde a su respuesta.
Special Instructions	Allow for multiple responses to be selected. 8th Radio button (WFQ050B_8): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’ If WFQ050B_7 Don’t Know is selected, output 9. If WFQ050B_8 Refused is selected, output 7. If Don’t know or Refused selected, clear answer choices 1-6.

Have you heard of the Health Insurance Marketplace?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ050C
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 3 Don’t know 4 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ050D
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button : If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’If 3^rd Radio button: Don’t Know, output 9 If 4^th Radio button: Refused, output 7

Have you heard of health insurance exchanges?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ050D
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 3 Don’t know 4 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ050E
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button : If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’ If 3^rd Radio button: Don’t Know, output 9 If 4^th Radio button: Refused, output 7

Have you looked into purchasing health insurance coverage through the Health Insurance Marketplace?

Yes
No
Not sure
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ050E
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 3 Not sure 4 Don’t know 5 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ051
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	5^th Radio button: If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’If 4^th Radio button: Don’t Know, output 9 If 5^th Radio button: Refused, output 7

Section 8: Preventative Services

These next questions are about your lifestyle and use of preventive services. DURING THE

PAST 12 MONTHS, did a doctor or other health professional RECOMMEND that you

BEGIN or CONTINUE to do any type of exercise or physical activity?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ051
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ052
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, has a doctor or other health professional talked to you about your diet?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ052
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ053
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, have you had your blood pressure checked by a doctor, nurse, or other health professional?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ053
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ054
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, have you had your blood cholesterol checked by a doctor, nurse, or other health professional?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ054
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	If (SEX_V = 2) or (SEX_V=<blank> and SEX_C = 2) go to [WFQ055]; If (SEX_V = <7, 9, BLANK> or (SEX_V =<BLANK> and SEX_C = <7, 9, BLANK>))and SEX_SA=2), go to [WFQ055]; Else go to [WFQ057]
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, have you had a Pap smear or Pap test?

READ IF NECESSARY: A Pap smear or Pap test is a routine test for women in which the doctor examines the cervix, takes a cell sample from the cervix with a small stick or brush, and sends it to the lab.

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ055
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ056
Help Text	A Pap smear or Pap test is a routine test for women in which the doctor examines the cervix, takes a cell sample from the cervix with a small stick or brush, and sends it to the lab.
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	Only ask if: (SEX_V=2); (SEX_V=<blank> and SEX_C=2); (SEX_V=<7,9,blank> or SEX_V=<blank> and SEX_C=<7,9,blank>) and (SEX_SA=2) 4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, have you had a Mammogram?

READ IF NECESSARY: A mammogram is an X-ray of each breast to look for breast cancer.

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ056
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ057
Help Text	A mammogram is an x-ray of each breast to look for breast cancer.” It will be Help Text for respondents.
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	Only ask if: (SEX_V=2); (SEX_V=<blank> and SEX_C=2); (SEX_V=<7,9,blank> or SEX_V=<blank> and SEX_C=<7,9,blank>) and (SEX_SA=2) 4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, have you had any test done for colon cancer?

READ IF NECESSARY: Colon cancer tests include blood stool tests, colonoscopy and sigmoidoscopy. A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. A sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems.

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ057
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ058
Help Text	Colon cancer tests include blood stool tests, colonoscopy and sigmoidoscopy. A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. A sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems.
Edits/Errors	If blank, display: (English) Please select the response option that best describes your answer. (Spanish) Por favor seleccione la opción que mejor corresponde a su respuesta.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’ Add variable WFQ058_VISITED: If “NEXT” is selected, set WFQ058_VISITED= 1 If “NEXT” is not selected, WFQ058_VISITED= <blank>

Have you had a fasting test for high blood sugar or diabetes DURING THE PAST 12 MONTHS?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ058
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ059
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Section 9: Family Food Security

These next questions are about food used in your household and the ways you are managing to meet your food needs. The following are several statements that people have made about their food situation. For these statements, please tell us whether the statement was often true, sometimes true, or never true for you or your family in the last 30 days.

