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pdfPublic reporting burden for this collection of information is estimated to average 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: NIH, Project
Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0584). Do not return the
completed form to this address.
OMB#: 0925-0584
Exp. xx/xx/xxxx
HCHS/SOL Follow-up Interview Form
Contact Year 7 through 11
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
Contact
Occasion
SEQ #
0
1
ADMINISTRATIVE INFORMATION
0a. Completion Date:
/
/
0b. Staff ID:
Instructions: See the detailed QxQ instructions for completion of the Annual Follow-up form.
INTRODUCTION
Hello, my name is (interviewer name), and I am calling to follow up with (participant name) about the Hispanic
Community Health Study / Study of Latinos (SOL), a health study in which s/he is currently enrolled. Is s/he
available?
No
When would it be convenient to call back? ........ Thank you. I will call again.
Yes
Hello, (participant name), this is (interviewer name) with the Hispanic Community Health Study /
Study of Latinos (SOL). I’m calling to see how you have been since your last telephone interview
and to update our SOL records. Do you have a few minutes to speak on the phone?
No
When would it be convenient to call back? ..... Thank you. I will call again.
Yes We’d like to gather information about your general health and about specific medical conditions that
you may have had in the past year. I will ask you some questions about your health since the last
telephone interview with you on (date of last follow-up call). I want you to focus on what happened
from (date of last follow-up call) until today.
A. [GHE section for data entry screens begins here]
1. Participant status (choose one):
Participant contacted and alive, agrees to interview 1
Go to Question 2
Participant contacted and refused interview
2
Go to Contact tracking, Question 49
Designated respondent contacted, reported alive
3
Go to Hospitalizations, Question 3
Other respondent contacted, reported alive
4
Go to Contact tracking, Question 49
Not contacted, reported deceased
5
Continue to 1a, below
Unknown
9
Go to Contact tracking, Question 49
/
/
1.a.
What was the date of death?
1.b.
What city, state, and country did the death occur? _______________________________
1.c.Do you know if (insert decedent’s name) was hospitalized or visited an emergency room for any
reason since (date of last time interviewed) and his/her death?
End interview
Yes 1
Record date and name of each hospitalization and/or
No 0
ER visit. End interview after last event is reported.
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 1 of 23
Contact
Occasion
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
SEQ #
0
1
GENERAL HEALTH
2. Since our last telephone interview with you on (date), would you say, in general, your health is…?
Excellent 1
Very good 2
Good 3
Fair 4
Poor 5
[HOE section for data entry screens begins here]
B. HOSPITALIZED AND EMERGENCY ROOM EVENTS
“The following questions are about any hospitalizations or visits to an emergency room you may have had
since our last telephone interview with you on (date).” [ Note: This section will repeat depending upon
number of reported events ]
3. Since our last telephone interview with you on (date), have you at any time been admitted to a hospital
or seen in an emergency room?
No
0
Go to Question 5
Yes
1
Go to Question 5
Unsure 9
“The next few questions are about one event, if there were more than one we would like to talk about each
one separately, let’s start with the first event since our last telephone interview with you on (date).”
4. Was this visit to the emergency room only, a hospital admission only, or a visit to the emergency room
that resulted in being admitted to the hospital?
Emergency Department (only)
1
Hospital Admission (only)
2
Both
3
Unsure
9
4.a. What was the main reason for going to the (insert emergency room or hospital) that day?
[Check one and do not read choices]
Myocardial infarction, heart attack
0
Angina, chest pain
1
Heart failure
2
Stroke or TIA
3
Peripheral vascular disease
4
Venous thrombosis or pulmonary embolism
5
Chronic Obstructive Pulmonary Disease, emphysema, or chronic bronchitis 6
Asthma
7
Pregnancy related, birth, complication of pregnancy
8
Other:
9
Specify: _____
4.b. What was the date of this event?
/
/
4.c. What is the name of the medical facility?
4.d. What is the address of this medical facility?
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 2 of 23
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
Contact
Occasion
SEQ #
0
1
4.e. For clarification of our records, under what name is this record?
4.e1. First Name:
4.e2. Second Name:
4.e3. Last Name:
4.e4. Maternal Last Name:
4.f.
