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OMB #0920-xxxx
Exp. Date xx-xx-20xx
Women’s Preventive Health Services Survey
CATI Scripts
Public reporting burden of this collection of information is estimated to average 25 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; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-16AWP).
INTRO_1 Hello. I’m [INTERVIEWER NAME} calling on behalf of the CDC regarding a study on women’s preventive health services. For quality assurance, this call will be recorded or monitored. May I please speak with [NAME]?
READ IF NECESSARY: I'm calling regarding a study on women’s preventive health services. This is a nationwide study sponsored by the CDC. You may recall receiving a letter from us recently.
YES (TRANSFERRED)………………………………………………………1 [GO TO S_CRITP]
NO 2 [GO TO S1]
I AM THAT PERSON 3 [GO TO S3_INTRO]
BUSINESS 4 [GO TO TERM1]
TERMINATE THE INTERVIEW 6 [GO TO TERM1]
ANSWERING MACHINE 8 [GO TO AM_MSG]
S1 Is there a better time to contact [NAME]?
TRANSFERRED 1 [GO TO S_CRITP
YES 2 [SCHEDULE CALLBACK/APPT]
NO 3 [GO TO S5_BOX]
DON’T KNOW 77 [GO TO S5_BOX]
REFUSED 99 [GO TO S5_BOX]
S_CRITP Hi. My name is ________, and I’m calling from NORC at the University of Chicago. We recently sent you an invitation to complete the Women’s Preventive Health Services Survey. Have you received this invitation?
YES, CONTINUE………………………………………………………… 1 [GOTO S3_INTRO]
NO……………………………………………………………………………..2 [GO TO S_CRITCON]
GENERAL REFUSAL………………………………………………….… 99 [GOTO SOFT_77]
SOFT _77 Would you mind telling me the reason why you are not able to participate?
NOT INTERESTED 1 [GO TO S_CRTCON]
TOO BUSY 2 [GO TO S_CRITW]
DOES NOT BELIEVE SHE IS CORRECT RESPONDENT.........3 [GO TO S1]
OTHER (SUCCESSFULLY ADDRESS CONCERNS)……………...4 [GO TO S3_INTRO]
REFUSED/CANNOT ADDRESS CONCERNS……………………..99 [GO TO TERM1]
S_CRTCON We are conducting the Women’s Preventive Health Services Survey. This is a nationwide study sponsored by the Centers for Disease Control and Prevention. We recently sent a letter to your home inviting you to participate. We would like to ask you a few questions to see if you are eligible.
R WILL COMPLETE SURVEY ONLINE………………………………1 [GO TO EXIT]
R REQUESTS EMAIL ………………………………………………….3 [GO TO Z_CEMAIL]
DON’T KNOW 77 [GO TO TERM1]
REFUSED 99 [GO TO TERM1]
S_CRITW I completely understand. The survey should not take too long. Let’s start now to see if you are eligible.
R WILL COMPLETE SURVEY ONLINE………………………………1 [GO TO EXIT]
R REQUESTS EMAIL …………………………………….……………3 [GO TO Z_CEMAIL]
DON’T KNOW 77 [GO TO TERM1]
REFUSED 99 [GO TO TERM1]
S3_INTRO Great! As mentioned, we are conducting this survey on behalf of CDC. This survey will help CDC understand how women are accessing preventive health services, such as mammograms and pap smears. We have a few questions we would like to ask first to see if you are eligible for the study.
CONTINUE…………………………………………………………….1 [GO TO SCREENER QUESTIONS]
S5_BOX Could I leave a message for that person?
YES 1 [GO TO S5_LAW]
NO 2 [GO TO EXIT]
DK……………………………………………………………………..…… …77 [GO TO EXIT]
REF………………………………………………………………….…………99 [GO TO EXIT]
S5_LAW Please ask her to call us back at [INSERT TOLL FREE PHONE NUMBER]. We look forward to her input on this important study.
EXIT Thank you for your time.
ANSWERING MACHINE MESSAGES
AM_MSG **SPECIFIC VOICEMAIL**: Hello. My name is ________, and I’m calling from NORC at the University of Chicago. We are contacting you regarding the Women’s Preventive Health Services Survey sponsored by the CDC. We are calling to ask for your help with this study. Please call us, toll-free, at [TOLL-FREE NUMBER]. Again, that number is [TOLL-FREE NUMBER]. Thank you!