The first statement is:

“We worried whether our food would run out before we got money to buy more.” Was that often true, sometimes true, or never true for your family IN THE LAST 30 DAYS?

Often true
Sometimes true
Never true
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ059
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio buttons: 1 Often true 2 Sometimes true 3 Never true 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ060
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	5^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

"The food that we bought just didn't last, and we didn't have money to get more."

READ IF NECESSARY: Was that often true, sometimes true, or never true for your family in the last 30 days?

Often true
Sometimes true
Never true
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ060
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio buttons: 1 Often true 2 Sometimes true 3 Never true 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ061
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	5^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

"We couldn't afford to eat balanced meals."

READ IF NECESSARY: Was that often true, sometimes true, or never true for your family in the last 30 days?

Often true
Sometimes true
Never true
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ061
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio buttons: 1 Often true 2 Sometimes true 3 Never true 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	If <1,2> or [<3,D,R, BLANK> and [WFQ059 in <1,2> or WFQ060 in <1,2>]] go to [WFQ062]; else go to [WFQ069]
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	5^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE LAST 30 DAYS, did 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
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Spanish:

Screen Name	WFQ062
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	If <1> go to [WFQ063]; else go to [WFQ064]
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE LAST 30 DAYS, how many days did this happen?

Shape13 Shape12

Number of days:

Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ063
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Drop down: (Drop down with the following options 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) Radio Buttons (WFQ063_DR): 99 Don’t know 97 If interviewer=Refused; if respondent=’Prefer not to answer’
Skip Pattern(s)	Go to WFQ064
Help Text	None
Edits/Errors	If blank, display “Please select your answer from the drop-down list.”
Special Instructions	IF drop down selected, clear Don’t know and Refused. IF Don’t know refused selected, clear drop down. If Don’t Know is selected, output 99. If Refused is selected, output 97.

IN THE LAST 30 DAYS, did you ever eat less than you felt you should because there wasn't enough money for food?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ064
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ065
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE LAST 30 DAYS, were you ever hungry but didn't eat because there wasn't enough money for food?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ065
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to WFQ066
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE LAST 30 DAYS, did you lose weight because there wasn't enough money for food?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name
Pre-loaded Data
Question Wording
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	If <1> or [<2,7,9, BLANK> and [WFQ062 =<1> or WFQ064=<1> or WFQ065=<1>]] go to [WFQ067]; else go to [WFQ069]
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE LAST 30 DAYS, did you or other adults in your family ever not eat for a whole day because there wasn't enough money for food?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ067
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	If <1> go to [WFQ068]; else go to [WFQ069]
Help Text	None
Edits/Errors	If blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

IN THE LAST 30 DAYS, how many days did this happen?

Shape15 Shape14

Number of days:

Screen Name	WFQ068
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Drop down: (Drop down with the following options 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)
Skip Pattern(s)	Go to WFQ069
Help Text	None
Edits/Errors	If blank, display “Please select your answer from the drop-down list.”
Special Instructions	None

Section 10: Smoking

These next few questions are about cigarette smoking. Have you smoked at least 100 cigarettes in your ENTIRE LIFE?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ069
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’	Radio Buttons: 1 Sí 2 No 9 If interviewer = ‘Don’t know’; if respondent = ‘No sabe’ 7 If interviewer = ‘Refused’; if respondent = ‘Prefiere no responder’
Skip Pattern(s)	<1> go to [WFQ070] <2,7,9, BLANK> go to [WFQ073]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Do you NOW smoke cigarettes every day, some days or not at all?

Every day
Some days
Not at all
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ070
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Every day 2 Some days 3 Not at all 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,> go to [WFQ071] <3> go to [WFQ072] <7,9, BLANK> go to [WFQ073]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, have you stopped smoking for more than one day BECAUSE YOU WERE TRYING TO QUIT SMOKING?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ071
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ072
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, has a doctor or other health professional talked to you about your smoking?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ072
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to WFQ073
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Section 11: Marital & Employment Status

[If interviewer accessed: We’re almost finished with the interview.; If respondent accessed: You’re almost finished with the interview.] This next section asks general questions about your household.

