Nhcis

*These specifications will be programmed into Centurion to create one seamless data collection instrument to accommodate both modes
(Web and CATI). Respondents cannot have access to both versions at the same time (e.g., the online version if the telephone interview is
also occurring simultaneously in real time).

Attachment 3f NHCIS Multi-Mode Study (10 minutes)
Form approved

OMB No. 0920-0214
Approval Expires 08/31/2014

2013 National Health Interview Survey Follow-Back Survey on the
Affordable Care Act
Web and CATI Instrument Specifications*
Sponsored by the National Center for Health Statistics,
Centers for Disease Control and Prevention
Conducted by the United States Census Bureau
Questionnaire Version (5.7): January15, 2013
SECTION 1:
SECTION 2:
SECTION 3:
SECTION 4:
SECTION 5:
SECTION 6:
SECTION 7:
SECTION 8:
SECTION 9:
SECTION 10:
SECTION 11:
SECTION 12:

LOCATE ELIGIBLE 2012 NHIS SAMPLE ADULT RESPONDENT…………….
CONFIRM IDENTITY OF ELIGIBLE RESPONDENT…………………………...
INFORMED CONSENT………………….................................................................
FINANCIAL BURDEN OF MEDICAL CARE……..................................................
HEALTH STATUS…………………………………….............................................
ACCESS & UTILIZATION OF HEALTH CARE.....................................................
HEALTH INSURANCE.............................................................................................
PREVENTIVE SERVICES........................................................................................
FAMILY FOOD SECURITY…….............................................................................
SMOKING..................................................................................................................
MARITAL & EMPLOYMENT STATUS…..............................................................
CONTACT INFORMATION.....................................................................................

CALLBACK & ANSWERING MACHINE SCRIPTS.......................................................................

The following public burden estimate statement must available as a CATI and Web screen.
Assurance of Confidentiality (NOTICE): Information collected on this form which would permit identification of any individual or
establishment has been collected with a guarantee that it will be held in strict confidence and will only be used for statistical purposes
by employees or agents of NCHS. No information that would identify an individual or establishment will be disclosed or released to
others without the consent of the individual or 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 (44 USC 3501 note). 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.
Congress authorized the NHIS data collection in Section 306 of the Public Health Service Act (42 USC 242m(d)). Public reporting
burden of this collection of information is estimated to average about 15-20 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-24, Atlanta, GA 30333.
Data collection conducted under contract to the CDC by the United States Census Bureau.

TEXT FORMAT KEY
Yellow highlighted text:

Help screen text

Blue highlighted text:

Update or pre-fill with pertinent variable name, information, or data from
the 2012 NHIS.

[TEXT IN ALL CAPS & BRACKETS]: Programmer instructions for the 2013 Follow-Back Survey, or text fills.

Text in Italics

Information or examples that telephone interviewers need to read to 2013
Follow-Back CATI respondents. For web respondents, this text will
appear on the screen to read him/herself.

TEXT IN ALL CAPS & ITALICS:

Instructions to interviewers or response options that should not be read,
only selected if applicable

PRELOADED DATA FROM 2012 NHIS VARIABLES TO USE IN THE 2013 FOLLOW-BACK SURVEY:
2012 NHIS VARIABLE
NAME

2012 NHIS VARIABLE
NAME DESCRIPTION
Interview month
Interview year
Sample adult name (F, M, L)
Sample adult age and DOB
Sample adult sex
Household roster (names,
DOB, sex)

1

VARIABLE
TYPE

# OF CHARACTERS

SECTION 1:
Locate Eligible 2012 NHIS Sample Adult Respondent

[IF THIS IS AN INTERVIEWER-INITIATED FIRST CALL OR FOLLOW-UP CALL WITHOUT AN
APPOINTMENT, GO TO INTRO_A;
IF THIS IS AN INTERVIEWER-INITIATED FOLLOW-UP CALL WITH APPOINTMENT, GO TO
INTRO_B;
IF THIS IS A RESPONDENT-INITIATED CALL TO TOLL-FREE NUMBER IN RESPONSE TO
ADVANCE MAILING, EMAIL OR VOICE MAIL, GO TO ANSWER_C]

Scenario A: Interviewer-initiated first call or follow-up call without appointment
INTRO_A

IF AT ANY TIME THE PERSON WHO PICKS UP THE PHONE ASKS WHY WE’RE LOOKING
FOR THE PERSON WITH AT NAME OR THOSE CHARACTERISTICS, RESPOND WITH:
“We’re conducting a survey on health care cost and utilization among people who share the
same or similar characteristics, such as age or gender.”
DO NOT, UNDER ANY CIRCUMSTANCES, INDICATE IN ANY WAY THAT SOMEONE IN
THAT HOUSEHOLD, INCLUDING THE SA, PREVIOUSLY PARTICIPATED IN THE NHIS.
Hello, my name is _________________. I’m calling on behalf of the CDC's National Center for
Health Statistics or N-C-H-S.
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS, GENDER, AND AGE ARE
KNOWN: “May I please speak to the [FEMALE/MALE] whose [NAME IS/INITIALS ARE]
_____ and who is about [ESTIMATED AGE] years old?”]
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS AND AGE ARE KNOWN: “May I
please speak to the person whose [NAME IS/INITIALS ARE] _____ and who is about
[ESTIMATED AGE] years old?”]
[IF ONLY THE 2012 SAMPLE ADULT’S NAME OR INITIALS ARE KNOWN: “May I
please speak to [NAME/“a person whose initials are ____"]?”]
[IF ONLY THE 2012 SAMPLE ADULT’S GENDER AND AGE ARE KNOWN: “May I please
speak to the [MALE/FEMALE] adult who is about [ESTIMATED AGE] years old?”]
[IF ONLY GENDER IS KNOWN: “How many [MALES/FEMALES] live in your household?”
IF ONLY ONE PERSON OF THE SAMPLE ADULT GENDER, SAY: “May I please speak to
[HIM/HER]?”]
[IF ONLY AGE IS KNOWN: “Does someone live in your household who is about
[ESTIMATED AGE] years old?” IF YES, SAY: “Is there anyone else of that age in your
household?” IF ONLY ONE PERSON OF APPROXIMATE SAMPLE ADULT AGE, SAY:
“May I please speak to the person who is about [ESTIMATED AGE] years old?”]
1
I AM THAT PERSON
Skip Instructions: go to [PHONE]
2