**NEUTRAL VOICEMAIL**: Hello. My name is ________, from NORC at the University of Chicago. I’m calling regarding a study on women’s preventive health services. Please call us at [TOLL-FREE NUMBER]. Thank you.
**CALLBACK MESSAGE**: Hello. We spoke recently regarding the Women’s Preventive Health Services Survey. I am following up on our recent discussion about this study. Feel free to call us toll-free at [TOLL-FREE NUMBER].
EMAIL SCRIPTS/TEXT
Z_CEMAIL In order to email you login information, I will need to collect your name and email address. The email will contain a link to our secure website, your secure PIN and a toll-free number that you may call with any questions.
TERMINATE THE INTERVIEW 1 [TERMINATE]
REFUSED TO GIVE EMAIL ADDRESS INFORMATION 2 [TERMINATE]
COLLECT EMAIL ADDRESS 3 [GOTO Y_FEMAIL]
Y_FEMAIL What is your email address?
[GO TO P_NEWNAM]
P_NEWNAM Can you please provide us with your first and last name?
[GO TO Z_XEMA2]
Z_XEMA2 Dear [NAME]:
Thank you for your interest in the Women’s Preventive Health Services Survey, or WPHSS. This study is being conducted by NORC at the University of Chicago on behalf of the Centers for Disease Control and Prevention.
The information you provide help guide CDC’s future efforts on how public health can help make sure women are able to receive appropriate preventive health services, including cancer screenings. Using the study web link and your unique Personal Identification Number (PIN) below, please take a couple of minutes to answer a few questions to see if you are eligible to participate in this study. If you are eligible for the study, you will be directed to the full survey.
Survey URL: [INSERT SURVEY URL]
PIN: [INSERT PIN]
If you have any questions as you fill out the questionnaire, please call [TOLL-FREE NUMBER] or email [INSERT EMAIL ADDRESS] and a NORC staff person will assist you.
Thank you for your assistance.
The Women’s Preventive Health Services Survey Team
NORC at the University of Chicago
SCREENER QUESTIONS
SCREENER1. First, we need to confirm you are eligible for the study. Do you now have health insurance? Health insurance includes private insurance through an employer or purchased directly as well as public programs such as Medicaid, Medicare, TRICARE, and VA coverage.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO INELIGIBLE]
77. DON’T KNOW
99. REFUSED
SCREENER2. Are you between the ages 30 and 62?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO INELIGIBLE]
77. DON’T KNOW
99. REFUSED
[PROGRAMMER: IF ONE OR BOTH SCREENER QUESTIONS ARE MISSING, GO TO INELIGIBLE.]
ELIGIBLE. Okay, great! It sounds like you are eligible for the survey. We would like to continue now unless you have any questions.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.
CONTINUE [GO TO CONSENT]
77. DON’T KNOW
99. REFUSED
INELIGBLE. Unfortunately, you are not eligible for the study at this time. Thank you for your time and your interest.
CONSENT
The Women’s Preventive Health Services Survey (WPHSS), sponsored by the Centers for Disease Control and Prevention (CDC), is a three-year study that will ask women about health care screenings they have received. We will ask you to participate once a year for three years. Thank you for agreeing to share your experience with us.
We are asking you to take part in the study because [STATE PROGRAM NAME] staff identified you as someone who can tell us about the screening tests you received. Each year of the study we will contact you about completing a survey. We would also like to know if there have been any gaps in health insurance coverage, problems accessing health care, and if you are getting follow-up care. Your answers are valuable to our project. There are no right or wrong answers. This interview is not meant to evaluate you. Rather, it is meant to learn about your experience with your new health insurance policy.
The survey will take about 20 – 25 minutes.
The information we learn from this study will help us understand if women are getting the cancer prevention services they need. All information will be kept confidential. Data shared with CDC will not contain your personal contact information.
Your participation is voluntary. There are minimal risks to participating in the survey. You may choose not to answer any of the questions or you may choose not to participate without penalty. You can choose to stop the survey at any time for any reason.
Upon completion of this first survey, we will send you a $10 gift card. We will contact you next year to complete this survey again.
If you would like more information about this study, if you would like to withdraw from this study, or if you would like to know more about your rights as a participant, you may contact NORC toll-free at [project toll-free number] or via email at [project email].
I have read the above information. I consent voluntarily to be a participant in this study.
YES
NO
CONTACT INFORMATION |
Before we start the survey, we would like to confirm your contact information. This will allow us to mail your incentive to the right place and to contact you next year.