How many people including yourself, currently live in your household?

NUMBER OF PEOPLE

Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ073
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Text Box: [DROP DOWN; VALID RANGE: 01-25 or more] Radio Buttons(WFQ073_DR): 99 Don’t know 97 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’	’
Skip Pattern(s)	Go to [WFQ074]
Help Text	None
Edits/Errors	If blank, display “Please select your answer from the drop-down list.”
Special Instructions	2^nd Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’ IF drop down selected, clear Don’t know and Refused radio buttons. If Don’t know or Refused selected, clear drop down. If Don’t Know is selected, output 99. If Refused is selected, output 97.

How many children under age 18 currently live in your household?

NUMBER OF PEOPLE

Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ074
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Drop down AND Radio Buttons: (Drop down with the following options 0,1, 2, 3, 4, 5, 6, 7, 8, 9, 10) Radio Buttons(WFQ074_DR): 99 Don’t know 97 If interviewer = Refused; if Respondent = Prefer not to answer	respondent = ‘Prefiere no responder’
Skip Pattern(s)	Go to [WFQ075]
Help Text	None
Edits/Errors	If blank, display “Please select your answer from the drop-down list.”
Special Instructions	2^nd Radio button (97): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’/ ‘Prefiere no responder’ (Spanish) Allow a maximum of 50 characters in the text box. If 0 is selected from drop-down, output 00. If Don’t Know is selected, output 99. If Refused is selected, output 97.

Are you now married, widowed, divorced, separated, never married, or living with a partner?

Married
Widowed
Divorced
Separated
Never married
Living with partner
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ075
Pre-loaded Data	None
Question Wording	See sample image
Response Options	Radio Buttons: 1 Married 2 Widowed 3 Divorced 4 Separated 5 Never married 6 Living with partner 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,3,4,5,6,7,9, BLANK> go to [WFQ076]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	8^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Are you currently enrolled in school?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ076
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to [WFQ077]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

The next few questions are about employment.

DURING THE PAST 12 MONTHS, has there been a change in your employment status?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ077
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to [WFQ078]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Which of the following best describes what you were doing LAST WEEK? Were you…

READ ALL ANSWER CHOICES

Employed (even if you were on vacation or any type of short term, temporary leave)
Unemployed
Retired from any job (later you will be able to indicate whether you are working during your retirement)
On extended leave (e.g. medical, family, or maternity leave, etc.)
On permanent disability
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ078
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Employed (even if you were on vacation or any type of short term, temporary leave) 2 Unemployed 3 Retired from any job (later you will be able to indicate whether you are working during your retirement) 4 On extended leave (e.g. medical, family, or maternity leave, etc.) 5 On permanent disability 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,4> go to [WFQ080]; <2> go to [WFQ081]; <3> go to [WFQ079]; <5> go to [ADVNOT]; <7,9, BLANK> go to [WFQ082]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	Display “READ ALL ANSWER CHOICES” in all CAPS and italics only when interviewer accessed. 6^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Are you working for pay more than 1 hour per week during your retirement?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ079
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1> go to [WFQ080]; <2,7,9, BLANK> go to [WFQ082]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

English:

Approximately how many hours do you usually work per week?

NUMBER OF HOURS

Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ080
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Drop-Down AND Radio Buttons: (Drop down with the following options: 0-80) Radio Buttons (WFQ080_DR): 99 Don’t know 97 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	Go to [WFQ082]
Help Text	None
Edits/Errors	If left blank, display: “Please select your answer from the drop-down list.”
Special Instructions	2^nd Radio button (97): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’ IF drop down selected, clear Don’t know and Refused radio buttons. If Don’t know or Refused selected, clear drop down. If 0 is selected from the drop-down, output 00. If Don’t Know is selected, output 99. If Refused is selected, output 97.