2
YES, LET ME GET HIM OR HER
Skip Instructions: go to [INTRO_A]
3
LET ME GO GET AN ADULT
Skip Instructions: go to [INTRO_A]
4
NO, THAT PERSON HAS MOVED OR HAS A NEW PHONE NUMBER
Skip Instructions: go to [LOC_A]
5
NO, THAT PERSON HAS DIED
Skip Instructions: go to [DECEASED]
6
AM/VM INDICATES BUSINESS
Skip Instructions: go to [SALZ_BUS]
7

HUDI (HANG UP DURING INTRODUCTION)

8
RESPONDENT WANTS A COPY OF THE ADVANCE LETTER MAILED
Skip Instructions: go to [M1_NAME]
9

RESPONDENT SAYS THEY WILL CALL TOLL-FREE LINE AFTER
REVIEWING THE SURVEY WEBSITE OR ADVANCE LETTER
Skip Instructions: go to [EXIT]
10
RESPONDENT SAYS TO CALL BACK AT A LATER TIME
Skip Instructions: go to [CALBK]
11
RESPONDENT INDICATES THIS IS A BUSINESS LINE
Skip Instructions: go to [SALZ_BUS]
12
PERSON ON THE PHONE SAYS SAMPLE ADULT IS INCAPABLE
Skip Instructions: go to [DIFF_Q]
97
REFUSED
Skip Instructions: go to [UNKNOWN]
99
DON’T KNOW
Skip Instructions: go to [UNKNOWN]

Scenario B: Interviewer-initiated follow-up call with appointment
INTRO_B

IF AT ANY TIME THE PERSON WHO PICKS UP THE PHONE ASKS WHY WE’RE LOOKING
FOR THE PERSON WITH AT NAME OR THOSE CHARACTERISTICS, RESPOND WITH:
“We’re conducting a survey on health care cost and utilization among people who share the
same or similar characteristics, such as age or gender.”
DO NOT, UNDER ANY CIRCUMSTANCES, INDICATE IN ANY WAY THAT SOMEONE IN
THAT HOUSEHOLD, INCLUDING THE SA, PREVIOUSLY PARTICIPATED IN THE NHIS.

3

Hello, my name is _________________. I’m calling on behalf of the CDC's National Center for
Health Statistics. We spoke with someone at this phone number earlier [TODAY/THIS
WEEK/THIS MONTH] who asked us to call back at this time.
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS, GENDER, AND AGE ARE
KNOWN: “Is the [FEMALE/MALE] whose [NAME IS/INITIALS ARE] ______, and who is
about [ESTIMATED AGE] years old available?”]
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS AND AGE ARE KNOWN: “Is the
person whose [NAME IS/INITIALS ARE] ______ and who is about [ESTIMATED AGE] years
old available?”]
[IF ONLY THE 2012 SAMPLE ADULT’S NAME OR INITIALS ARE KNOWN: “Is [NAME/a
person whose initials are ______] available?”]
[IF ONLY THE 2012 SAMPLE ADULT’S GENDER AND AGE ARE KNOWN: “Is the
[MALE/FEMALE] adult who is about [ESTIMATED AGE] years old available?”]
[IF ONLY AGE IS KNOWN: “Is an adult who is about [ESTIMATED AGE] years old
available?”]
[IF GENDER IS KNOWN: “Is a [MALE/FEMALE] adult available?”]
[IF NO INFORMATION IS KNOWN: “Is the person I previously spoke to available?”]
1
I AM THAT PERSON
Skip Instructions: go to [PHONE]
2
YES, LET ME GET HIM OR HER
Skip Instructions: go to [INTRO_A]
3
LET ME GO GET AN ADULT
Skip Instructions: go to [INTRO_A]
4
NO, THAT PERSON HAS MOVED OR HAS A NEW PHONE NUMBER
Skip Instructions: go to [LOC_A]
5
NO, THAT PERSON HAS DIED
Skip Instructions: go to [DECEASED]
6
AM/VM INDICATES BUSINESS
Skip Instructions: go to [SALZ_BUS]
7

HUDI (HANG UP DURING INTRODUCTION)

8
RESPONDENT WANTS A COPY OF THE ADVANCE LETTER MAILED
Skip Instructions: go to [M1_NAME]
9

RESPONDENT SAYS THEY WILL CALL TOLL-FREE LINE AFTER
REVIEWING THE SURVEY WEBSITE OR ADVANCE LETTER
Skip Instructions: go to [EXIT]
4

10
RESPONDENT SAYS TO CALL BACK AT A LATER TIME
Skip Instructions: go to [CALBK]
11
RESPONDENT INDICATES THIS IS A BUSINESS LINE
Skip Instructions: go to [SALZ_BUS]
12
PERSON ON THE PHONE SAYS SAMPLE ADULT IS INCAPABLE
Skip Instructions: go to [DIFF_Q]
97
REFUSED
Skip Instructions: go to [UNKNOWN]
99
DON’T KNOW
Skip Instructions: go to [UNKNOWN]

Scenario C: Respondent-initiated call to toll-free number in response to advance mailing, email or voice
mail
ANSWER_C

ANSWER THE PHONE AND SAY THE FOLLOWING OR SIMILAR:
Hello, this is the call center for the CDC's National Center for Health Statistics.my
name is _________________. How may I assist you?
AFTER RESPONDENT INDICATES HE OR SHE IS CALLING ABOUT THE
FOLLOW-BACK SURVEY, SAY:
Thank you for your interest in the survey and for taking the time to call us to
participate. Let me first collect some basic information from you.

FNAME_C

What is your first name?
____________________ENTER NAME
97
REFUSED
99
DON’T KNOW

MNAME_C

What is your middle name or initial?
____________________ENTER MIDDLE NAME OR INITIAL
97
REFUSED
99
DON’T KNOW

LNAME_C

What is your last name?
____________________ ENTER LAST NAME
97
REFUSED
99
DON’T KNOW

TITLE_C

What is your title?
____________________ ENTER TITLE
97
REFUSED
99
DON’T KNOW
5

DOB_C

What is your date of birth?
[IF MONTH_C OR DAY_C OR YEAR_C IN (97, 99, 997, 9999):
It is critical that we know your [MONTH/DAY/YEAR] of birth.