[PROGRAMMER: IF ADDRESS IS KNOWN, PRELOAD AND ASK:] We have recorded the address below for you. If all is correct, please hit ‘Next’ to continue. If you need to make updates, please do so in the fields below.
[IF ADDRESS IS NOT KNOWN:] Please enter your current home address.
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[PROGRAMMER; IF PHONE NUMBER IS KNOWN, PRELOAD AND ASK:] We have the following phone number for you. Is this the best phone number to reach you? If so, please hit ‘Next’ to continue. If not, please enter the best phone number for you.
[IF PHONE NUMBER IS NOT KNOWN:] Please enter the best phone number where you can be reached.
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Phone Number |
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Please provide a name of a person who can serve as a point of contact if we cannot reach you.
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First Name |
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Please enter your point of contact’s phone number.
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Point of Contact’s Phone Number |
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DEMOGRAPHICS |
1. What is your date of birth?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
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77 DON’T KNOW
99 REFUSED
2a. Are you of Hispanic, Latina, or Spanish origin?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
2b. Which of these groups represents your race? Please select all that apply.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Alaska Native or American Indian
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
77 DON’T KNOW
99 REFUSED
3. What is the highest grade or year of school you completed?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Never attended school or only attended kindergarten
Grades 1 through 8 (Elementary)
Grades 9 through 11 (Some high school)
Grade 12 or GED (High school graduate)
College 1 year to 3 years (Some college or technical school)
College 4 years or more (College graduate)
Graduate school (Masters, Doctorate)
77 DON’T KNOW
99 REFUSED
4. Are you currently…? If more than one category applies, please select the best option.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Employed for wages
Self-employed
Out of work for 1 year or more
Out of work for less than 1 year
A Homemaker
A Student
Retired
Unable to work
77 DON’T KNOW
99 REFUSED
5. Are you…?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Married
Divorced
Widowed
Separated
Never been married
A member of an unmarried couple
77 DON’T KNOW
99 REFUSED
6a. How many children less than 18 years of age live in your household?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
_________________ Number of children
77 DON’T KNOW
99 REFUSED
6b. How many adults, 18 years of age and older, live in your household?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
_________________ Number of adults
77 DON’T KNOW
99 REFUSED
6c. Are you currently pregnant?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NP
77 DON’T KNOW
99 REFUSED
6d. Have you given birth in the past 12 months?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
7. Thinking about members of your family living in your household, what is your combined annual income, meaning the total pre-tax income from all sources earned in the past year? Please include the income of anyone you consider a member of your family living in your household.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
77 DON’T KNOW 99 REFUSED
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IF NEEDED: Please answer weekly or monthly below.
77 DON’T KNOW 99 REFUSED
77 DON’T KNOW 99 REFUSED
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8. Do you own your home, rent it, or is there some other arrangement?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
OWN
RENT
SOME OTHER ARRANGEMENT
77 DON’T KNOW
99 REFUSED
HEALTH INSURANCE STATUS |
9a. Do you have any kind of health care coverage, including private health insurance through an employer or purchased directly, prepaid plans such as HMOs, or government plans such as Medicaid and Medicare?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 9e]
77 DON’T KNOW [GO TO QUESTION 19]
99 REFUSED [GO TO QUESTION 19]
9b. What type of insurance or health care plan are you currently covered by?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Private health insurance (through an employer or purchased directly)
Military health care (TRICARE/VA/CHAMP-VA)
Medicaid
Indian Health Service
Medicare
Other (Please specify): __________________________
77 DON’T KNOW
99 REFUSED
[PROGRAMMER: IF Q9a=1 AND Q9B=1, ASK Q9c; OTHERWISE, GO TO Q9d.]