Are you currently looking for work?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ081
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to [ADVNOT]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

DURING THE PAST 12 MONTHS, have you had a period of unemployment?

Yes
No
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	WFQ082
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes 2 No 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to [ADVNOT]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

Section 12: Contact Information

Do you remember seeing an email or advance letter notifying you about this survey?

IF RESPONDENT SAYS ONLY “YES” ASK ABOUT EACH ONE SEPARATELY.

Yes, email
Yes, advance letter
Yes, both email and letter
No
Other, ENTER RESPONSE
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	ADVNOT
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Yes, email 2 Yes, advance letter 3 Yes, both email and letter 4 No 5 Other,_________ENTER RESPONSE(ADVNOT_S) 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	[PHONE CATI: go to [PHONEDEV]]; [RSW-AWI: go to [WEBDEV]]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	7^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to Text box should be 50 characters.

Did you complete this survey on a landline or cell phone?

Landline
Cell phone
Don’t know
If interviewer= ‘Refused’; if respondent = ‘Prefer not to answer’

Screen Name	PHONEDEV
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Landline 2 Cell phone 9 Don’t know 7 If interviewer = ‘Refused’; if respondent = ‘Prefer not to answer’
Skip Pattern(s)	<1,2,7,9, BLANK> go to [RECONT]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	4^th Radio button (7): If interviewer accessed the response = ‘Refused’; if respondent accessed = ‘Prefer not to answer’

On what kind of device did you complete this survey?

Computer (e.g., PC or Mac desktop or laptop)
Smartphone

Tablet
Other, please specify ENTER RESPONSE

Screen Name	WEBDEV
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Computer (e.g., PC or Mac desktop or laptop) 2 Smartphone 3 Tablet 4 Other, please specify__________ENTER RESPONSE(WEBDEV_S)
Skip Pattern(s)	<1,2,3,4, BLANK> go to [RECONT]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	"For 'Other, please specify' response, include write-in field that allows alpha characters and the following special characters: period (.), apostrophe ('), quote ("), and dash (-)." & "Allow 50 characters."

Since we are interested in how health changes over time, we may be re-contacting you in the future. How would you prefer to complete future surveys? Would you like…

READ ALL ANSWER CHOICES

A questionnaire sent in the mail
An email with a link to an internet questionnaire that you can fill out online
A telephone interview
Something else ENTER RESPONSE
No preference
Don’t know
If interviewer = ‘Refused/Does not want to participate in the future’; if respondent = ‘Prefer not to participate in future surveys’

Screen Name	RECONT
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 A questionnaire sent in the mail 2 An email with a link to an internet questionnaire that you can fill out online 3 A telephone interview 4 Something else __________ENTER RESPONSE(RECONT_S) 5 No preference 9 Don’t know 7 If interviewer = ‘Refused/Does not want to participate in the future’; if respondent = ‘Prefer not to participate in future surveys’
Skip Pattern(s)	<7, BLANK> go to [CLOSING]; <5,9> go to [CONTACT]; If PHONE CATI and <1, 2, 3, 4>else go to [MODESEL_I]; If RSW-AWI and <1, 2, 3, 4 > go to [MODESEL_R]
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	Display “READ ALL ANSWER CHOICES” in all CAPS and italics if interviewer accessed. 7^th Radio button (7): If interviewer accessed the response = ‘Refused/Does not want to participate in the future’; if respondent accessed = ‘Prefer not to participate in future surveys’

What makes this your preferred choice to complete future surveys?