MONTH_C

ENTER MONTH
__
[VALID RANGE: 1 THROUGH 12]
97
REFUSED
99
DON’T KNOW
[ADD RANGE CHECK]

DAY_C

ENTER DAY
__
[VALID RANGE: 1 THROUGH 31]
97
REFUSED
99
DON’T KNOW
[ADD RANGE CHECK; ALLOW FOR EXTRA DAY IN LEAP YEARS]

YEAR_C

ENTER YEAR
____ [VALID RANGE: 1900 THROUGH 2000]
9997 REFUSED
9999 DON’T KNOW
[ADD RANGE CHECK]

AGE_YR

What is your age?
___
ENTER AGE [VALID RANGE: 018 THROUGH 125]
997
REFUSED
999
DON’T KNOW
[ADD RANGE CHECK]

SEX_C

Are you male or female?
1
MALE
2
FEMALE
7
REFUSED
9
DON’T KNOW

ROSTER_C

[COMPUTER DISPLAYS HOUSEHOLD ROSTER FROM 2012 NHIS;
INCLUDE NAMES, ALIASES, GENDER, AGE, DOB FOR ALL HH MEMBERS;
OFFSET SAMPLE ADULT INFORMATION AT TOP OF LIST, IN ALL CAPS]
COMPARE RESPONDENT INFORMATION TO HOUSEHOLD ROSTER
1

RESPONDENT DEMOGRAPHICS MATCH UP WITH THOSE OF THE
SA
Skip Instructions: go to [V0]
6

2

DEMOGRAPHICS MATCH UP WITH SOMEONE ELSE IN THE SA’S
HOUSEHOLD
Skip Instructions: go to [INTRO_C]
3

DEMOGRAPHICS DO NOT MATCH UP WITH ANYONE IN THE
HOUSEHOLD
Skip Instructions: go to [IN_EXIT]

INTRO_C

IF AT ANY TIME THE PERSON WHO PICKS UP THE PHONE ASKS WHY WE’RE LOOKING
FOR THE PERSON WITH AT NAME OR THOSE CHARACTERISTICS, RESPOND WITH:
“We’re conducting a survey on health care cost and utilization among people who share the
same or similar characteristics, such as age or gender.”
DO NOT, UNDER ANY CIRCUMSTANCES, INDICATE IN ANY WAY THAT SOMEONE IN
THAT HOUSEHOLD, INCLUDING THE SA, PREVIOUSLY PARTICIPATED IN THE NHIS.
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS, GENDER, AND AGE ARE
KNOWN: “We are looking for the [FEMALE/MALE] whose [NAME IS/INITIALS ARE]
_____ and who is about [ESTIMATED AGE] years old.” Is [HE/SHE] available?]
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS AND AGE ARE KNOWN: “We are
looking for the person whose [NAME IS/INITIALS ARE] _____ and who is about
[ESTIMATED AGE] years old.” Is [HE/SHE] available?]
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS ARE KNOWN: “We’re looking for
[SAMPLE ADULT NAME]. Is that person available?]”
[IF ONLY THE 2012 SAMPLE ADULT’S GENDER AND AGE ARE KNOWN: “We’re
looking for the [MALE/FEMALE] who is about [ESTIMATED AGE]. Is [HE/SHE] available?”]
[IF ONLY GENDER IS KNOWN AND SA GENDER IS DIFFERENT THAN RESPONDENT
GENDER: “We are looking for the [MALE/FEMALE] adult who lives in your household? “Is
[HE/SHE] available?”]
[IF ONLY GENDER IS KNOWN AND SA GENDER IS THE SAME AS RESPONDENT
GENDER: “We are looking for the other [MALE/FEMALE] adult who lives in your household?
“Is [HE/SHE] available?”]
[IF ONLY AGE IS KNOWN: “We’re looking for the adult who is about [ESTIMATED AGE]
years old. Is that person available?”]
1
I AM THAT PERSON
Skip Instructions: go to [PHONE]
2
YES, LET ME GET HIM OR HER
Skip Instructions: go to [INTRO_A]
3
LET ME GO GET AN ADULT
Skip Instructions: go to [INTRO_A]
7

4
NO, THAT PERSON HAS MOVED OR HAS A NEW PHONE NUMBER
Skip Instructions: go to [LOC_A]
5
NO, THAT PERSON HAS DIED
Skip Instructions: go to [DECEASED]
6
AM/VM INDICATES BUSINESS
Skip Instructions: go to [SALZ_BUS]
7

HUDI (HANG UP DURING INTRODUCTION)

8
RESPONDENT WANTS A COPY OF THE ADVANCE LETTER MAILED
Skip Instructions: go to [M1_NAME]
9

RESPONDENT SAYS THEY WILL CALL TOLL-FREE LINE AFTER
REVIEWING THE SURVEY WEBSITE OR ADVANCE LETTER
Skip Instructions: go to [EXIT]
10
RESPONDENT SAYS TO CALL BACK AT A LATER TIME
Skip Instructions: go to [CALBK]
11
RESPONDENT INDICATES THIS IS A BUSINESS LINE
Skip Instructions: go to [SALZ_BUS]
12
PERSON ON THE PHONE SAYS SAMPLE ADULT IS INCAPABLE
Skip Instructions: go to [DIFF_Q]
97
REFUSED
Skip Instructions: go to [UNKNOWN]
99
DON’T KNOW
Skip Instructions: go to [UNKNOWN]

PHONE

Are you speaking on a landline or cell phone?
1
LANDLINE
2
CELL PHONE
7
REFUSED
9
DON’T KNOW
Skip Instructions: <1> go to [V0]; <2,7,9> go to [DRIVE]

DRIVE

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
1
NO
2
YES
3
R PREFERS DIFFERENT NUMBER
4
WRONG TIME ZONE
Skip Instructions: <1> go to [V0]; <2, 3, 4> go to [CALBK]
8