9c. Is this plan for yourself only or for you and your family?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Self only plan
Family plan through you
Family plan through spouse or other family member
Other (Please specify): ____________________________
77 DON’T KNOW
99 REFUSED
9d. About how long have you had this coverage?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
6 months or less
More than 6 months, but not more than 1 year ago
More than 1 year, but not more than 3 years ago
More than 3 years
77 DON’T KNOW
99 REFUSED
9e. You are not currently covered, for what reason are you not enrolled in health insurance?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
The costs are too high. |
1 |
2 |
77 |
99 |
I didn’t understand the plans that were offered. |
1 |
2 |
77 |
99 |
The plans do not cover the benefits I am looking for. |
1 |
2 |
77 |
99 |
The choice of doctors, hospitals, and other providers in the plans’ networks is too limited. |
1 |
2 |
77 |
99 |
I am still weighing my options and I am not ready to enroll. |
1 |
2 |
77 |
99 |
I would rather pay the penalty for not having health insurance. |
1 |
2 |
77 |
99 |
I do not have enough money right now. |
1 |
2 |
77 |
99 |
Other (please specify): __________________________ |
1 |
2 |
77 |
99 |
10. Before you had this coverage or became uninsured, what type of insurance or health care plan were you previously covered by?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Private health insurance (through an employer or purchased directly)
Military health care (TRICARE/VA/CHAMP-VA)
Medicaid
Indian Health Service
Medicare
Other (Please specify): __________________________
No coverage of any type
77 DON’T KNOW
99 REFUSED
[PROGRAMMER: IF Q9a=1, ASK Q11a; IF Q9b=2, ASK Q11b.]
11a.In the past 12 months, was there any time when you did not have any health insurance?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 11d]
77 DON’T KNOW [GO TO QUESTION 11d]
99 REFUSED [GO TO QUESTION 11d]
11b. In the past 12 months, about how many months were you without coverage?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
____________________ Months
77 DON’T KNOW
99 REFUSED
11c. What was the main reason for not having coverage?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
The costs are too high. |
1 |
2 |
77 |
99 |
I didn’t understand the plans that were offered. |
1 |
2 |
77 |
99 |
The plans do not cover the benefits I am looking for. |
1 |
2 |
77 |
99 |
The choice of doctors, hospitals, and other providers in the plans’ networks is too limited. |
1 |
2 |
77 |
99 |
I am still weighing my options and I am not ready to enroll. |
1 |
2 |
77 |
99 |
I would rather pay the penalty for not having health insurance. |
1 |
2 |
77 |
99 |
I do not have enough money right now. |
1 |
2 |
77 |
99 |
Other (please specify): ______________________________ |
1 |
2 |
77 |
99 |
[PROGRAMMER: IF Q11a=2, 77, OR 99, ASK Q11d; OTHERWISE GO TO Q12.]
11d. In the past 12 months, have you continued to receive any assistance with clinical services such as screening, education or follow-up tests through the [STATE’S BCCCP]?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
ENROLLMENT PATTERNS |
[PROGRAMMER: IF 9A = NO, DK, OR REF, GO TO QUESTION 16.]
12a. How did you enroll in your current health insurance?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
Website |
1 |
2 |
77 |
99 |
Call center |
1 |
2 |
77 |
99 |
Assistance from navigators, application assisters, certified application counselors, or community health workers |
1 |
2 |
77 |
99 |
Assistance from an insurance agent or broker |
1 |
2 |
77 |
99 |
Assistance from family or friends |
1 |
2 |
77 |
99 |
Assistance from an employer |
1 |
2 |
77 |
99 |
Assistance from a tax preparer |
1 |
2 |
77 |
99 |
Assistance from a hospital, doctor’s office, or clinic |
1 |
2 |
77 |
99 |
Through your job |
1 |
2 |
77 |
99 |
Through marriage or a family member’s insurance |
1 |
2 |
77 |
99 |
Other (please specify): ___________________________ |
1 |
2 |
77 |
99 |
12b. We would now like to ask you about how easy or how difficult it was to enroll. Did you find it easy to enroll?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 12c]
77 DON’T KNOW [GO TO QUESTION 12c]
99 REFUSED [GO TO QUESTION 12c]
12b1.What made it easy to enroll?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
Website easy to use |
1 |
2 |
77 |
99 |
Telephone help available |
1 |
2 |
77 |
99 |
Translator available |
1 |
2 |
77 |
99 |
Information easy to understand |
1 |
2 |
77 |
99 |
Plan met my needs |
1 |
2 |
77 |
99 |
In person assistance |
1 |
2 |
77 |
99 |
Very affordable |
1 |
2 |
77 |
99 |
Other (please specify): _________________________ |
1 |
2 |
77 |
99 |
12c. Did you find it difficult to enroll?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 13a]
77 DON’T KNOW [GO TO QUESTION 13a]
99 REFUSED [GO TO QUESTION 13a]
12c1. What made it difficult to enroll?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
Tried to enroll in a plan but the website was not working |
1 |
2 |
77 |
99 |
Website was too difficult to move through |
1 |
2 |
77 |
99 |
Information was too difficult to understand |