READ ANSWER CHOICES IF NECESSARY

SELECT ALL THAT APPLY

Convenience
Faster time
Other, please specify________
Doesn’t have internet access
Doesn’t use/feel comfortable using computers
Don’t know
Refused

Screen Name	MODESEL_I
Pre-loaded Data
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Convenience 2 Faster time 3 Other, please specify_________ 4 Doesn’t have internet access 5 Doesn’t use/feel comfortable using computers 9 Don’t know 7 Refused
Skip Pattern(s)	<7, BLANK> go to [CLOSING]; else go to CONTACT
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	Allow multiple responses. For “Other, please specify” response, include write-in field that allows alpha characters and the following special characters: period (.), apostrophe (‘), quote (“), and dash (-). IF Don’t know or Refused selected, clear answer choices 1-5. 150 characters max.

What makes this your preferred choice to complete future surveys?

PLEASE SELECT ALL THAT APPLY

Convenience
Faster time
Other, please specify________
Don’t know
Prefer not to answer

Screen Name	MODESEL_R
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Radio Buttons: 1 Convenience 2 Faster time 3 Other, please specify_________(MODESEL_RS) 9 Don’t know 7 Prefer not to answer
Skip Pattern(s)	<7, BLANK> go to [CLOSING]; else go to CONTACT
Help Text	None
Edits/Errors	If left blank, display: Please select the response option that best describes your answer.
Special Instructions	Allow multiple responses. For “Other, please specify” response, include write-in field that allows alpha characters and the following special characters: period (.), apostrophe (‘), quote (“), and dash (-). If Don’t know or Refused selected, clear answer choices 1-3. 150 characters max.

Please provide phone number, e-mail and address information where you can be reached.

ENTER RESPONSES…

Daytime phone number ________________ ___

Evening phone number ____________________

E-mail address ____________________________

Verify e-mail ______________________________

Address number/street ____________________

City/town ________________________________

State select from drop-down list

Zipcode ___________________________________

Screen Name	CONTACT
Pre-loaded Data	None
Question Wording	See sample image.
Response Options	Write in fields for daytime phone number, evening phone number, email address, verify email address, address number/street. City/town and zipcode. Drop down of valid states: AL, AK, AZ, AR, CA, CO, CT, DE, DC, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, MT, NE, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VT, VA, WA, WV, WI, WY
Skip Pattern(s)	Go to [CLOSING]
Help Text	None
Edits/Errors	If left blank, display: Please tell us how you can be reached in case we need to verify your answers or want to get in touch with you about future surveys. IF E-mail address NE Verify e-mail, display: Please verify e-mail address. If Email-address or Verify email-mail does not contain an @ sign, display: Please verify e-mail address.
Special Instructions	Write-in fields; Allow any of these to be left blank For phone, allow only numeric characters and pre-format field as XXX-XXX-XXXX. Allow 10 characters. For email and verify email, allow alphanumeric and special characters; must contain @ sign. Allow 75 characters. Verify that entry in 'E-mail address' matches the ‘'Verify e-mail address'. If "E-mail address" and "Verify e-mail" fields do not match, display "Please verify e-mail address." For address fields, allow alphanumeric and period (.), apostrophe (‘), quote (“) and dash (-). Allow 50 characters. For city allow 50 characters. For State allow 2 characters. For zip code, only allow 5 characters.

Those are all the questions [IF interviewer: “I”/ IF respondent: “we”] have. [IF interviewer: “I would”/IF respondent: “We would”] like to thank you on behalf of the CDC’s National Center for Health Statistics for the time and effort you’ve spent answering these questions. [IF interviewer: If you have any questions about this survey, you may call my supervisor toll-free at 1-888-369-3598.] If you have questions about your rights as a survey participant, you may call the chairperson of the NCHS Research Ethics Review Board at 1-800-223-8118 and say you are calling about protocol 2009-16. Thank you again.

Screen Name	CLOSING
Pre-loaded Data	None
Question Wording	See sample image.
Response Options
Skip Pattern(s)	Go To Main Menu
Help Text	None
Edits/Errors
Special Instructions	Submit Interview - Set IS_SUBMITTED = 1

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Stephanie Kukich
File Modified	0000-00-00
File Created	2021-01-28