Were you admitted to a hospital or seen at an ER at any another time since your last telephone
interview?
No
0
Go to Question 5
Yes
1
(Line entry saved, screen refreshes to a new series at Question 4)
[OPE section for data entry screens begins here]
C. OUT-PATIENT SELF-REPORTED CONDITIONS
“Now I would like to ask you about conditions that may have resulted in you seeing a doctor or health
profession at a clinic or doctor’s office, but not actually being admitted to the hospital or visiting an
emergency room.”
5. Since our last telephone interview with you on (date), has a doctor or health professional told you that
you had emphysema, chronic bronchitis, or chronic obstructive pulmonary disease (COPD)? This does
not include doctor’s visits for tuberculosis or TB.
No
0
Go to Question 6
Yes
1
Unsure 9
Go to Question 6
Did your doctor or healthcare professional order any of the following tests to help make the diagnosis?
5.a. Breathing test or pulmonary function test?
No 0
Yes 1
Unsure 9
5.b. Chest X-ray:
No 0
Yes 1
Unsure 9
5.c. CT Scan of your chest: No 0
Yes 1
Unsure 9
5.d. Were you told by a doctor or health professional that you were having an attack, worsening or
an exacerbation of your emphysema, chronic obstructive pulmonary disease (COPD), or
chronic bronchitis?
No
0
Go to Question 6
Yes
1
Unsure
9
Go to Question 6
5.e. Did the doctor or health care professional prescribe a change in your medication, such as
increasing your inhalers, oxygen or pills for your lungs or prescribing a steroid pill for your
lungs?
No 0
Yes 1
Unsure 9
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 3 of 23
Contact
Occasion
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
SEQ #
0
1
For Females ONLY- Reported Pregnancies
6. Since our last contact with you on (date), have you been or are you currently pregnant?
Go to Question 14
No
0
Yes
1
7. Are you currently pregnant?
No 0
Go to Question 8
Yes 1
7.a. How many weeks pregnant are you? _____ _____
7.b. If currently pregnancy AND more than 20 weeks: Have you had any of these illnesses or
complications during this pregnancy?
7.b1. High blood pressure or hypertension?
No
0
Go to Question 8
Yes
1
Unsure
9
Go to Question 8
7.b1.i. Did you have high blood pressure or hypertension before this pregnancy?
No
0
Yes
1
7.b2. Preeclampsia or toxemia?
No
0
Skip Questions 7d, 7d1, 7d2, 7d3
Yes
1
Unsure
9
Skip Questions 7d, 7d1, 7d2, 7d3
7.b3. Diabetes?
No
0
Yes
1
Unsure
9
Go to Question 8
Go to Question 8
7.b3.i. Did you take medication for your blood sugar during your pregnancy?
No
0
Yes, pills only
1
Yes, insulin only
2
Yes, pills and insulin
3
7.b3.ii. Did you have diabetes before this pregnancy?
No
0
Yes
1
Unsure 9
7.c. Have you received prenatal care for this pregnancy?
No
0
Yes 1
Unsure 9
7.d. If yes to pre-eclampsia, eclampsia, or gestational diabetes, AND received prenatal care THEN
What is the clinic or facility in which you have received prenatal care?
___________________________________________________________
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 4 of 23
Contact
Occasion
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
SEQ #
0
1
7.d1. Address of clinic or facility:___________________________________________________
City:______________________________ State: _________ zip:________________
7.d2. What is the name of the physician or provider that you see for prenatal care
_________________________________________________________
7.d3. For clarification of our records, under what name are you seen?
7.d3.i. First name______________________________________________
7.d3.ii. Second name _____________________________________________
7.d3.iii. Last Name_______________________________________________
7.d3.iv. Maternal Last Name_________________________________________
8. Excluding current pregnancies, how many times have you been pregnant since the last study contact?
times
FOR EACH PREGNANCY SINCE LAST TELEPHONE / STUDY VISIT:
/
9. What was the date that this pregnancy ended?
10. How did this pregnancy end?
Live birth, Vaginal birth
Live birth, C-section
Stillbirth
Abortion
Miscarriage
Tubal / Ectopic
/
(MM/DD/YYYY)
Go to Question 16
11. How many months or weeks had you been pregnant when (the baby was born/the [multi] were born/the
pregnancy ended)?
months
weeks
11.a. If unknown, preterm delivery is one that occurs at 36 weeks or earlier in pregnancy. As far as
you know, did you have a preterm delivery?