1 |
2 |
77 |
99 |
Information was not available in my native language |
1 |
2 |
77 |
99 |
No telephone help was available |
1 |
2 |
77 |
99 |
There were too man plan choices |
1 |
2 |
77 |
99 |
Costs were too high |
1 |
2 |
77 |
99 |
Other (please specify): _______________________________ |
1 |
2 |
77 |
99 |
13a. A premium is how much you spend each month to have health insurance. Do you or a family member pay a premium for your health insurance?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 14a]
77 DON’T KNOW [GO TO QUESTION 14a]
99 REFUSED [GO TO QUESTION 14a]
13b. Would you say that the cost of your premium is a financial burden to you/your family?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
14a. A deductible is the amount you have to pay before your health insurance or health coverage plan will start paying your medical bills. Do you pay a deductible for your health insurance?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 15a]
77 DON’T KNOW [GO TO QUESTION 15a]
99 REFUSED [GO TO QUESTION 15a]
14b. Would you say that the cost of the deductible is a financial burden to you/your family?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
15a. Do you pay for any medical services that are not covered by your health insurance plan? For example, this may include refills for certain drugs, a visit to a specialist, or exceeding the number of days covered for certain benefits.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 16]
77 DON’T KNOW [GO TO QUESTION 16]
99 REFUSED [GO TO QUESTION 16]
15b. Would you say that these health care costs are a financial burden to you/your family?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
16. Because of the amount that you (or your family) have spent on different types of health care over the last 12 months, have you (or your family) done any of the following?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
Cut back on seeking health care |
1 |
2 |
77 |
99 |
Cut back on other types of spending |
1 |
2 |
77 |
99 |
Cut back on savings or taken money out of savings |
1 |
2 |
77 |
99 |
Added hours at current job or took another job to help cover the costs of health care |
1 |
2 |
77 |
99 |
Had to borrow or take on credit card debt |
1 |
2 |
77 |
99 |
Had to declare bankruptcy |
1 |
2 |
77 |
99 |
Made some other changes (please specify): ____________________________________ |
1 |
2 |
77 |
99 |
17. Was there a time in the past 12 months when you needed to see a doctor or health care provider but could not because of cost?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
18. During the past 12 months, were you prescribed medications by a doctor or other health professional?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 19]
77 DON’T KNOW [GO TO QUESTION 19]
99 REFUSED [GO TO QUESTION 19]
18a. Was there a time in the past 12 months when you did not take your medication as prescribed because of cost? This could include skipping doses, taking less medicine, delaying filling a prescription, or using alternative therapies. Do not include over-the-counter medication.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
NO MEDICATION WAS PRESCRIBED
77 DON’T KNOW
99 REFUSED
ACCESS TO PREVENTIVE HEALTH SERVICES |
19. Do you have one person you think of as your personal doctor or health care provider, including your OB/GYN?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
MORE THAN ONE
77 DON’T KNOW
99 REFUSED
20. What kind of place do you go to most often for healthcare services?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Private doctor’s office or HMO
Community Health Center
Health Department
Family Planning Clinic
Urgent Care/Walk-in clinic
Hospital Emergency Room
Free local clinic
Other (Please specify):__________________________
77 DON’T KNOW
99 REFUSED
21a. Have you had a routine health check or exam in the past 12 months? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 22]
77 DON’T KNOW [GO TO QUESTION 22]
99 REFUSED [GO TO QUESTION 22]
21b. During your last routine check-up, did staff do any of the following? Please select all that apply.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
Talk to you about your health |
1 |
2 |
77 |
99 |
Help you schedule an appointment |
1 |
2 |
77 |
99 |
Help you with transportation |
1 |
2 |
77 |
99 |
Provide a translator/translation |
1 |
2 |
77 |
99 |
Arrange child or eldercare |
1 |
2 |
77 |
99 |
Call to remind you of the appointment |
1 |
2 |
77 |
99 |
Follow up with you to make sure you got your test results |
1 |
2 |
77 |
99 |
Helped you get any follow-up test or treatment needed |
1 |
2 |
77 |
99 |
21c. In the last 12 months, how often did your healthcare provider give you an easy to understand explanation about the next steps for your health questions or concerns?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Never
Sometimes
Usually
Always
77 DON’T KNOW
99 REFUSED
21d. In the last 12 months, did you feel you could trust your healthcare provider with your medical care?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES, DEFINITEELY
YES, SOMEWHAT
NO
77 DON’T KNOW
99 REFUSED
(PROGRAMMER: IF Q21A=YES, GO TO Q23.)