CALBK

I will call you back at another time. What day and time is convenient for you?
1
Agrees to call back
2
Refuses call back
3
Asks if web survey available
Skip Instructions: <1> go to [CB_DATE]; <2,3> go to [WEB_OFFER]

CB_DATE

ENTER DAY
__
[VALID RANGE: 1 THROUGH 31]
97
REFUSED
99
DON’T KNOW
[ADD RANGE CHECK; ALLOW FOR EXTRA DAY IN LEAP YEARS]
ENTER MONTH
__
[VALID RANGE: 1 THROUGH 12]
97
REFUSED
99
DON’T KNOW
[ADD RANGE CHECK]

CB_TIME

ENTER TIME
__:__ [FORMAT: HH:MM]
97
REFUSED
99
DON’T KNOW

CB_AMPM

ENTER AM OR PM
1
AM
2
PM
7
REFUSED
9
DON’T KNOW

NUMBER

At which number would you like me to call you?
1
SAME NUMBER
[PRE-LOAD NUMBER]
2
DIFFERENT NUMBER; __ RECORD [ADD LINE TO ALLOW RECORDING
OF NEW NUMBER; FORMAT: XXX-XXX-XXXX]
7
REFUSED
9
DON’T KNOW

CELL_TZ

In what time zone are you located?
1
KEEP SAME TIME ZONE
2
ATLANTIC
3
EASTERN STANDARD
4
CENTRAL STANDARD
5
STANDARD MOUNTAIN
6
US STANDARD MOUNTAIN (ARIZONA)
7
PACIFIC STANDARD
8
ALASKAN STANDARD
9
HAWAIIAN STANDARD
9

97
REFUSED
99
DON’T KNOW
Skip Instructions: <1-99> go to [CB_EXIT]

SALZ_BUS

We are interviewing only private residences. Thank you very much. [END CALL]

M1_NAME

TO SEND A LETTER TO THE PERSON ANSWERING THE PHONE SAY:
In order to send you a letter, I will need to collect your name and mailing address. The letter will
contain a toll-free number that you may call to complete the interview at your convenience.
READ IF NECESSARY: If you feel uncomfortable giving me your name, I can send the letter to
"Resident".)
M1_NAME
Name:
M1_Street1
Street1:
M1_Street2
Street2:
M1_City
City:
M1_State
State:
M1_Zip
Zip:
1
Terminate the interview
7
REFUSED
9
DON’T KNOW
Skip Instructions: <1-9> go to [EXIT]

LOC_A

Do you know what their new telephone number is?
1
RESPONDENT CAN PROVIDE A NUMBER
2
NO TELEPHONE
7
REFUSED
9
DON’T KNOW
Skip Instructions: <1> go to [LOC_AA]; <2-9> go to [LOC_F]

LOC_AA

ENTER NUMBER
__
[FORMAT: XXX-XXX-XXXX]
97
DON’T KNOW
88
NONE
97
REFUSED
99
DON’T KNOW

LOC_B

Is that a landline or cell phone number?
1
LANDLINE
2
CELL
7
REFUSED
9
DON’T KNOW

LOC_C

Does this person have any other number where they might be reached?
1
YES
10

2
NO
7
REFUSED
9
DON’T KNOW
Skip Instructions: <1> go to [LOC_D]; <2-9> go to [LOC_F]

LOC_D

What is that telephone number?
__
ENTER NUMBER [FORMAT: XXX-XXX-XXXX]
88
NONE
97
REFUSED
99
DON’T KNOW
Skip Instructions: <97-99> go to [LOC_F]; else go to [LOC_E]

LOC_E

Is that a landline or cellular telephone number?
1
LANDLINE
2
CELL
7
REFUSED
9
DON’T KNOW

LOC_F

What is their name?
__
ENTER VERBATIM RESPONSE [ALLOW UP TO 50 CHARACTERS]
97
REFUSED
99
DON’T KNOW
Skip Instructions: go to [LOC_EXIT]

UNKNOWN Do you know anyone who would be able to tell us how to get in contact with this person?
1
YES
2
NO
7
REFUSED
9
DON’T KNOW
Skip Instructions: <1> go to [INFNAM]; <2-9> go to [EXIT]

INFNAM

What is their name?
__
ENTER VERBATIM RESPONSE [ALLOW UP TO 50 CHARACTERS]
97
REFUSED
99
DON’T KNOW
Skip Instructions: <1-99> go to [INFNUM]

INFNUM

What is [INFNAM/that person’s] number?
__
ENTER NUMBER [FORMAT: XXX-XXX-XXXX]
88
NONE
97
REFUSED
99
DON’T KNOW
Skip Instructions: <97-99> go to [LOC_EXIT]
11

DIFF_Q

What difficulty does [SA NAME] have that prevents [HIM/HER] from participating?
1
Hearing difficulty
2
Speech difficulty
3
Cognitive barrier
4
Physical barrier
7
REFUSED
9
DON’T KNOW
Skip Instructions: <1,2,4,9> go to [WEB_OFFER]; <3, 7> go to [PROXY]

PROXY

Is an adult available who knows about [SA NAME]’s health and healthcare who can answer
questions on [HIS/HER] behalf?
1
YES, CURRENTLY ON PHONE
2
NOT CURRENTLY AVAILABLE [GO TO PROXNAM]
7
REFUSED
9
DON’T KNOW
Skip Instructions: <1> go to [PROXINT]; <2> go to [PROXNAM]; <7,9> go to [EXIT]

PROXINT

Because [SA NAME] cannot be interviewed and you are knowledgeable about [HIS/HER] health
and healthcare, the CDC would like to interview you in [HIS/HER] place. Please keep in mind
that these questions are written to be asked of [SA NAME] directly, so answer the questions as if
they were being asked of [HIM/HER].
1
Agrees to continue
2
Doesn’t have time right now
3
Refused
Skip Instructions: <1> go to [VSANAME]; <2> go to [CALBK]; <3> go to [EXIT]

PROXNAM

What is their name?
__
ENTER VERBATIM RESPONSE [ALLOW UP TO 50 CHARACTERS]
97
REFUSED
99
DON’T KNOW
Skip Instructions: <1-99> go to [PROXNUM]