No
0
Yes
1
Unsure
9
12. Where did you give birth?
In a hospital
In a birthing center
In your home or home other place
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Go to Question 13
Page 5 of 23
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
Contact
Occasion
SEQ #
0
1
If this birth happened in a hospital or birthing center:
12.a. What was the name of the facility where you gave birth?_____________________________
12.b. What was the address of the facility?___________________________________________
City:______________________________ State: _________ zip:________________
12.c. For clarification of our records, under what name are these records?
12.c1. First name______________________________________________
12.c2. Second name _____________________________________________
12.c3. Last Name_______________________________________________
12.c4. Maternal Last Name_________________________________________
lbs
13. How much weight did you gain during this pregnancy?
OR
kgs
END of questions for women only
ALL PARTICIPANTS
14. Since our last telephone interview with you on (date), has a doctor or health professional told you that
you had asthma?
No
0
Go to Question 7
Yes
1
Go to Question 7
Unsure 9
15. Did your doctor or healthcare professional order any of the following tests to help make the diagnosis?
15.a. Breathing test or pulmonary function test
No 0
Yes 1
Unsure 9
15.b. Chest X-ray
No 0
Yes 1
Unsure 9
15.c. CT Scan of your chest
No 0
Yes 1
Unsure 9
15.d. Were you told by a doctor or health professional that you were having an attack, worsening or
an exacerbation of your asthma?
No
0
Go to Question 7
Yes
1
Unsure 9
Go to Question 7
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 6 of 23
ID NUMBER:
FORM CODE: FE7
VERSION: 1, 1/17/2014
Contact
Occasion
SEQ #
0
1
15.e. Did the doctor or health care professional prescribe a change in your medication, such as
increasing your inhalers, oxygen or pills for your lungs or prescribing a steroid pill for your
lungs?
No 0
Yes 1
Unsure 9
16. Since our last telephone interview with you on (date), has a doctor or health professional told you that
you had diabetes or high sugar in the blood?
No
0
Go to Question 8
Yes
1
Unsure 9
Go to Question 8
16.a. Did the doctor recommend any new or different treatments?
No
0
Go to Question 8
Yes
1
Unsure
9
Go to Question 8
16.b. What treatment was recommended? (Do not prompt for specific response. Mark all that apply)
Pills
Insulin Alone
Insulin and pills
Referred for eye exam
Advice to change diet
Advice to stop smoking
Advice to increase exercise
Other
Specify: ____________________________________
17. Since our last telephone interview with you on (date), has a doctor or health professional told you that
you had high blood pressure or hypertension?
Go to Question 9
No
0
Yes
1
Unsure 9
Go to Question 9
17.a. Did the doctor recommend any new or different treatments?
Go to Question 9
No
0
Yes
1
Unsure 9
Go to Question 9
17.b. What treatment was recommended? (Do not prompt for specific response. Mark all that apply)
Start new medicine
Increase dose of existing medicine
Advice to lose weight
Advice to change diet
Advice to stop smoking
Advice to increase exercise
Specify: _______________________________
Other
18. Since our last telephone interview with you on (date), has a doctor or health professional told you that
you had high blood cholesterol?
No
0
Go to Question 10
Yes
1
Unsure 9
Go to Question 10
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 7 of 23
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
Contact
Occasion
SEQ #
0
1
18.a.
Did the doctor recommend any new or different treatments?
No
0
Go to Question 10
Yes
1
Go to Question 10
Unsure 9
18.b.
What treatment was recommended? (Do not prompt for specific response. Mark all that
apply.)
Start new medicine
Increase dose of existing medicine
Advice to lose weight
Advice to change diet
Advice to stop smoking
Advice to increase exercise
Other
Specify: _________________________________
[EVE section for data entry screens begins here]
D. SELF REPORT OF EVENTS
“Now I would like to ask you about symptoms you may have had since our last telephone interview with you
on (date).”