22. If you have not had a routine health check or exam in the past 12 months, what is the main reason?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Seldom or never get sick
Recently moved to area
Don’t know where to go for care
Usual source for preventive care is no longer available
Can’t find a provider who speaks my language
Like to go to different places for different health needs
Just changed insurance plans
Don’t think preventive healthcare is important
Don’t have time
Other (Please specify): _______________
77 DON’T KNOW
99 REFUSED
23. In the past 12 months, did you experience any of the following difficulties getting a routine check-up?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
You couldn’t get through on the telephone. |
1 |
2 |
77 |
99 |
You couldn’t get an appointment soon enough. |
1 |
2 |
77 |
99 |
No one to translate. |
1 |
2 |
77 |
99 |
Once you got there, you had to wait too long to see the doctor. |
1 |
2 |
77 |
99 |
The clinic/doctor’s office wasn’t open when you got there. |
1 |
2 |
77 |
99 |
You didn’t have transportation. |
1 |
2 |
77 |
99 |
You didn’t have childcare or eldercare. |
1 |
2 |
77 |
99 |
You had trouble getting off work. |
1 |
2 |
77 |
99 |
You didn’t have insurance. |
1 |
2 |
77 |
99 |
Previous doctor is not available/moved. |
1 |
2 |
77 |
99 |
Too expensive/cost. |
1 |
2 |
77 |
99 |
Other (please specify): ________________________________ |
1 |
2 |
77 |
99 |
24. In general, how satisfied are you with the health care you received at your routine check-up in the past 12 months?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
77 DON’T KNOW
99 REFUSED
PARTICIPATION IN SCREENING SERVICES |
25a. A mammogram is an x-ray of each breast to look for breast cancer. During the last 12 months, has your healthcare provider recommended you receive a mammogram?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
25b. Have you had a mammogram in the last 12 months?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 26a]
77 DON’T KNOW [GO TO QUESTION 26a]
99 REFUSED [GO TO QUESTION 26a]
25c. Did health care staff do any of the following related to your mammogram?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
Provide education or counseling about mammograms |
1 |
2 |
77 |
99 |
Help you schedule an appointment |
1 |
2 |
77 |
99 |
Help you with transportation |
1 |
2 |
77 |
99 |
Provide a translator/translation |
1 |
2 |
77 |
99 |
Arrange child or eldercare |
1 |
2 |
77 |
99 |
Call to remind you of the appointment |
1 |
2 |
77 |
99 |
Follow up with you to make sure you got your test results |
1 |
2 |
77 |
99 |
Help you get the follow up test or treatment needed |
1 |
2 |
77 |
99 |
25d.Was it recommended for you to have follow-up tests?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 26a]
77 DON’T KNOW [GO TO QUESTION 26a]
99 REFUSED [GO TO QUESTION 26a]
25e. Did you follow the recommendation to have the follow-up tests?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 25g]
77 DON’T KNOW [GO TO QUESTION 25g]
99 REFUSED [GO TO QUESTION 25g]
25f. How much did you pay for the follow-up tests? Please also include co-pay costs, if applicable, when answering this question.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
No costs
Less than $100
More than $100
77 DON’T KNOW
99 REFUSED
[PROGRAMMER: IF Q25e=1, GO TO Q26a.]