PROXNUM

What is [INFNAM/that person’s] number?
__
ENTER NUMBER [FORMAT: XXX-XXX-XXXX]
88
NONE
97
REFUSED
99
DON’T KNOW
Skip Instructions: <97-99> go to [LOC_EXIT]

WEB_OFFER We have a web-based survey available. [WOULD YOU LIKE TO / CAN HE/SHE] complete
the survey using the web?
1
YES
2
NO
Skip Instructions: <1> go to [WEB_INST]; [if <2> and SA on the phone] go to [EXIT]; [if <2>
and person other than SA on the phone] go to [PROXY]
12

WEB_INST

We can email or mail a letter to you with directions on completing the survey via web. Which
would you prefer?
1
EMAIL WEB LETTER
2
MAIL WEB LETTER
Skip Instructions: <1> go to [WL_EMAIL]; <2> go to [WL_MAIL]

WL_EMAIL What is [YOUR / HIS/HER] email address? ___________@_______________._______
1
Continue [GO TO WL_EXIT]
7
Refused to give information
Skip Instructions: <1> go to [WL_EXIT]; <7> go to

WL_MAIL

What is [YOUR / HIS/HER] mailing address?
ADDRESS COLLECTION GRID
1
Continue [GO TO WL_EXIT]
7
Refused to give information
Skip Instructions: <1> go to [WL_EXIT]; <7> go to

WL_EXIT

[YOU / HE/SHE] will be receiving 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.
TERMINATE CALL

EXIT

Thank you for your time. Have a nice day. TERMINATE CALL

CB_EXIT

Thank you for your time. We look forward to speaking with you on [CB_DATE] at [CB_TIME]
[CB_AMPM]. TERMINATE CALL

IN_EXIT

Those are all the questions I have. You are not eligible for this survey. I’d 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.
TERMINATE CALL

LOC_EXIT

Thank you for providing this contact information. We will try to contact [HIM/HER]. Thanks for
your time and have a nice day.
TERMINATE CALL THEN SET CALLING RULES TO
• IMMEDIATELY DIAL THE NUMBER ENTERED AT LOC_AA
• THEN TRY THE NUMBER ENTERED AT LOC_D IF LOC_AA IS NOT SUCCESSFUL

DECEASED I’m sorry to hear that. I do not need to continue. Thank you, and please accept my condolences.
Goodbye. TERMINATE CALL
13

SECTION 2:
Confirm Identity of Eligible Respondent
[RESPONDENT SELF-ADMINISTERED WEB INSTRUMENT (RS-AWI) BEGINS HERE]

VSANAME

[DISPLAY PRELOADS AND ALLOW EDITING OF THE DATA IN EACH FIELD
BELOW VSA_TITLE THROUGH VSA_SUFFIX AS NEEDED]
We want to make sure our records are correct. Is your name [PRE-LOADED TITLE,
FIRST NAME, MIDDLE NAME/INITIAL, LAST NAME, SUFFIX]?
1
YES
2
NOT EXACTLY, MAKE CORRECTION [ALLOW EDITS TO PRELOADED FIELDS]
3
NO
7
[PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
VSA_TITLE
Title:
^I_SATITLE
VSA_FNAME
First Name: ^I_SAFNAME
VSA_MNAME
Middle Name: ^I_SAMNAME
VSA_LNAME
Last Name: ^I_SALNAME
VSA_SUFFX
Suffix: ^I_SASUFFIX
Skip Instructions: <1,2, 7,9> go to [VSADOB]; <3> go to [FNAME_V]

VSADOB

What is your date of birth?
[DISPLAY PRELOADS AND ALLOW EDITING OF THE DATA IN EACH FIELD
BELOW VSAMO THROUGH VSAYR AS NEEDED]
9997 [PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
9999 DON’T KNOW
VSAMONTH
Month:
^I_SAMONTH
VSADAY
Day:
^I_SADAY
VSAYR
Year:
^I_SAYEAR
Skip Instructions: go to SEX_C

FNAME_V

What is your first name?
__
ENTER VERBATIM RESPONSE [ALLOW UP TO 50 CHARACTERS]
97
[PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
99
DON’T KNOW

MNAME_V

What is your middle name or initial?
__
ENTER VERBATIM RESPONSE [ALLOW UP TO 50 CHARACTERS]
97
[PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
99
DON’T KNOW

LNAME_V

What is your last name?
__
ENTER VERBATIM RESPONSE [ALLOW UP TO 50 CHARACTERS]
97
[PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
99
DON’T KNOW
14

TITLE_V

What is your title?
__
ENTER VERBATIM RESPONSE [ALLOW UP TO 10 CHARACTERS]
97
[PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
99
DON’T KNOW

DOB_V

What is your date of birth?
[IF MONTH OR DAY OR YEAR IN (97, 99, 997, 9999) ]
It is critical that we know your [MONTH/DAY/YEAR] of birth.
ENTER MONTH
__
[VALID RANGE: 1 THROUGH 12]
97
[PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
99
DON’T KNOW
[ADD RANGE CHECK]

ENTER DAY
__
[VALID RANGE: 1 THROUGH 31]
97
[PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
99
DON’T KNOW
[ADD RANGE CHECK; ALLOW FOR EXTRA DAY IN LEAP YEARS]

ENTER YEAR
____ [VALID RANGE: 1900 THROUGH 2000]
9997 [PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
9999 DON’T KNOW
[ADD RANGE CHECK]

AGE_V

What is your age?
___
[VALID RANGE: 018 THROUGH 125]
997
[PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
999
DON’T KNOW
[ADD RANGE CHECK]

SEX_V

Are you male or female?
1
MALE
2
FEMALE
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

V0

Around [MONTH] of last year, did someone [FILL BASED ON COMPLETION MODE
OF 2012 NHIS: VISIT YOUR HOME AND CONDUCT THE NATIONAL HEALTH
INTERVIEW SURVEY / CONDUCT THE NATIONAL HEALTH INTERVIEW
SURVEY OVER THE TELEPHONE] with you?
15

1

YES
2
7
9

NO
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
DON’T KNOW

16

SECTION 3:
Informed Consent

INTRO_IC

Thank you for completing the National Health Interview Survey last year. As you might recall, at
that time 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.

CONSENT

Before we continue, I'd like you to know that taking part 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. [In appreciation for your time, we will send you [$10/$20]
after you complete the interview.] 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.
1
2

ACCEPT, CONTINUE TO SURVEY
DECLINE, EXIT SURVEY

17

SECTION 4:
Financial Burden of Medical Care
WFQ001

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?
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
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ002

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.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ003

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.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: [<1,2,7,9> and WFQ002=2] go to [WFQ005]; else go to [WFQ004]

WFQ004
1

Do you currently have any medical bills that you are unable to pay at all?
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ005

If you get sick or have an accident, how worried are you that you will be able to pay your
medical bills? Would you say you are very worried, somewhat worried, or not at all worried?
1
VERY WORRIED
2
SOMEWHAT WORRIED
3
NOT AT ALL WORRIED
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
18

9

DON’T KNOW

SECTION 5:
Health Status
WFQ006

Would you say your health in general is excellent, very good, good, fair, or poor?
1
EXCELLENT
2
VERY GOOD
3
GOOD
4
FAIR
5
POOR
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ007

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.
DO NOT READ ANSWER CHOICES—SELECT BASED ON RESPONDENT’S ANSWER; IF
ANSWER UNCLEAR, READ CHOICES
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
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ008

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.
DO NOT READ ANSWER CHOICES—SELECT BASED ON RESPONDENT’S ANSWER; IF
ANSWER UNCLEAR, READ CHOICES
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
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ009

DURING THE PAST 12 MONTHS, were you prescribed medication by a doctor or other health
professional?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
19

9

DON’T KNOW

SECTION 6:
Access and Utilization of Health Care
WFQ010

Is there a place that you USUALLY go to when you are sick or need advice about your health?
1
YES
2
THERE IS NO PLACE
3
THERE IS MORE THAN ONE PLACE
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: <1,3> go to [WFQ011]; else go to [WFQ012]

WFQ011

[IF WFQ010=1: “What kind of 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?”]
DO NOT READ ANSWER CHOICES—SELECT BASED ON RESPONDENT’S ANSWER; IF
ANSWER UNCLEAR, READ CHOICES
1
CLINIC OR HEALTH CENTER
2
DOCTOR'S OFFICE OR HMO
3
HOSPITAL EMERGENCY ROOM
4
HOSPITAL OUTPATIENT DEPARTMENT
5
SOME OTHER PLACE
6
DOESN'T GO TO ONE PLACE MOST OFTEN
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: <6> go to [WFQ012]; else go to [WFQ013]

WFQ012

What is the main reason you do not have a usual source of medical care?
DO NOT READ ANSWER CHOICES—SELECT BASED ON RESPONDENT’S ANSWER; IF
ANSWER UNCLEAR, READ CHOICES
01
DOESN'T NEED A DOCTOR/HAVEN'T HAD ANY PROBLEMS
02
DOESN'T LIKE/TRUST/BELIEVE IN DOCTORS
03
DOESN'T KNOW WHERE TO GO
04
PREVIOUS DOCTOR IS NOT AVAILABLE/MOVED
05
TOO EXPENSIVE/NO INSURANCE/COST
06
SPEAK A DIFFERENT LANGUAGE
07
NO CARE AVAILABLE/CARE TOO FAR AWAY, NOT CONVENIENT
08
PUT IT OFF/DIDN'T GET AROUND TO IT
09
OTHER
97
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99
DON’T KNOW
Skip Instructions: <01-99> go to [WFQ025]

WFQ013

IN THE PAST 12 MONTHS, did you visit your usual provider for a check-up or routine care?
20

1
2
7
9

YES
NO
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
DON’T KNOW

WFQ014

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? Would
you say never, sometimes, usually, or always?
1
NEVER
2
SOMETIMES
3
USUALLY
4
ALWAYS
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ015

IN THE PAST 12 MONTHS, how often did this provider explain things in a way that was easy
to understand?
READ IF NECESSARY: Would you say never, sometimes, usually, or always?
1
NEVER
2
SOMETIMES
3
USUALLY
4
ALWAYS
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ016

IN THE PAST 12 MONTHS, how often did this provider listen carefully to you?
READ IF NECESSARY: Would you say never, sometimes, usually, or always?
1
NEVER
2
SOMETIMES
3
USUALLY
4
ALWAYS
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ017

IN THE PAST 12 MONTHS, how often did this provider seem to know the important
information about your medical history?
READ IF NECESSARY: Would you say never, sometimes, usually, or always?
1
NEVER
2
SOMETIMES
3
USUALLY
4
ALWAYS
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ018

IN THE PAST 12 MONTHS, how often did this provider show respect for what you had to say?
READ IF NECESSARY: Would you say never, sometimes, usually, or always?
21

1
2
3
4
7
9

NEVER
SOMETIMES
USUALLY
ALWAYS
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
DON’T KNOW

WFQ019

IN THE PAST 12 MONTHS, how often did this provider spend enough time with you?
READ IF NECESSARY: Would you say never, sometimes, usually, or always?
1
NEVER
2
SOMETIMES
3
USUALLY
4
ALWAYS
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ020

IN THE PAST 12 MONTHS, did this provider order a blood test, x-ray, or other test for you?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: <1> go to [WFQ021]; <2,7,9> go to [WFQ022]

WFQ021

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?
READ IF NECESSARY: Would you say never, sometimes, usually, or always?
1
NEVER
2
SOMETIMES
3
USUALLY
4
ALWAYS
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ022

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 drink alcohol?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ023

At your last routine checkup, were you asked in person or on a form how much you drink?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
22

WFQ024

At your last routine checkup, were you offered advice about what level of drinking is harmful or
risky to your health?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ025

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)?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ026

...A doctor who specializes in women's health (an obstetrician/gynecologist)?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Universe: Female Sample Adults

WFQ027

...An optometrist, ophthalmologist (AHF-thal-MOL-oh-jist), or eye doctor (someone who
prescribes eyeglasses)?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ028

…A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical
social worker?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ029

...A medical doctor who specializes in a particular medical disease or problem (other than
obstetrician/gynecologist, psychiatrist, or ophthalmologist (AHF-thal-MOL-ohjist))?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
23

WFQ030

WFQ031

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?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they did
not accept your health care coverage?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ032

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.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ033

DURING THE PAST 12 MONTHS, was there any time when you needed medical care but DID
NOT GET IT because you couldn't afford it?
Please do not include dental care in your answer.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ034

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?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ035

DURING THE PAST 12 MONTHS, was there any time you needed to see a specialist for care
but did not get the care because you couldn’t afford it?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

24

WFQ036

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?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ037

DURING THE PAST 12 MONTHS, are any of the following true for you?
…You skipped medication doses to save money.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ038

READ IF NECESSARY: DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You took less medicine to save money.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ039

READ IF NECESSARY: DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You delayed filling a prescription to save money.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ040

READ IF NECESSARY: DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You asked your doctor for a lower cost medication to save money.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ041

READ IF NECESSARY: DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You bought prescription drugs from another country to save money.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
25

WFQ042

READ IF NECESSARY: DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You used alternative therapies to save money.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

SECTION 7:
Health Insurance
WFQ043

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. Do you have…
SELECT ALL THAT APPLY.
01
Private health insurance
02
Medicare
03
Medi-Gap
04
Medicaid
05
Military health care (Tricare/Va/Champ-Va)
06
Indian Health Service
07
Other type of health plan
08
Single service plan (e.g., dental, vision, prescriptions)
09
No coverage of any type
97
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99
DON’T KNOW
Skip Instructions: if response contains <1,3> go to [WFQ045]; if response contains <7> go to
[WFQ044]; if response contains <9> go to [WFQ047]; else go to [WQF046]

WFQ044

What is the name of your plan?
Name of plan: __________________________________

WFQ045

Which one of these categories best describes how this plan was obtained?
01
Through employer, union, or professional association
02
Purchased directly
03
Through school
04
Through a parent
05
Through a state/local government or community program
06
Other
97
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99
DON’T KNOW
26

WFQ046

IN THE PAST 12 MONTHS, was there any time when you did NOT have ANY health
insurance or coverage?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: <1> go to [WFQ047]; <2,7,9> go to [WFQ048]

WFQ047

IN THE PAST 12 MONTHS, about how many months were you without coverage?
0
LESS THAN ONE MONTH
1-12 1-12 MONTHS WITHOUT COVERAGE
97
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99
DON’T KNOW

WFQ048

In regard to your health insurance or health care coverage, how does it compare to a year ago? Is
it better, worse, or about the same?
1
BETTER
2
WORSE
3
ABOUT THE SAME
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ049

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. Would
you say very confident, somewhat confident, not to confident, not confident at all?
1
VERY CONFIDENT
2
SOMEWHAT CONFIDENT
3
NOT TOO CONFIDENT
4
NOT CONFIDENT AT ALL
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ050-A

A health insurance premium is…
1
WHAT A PERSON PAYS WHEN THEY GO TO A MEDICAL APPOINTMENT
2
WHAT A PERSON PAYS AFTER INSURANCE PAYS FOR PART OF THE COST
OF MEDICAL SERVICES
3
WHAT A PERSON PAYS EACH MONTH TO HAVE HEALTH INSURANCE
4
THE BEST INSURANCE A HEALTH INSURANCE COMPANY OFFERS
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ050-B

If a health insurance premium is subsidized based on income, that means that…
1
THE PREMIUM AMOUNT DEPENDS ON THE TYPE OF MEDICAL SERVICES
RECEIVED
27

2
THE PREMIUM AMOUNT DEPENDS ON THE FAMILY’S INCOME, THAT IS,
THE INCOME OF EVERYONE IN THE FAMILY THAT USES THE INSURANCE
3
THE PREMIUM AMOUNT DEPENDS ON HOW HEALTHY THE FAMILY IS
4
THE PREMIUM AMOUNT DEPENDS ON WHAT TYPE OF INSURANCE PLAN
I BUY
5
THE PREMIUM AMOUNT DEPENDS ON THE INCOME OF THE HEALTH
INSURANCE COMPANY
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ050-C

Have you heard of the Health Insurance Marketplace?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ050-D

Have you heard of health insurance exchanges?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ050-D

DURING THE PAST 3 MONTHS, did you look into purchasing health insurance
through an exchange set up by your state?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

SECTION 8:
Preventive Services
WFQ051

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?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ052

DURING THE PAST 12 MONTHS, has a doctor or other health professional talked to you about
your diet?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
28

9

DON’T KNOW

WFQ053

DURING THE PAST 12 MONTHS, have you had your blood pressure checked by a doctor,
nurse, or other health professional?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ054

DURING THE PAST 12 MONTHS, have you had your blood cholesterol checked by a doctor,
nurse, or other health professional?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ055

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.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Universe: Female Sample Adults

WFQ056

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.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Universe: Female Sample Adults

WFQ057

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.
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

29

WFQ058

Have you had a fasting test for high blood sugar or diabetes DURING THE PAST 12
MONTHS?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

SECTION 9:
Family Food Security
WFQ059

These next questions are about whether you were always able to afford the food you needed in
the last 30 days. Below 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?
1
OFTEN TRUE
2
SOMETIMES TRUE
3
NEVER TRUE
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ060

"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?
1
OFTEN TRUE
2
SOMETIMES TRUE
3
NEVER TRUE
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ061

"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?
1
OFTEN TRUE
2
SOMETIMES TRUE
3
NEVER TRUE
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: <1,2> or [<3,D,R> and [WFQ059 in <1,2> or WFQ060 in <1,2>]] go to
[WFQ062]; else go to [WFQ069]

WFQ062

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?
30

1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: <1> go to [WFQ063]; else go to [WFQ064]

WFQ063

IN THE LAST 30 DAYS, how many days did this happen?
Number of days: _____ [SELECT FROM DROP-DOWN LIST]

WFQ064

IN THE LAST 30 DAYS, did you ever eat less than you felt you should because there wasn't
enough money for food?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ065

IN THE LAST 30 DAYS, were you ever hungry but didn't eat because there wasn't enough
money for food?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ066

IN THE LAST 30 DAYS, did you lose weight because there wasn't enough money for food?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: <1> or [<2,R,D> and [WFQ062 or WFQ064 or WFQ065=<1>]] go to
[WFQ067]; else go to [WFQ069]

WFQ067

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?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: <1> go to [WFQ068]; else go to [WFQ069]

WFQ068

IN THE LAST 30 DAYS, how many days did this happen?
Number of days: _____ [SELECT FROM DROP-DOWN LIST]

SECTION 10:
31

Smoking
WFQ069

These next few questions are about cigarette smoking. Have you smoked at least 100 cigarettes
in your ENTIRE LIFE?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: <1> go to [WFQ070]; else go to [WFQ073]

WFQ070

Do you NOW smoke cigarettes every day, some days or not at all?
1
Every day
2
Some days
3
Not at all
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: <1,2,3> go to [WFQ071]; else go to [WFQ073]

WFQ071

DURING THE PAST 12 MONTHS, have you stopped smoking for more than one day
BECAUSE YOU WERE TRYING TO QUIT SMOKING?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ072

DURING THE PAST 12 MONTHS, has a doctor or other health professional talked to you about
your smoking?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

SECTION 11:
Marital & Employment Status
WFQ073

We’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?
__
ENTER NUMBER OF PEOPLE
97
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99
DON’T KNOW

WFQ074

How many children under age 18 currently live in your household?
__
ENTER NUMBER OF CHILDREN UNDER 18
32

97
99

[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
DON’T KNOW

WFQ075

Are you now married, widowed, divorced, separated, never married, or living with a partner?
1
MARRIED
2
WIDOWED
3
DIVORCED
4
SEPARATED
5
NEVER MARRIED
6
LIVING WITH PARTNER
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ076

Are you currently enrolled in school?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ077

The next few questions are about employment.
DURING THE PAST 12 MONTHS, has there been a change in your employment status?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

WFQ078

Which of the following best describes what you were doing LAST WEEK? Were you…
1
Employed (select this option if you held a job but were on vacation or any type of
short-term, temporary leave)
2
Unemployed
3
Retired (from any job; 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.)
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: <1,4> go to [WFQ080]; <2> go to [WFQ081]; <3> go to [WFQ079]; else go
to [WFQ082]

WFQ079

Are you working for pay more than 1 hour per week during your retirement?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: <1> go to [WFQ080]; else go to [WFQ082]
33

WFQ080

Approximately how many hours do you usually work per week?
__
NUMBER OF HOURS [SELECT FROM DROP-DOWN LIST]
97
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99
DON’T KNOW
Skip Instructions: go to [WFQ082]

WFQ081

Are you currently looking for work?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions: go to [ADVNOT]

WFQ082

DURING THE PAST 12 MONTHS, have you had a period of unemployment?
1
YES
2
NO
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

SECTION 12:
Contact Information
ADVNOT

Thank you. We’re almost finished.
Do you remember seeing an email or advance letter notifying you about this survey?
IF RESPONDENT SAYS ONLY “YES” ASK ABOUT EACH ONE SEPARATELY.
1
YES, EMAIL
2
YES, ADVANCE LETTER
3
YES, BOTH EMAIL AND LETTER
4
NO
5
OTHER, ___________________ ENTER RESPONSE
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW
Skip Instructions:
PHONE CATI: go to [PHONEDEV]
RS-AWI: go to [WEBDEV]

PHONDEV

Did you complete this survey on a landline or cell phone?
1
LANDLINE
2
CELL PHONE
7
REFUSED
9
DON’T KNOW
34

Skip Instructions: go to [RECONT]

WEBDEV

On what kind of device did you complete this survey?
1
Computer (e.g., PC or Mac desktop or laptop)
2
Smartphone
3
Tablet
4
Other, please specify ____________________ ENTER RESPONSE

RECONT

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…
1
A questionnaire sent in the mail
2
An email with a link to an internet questionnaire that you can fill out on the online
3
A telephone interview
4
Something else ________________ ENTER RESPONSE
5
No preference
7
[PHONE CATI: REFUSED/DOES NOT WANT TO PARTICIPATE IN THE
FUTURE / RS-AWI: “PREFER NOT TO PARTICIPATE IN FUTURE
SURVEYS”]
9
DON’T KNOW
Skip Instructions: <7> go to [CLOSING]; <5, 9> go to [CONTACT]; else go to [MODESEL]

MODESEL

What makes this your preferred choice to complete future surveys?.
[IF RS-AWI, DISPLAY ONLY ANSWER CHOICES 1-3. IF PHONE CATI, DISPLAY ALL
ANSWER CHOICES IN ALL CAPS AND ITALICS]
1
Convenience
2
Faster time
3
Other, please specify ________________________
4
DOESN’T HAVE INTERNET ACCESS
5
DOESN’T USE/FEEL COMFORTABLE USING COMPUTERS
7
[PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9
DON’T KNOW

CONTACT

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
ZIP CODE _________

35

CLOSING

Those are all the questions [IF PHONE CATI: “I” / IF RS-AWI: “we”] have. [IF PHONE CATI:
“I would” / IF RS-AWI: “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 you have
any questions about this survey, you may call my supervisor toll-free at [NUMBER]. 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
XXXX-XX. Thank you again.

36

CALLBACK & ANSWERING MACHINE SCRIPTS
NO CONTACT YET:
Hello. I’m calling on behalf of the CDC’s National Center for Health Statistics. We are conducting a survey on
health, the health care system, and insurance. Should you be eligible to participate, we will send you $10 after
you complete the interview in appreciation for your time. If you would like to participate right away, please
call our toll-free number, at [NUMBER]. Thank you.

RE-CONTACT WITH ELIGIBLE SA (NO APPOINTMENT):
Hello. I am calling on behalf of the CDC’s National Center for Health Statistics regarding a survey about health,
the health care system, and insurance. When we spoke previously about this important study, you requested
that we call you back. I'm sorry that we've missed you. We'll try to contact you again soon but please feel free to
return our call anytime at [NUMBER]. In appreciation for your time, we will send you $10 after you complete
the interview. Thank you.

SCHEDULED INTERVIEW APPOINTMENTS:
Hello. I am calling on behalf of the CDC’s National Center for Health Statistics regarding a survey about health,
the health care system, and insurance. When we spoke previously about this important study, you requested
that we call you back at this time. I'm sorry that we've missed you. We'll try to contact you again soon but
please feel free to return our call anytime at [NUMBER]. In appreciation for your time, we will send you $10
after you complete the interview. Thank you.

37