19. Since our last telephone interview with you on (date), has a doctor or health professional told you that
you had atrial fibrillation?
Yes 1
Unsure 9
No
0
20. Since our last telephone interview with you on (date), has a doctor or health professional told you that
you had heart failure?
Yes 1
Unsure 9
No
0
21. Since our last telephone interview with you on (date), has a doctor or health professional told you that
you had a blood clot in your leg vein or lung requiring blood thinning medicine?
Yes 1
Unsure 9
No
0
22. Since our last telephone interview with you on (date), do you often have swelling in your feet or ankles
at the end of the day?
Yes 1
Unsure 9
No
0
23. Since our last telephone interview with you on (date), are there times when you wake up at night
because of difficulty breathing?
No
0
Yes 1
Unsure 9
24. Since our last telephone interview with you on (date), are there times when you have been troubled by
shortness of breath when hurrying on level ground or walking up a slight hill?
Yes 1
Unsure 9
No
0
25. Since our last telephone interview with you on (date), are there times when you stop for breath when
walking at your own pace on level ground?
Yes 1
Unsure 9
No
0
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 8 of 23
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
Contact
Occasion
SEQ #
0
1
26. Since our last telephone interview with you on (date), are there times when you have difficulty breathing
when you are not walking or active?
Yes 1
Unsure 9
No
0
27. Since our last telephone interview with you on (date), have you had a cough on most days or nights of
the week during at least 3 months in a row?
Yes 1
Unsure 9
No
0
28. Since our last telephone interview with you on (date), have you brought up phlegm from your chest on
most days or nights of the week during at least 3 months in a row?
Yes 1
Unsure 9
No
0
29. Since our last telephone interview with you on (date), have you had wheezing or whistling in your
chest?
No
0
Go to Question 21
Yes
1
Unsure 9
Go to Question 21
29.a. Have you had an attack of wheezing or whistling in the chest that has made you feel short of
breath?
No
0
Yes 1
Unsure 9
30. Since our last telephone interview with you on (date), has a doctor or health professional told you that
you have sleep apnea?
No
0
Go to Question 22
Yes
1
Unsure 9
Go to Question 22
30.a. Has your sleep apnea been treated with any of the following? (check all that apply)
Surgery
Use of a dental appliance during sleep (a device put in your mouth at night that moves
the jaws open)
Use of oxygen during sleep
A pressure machine such as CPAP or BILEVEL?
31. How often do you snore now?
Never
Rarely (1-2 nights a week)
Sometimes (3-5 nights a week)
Always or almost always (6-7 nights a week)
Don’t know
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
1
2
3
4
9
Page 9 of 23
Contact
Occasion
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
SEQ #
0
1
[MEE section for data entry screens begins here]
E. Medication Use Interview
Now I would like to ask about a few specific medications.
32. Were any of the medications you took during the last four weeks for:
32.a. Asthma
Yes 1
No 0
32.a1. How long have you been taking this medication?
32.b. Chronic bronchitis or emphysema
Yes 1
No 0
No 0
32.f. Chest pain or angina
32.f1. How long have you been taking this medication?
32.h. Heart failure
No 0
< 1 year,
< 1 year,
< 1 year,
Yes 1
32.i1. How long have you been taking this medication?
1-5 years,
> 5 years
1-5 years,
> 5 years
1-5 years,
> 5 years
1-5 years,
> 5 years
Unknown 9
Yes 1
32.h1. How long have you been taking this medication?
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
< 1 year,
No 0
Unknown 9
Unknown 9
Yes 1
32.g1. How long have you been taking this medication?
32.i. Blood thinning
< 1 year,
No 0
> 5 years
Unknown 9
Yes 1
No 0
32.g. Abnormal heart rhythm
< 1 year,
Yes 1
32.e1. How long have you been taking this medication?
1-5 years,
Unknown 9
Yes 1
No 0
32.d1. How long have you been taking this medication?
32.e. High blood cholesterol
< 1 year,
Yes 1
32.c1. How long have you been taking this medication?
32.d. High blood pressure or hypertension
< 1 year,
No 0
32.b1. How long have you been taking this medication?
32.c. High blood sugar or diabetes
Unknown 9
< 1 year,
1-5 years,
> 5 years
Unknown 9
1-5 years,
> 5 years
Unknown 9
1-5 years,
> 5 years
Unknown 9
1-5 years,
> 5 years
Page 10 of 23
Contact
Occasion
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
32.j. Stroke
No 0
Yes 1
32.j1. How long have you been taking this medication?
32.k. Mini-stroke or TIA
Yes 1
32.k1. How long have you been taking this medication?
32.l. Leg pain while walking or claudication No 0
32.m. Depression
< 1 year,
Yes 1
32.l1. How long have you been taking this medication?
Yes 1
32.m1. How long have you been taking this medication?
32.n. Anxiety
No 0
32.o. Glaucoma
< 1 year,
Yes 1
32.n1. How long have you been taking this medication?
Yes 1
32.o1. How long have you been taking this medication?
32.p. A disease of the thyroid
No 0
< 1 year,
Yes 1
32.p1. How long have you been taking this medication?
1-5 years,
> 5 years
Unknown 9
1-5 years,
> 5 years
1-5 years,
> 5 years
Unknown 9
1-5 years,
> 5 years
Unknown 9
< 1 year,
No 0
1
Unknown 9
< 1 year,
No 0
0
Unknown 9
< 1 year,
No 0
SEQ #
< 1 year,
1-5 years,
> 5 years
Unknown 9
1-5 years,
> 5 years
Unknown 9
1-5 years,
> 5 years
33. During the last four weeks, did you take any aspirin or aspirin-containing products including AlkaSeltzer, cold and allergy medication or headache powder? This excludes acetaminophen (for example,
Tylenol), ibuprofen (for example, Advil, Motrin or Nuprin), and naproxen (for example, Aleve).
Show participant List #1: Commonly Used Aspirin or Aspirin-Containing Products
No
Yes
Unknown
0
1
9
GO TO QUESTION 39
GO TO QUESTION 39
34. How many days during the last four weeks did you take aspirin or aspirin-containing medication?
Number of days
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
If number of days equals “00” GO TO QUESTION 39
Page 11 of 23
Contact
Occasion
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
SEQ #
0
1
35. For what purpose are you taking aspirin? (Interviewer: Do NOT read choices.)
Participant mentioned avoiding heart attack or stroke
1
Participant did not mention avoiding heart attack or stroke 2
36. During the past four weeks, did you take any [other] medication for arthritis, fever, or muscle aches and
pains, or cramps? (Read bracketed “other” unless no medications were reported.)
No
0
Yes
1
Unknown
9
37. Excluding aspirin, acetaminophen (for example, Tylenol), and corticosteroids (for example prednisone),
are you NOW taking other anti-inflammatory or arthritis medications on a regular basis? Common
examples are shown on this list.
Show participant List #2: Commonly Used Non-Steroidal Anti-Inflammatory Drugs, NSAIDS
No
0
Yes
1
Unknown
9
Thank you so much for answering these questions. We greatly appreciate your participation in the SOL
study. Now, I’d just like to make sure our records are up to date.
G. PARTICIPANT TRACKING [CIE section for data entry screens begins here.]
Interviewer: Current tracking information from SOL database is shown below. Record tracking information
changes reported during the interview in the space provided.
“It is very important for this study to be able to reach you in the future. Although you provided your contact
information at the time of your visit, in order to keep our records up to date please provide us with your
current home address. All information you give us in strictly confidential and will not be shared with anyone
else”.
38. Current home address*
38.A.1. PO Box, Box &/or Route and Number
38.B.1. Street Number Prefix
38.B.2. Street Number
38.B.3. Street Number Suffix
38.C.1. Street Name Prefix
38.C.2. Street Name
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 12 of 23
ID NUMBER:
FORM CODE: FE7
VERSION: 1, 1/17/2014
Contact
Occasion
SEQ #
0
1
38.C.3. Street Name Type
38.C.4. Street Name Suffix
38.D.1. Unit Type
38.D.2. Unit Type Identifier
38.D.3. Unit Subtype
38.D.4. Unit Subtype Identifier
38.E.1. Other
38.F.1. City
38.G.1. County
38.H.1. State
38.I.1. Country/Territory (Select code from list)
38.J.1. Zip Code
–
About how long have you lived at this address? Since…
38.K.1. Year
38.K.2. Month
IF UNKNOWN, ENTER 99
38.K.3. Day
IF UNKNOWN, ENTER 99
*IF THE PARTICIPANT LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE
EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO
THE HOME LOCATION IN 38.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 38.E.1.
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 13 of 23
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
Contact
Occasion
SEQ #
0
1
IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER
IT IN 38.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE
ACTUAL HOME LOCATION IN 38.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 38.E.1.
(
39. Primary Phone Number: +
(Country Code)
39.a. This is a: Cell Phone
1
)
-
(Area Code)
Home Phone 2
40. What is the best time of day to reach you at this number?
Morning
1
Afternoon
2
Evening
3
(
41. Secondary Phone Number: +
(Country Code)
41.a. This is a: Cell Phone
1
)
-
(Area Code)
Home Phone 2
42. What is the best time of day to reach you at this number?
Morning
1
Afternoon
2
Evening
3
43. Email address 1:
43.a. Email address 2:
44. How do you prefer to receive information from us? (select only one)
Regular Mail
1
Electronic mail (email)
2
Social Media (Facebook and Twitter)
4
In Person at time of clinic visit
5
Text messages
6
Other
7
Specify: ______________________
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 14 of 23
Contact
Occasion
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
SEQ #
0
1
Local Contact 1
45. a. Title: _______________
b. First Name:
c. Second Name: ________________________________________
d. Last Name: ___________________________________________
e. Maternal Last Name: ______________________________________
46. Relationship: ______________________
46.a. is this ARE contact?
No
0
Yes
1
47. Current home address of primary contact*
47.A.1. PO Box, Box &/or Route and Number
47.B.1. Street Number Prefix
47.B.2. Street Number
47.B.3. Street Number Suffix
47.C.1. Street Name Prefix
47.C.2. Street Name
47.C.3. Street Name Type
47.C.4. Street Name Suffix
47.D.1. Unit Type
47.D.2. Unit Type Identifier
47.D.3. Unit Subtype
47.D.4. Unit Subtype Identifier
47.E.1. Other
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 15 of 23
Contact
Occasion
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
SEQ #
0
1
47.F.1. City
47.G.1. County
47.H.1. State
47.I.1. Country/Territory (Select code from list)
47.J.1. Zip Code
–
*IF THE PERSON LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE
EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO
THE HOME LOCATION IN 47.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 47.E.1.
IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER
IT IN 47.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE
ACTUAL HOME LOCATION IN 47.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 47.E.1.
(
48. Telephone: +
(Country Code)
)
(Area Code)
48.a. This is a: Cell Phone
1
number
Home Phone 2
49. Email address 1:
49.a. Email address 2:
Local Contact 2
50. a. Title: _______________
b. First Name:
c. Middle/Second Name: __________________________________
d. Paternal Last Name: ____________________________________
e. Maternal Last Name: ______________________________________
51. Relationship: __________________
51.a. is this ARE contact?
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
No
0
Yes
1
Page 16 of 23
ID NUMBER:
FORM CODE: FE7
VERSION: 1, 1/17/2014
Contact
Occasion
SEQ #
0
1
52. Current home address of secondary contact*
52.A.1. PO Box, Box &/or Route and Number
52.B.1. Street Number Prefix
52.B.2. Street Number
52.B.3. Street Number Suffix
52.C.1. Street Name Prefix
52.C.2. Street Name
52.C.3. Street Name Type
52.C.4. Street Name Suffix
52.D.1. Unit Type
52.D.2. Unit Type Identifier
52.D.3. Unit Subtype
52.D.4. Unit Subtype Identifier
52.E.1. Other
52.F.1. City
52.G.1. County
52.H.1. State
52.I.1. Country/Territory (Select code from list)
52.J.1. Zip Code
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
–
Page 17 of 23
Contact
Occasion
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
(
53. Telephone: +
(Country Code)
)
(Area Code)`
53.a. This is a: Cell Phone
1
SEQ #
0
1
number
Home Phone 2
54. Email address 1:
54.a. Email address 2:
*IF THE PERSON LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE
EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO
THE HOME LOCATION IN 52.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 52.E.1.
IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER
IT IN 52.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE
ACTUAL HOME LOCATION IN 52.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 52.E.1.
Local Contact 3
55. a. Title: _______________
b. First Name:
c. Middle/Second Name: __________________________________
d. Paternal Last Name: ____________________________________
e. Maternal Last Name: ______________________________________
56. Relationship: __________________
56.a. is this ARE contact?
No
0
Yes
1
57. Current home address of third contact*
57.A.1. PO Box, Box &/or Route and Number
57.B.1. Street Number Prefix
57.B.2. Street Number
57.B.3. Street Number Suffix
57.C.1. Street Name Prefix
57.C.2. Street Name
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 18 of 23
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
Contact
Occasion
SEQ #
0
1
57.C.3. Street Name Type
57.C.4. Street Name Suffix
57.D.1. Unit Type
57.D.2. Unit Type Identifier
57.D.3. Unit Subtype
57.D.4. Unit Subtype Identifier
57.E.1. Other
57.F.1. City
57.G.1. County
57.H.1. State
57.I.1. Country/Territory (Select code from list)
57.J.1. Zip Code
–
(
58. Telephone: +
(Country Code)
)
-
(Area Code)
58.a. This is a: Cell Phone
1
Home Phone 2
59. Email address 1:
59.a. Email address 2:
*IF THE PERSON LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE
EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO
THE HOME LOCATION IN 57.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 57.E.1.
IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER
IT IN 57.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE
ACTUAL HOME LOCATION IN 57.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 57.E.1.
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 19 of 23
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
Contact
Occasion
SEQ #
0
1
H. About Health Insurance
60. Do you have health insurance or health care coverage? Select only one answer.
GO TO QUESTION 65
No
0
Yes
1
Refused
8
GO TO QUESTION 65
Don't know/Not Sure 9
GO TO QUESTION 65
61. Are you CURRENTLY covered by any of the following types of health insurance or health coverage
plans? Mark "Yes" or "No" for EACH type of coverage in items a – h.
No
Yes
a. Insurance through a current or former employer or union (of this
person or another family member)
0
1
b. Insurance purchased directly from an insurance company (by
this person or another family member)
0
1
c. Medicare, for people 65 and older, or people with certain
disabilities
0
1
d. Medicaid, Medi-Cal, or any kind of government-assistance plan
for those with low income or a disability
0
1
e. Veterans Administration (VA) (including those who have ever
used or enrolled for VA health care)
0
1
f.
0
1
g. Indian Health Service
0
1
h. Any other type of health insurance or health coverage plan
(Specify____________)
0
1
i.
Refused
8
j.
Don’t know/Not Sure
9
TRICARE, CHAMPUS or other military health care plan
62. The health reform law (commonly known as “Obamacare”) establishes new federal and state
marketplaces (also called exchanges) where the uninsured and workers in small businesses can go to
purchase insurance. Have you acquired coverage through one of these new marketplaces (Covered
California; nystateofhealth; HealthCare.gov; CuidadodeSalud.gov)? Select only one answer.
No
0
Yes
1
Refused
8
Don't know/Not Sure
9
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 20 of 23
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
Contact
Occasion
SEQ #
0
1
63. In the past 12 months, have you received coverage for medical expenses through Emergency
Medicaid? Select only one answer.
No
0
Yes
1
Refused
8
Don't know/Not Sure
9
64. A catastrophic health insurance plan covers 3 annual primary care visits, and only provides coverage for
medical expenses after the individual pays thousands of dollars (for example, the first $6,000 or more in
medical expenses). Have you purchased a catastrophic health insurance plan? [Note to the
interviewers: Catastrophic health plans cover persons younger than age 30 years.] Select only one
answer.
No
0
Yes
1
Refused
8
Don't know/Not Sure
9
65. About how long has it been since you last had health insurance coverage? Select only one answer.
6 months or less
1
More than 6 months, but not more than 1 year 2
More than 1 year, but not more than 3 years
3
More than 3 years
4
Never had insurance
5
Refused
8
Don't know/Not Sure
9
66. What are the main reasons you do not currently have health insurance (check all that apply)?
a. It is too expensive/ the cost is too high
b. I am not eligible for coverage through my employer
c. My employer or my spouse’s/partner’s (or other relative’s) employer does not offer
insurance coverage
d. I was denied insurance coverage due to a previous medical condition
e. I am not eligible for Medicaid or have recently lost my Medicaid coverage
f. I lost the ability to purchase health insurance coverage through my spouse, partner
or other relative
g. I am not eligible for premium tax credits or other tax credits
h. I am not eligible due to my citizenship status
i. I don’t need insurance
j. I don’t know how to get insurance
k. Other (Specify __________)
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 21 of 23
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
Contact
Occasion
SEQ #
0
1
l. Refused
m. Don’t know/Not Sure
67. In the past 12 months, have you received coverage for medical expenses through Emergency
Medicaid? Select only one answer.
I.
No
0
Yes
1
Refused
8
Don't know/Not Sure
9
ABOUT PLACE OF BIRTH AND CITIZENSHIP STATUS
The nature of these questions is sensitive, and some participants may not want to answer them.
Participants should be assured that they may choose not to answer them, and their refusal will not have
any impact on their participation in the study nor will affect any referrals that have already been
schedule. For those participants who choose to answer these questions, assurance about
confidentiality, and that their responses will be blocked and not disclosed to the public should be
underlined.
These questions will be asked to all participants.
68. Where were you born? Select only one answer.
In the U.S.
Specify State:
Outside of the U.S
Specify country
Specify city or town
1
2
69. Are you a U.S. citizen? Select only one answer.
No, not a U.S. citizen
0
Yes, was born in the United States
1
End Questionnaire
Yes, was born in Puerto Rico, Guam, and the U.S. Virgin Islands
or Northern Marianas
2
End Questionnaire
Yes, was born abroad to a U.S. citizen parent or parents
3
End Questionnaire
Yes, is a citizen by naturalization
4
End Questionnaire
Refused
8
End Questionnaire
Don’t know/Not Sure
9
End Questionnaire
Specify year:
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
Page 22 of 23
FORM CODE: FE7
VERSION: 1, 1/17/2014
ID NUMBER:
Contact
Occasion
SEQ #
0
1
70. If the previous answer is “No”, what of the following situations describes you best? Select only one
answer.
Permanent resident card holder (“Green card” holder)
1
Have applied for a “Green card”
2
Holder of another type of visa
3
Specify:
None of the above
4
Refused
8
Don’t know/Not Sure
9
J. END OF THIS PORTION OF THE CALL
“Thank you for answering the questions about your health. We wish to continue to stay in touch with you
and will be contacting you again next year”
Location Codes for Questions 45, 49, 56, 60, 64
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
Afghanistan
Anguilla
Antigua and
Barbuda
Argentina
Aruba
Australia
Austria
Bangladesh
Belgium
Belize
Bolivia
Brazil
Canada
Chile
China
Colombia
Costa Rica
Cuba
Czech Republic
Denmark
Dominican
Republic
Ecuador
El Salvador
Finland
France
Germany
Great Britain
Greece
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
Guam
Guatemala
Haiti
Holland
Honduras
Hungary
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Japan
Korea
Lebanon
Malaya
Mexico
New Zealand
Nicaragua
Norway
Pakistan
Panama
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Russia
AFU-Y7-11 Annual Followup_1-17-2014_English.doc
59
60
61
62
63
64
65
66
67
99
South Africa
Spain
Sweden
Switzerland
United States
Uruguay
Venezuela
Virgin Islands
Other
Unknown/refused
Page 23 of 23
| File Type | application/pdf |
| File Title | Microsoft Word - AFU-Y7-11 Annual Followup_1-17-2014_English.doc |
| Author | uccmey |
| File Modified | 2014-01-21 |
| File Created | 2014-01-21 |