25g. What is the most important reason you did not follow the recommendation to have follow-up tests?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
No reason/never thought about it
Put it off/didn’t get around to it
Too expensive/cost
Worried tests would be too painful/unpleasant/embarrassing
Don’t have a doctor
Fear of finding cancer
Other (Please specify): __________________________
77 DON’T KNOW
99 REFUSED
26a. A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you had a clinical breast exam in the last 12 months?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 27a]
77 DON’T KNOW [GO TO QUESTION 27a]
99 REFUSED [GO TO QUESTION 27a]
26b. Did health care staff do any of the following related to your breast exam?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
Provide education or counseling about breast exams |
1 |
2 |
77 |
99 |
Help you schedule an appointment |
1 |
2 |
77 |
99 |
Help you with transportation |
1 |
2 |
77 |
99 |
Provide a translator/translation |
1 |
2 |
77 |
99 |
Arrange child or eldercare |
1 |
2 |
77 |
99 |
Call to remind you of the appointment |
1 |
2 |
77 |
99 |
Follow up with you to make sure you got your test results |
1 |
2 |
77 |
99 |
Help you get the follow up test or treatment needed |
1 |
2 |
77 |
99 |
27a. A Pap test is a test for cervical cancer. During the last 12 months, has your healthcare provider recommended you receive a Pap test?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
27b. Have you had a Pap test in the last 12 months?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 28a]
77 DON’T KNOW [GO TO QUESTION 28a]
99 REFUSED [GO TO QUESTION 28a]
27c. Did health care staff do any of the following related to your Pap test?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
Provide education or counseling about Pap tests |
1 |
2 |
77 |
99 |
Help you schedule an appointment |
1 |
2 |
77 |
99 |
Help you with transportation |
1 |
2 |
77 |
99 |
Provide a translator/translation |
1 |
2 |
77 |
99 |
Arrange child or eldercare |
1 |
2 |
77 |
99 |
Call to remind you of the appointment |
1 |
2 |
77 |
99 |
Follow up with you to make sure you got your test results |
1 |
2 |
77 |
99 |
Help you get the follow up test or treatment needed |
1 |
2 |
77 |
99 |
27d. Was it recommended for you to have follow-up tests?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 28a]
77 DON’T KNOW [GO TO QUESTION 28a]
99 REFUSED [GO TO QUESTION 28a]
27e. Did you follow the recommendation to have the follow-up tests?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 27g]
77 DON’T KNOW [GO TO QUESTION 28a]
99 REFUSED [GO TO QUESTION 28a]
27f.How much did you pay for the follow-up tests? Please also include co-pay costs, if applicable, when answering this question.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
No costs
Less than $100
More than $100
77 DON’T KNOW
99 REFUSED
[PROGRAMMER: AFTER 27f, GO TO QUESTION 28a.]
27g. What is the most important reason you did not follow the recommendation
to have follow-up tests?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
No reason/never thought about it
Put it off/didn’t get around to it
Too expensive/cost
Worried tests would be too painful/unpleasant/embarrassing
Don’t have a doctor
Fear of finding cancer
Other (Please specify): __________________________
77 DON’T KNOW
99 REFUSED
28a. A home blood stool test is a test to determine whether you have blood in your stool or bowel movement. The blood stool test is done at home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab. Has your healthcare provider recommended you receive a blood stool test in the last 12 months?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
28b. Have you had this test using a home kit in the last 12 months?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 29a]
77 DON’T KNOW [GO TO QUESTION 29a]
99 REFUSED [GO TO QUESTION 29a]
28c. Did health care staff do any of the following related to your results of this
home kit test?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
Yes |
No |
DON’T KNOW |
REFUSED |
Provide education or counseling about blood stool tests |
1 |
2 |
77 |
99 |
Help you schedule an appointment |
1 |
2 |
77 |
99 |
Help you with transportation |
1 |
2 |
77 |
99 |
Provide a translator/translation |
1 |
2 |
77 |
99 |
Arrange child or eldercare |
1 |
2 |
77 |
99 |
Call to remind you of the appointment |
1 |
2 |
77 |
99 |
Follow up with you to make sure you got your test results |
1 |
2 |
77 |
99 |
Help you get the follow up test or treatment needed |
1 |
2 |
77 |
99 |
28d. Was it recommended for you to have follow-up tests?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 29a]
77 DON’T KNOW [GO TO QUESTION 29a]
99 REFUSED [GO TO QUESTION 29a]
28e. Did you follow the recommendation to have the follow-up tests?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 28g]
77 DON’T KNOW [GO TO QUESTION 29a]
99 REFUSED [GO TO QUESTION 29a]
28f. How much did you pay for the follow-up tests? Please also include co-pay costs, if applicable, when answering this question.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
No costs
Less than $100
More than $100
77 DON’T KNOW
99 REFUSED
[PROGRAMMER: AFTER 28f, GO TO QUESTION 29a.]
