37.6 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

60M Questionnaire –Adult, Phase 2g

OMB Specification

60M Questionnaire - Adult

Event Category:	Time-Based
Event:	60M
Administration:	N/A
Instrument Target:	Primary Caregiver
Instrument Respondent:	Primary Caregiver
Domain:	Questionnaire
Document Category:	Questionnaire
Method:	Data Collector Administered
Mode (for this instrument*):	In-Person, CAI; Phone, CAI
OMB Approved Modes:	In-Person, CAI; Phone, CAI; Web-Based, CAI
Estimated Administration Time:	2 minutes
Multiple Child/Sibling Consideration:	Per Event
Special Considerations:	N/A
Version:	1.0
MDES Release:	4.0

*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

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60M Questionnaire - Adult

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS 3

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60M Questionnaire - Adult

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS

(TIME_STAMP_HCA_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) AND RESPONDENT ID (R_P_ID?) FOR ADULT CAREGIVER.

HCA01000. Next, I’d like to ask some questions about your race and ethnicity.

HCA02000/(ETHNIC_ORIGIN). Are you of Hispanic, Latino/a or Spanish origin?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF ETHNIC_ORIGIN = 1, TO TO ETHNIC_ORIGIN_2.

• IF ETHNIC_ORIGIN ≠ 1 AND
  
  

• IF MODE = CAPI, GO TO RACE_NEW.

• IF MODE = CATI, GO TO RACE_1.

HCA03000/(ETHNIC_ORIGIN_2). Are you one or more of the following?

INTERVIEWER INSTRUCTIONS

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

Label	Code	Go To
Mexican, Mexican American, Chicano/a	1
Puerto Rican	2
Cuban	3
Another Hispanic, Latino/a, or Spanish origin	4
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF ETHNIC_ORIGIN_2 = -5, OR ANY COMBINATION OF 1 THROUGH 4 AND -5, GO TO ETHNIC_ORIGIN_2_OTH.

• IF ETHNIC_ORIGIN_2 = ANY COMBINATION OF 1 THROUGH 4, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING ETHNIC_ORIGIN_2_OTH.

• IF ETHNIC_ORIGIN_2 = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PROGRAMMER INSTRUCTIONS FOLLOWING ETHNIC_ORIGIN_2_OTH.

HCA04000/(ETHNIC_ORIGIN_2_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF MODE = CAPI, GO TO RACE_NEW.

• OTHERWISE, IF MODE = CATI, GO TO RACE_1. 

HCA05000/(RACE_NEW). What is your race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• SELECT ALL THAT APPLY.

• CODE “SOME OTHER RACE” ONLY IF VOLUNTEERED.

• PROBE: Anything else?

Label	Code	Go To
WHITE	1
BLACK OR AFRICAN AMERICAN	2
AMERICAN INDIAN OR ALASKA NATIVE	3
ASIAN INDIAN	4
CHINESE	5
FILIPINO	6
JAPANESE	7
KOREAN	8
VIETNAMESE	9
OTHER ASIAN	10
NATIVE HAWAIIAN	11
GUAMANIAN OR CHAMORRO	12
SAMOAN	13
OTHER PACIFIC ISLANDER	14
SOME OTHER RACE	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF RACE_NEW = ANY COMBINATION OF 1 THROUGH 14, GO TO PARTICIPANT_SEX.

• IF RACE_NEW = -5, OR ANY COMBINATION OF 1 THROUGH 14 AND -5, GO TO RACE_NEW_OTH.

• IF RACE_NEW =  -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PARTICIPANT_SEX.

HCA06000/(RACE_NEW_OTH). SPECIFY: _____________________________ 

Label	Code	Go To
REFUSED	-1	PARTICIPANT_SEX
DON'T KNOW	-2	PARTICIPANT_SEX

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• GO TO PARTICIPANT_SEX.

HCA07000/(RACE_1). What is your race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• ONLY USE  “SOME OTHER RACE” IF VOLUNTEERED.

• SELECT ALL THAT APPLY.

Label	Code	Go To
White	1
Black or African American	2
American Indian or Alaska native	3
Asian	4
Native Hawaiian or other Pacific Islander	5
SOME OTHER RACE	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

IF RACE_1 = ANY COMBINATION OF 1 THROUGH 3, GO TO PARTICIPANT_SEX.
IF RACE_1 = 4 OR ANY COMBINATION OF 4 AND 1, 2, 3, AND/OR 5, GO TO RACE_2.
IF RACE_1 = 5 OR ANY COMBINATION OF 5 AND 1 THROUGH 3, GO TO RACE_3.
IF RACE_1 = -5, OR ANY COMBINATION OF 1 THROUGH 5 AND -5, GO TO RACE_1_OTH.
IF RACE_1 = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PARTICIPANT_SEX.

HCA08000/(RACE_1_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

DATA COLLECTOR INSTRUCTIONS

• IF RACE_1 = 4 OR ANY COMBINATION OF 4 AND 1, 2, 3, AND/OR 5, GO TO RACE_2.

• IF RACE_1 = 5 OR ANY COMBINATION OF 5 AND 1 THROUGH 3, GO TO RACE_3.

• OTHERWISE, GO TO PARTICIPANT_SEX.

HCA09000/(RACE_2). What is your race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY.

Label	Code	Go To
Asian Indian	1
Chinese	2
Filipino	3
Japanese	4
Korean	5
Vietnamese	6
Other Asian	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF RACE_1 = ANY COMBINATION WITH 4 AND 5, GO TO RACE_3.

• OTHERWISE, GO TO PARTICIPANT_SEX

HCA10000/(RACE_3). What is your race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY.

Label	Code	Go To
Native Hawaiian	1
Guamanian or Chamorro	2
Samoan	3
Other Pacific Islander	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

HCA11000/(PARTICIPANT_SEX). WHAT IS THE SEX OF THE PARENT/CAREGIVER?

INTERVIEWER INSTRUCTIONS

• DO NOT ADMINISTER THIS QUESTION TO THE ADULT CAREGIVER.

Label	Code	Go To
MALE	1
FEMALE	2
DON'T KNOW	-2

HCA12000/(ENGLISH_WELL ). How well do you speak English? Would you say…

Label	Code	Go To
Very well	1
Well	2
Not well	3
Not at all	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

HCA13000/(HH_NONENGLISH_NEW). Do you speak a language other than English at home?

Label	Code	Go To
YES	1
NO	2	DIFF_HEAR
REFUSED	-1	DIFF_HEAR
DON'T KNOW	-2	DIFF_HEAR

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

HCA14000/(OTHER_LANG ). What is this language?

Label	Code	Go To
Spanish	1	DIFF_HEAR
Other	-5
REFUSED	-1	DIFF_HEAR
DON'T KNOW	-2	DIFF_HEAR

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

HCA15000/(OTHER_LANG_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

HCA16000/(DIFF_HEAR). Are you deaf or do you have serious difficulty hearing?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

HCA17000/(DIFF_SEE). Are you blind or do you have serious difficulty seeing, even when wearing glasses?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

HCA18000/(DIFF_CONCENTRATE). Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

HCA19000/(DIFF_WALK). Do you have serious difficulty walking or climbing stairs?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

HCA20000/(DIFF_DRESS). Do you have difficulty dressing or bathing?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

HCA21000/(DIFF_ERRAND). Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

(TIME_STAMP_HCA_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 2 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.