28g. What is the most important reason you did not follow the recommendation to have follow-up tests?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
No reason/never thought about it
Put it off/didn’t get around to it
Too expensive/cost
Worried tests would be too painful/unpleasant/embarrassing
Don’t have a doctor
Fear of finding cancer
Other (Please specify): __________________________
77 DON’T KNOW
99 REFUSED
29a. 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. Has your healthcare provider recommended you receive a sigmoidoscopy or colonoscopy in the last 12 months?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
29b. Have you had either a sigmoidoscopy or colonoscopy in the last 12 months?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 30]
77 DON’T KNOW [GO TO QUESTION 30]
99 REFUSED [GO TO QUESTION 30]
29c. Did health care staff do any of the following related to your sigmoidoscopy or colonoscopy?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
Provide education or counseling about sigmoidoscopy or colonoscopy |
1 |
2 |
77 |
99 |
Help you schedule an appointment |
1 |
2 |
77 |
99 |
Help you with transportation |
1 |
2 |
77 |
99 |
Provide a translator/translation |
1 |
2 |
77 |
99 |
Arrange child or eldercare |
1 |
2 |
77 |
99 |
Call to remind you of the appointment |
1 |
2 |
77 |
99 |
Follow up with you to make sure you got your test results |
1 |
2 |
77 |
99 |
Help you get the follow up test or treatment needed |
1 |
2 |
77 |
99 |
29d. Was it recommended for you to have follow-up tests?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 30]
77 DON’T KNOW [GO TO QUESTION 30]
99 REFUSED [GO TO QUESTION 30]
29e. Did you follow the recommendation to have the follow-up tests?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO QUESTION 29g]
77 DON’T KNOW [GO TO QUESTION 30]
99 REFUSED [GO TO QUESTION 30]
29f. How much did you pay for the follow-up tests? Please also include co-pay costs, if applicable, when answering this question.
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
No costs
Less than $100
More than $100
77 DON’T KNOW
99 REFUSED
[PROGRAMMER: AFTER 29f, GO TO QUESTION 30.]
29g. What is the most important reason you did not follow the recommendation to have follow-up tests?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
No reason/never thought about it
Put it off/didn’t get around to it
Too expensive/cost
Worried tests would be too painful/unpleasant/embarrassing
Don’t have a doctor
Fear of finding cancer
Other (Please specify): __________________________
77 DON’T KNOW
99 REFUSED
30. Have you had your blood pressure checked by a doctor, nurse, pharmacist, or other health professional in the last 12 months?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
31. Have you had a flu vaccination (shot or nasal spray) in the last 12 months?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
32. Have you had a test for high blood sugar or diabetes within the last 12 months?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
33. In terms of the screening services you have received, how satisfied are you with your health care provider?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
77 DON’T KNOW
99 REFUSED
HEALTH OUTCOMES |
34. Would you say that in general your health is?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
Excellent
Very Good
Good
Fair
Poor
77 DON’T KNOW
99 REFUSED
35. Do you have any medical conditions that require you to visit a doctor or health care provider (including specialists) regularly (e.g., quarterly, monthly, weekly)?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO
77 DON’T KNOW
99 REFUSED
36a. Have you ever been diagnosed with cancer?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
YES
NO [GO TO Q37]
77 DON’T KNOW [GO TO Q37]
99 REFUSED [GO TO Q37]
36b. Which of the following cancers have you been diagnosed with?
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
Breast cancer |
1 |
2 |
77 |
99 |
Cervical cancer |
1 |
2 |
77 |
99 |
Colorectal cancer |
1 |
2 |
77 |
99 |
Lung cancer |
1 |
2 |
77 |
99 |
Ovarian cancer |
1 |
2 |
77 |
99 |
Skin cancer |
1 |
2 |
77 |
99 |
Blood cancer |
1 |
2 |
77 |
99 |
Bone cancer |
1 |
2 |
77 |
99 |
Lymphoma |
1 |
2 |
77 |
99 |
Other (please specify): _____________________ |
1 |
2 |
77 |
99 |
37. This last question is about your family history of cancer. Has your biological father, mother, or sibling(s) ever been diagnosed with any of the following cancers:
[INTERVIEWER INSTRUCTION: DO NOT READ ITEMS IN ALL CAPS.]
|
YES |
NO |
DON’T KNOW |
REFUSED |
Breast cancer |
1 |
2 |
77 |
99 |
Cervical cancer |
1 |
2 |
77 |
99 |
Colorectal cancer |
1 |
2 |
77 |
99 |
Lung cancer |
1 |
2 |
77 |
99 |
Ovarian cancer |
1 |
2 |
77 |
99 |
Prostate cancer |
1 |
2 |
77 |
99 |
Skin cancer |
1 |
2 |
77 |
99 |
Blood cancer |
1 |
2 |
77 |
99 |
Bone cancer |
1 |
2 |
77 |
99 |
Lymphoma |
1 |
2 |
77 |
99 |
Other (please specify): ____________________ |
1 |
2 |
77 |
99 |
THANK YOU FOR PARTICIPATING IN THIS SURVEY!
We appreciate your time in providing us with this important information.
We will send out this survey to you again next year for follow-up purposes.
|
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Information Technology |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |