Suggested Scripts and Data Collection Forms for Presumed

The NHANES Longitudinal Study – Feasibility Component

Att 3b_Living SP Forms_Visit_170209

Field Feasibility Test Home Visit

OMB: 0920-1176

Document [docx]

Download: docx | pdf

Attachment 3b

Suggested Scripts and Data Collection Forms

for Presumed Living Participants –

Home Visit

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition, NCHS complies with the Cybersecurity Enhancement Act of 2015. This law requires the Federal government to protect its information by using computer security programs to identify cybersecurity risks against federal computer networks.

NOTICE - CDC estimates the average public reporting burden for this collection of information as 1 hour per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, Georgia, 30333; ATTN: PRA (0920-xxxx).

Attachment 3b. Suggested Scripts and Data Collection Forms for Presumed Living Participants – Home Visit

TABLE OF CONTENTS

SUGGESTED INTRODUCTORY SCRIPTS 4

VERIFICATION PROCEDURE AND QUESTIONNAIRE 6

Verification Procedure 6

Verification Questionnaire 7

SAMPLE PERSON QUESTIONNAIRE 14

Section Contents 14

Respondent Information (RIQ) 21

Hospital Utilization and Access to Care (HUQ) 26

Medical Conditions (MCQ) 28

Diabetes (DIQ) 43

Vision (VIQ) 52

Neuropathy (PNQ) 54

Blood Pressure and Cholesterol (BPQ) 57

Cardiovascular Disease (CDQ) 61

Kidney Conditions (KIQ) 64

Physical Activity (PAQ) 66

Disability (DLQ) 73

Sleep Disorders (SLQ) 77

Weight History (WHQ) 79

Cigarette Smoking (SMQ) 84

Alcohol Use (ALQ) 87

Demographic Information (DMQ) 91

Health Insurance (HIQ) 106

Aspirin and Prescription Medication Use (RXQ – Part 1) 111

Hospitalizations (HVQ) 113

Contact Information (MAQ) 125

Tracking and Tracing (TTQ) 129

Prescription Medication Use (RXQ – Part 2) 134

HOME EXAMINATION DATA COLLECTION 141

Body Measurements 142

Blood Pressure 145

Peripheral Neuropathy Assessment 147

Capillary Blood Collection 151

Suggested Introductory Scripts – Presumed Living Participants

Unscheduled In-Person Visit		Scheduled In-Person Visit
“Hello, my name is ___________ and I am conducting a health survey for the National Center for Health Statistics, part of the Centers for Disease Control and Prevention (CDC). (SHOW ID CARD). I would like to speak with {SP NAME}. Is s/he at home?”		“Hello, my name is ___________ from the National Center for Health Statistics, part of the Centers for Disease Control and Prevention (CDC). (SHOW ID CARD). I have an appointment with {SP NAME} at {APPOINTMENT TIME}.”

Participant Not at Home or Unavailable	Speaking to the Participant	Participant Not at Home or Unavailable	Speaking to the Participant
OBTAIN INFORMATION ON BEST TIME TO REACH THE PARTICIPANT.	“Hello, my name is ___________ and I am conducting a health survey for the National Center for Health Statistics, part of the Centers for Disease Control and Prevention (CDC). (SHOW ID CARD). A letter was sent to you recently to thank you for your participation in the National Health and Nutrition Examination Survey and inviting you to take part in a follow-up study. [IF SP DOES NOT REMEMBER LETTER, HAND NEW COPY.] The study focuses on health conditions such as heart disease and diabetes, and takes place in your home.”	obtain information on best time to reach THE PARTICIPANT.	ASK WHERE WOULD BE A SUITABLE PLACE TO SET UP LAPTOP AND OTHER EQUIPMENT. PROCEED WITH VERIFICATION (UNLESS PREVIOUSLY COMPLETED) AND OBTAIN CONSENT ONCE VERIFIED.

	ANSWER ANY QUESTIONS THE RESPONDENT HAS. PROCEED WITH VERIFICATION AND OBTAINING CONSENT ONCE VERIFIED.

If during the in-person visit, the Health Representative learned that the participant is deceased, the following script is suggested:

“I am sorry for your loss. Please accept my condolences. I would like to ask a few questions about {SP NAME} to make sure we are talking about the same person. Is this a good time?”

If the respondent answered “yes”, the Health Representative will proceed with verification using decedent proxy module (Attachment 3d).

If the respondent expressed that he/she did not want to be interviewed at that time, the Health Representative will thank the respondent and try to visit at another time to complete the verification.

Verification Procedure and Questionnaire - Presumed Living Participants

Two separate sets of questions will be used to verify the presumed living and deceased participants. These questions and verification criteria are adapted from the NHANES I Epidemiologic Follow-up Study (NHEFS).

For presumed living participants

A participant will be considered as successfully traced if the person or a proxy (in the case of those incapacitated) can verify the name of the participant and fulfill one of the criteria below:

Verify at least two of the following three items:

Previously participated in the NHANES
Date of birth
The address at the time of original NHANES interview

Match the last 4 digits of the social security number on file

VERIFICATION – VRQ – PRESUMED LIVING PARTICIPANT

Target Group: SPs 20+ and Proxies

VRQ.005 INTERVIEWER: SELECT INTERVIEW MODE.

IN-PERSON 1

TELEPHONE 2

VRQ.010 INTERVIEWER: SELECT RESPONDENT.

SP 1 (VRQ.020)

PROXY FOR LIVING SP 2

PROXY FOR DECEASED SP 3

VRQ.015 INTERVIEWER: ASK IF PHONE INTERVIEW OR FOR ALL PERSONS WHO APPEAR UNDER 30 YEARS OF AGE.

{Before we begin, I would like to verify your age./First, I need to verify your age.} Are you 18 years or older?

CAPI INSTRUCTION:

IF VRQ.010 = 2 (PROXY FOR LIVING SP), DISPLAY: “Before we begin, I would like to verify your age.”

IF VRQ.005 = 1 AND VRQ.010 = 3 (IDENTIFIED A DECEASED SP DURING HOME VISIT), DISPLAY: “Before we begin, I would like to verify your age.”

IF VRQ.005 = 2 AND VRQ.010 = 3 (PROXY FOR DECEASED SP), DISPLAY: “First, I need to verify your age.”

YES 1

NO 2 (VRQ.270)

BOX 1

CHECK ITEM VRQ.017:

IF VRQ.010 = 2 (PROXY FOR LIVING SP), CONTINUE.

OTHERWISE (PROXY FOR DECEASED SP), GO TO DECEDENT PROXY MODULE (ATTACHMENT 3D)

VRQ.020 {In {BASELINE YEAR} you took part in the National Health and Nutrition Examination Survey (NHANES).}

I’d like to ask you a few questions to verify that {I have/we are talking about} the correct person.

I have {your/SP’s} name as: {SP NAME AT BASELINE}.

INTERVIEWER: READ FULL NAME AND CONFIRM ALL SPELLINGS.

Is that correct?

YES, NO CORRECTIONS 1 (BOX 2)

YES, MINOR CORRECTIONS 2

NO, DIFFERENT NAME 3

REFUSED 7 (BOX 2)

DON’T KNOW 9 (BOX 2)

CAPI INSTRUCTION:

DISPLAY “In {BASELINE YEAR} you took part in the National Health and Nutrition Examination Survey (NHANES).” ONLY IF VRQ.010=1 (RESPONDENT IS THE SP).

IF VRQ.010=1 (RESPONDENT IS THE SP), DISPLAY “I have”.

IF VRQ.010=2 (RESPONDENT IS A PROXY FOR A LIVING SP), DISPLAY “we are talking about”

DISPLAY SP’S FIRST, MIDDLE, LAST NAME AND SUFFIX AT BASELINE.

VRQ.023 INTERVIEWER: MAKE CORRECTIONS OR ENTER DIFFERENT NAME. ENTER “NMN” IF SP DOES

a/b/c/d NOT HAVE A MIDDLE NAME.

a. First name b. Middle name c. Last name d. Suffix

CAPI INSTRUCTION:

PRE-FILL WITH SP’S FIRST, MIDDLE, LAST NAME AND SUFFIX AT BASELINE AND ALLOW INTERVIEWER TO MODIFY FIELDS.

BOX 2

CHECK ITEM VRQ.025:

IF NAME IS A MATCH (VRQ.020 = 1 OR 2), GO TO BOX 3.

OTHERWISE, CONTINUE.

VRQ.030 {Have you/Has he/Has she} ever used this name: {NAME AT BASELINE}?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

DISPLAY SP’S FIRST, MIDDLE, LAST NAME AND SUFFIX AT BASELINE.

BOX 3

CHECK ITEM VRQ.035:

IF VRQ.010 = 2 (PROXY FOR LIVING SP), GO TO VRQ.050.

OTHERWISE, CONTINUE.

VRQ.040 Do you remember participating in NHANES previously?

INTERVIEWER PROMPT: This involved an interview in your home and, a few days later, an examination in the NHANES trailers.

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

VRQ.050 What is {your/SP’s} date of birth?

M/D/Y

|___|___|

ENTER MONTH

|___|___|

ENTER DAY

|___|___|___|___|

ENTER YEAR

REFUSED 7--7

DON’T KNOW 9--9

BOX 4

CHECK ITEM VRQ.055:

IF SP’S ADDRESS AT BASELINE AND SP’S MOST RECENT ADDRESS ARE THE SAME, GO TO VRQ.080.

OTHERWISE, CONTINUE.

VRQ.060 What was {your/SP’s} address in {BASELINE MONTH AND YEAR}?

a/b/c/d/e/

g/h/i __________ _________ _____________________ ___________ ___________ _________

a. STREET # b. DIR PRE c. STREET NAME d. ST/RD/AVE e. DIR POST f. UNIT

___________ ___________________ __________

g. UNIT # h. CITY i. STATE

REFUSED 7 (VRQ.070)

DON’T KNOW 9 (VRQ.070)

CAPI INSTRUCTION:

CHECK TWO-CHARACTER STATE ABBREVIATION AGAINST STATE LOOK-UP TABLE.

BOX 5

CHECK ITEM VRQ.065:

IF ADDRESS IN VRQ.060 IS AN EXACT MATCH WITH ADDRESS AT BASELINE, GO TO VRQ.080. ALL INFORMATION AND SPELLINGS MUST BE THE SAME FOR AN EXACT MATCH.

OTHERWISE, CONTINUE.

VRQ.070 I’m going to read you three different addresses. Please tell me which of these may have been {your/SP’s}

a/b address in {DISPLAY BASELINE MONTH AND BASELINE YEAR}.

ADDRESS #1: {ADDRESS 1}

ADDRESS #2: {ADDRESS 2}

ADDRESS #3: {ADDRESS 3}

ADDRESS 1 1

ADDRESS 2 2

ADDRESS 3 3

NONE 4

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

GENERATE TWO FAKE ADDRESSES WITH THE SAME CITY AND STATE AS THE SP’S BASELINE ADDRESS. ALL OTHER ADDRESS FIELDS SHOULD BE DIFFERENT THAN THE BASELINE ADDRESS.
DISPLAY EACH OF THE FAKE ADDRESSES AND THE COMPLETE ADDRESS AT BASELINE BELOW THE QUESTION TEXT. THE ORDER OF THE ADDRESSES SHOULD BE RANDOM SO THAT THE BASELINE ADDRESS DOESN’T ALWAYS APPEAR IN THE SAME POSITION IN THE LIST.
SAVE THE DISPLAY LOCATION OF THE BASELINE ADDRESS (I.E., 1, 2 OR 3) AS VRQ.070b.

VRQ.080 We would like to ask for the last four digits of {your/SP’s} Social Security Number. This information will help us be certain we have the right NHANES information for {you/SP}. This information will be used for research purposes only. Providing this information is voluntary. Federal laws authorize us to ask for this information and require us to keep it confidential. There will be no effect on {your/SP’s} benefits if you do not provide this information.

What are the last four digits of {your/SP’s} Social Security Number?

|___|___|___|___|

ENTER LAST 4 DIGITS OF SSN

REFUSED 77777

DON'T KNOW 99999

BOX 6

CHECK ITEM VRQ.085:

APPLY LIVING SP MATCHING CRITERIA.

SP IS A MATCH IF

NAME AT BASELINE AND AT VERIFICATION ARE THE SAME AND LAST 4 DIGITS OF SSN AT BASELINE AND AT VERIFICATION ARE THE SAME.

NAMES ARE A MATCH IF VRQ.020 = 1 OR 2, OR R REPORTS USING BASELINE NAME IN THE PAST (VRQ.030 = 1).

NAME AT BASELINE AND AT VERIFICATION ARE THE SAME AND ANY TWO OF THE FOLLOWING CRITERIA ARE MET:

SP REMEMBERS PARTICIPATING IN NHANES (VRQ.040 = 1).
DATE OF BIRTH AT BASELINE AND AT VERIFICATION ARE THE SAME.
CORRECT BASELINE ADDRESS WAS PROVIDED. VRQ.060 IS AN EXACT MATCH WITH BASELINE ADDRESS OR R CORRECTLY IDENTIFIES BASELINE ADDRESS IN VRQ.070.

OTHERWISE, SP IS NOT A MATCH.

BOX 7

CHECK ITEM VRQ.087:

IF VRQ.010 = 2, GO TO VRQ.210.

OTHERWISE, GO TO BOX 13.

VRQ.210 May I have your name?

a/b/c/d

a. First name b. Middle name c. Last name d. Suffix

REFUSED 7

VRQ.220 INTERVIEWER: ASK OR MARK IF KNOWN.

(What is your relationship to {SP}?)

SPOUSE (WIFE/HUSBAND) OR
PARTNER 1

DAUGHTER OR SON (BIOLOGICAL/
ADOPTIVE/IN-LAW/STEP/FOSTER) 2

PARENT (BIOLOGICAL/ADOPTIVE/
STEP/FOSTER) 3

GRANDPARENT (GRANDMOTHER/
GRANDFATHER) 4

BROTHER/SISTER 5

OTHER RELATIVE 6

NON-RELATIVE 7

REFUSED 77

DON'T KNOW 99

BOX 13

CHECK ITEM VRQ.230:

CREATE VERIFICATION MATCH VARIABLE

IF “MATCH” IDENTIFIED IN BOX 6, SET VERIFICATION MATCH TO 1 (MATCH). GO TO VRQ.260.
IF NAME MATCHING CRITERIA NOT MET (VRQ.030 = 2, 7, 9), SET VERIFICATION MATCH TO 2 (NO MATCH - NAMES). GO TO VRQ.240.
IF “NOT A MATCH” IDENTIFIED IN BOX 6, SET VERIFICATION MATCH TO 3 (NO MATCH – OTHER). GO TO VRQ.240.

VRQ.240 Thank you very much but I am not sure whether {you are/SP is} the person we are looking for. I will check the information you have given me against our records. I appreciate your time.

CAPI INSTRUCTION:

IF VRQ.010=1, DISPLAY “you are”.

IF VRQ.010=2 OR 3, DISPLAY “SP is”

BOX 14

CHECK ITEM VRQ.250:

GO TO VRQ.270.

VRQ.260 Thank you very much for answering these questions.

Now I’d like to tell you more about the study.

INTERVIEWER INSTRUCTION: PROCEED WITH CONSENT.

VRQ.270 SET VERIFICATION INSTRUMENT STATUS

COMPLETE 1 (END)

PARTIAL 2

NOT DONE 3

CAPI INSTRUCTION:

SET TO COMPLETE IF ALL ELIGIBLE ITEMS IN PATH HAVE A RESPONSE.

SET TO PARTIAL IF AT LEAST ONE ELIGIBLE ITEM IN PATH HAS NO RESPONSE (e.g., INTERVIEWER BREAKS OFF THE INSTRUMENT).

VRQ.280 REASON FOR PARTIAL OR NOT DONE

SP REFUSAL 2 (END)

NO TIME 3 (END)

COMMUNICATION PROBLEM 5 (END)

EQUIPMENT FAILURE 6 (END)

SP ILL/EMERGENCY 7 (END)

INTERRUPTED 14 (END)

LANGUAGE BARRIER 122 (END)

OTHER, SPECIFY 99 (END)

BOX 15

PROGRAMMER INSTRUCTIONS:

VERIFICATION INSTRUMENT SHOULD ALWAYS BE ENABLED IN BFOS. INSTRUMENT MAY BE ADMINISTERED MORE THAN ONCE.
RETAIN EACH ADMINISTRATION OF THE INSTRUMENT AS A SEPARATE RECORD.
PASS VERIFICATION MATCH VARIABLE TO BFOS.
CONSENT INSTRUMENT CANNOT BE ADMINISTERED UNLESS VERIFICATION MATCH = 1 AND VRQ.010 = 1, 2.

Sample Person Questionnaire for Living Participants

Component	Description	Baseline Question⁰	Source (For Non-Baseline Questions)
Sociodemographic Information
Respondent information (RIQ)	Permission to audio-record the interview Proxy respondent (if used): name, relationship to the sampled participant Interpreter (if used): name, gender, age, and phone number; language used; how the interpreter was obtained	Yes
Demographic information of the sampled participant (DMQ)	Verify name, date of birth, age, and gender Current marital status Employment status in the previous week; for those not working in the previous week, the reason of not working Family composition (number of people in the family and relationships), and family income	Yes
Participant’s contact information (MAQ)	Addresses and phone numbers	Yes
Participant’s contact information (MAQ)	E-mail address	No	New question
Tracking and tracing information (TTQ)	Name, address, and phone number of two persons who can help locate the respondent in the future	Yes
Health Status and Medical Conditions
Medical conditions (MCQ)	Being diagnosed with the following conditions since baseline; the age of onset; related hospitalizations Congestive heart failure, coronary heart disease, angina, heart attack, stroke, asthma, chronic obstructive pulmonary disease	Yes
Medical conditions (MCQ)	Having the following surgeries or procedures on heart or blood vessels, ever and since baseline; the age of surgery Coronary bypass, repair of an aortic aneurysm, a pacemaker or implanted cardioverter defibrillator (ICD) placed, angioplasty or stenting of the coronary arteries, surgery on the arteries in the neck or legs, or other heart or blood vessel surgery Having toe or leg amputation since the baseline; the age of surgery	No	Adapted from NIH’s REasons for Geographic and Racial Differences in Stroke (REGARDS) project; modifications were made with input from CCQDER
Diabetes (DIQ)	Being diagnosed with diabetes, prediabetes, or gestational diabetes since baseline (only be asked to persons who did not report these conditions at baseline); the age of onset The following items are collected to be used as covariates for diabetes related analysis Having close blood relatives with diabetes Current use of insulin, diabetic pills, and other diabetic medicine requiring a needle Having ever seen a diabetes nurse educator or dietitian or nutritionist Having a regular doctor for diabetes in the last 12 months Self-checking blood sugar in the last 12 months Having hemoglobin A1c checked in the last 12 months	Yes
Diabetes (DIQ)	Ever being diagnosed with peripheral arterial disease or peripheral vascular disease	No	Atherosclerosis Risk in Communities Study (ARIC)
Vision (VIQ)	When was the last eye exam Ever being diagnosed with cataract, glaucoma, retinopathy, or macular degeneration	No	NHANES 2007-08 ophthalmology component
Vision (VIQ)	Having lost vision because of diabetic retinopathy or macular degeneration	No	NHIS questionnaire
Neuropathy (PNQ)	The module includes 14 questions on the sensory/feeling in the legs and feet, and needs to be administered in its entirety to create the MNSI score indicating the likelihood of neuropathy	No	Michigan Neuropathy Screening Instrument (MNSI)
Blood pressure and cholesterol (BPQ)	Being diagnosed with hypertension since baseline; the age of onset; being told to take prescription medicine for hypertension (only be asked to persons who did not provide affirmative responses at baseline) Currently taking prescription medicine for hypertension Being diagnosed with high cholesterol since baseline; being told to take prescription medicine for high cholesterol (only be asked to persons who did not provide affirmative responses at baseline) Currently taking prescription medicine for high cholesterol	Yes
Cardiovascular disease (CDQ)	Identifying undiagnosed angina (only be asked to persons who were not identified with undiagnosed angina at baseline)	Yes
Kidney conditions (KIQ)	Being diagnosed with failing kidneys since baseline Having received dialysis in the last 12 months	Yes
Kidney conditions (KIQ)	Ever being diagnosed with chronic kidney disease or having a kidney transplant	No	New questions developed based on Tuot DS, Zhu Y, Velasquez A, et al. Clin J Am Soc Nephrol. 2016 Jun 23. CJN.00490116.
Disability (DLQ)	Use of eyeglasses or contact lenses, or hearing aid Level of difficulty seeing, hearing, walking or climbing steps, communicating in usual language, remembering, concentrating, self-caring such as washing or dressing, raising a 2-liter bottle, using hands and fingers, doing errands alone, participating in social activities Frequency of feeling worried, nervous, or anxious; level of these feelings Frequency of feeling depressed; level of depressed Whether a physical, mental, or emotional problem prevent working	No	Washington Group on Disability Statistics’ Extended Set on Functioning (WG ES-F) module. They have been cognitive and field tested in all regions of the world: http://www.washingtongroup-disability.com/methodology-and-research/testing-methodology/. These questions have been included in the NHIS since 2009, and are also included in the re-designed 2018 NHIS.
Health Care Services
Hospital utilization and access to care (HUQ)	Regular source and place of care	Yes
Health insurance (HIQ)	Current health insurance coverage; type of health insurance Medicare health insurance claim number – for Medicare/Medicaid linkage	Yes
Hospitalizations (HVQ)	List of overnight hospital stays since baseline HIPAA authorization for obtaining hospitalization records	No	New questions developed with input from CCQDER
Health Behaviors
Physical activity (PAQ)	How much vigorous and moderate physical activities are done at work, for transportation, and recreationally, in a typical week Time spent on sitting in a typical day	Yes
Sleep disorders (SLQ)	Hours of sleep on weekdays Self-observed symptoms of obstructive sleep apnea in the last 12 month Self-evaluation on excessively or overly sleepiness during the day In the past month Sought medical evaluation for sleeping disorder	No	NHANES 2015-16
Weight history (WHQ)	Participants’ self-reported heights and weights, their self-perception of weight status, and their weight control practices in the last 12 months.	Yes
Cigarette smoking (SMQ)	Identifying new cigarette smokers since baseline; and the age of starting smoking The amount of cigarettes smoked daily by current smokers Identifying any cigarette smokers who quit smoking since baseline, the time of cessation, and the amount of cigarettes smoked daily prior to cessation	Yes
Alcohol use (ALQ)	Identifying new drinkers since baseline; and the age of starting drinking The amount of drinks consumed in the past 12 months by current drinkers Identifying any heavy or binge drinkers in the past 12 months	Yes
Aspirin and prescription medication use (RXQ)	Current use of prescription medications and the reason(s) of use	Yes
	Current use of low-dose aspirin	No	NHANES 2011-12
	For aspirin users: reason(s) of use For non-aspirin users: having a health problem or condition that makes taking aspirin unsafe	No	New questions developed based on NHANES prescription medication questions

NHANES Longitudinal Study Sample Person Questionnaire for Living Participants

RESPONDENT INFORMATION – RIQ

Target Group: SPs 20+

RIQ.INTRO Thank you for agreeing to participate in this phase of NHANES. Taking part in this study will help us learn how to better measure the health of persons, such as yourself, who live in the U.S.

RIQ.231 CAPI INSTRUCTION: BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING.

A standard part of our quality control procedures is to record the home visit. The information being recorded is protected and kept confidential, the same as all of your answers to the survey. This recording will be used to improve the quality of our survey and to review the quality of my work.

The computer is now recording our conversation.

Do I have your permission to continue recording?

YES 1

NO 2

CAPI INSTRUCTION: IF RIQ.231 = 2/NO, STOP RECORDING.

RIQ.001 INTERVIEWER: SELECT INTERVIEW MODE

IN-PERSON 1

PHONE 2

SOFT EDIT:

2, ERROR MESSAGE ”Please verify that interview mode is phone.”

RIQ.002 INTERVIEWER: SELECT RESPONDENT FOR THE SP QUESTIONNAIRE.

SP 1 (INT.001)

PROXY 2

RIQ.014 INTERVIEWER: ASK OR MARK IF KNOWN.

(What is your relationship to {SP}?)

SPOUSE (WIFE/HUSBAND) OR
PARTNER 1

DAUGHTER OR SON (BIOLOGICAL/
ADOPTIVE/IN-LAW/STEP/FOSTER) 2

PARENT (BIOLOGICAL/ADOPTIVE/
STEP/FOSTER) 3

GRANDPARENT (GRANDMOTHER/
GRANDFATHER) 4

BROTHER/SISTER 5

OTHER RELATIVE 6

NON-RELATIVE 7

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

Living with an ex-spouse or ex-partner should be coded as a non-relative.

RIQ.039 WHY IS INTERVIEW BEING CONDUCTED WITH A PROXY?

SP HAS COGNITIVE PROBLEMS 1

SP HAS PHYSICAL PROBLEMS

(SPECIFY) 2

INT.001 IS AN INTERPRETER BEING USED FOR INTERVIEW?

YES 1

NO 2 (DMQ.010)

INT.003 LANGUAGE USED FOR INTERVIEW

AMERICAN SIGN LANGUAGE 1 (INT.015)

CHINESE (CANTONESE) 2 (INT.015)

CHINESE (MANDARIN) 3 (INT.015)

FRENCH 4 (INT.015)

GERMAN 5 (INT.015)

ITALIAN 6 (INT.015)

JAPANESE 7 (INT.015)

KOREAN 8 (INT.015)

RUSSIAN 9 (INT.015)

SPANISH (READER) 10 (INT.015)

VIETNAMESE 11 (INT.015)

OTHER SPECIFY 99

INT.004 ENTER LANGUAGE USED FOR INTERVIEW

_________________________________

INT.015 HOW WAS INTERPRETER OBTAINED

ARRANGED IN ADVANCE OF VISIT 1 (INT.009)

RECRUITED DURING VISIT/APPOINTMENT 2

INT.007 SELECT INTERPRETER SOURCE

RELATIVE LIVING IN HOUSEHOLD 1

NON-RELATIVE LIVING IN HOUSEHOLD 2

NEIGHBOR, RELATIVE OR FRIEND –
NOT IN HOUSEHOLD 3

INT.009 ENTER NAME OF INTERPRETER

______________________________________

INT.010 ENTER PHONE # OF INTERPRETER

___ - ___ ____

INT.011 ENTER AGE RANGE OF INTERPRETER

{AGE RANGE CAN BE A PULL DOWN LIST}

RANGES = 18-29

30-59

60+

INT.012 ENTER GENDER OF INTERPRETER

MALE 1

FEMALE 2

DMQ.010 I would like to begin the health interview by verifying some information about {you/SP}.

VERIFY OR ASK DATE OF BIRTH.

CAPI INSTRUCTION:

DISPLAY NAME, DOB MONTH, DAY AND YEAR. ALLOW DOB FIELDS TO BE UPDATED.

PUT DMQ.010 AND DMQ.012 ON THE SAME SCREEN.

DMQ.012 VERIFY OR ASK AGE.

CAPI INSTRUCTION:

DISPLAY NAME AND AGE IN YEARS. ALLOW AGE FIELD TO BE UPDATED.

PUT DMQ.010 AND DMQ.012 ON THE SAME SCREEN.

DMQ.020 VERIFY GENDER.

MALE 1

FEMALE 2

CAPI INSTRUCTION:

PREFILL WITH GENDER FROM BASELINE AND ALLOW UPDATE.

SOFT EDIT: IF THE GENDER IS DIFFERENT FROM BASELINE, DISPLAY THE FOLLOWING MESSAGE: “CODED VALUE IS DIFFERENT THAN GENDER REPORTED AT BASELINE. PLEASE CHECK VALUE ENTERED.”

DMQ.042 VERIFY OR ASK PREFIX.

Dr 1

Mr 2

Mrs 3

Ms 4

Miss 5

Master 6

DMQ.044 VERIFY OR ASK FIRST NAME

First Name: __________________________

CAPI INSTRUCTION:

PREFILL FIRST NAME. ALLOW UPDATES.

DMQ.048 VERIFY OR ASK MIDDLE NAME

INTERVIEWER INSTRUCTION:

ENTER “NMN” IF NO MIDDLE NAME.

Middle Name#1: __________________________

Middle Name #2: __________________________

CAPI INSTRUCTION:

PREFILL MIDDLE NAME. ALLOW UPDATES.

DMQ.062 VERIFY OR ASK LAST NAME.

A/B

Last Name #1: __________________________

Last Name #2: __________________________

CAPI INSTRUCTION:

PREFILL LAST NAME. ALLOW UPDATES.

DMQ.068 VERIFY OF OR ASK SUFFIX

Suffix: _________

CAPI INSTRUCTION:

PREFILL SUFFIX. ALLOW UPDATES.

ALLOW SUFFIX FIELD TO BE LEFT BLANK/NULL.

HOSPITAL UTILIZATION AND ACCESS TO CARE - HUQ
Target Group: SPs 20+

HUQ.010 Next I have some general questions about {your/SP's} health.

Would you say {your/SP's} health in general is . . .

excellent, 1

very good, 2

good, 3

fair, or 4

poor? 5

REFUSED 7

DON'T KNOW 9

HUQ.030 Is there a place that {you/SP} usually {go/goes} when {you are/he/she is} sick or {you/s/he} need{s} advice about {your/his/her} health?

YES 1

THERE IS NO PLACE 2 (END OF SECTION)

THERE IS MORE THAN ONE PLACE 3

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HELP SCREEN:

Usual Place: Include walk-in clinic, doctor's office, clinic, health center, Health Maintenance Organization or HMO, hospital emergency room or outpatient clinic, or a military or VA health care facility.

HUQ.041 {What kind of place is it – a clinic, doctor's office, emergency room, or some other place?}

{What kind of place {do you/does SP} go to most often – a clinic, doctor’s office, emergency room, or some other place?}

CLINIC OR HEALTH CENTER 1

DOCTOR'S OFFICE OR HMO 2

HOSPITAL EMERGENCY ROOM 3

HOSPITAL OUTPATIENT DEPARTMENT 4

SOME OTHER PLACE 5

DOESN’T GO TO ONE PLACE MOST

OFTEN 6

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF HUQ.030 = 1 DISPLAY “What kind of place is it – a clinic, doctor's office, emergency room, or some other place?”

IF HUQ.030 = 3 DISPLAY “What kind of place {do you/does SP} go to most often – a clinic, doctor's office, emergency room, or some other place?”

HELP SCREEN FOR HUQ.041:

Clinic: Refers to a facility where medical care and advice are given by doctors, nurses, or other medical professionals, that is not located at a hospital. (Do not include hospital outpatient departments.) Include a clinic operated solely for employees of a company or industry, regardless of where the clinic is located.

Doctor's Office: In Hospital - An individual office in a hospital where patients are seen on an outpatient basis, or several doctors might occupy a suite of offices in a hospital where patients are treated as outpatients.

Doctor's Office: Not in Hospital - An individual office in the doctor's home or office building, or a suite of offices occupied by several doctors. Suites of doctors offices are not considered clinics.

Health Center: Refers to a facility where medical care and advice are given by doctors, nurses, or other medical professionals that is not located at a hospital.

HMO Clinic: A medical facility sponsored by an HMO that typically includes a group of doctors on staff.

Hospital Emergency Room: Emergency Room may also be called “the ER” or Emergency Department or ED.

Hospital Outpatient Department: A unit of a hospital providing health and medical services to individuals who receive services from the hospital but do not require hospitalization overnight, such as outpatient surgery centers. Examples of outpatient departments include the following:

Well-baby clinics/pediatric OPD;

Obesity clinics;

Eye, ear, nose, and throat clinics;

Cardiology clinic;

Internal medicine department;

Family planning clinics;

Alcohol and drug abuse clinics;

Physical therapy clinics; and

Radiation therapy clinics.

Hospital outpatient departments may also provide general primary care.

MEDICAL CONDITIONS – MCQ

Target Group: SPs 20+

The following questions are about different medical conditions. We are only interested in health conditions that may have occurred since {BASELINE YEAR} when {you were/SP was} {AGE AT BASELINE} years old, which is when {you/she/he} last told us about {your/his/her} health in the NHANES mobile exam center.

MCQ.162
Since {you were/SP was} {AGE AT BASELINE} years old, that is, since we asked about {your/his/her} health during {your/his/her} original NHANES interview, has a doctor or other health professional told {you/SP} that {you/s/he} . . .

CAPI INSTRUCTION:

DISPLAY QUESTION TEXT ABOVE FOR MCQ.162b.

[Since {you were/SP was} {AGE AT BASELINE} years old, has a doctor or other health professional told {you/SP} that {you/s/he}…]

CAPI INSTRUCTION:

DISPLAY QUESTION TEXT ABOVE FOR MCQ.162c-q.

MCQ.182
How old {were you/was SP} when
{you were/s/he was} told
you/s/he} . . .

INTERVIEWER INSTRUCTION:
IF THE SP WAS TOLD ON MULTIPLE OCCASIONS AFTER THEIR ORIGINAL NHANES INTERVIEW IN {BASELINE YEAR} THAT {SP/S/HE} HAD A CONDITION, RECORD THE AGE WHEN THEY WERE FIRST TOLD ABOUT THE CONDITION AFTER THEIR ORIGINAL NHANES INTERVIEW.

HARD EDIT:
REPORTED AGE NEEDS TO BE EQUAL TO OR OLDER THAN THE BASELINE AGE.

MCQ.197
Since {you were/SP was} {AGE AT BASELINE} years old {have you/has SP} stayed overnight in the hospital for . .

b. had congestive heart failure?

YES 1

NO 2 (MCQ.162c)

REFUSED 7 (MCQ.162c)

DON'T KNOW 9 (MCQ.162c)

had congestive heart failure?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

congestive heart failure?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

c. had coronary (kor-o-nare-ee) heart disease?

YES 1

NO 2 (MCQ. 162d)

REFUSED 7 (MCQ. 162d)

DON'T KNOW 9 (MCQ. 162d)

had coronary heart disease?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

coronary heart disease?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

d. had angina (an-gī-na), also called angina pectoris?

YES 1

NO 2 (MCQ.162e)

REFUSED 7 (MCQ.162e)

DON'T KNOW 9 (MCQ.162e)

had angina, also called angina pectoris?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

angina pectoris?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

e. had a heart attack (also called myocardial infarction (my-O-car-dee-al in-fark-shun))?

YES 1

NO 2 (MCQ.162f)

REFUSED 7 (MCQ.162f)

DON'T KNOW 9 (MCQ.162f)

had a heart attack (also called myocardial infarction)?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

a heart attack?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

f. had a stroke?

YES 1

NO 2 (MCQ.162p)

REFUSED 7 (MCQ.162p)

DON'T KNOW 9 (MCQ.162p)

had a stroke?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

a stroke?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

p. had asthma (az-ma)?

YES 1

NO 2 (MCQ.162q)

REFUSED 7 (MCQ.162q)

DON'T KNOW 9 (MCQ.162q)

had asthma?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

asthma?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

q. had COPD, emphysema or chronic bronchitis?

YES 1

NO 2 (MCQ.400)

REFUSED 7 (MCQ.400)

DON'T KNOW 9 (MCQ.400)

had COPD, emphysema or chronic bronchitis?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

COPD, emphysema or chronic bronchitis?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREENS FOR MCQ.162

MCQ162b

Congestive Heart Failure: Is when the heart can't pump enough blood to the body. Blood and fluid "back up" into the lungs, which makes you short of breath. Heart failure causes fluid buildup in and swelling of the feet, legs and ankles.

INTERVIEWER: DO NOT COUNT HEART MURMURS, IRREGULAR HEART BEATS, CHEST PAIN OR HEART ATTACKS.

MCQ162c

Coronary Heart Disease: Is when the blood vessels that bring blood to the heart muscle become narrow and hardened due to plaque (plak). Plaque buildup is called atherosclerosis (ATH-er-o-skler-O-sis). Blocked blood vessels to the heart can cause chest pain or a heart attack.

INTERVIEWER: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR CORONARY HEART DISEASE.

MCQ162d

Angina (Angina Pectoris): (AN-ji-na or an-JI-na). Angina is chest pain or discomfort that occurs when the heart does not get enough blood.

INTERVIEWER: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR ANGINA.

MCQ162e

Heart Attack (Myocardial Infarction): A heart attack happens when there is narrowing of a blood vessel that supplies the heart. A blood clot can form and suddenly cut off the blood supply to the heart muscle. This damage causes crushing chest pain that may also be felt in the arms or neck. There can also be nausea, sweating, or shortness of breath.

MCQ162f

Stroke: Is when the blood supply to a part of the brain is suddenly cut off by a blood clot or a burst blood vessel in the brain. The part of the brain affected can no longer do its job. There can be numbness or weakness on one side of the body; trouble speaking or understanding speech; loss of eyesight; trouble with walking, dizziness, loss of balance or coordination; or severe headache.

MCQ162p

Asthma: Is a disease of the airways that carry air in and out of your lungs. It causes wheezing or whistling sounds when you breathe and can make you short of breath.

INTERVIEWER: DO NOT ACCEPT SELF-DIAGNOSED OR DIAGNOSED BY A PERSON WHO IS NOT A DOCTOR OR OTHER HEALTH PROFESSIONAL.

MCQ162q

COPD: stands for “Chronic Obstructive Pulmonary Disease.” It includes both Emphysema and Chronic Bronchitis. It is lung problem where you have trouble getting air in and out of your lungs. You may also have constant cough and phlegm.

Emphysema: Is disease where the tiny air sacs in the lungs become damaged so less air goes in and out. As a result, the body does not get the oxygen it needs. Emphysema makes it hard to catch your breath. It is often due to smoking.

Chronic Bronchitis: Is a long lasting breathing problem where you constantly cough up phlegm. Often there is a daily cough with phlegm for several months at a time for two or more years and you are short of breath. It is often due to smoking.

MCQ.400 I am now going to ask about surgeries or procedures {you/SP} may have had on {your/his/her} heart or blood vessels.

{Have you/has SP} ever had coronary bypass surgery, such as a graft, CABG (cabbage) or a bypass procedure on the arteries of {your/his/her} heart?

YES 1

NO 2 (MCQ.410)

REFUSED 7 (MCQ.410)

DON'T KNOW 9 (MCQ.410)

HELP SCREEN:

Coronary bypass surgery, which may also be called a graft, CABG, or bypass procedure, is surgery on the coronary arteries. The coronary arteries provide blood to the heart. The surgery to the coronary arteries is done to improve blood flow to the heart. When coronary bypass surgery is performed, a vein or artery taken from another part of your body is used to bypass narrowed areas of the coronary artery. Many people who have this surgery stay in the hospital for 3 or more days following the surgery and may have a scar in the middle of their chest.

MCQ.405 How old {were you/was SP} when {you/s/he} first had this coronary bypass surgery, a graft, CABG or bypass procedure?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

BOX 1

CHECK ITEM MCQ.406:

IF THE AGE REPORTED IN MCQ.405 IS OLDER THAN THE AGE AT BASELINE, GO TO MCQ.410.

OTHERWISE, CONTINUE.

MCQ.407 {Have you/Has SP} had any other coronary bypass surgery, a graft, CABG or bypass procedure since {BASELINE YEAR} when {you were/SP was} {AGE AT BASELINE} years old?

YES 1

NO 2 (MCQ.410)

REFUSED 7 (MCQ.410)

DON'T KNOW 9 (MCQ.410)

MCQ.408 How old {were you/was SP} when {you/s/he} had that coronary bypass surgery, a graft, CABG or bypass procedure?

INTERVIEWER INSTRUCTION:

IF THE SP HAD THE PROCEDURE DONE MULTIPLE TIMES SINCE BASELINE, RECORD THE AGE WHEN THEY FIRST HAD THE PROCEDURE AFTER THEIR ORIGINAL NHANES INTERVIEW.

HARD EDIT:

REPORTED AGE NEEDS TO BE EQUAL TO OR OLDER THAN THE BASELINE AGE.

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

MCQ.410 {Have you/Has SP} ever had a surgery or procedure on the arteries in {your/his/her} neck?

YES 1

NO 2 (MCQ.420)

REFUSED 7 (MCQ.420)

DON'T KNOW 9 (MCQ.420)

HELP SCREEN:

On each side of the neck is a large artery called the carotid artery. The procedure to this artery is done to remove blockages and improve blood flow to the brain. Sometimes doctors call this surgery carotid endarterectomy, carotid artery stenosis surgery, or carotid artery endarterectomy.

MCQ.415 How old {were you/was SP} when {you/s/he} first had this surgery or procedure on the arteries in {your/his/her} neck?

INTERVIEWER INSTRUCTION:

IF THE SP HAD THE PROCEDURE DONE MULTIPLE TIMES SINCE BASELINE, RECORD THE AGE WHEN THEY FIRST HAD THE PROCEDURE AFTER THEIR ORIGINAL NHANES INTERVIEW.

HARD EDIT:

REPORTED AGE NEEDS TO BE EQUAL TO OR OLDER THAN THE BASELINE AGE.

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

BOX 2

CHECK ITEM MCQ.416:

IF THE AGE REPORTED IN MCQ.415 IS OLDER THAN THE AGE AT BASELINE, GO TO MCQ.420.

OTHERWISE, CONTINUE.

MCQ.417 {Have you/Has SP} had any other surgery or procedure on the arteries in {your/his/her} neck since {you were/SP was} {AGE AT BASELINE} years old?

YES 1

NO 2 (MCQ.420)

REFUSED 7 (MCQ.420)

DON'T KNOW 9 (MCQ.420)

MCQ.418 How old {were you/was SP} when {you/s/he} had that surgery on the arteries in {your/his/her} neck?

INTERVIEWER INSTRUCTION:

IF THE SP HAD THE PROCEDURE DONE MULTIPLE TIMES SINCE BASELINE, RECORD THE AGE WHEN THEY FIRST HAD THE PROCEDURE AFTER THEIR ORIGINAL NHANES INTERVIEW.

HARD EDIT:

REPORTED AGE NEEDS TO BE EQUAL TO OR OLDER THAN THE BASELINE AGE.

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

MCQ.420 {Have you/Has SP} ever had a repair of an aortic (a-ORT-ick) aneurysm (AN-yur-ism)?

YES 1

NO 2 (MCQ.430)

REFUSED 7 (MCQ.430)

DON'T KNOW 9 (MCQ.430)

HELP SCREEN:

An aortic aneurysm is a balloon-like bulge in the aorta, the large artery that carries blood from the heart through the chest and abdomen (or belly). If the bulging stretches the artery too far, this vessel may burst. The surgery is done when the aneurysm gets too big or causes severe health problems.

MCQ.425 How old {were you/was SP} when {you/s/he} first had this repair of an aortic aneurysm?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

BOX 3

CHECK ITEM MCQ.426:

IF THE AGE REPORTED IN MCQ.425 IS OLDER THAN THE AGE AT BASELINE, GO TO MCQ.430.

OTHERWISE, CONTINUE.

MCQ.427 {Have you/Has SP} had any other repair of an aortic aneurysm since {you were/SP was} {AGE AT BASELINE} years old?

YES 1

NO 2 (MCQ.430)

REFUSED 7 (MCQ.430)

DON'T KNOW 9 (MCQ.430)

MCQ.428 How old {were you/was SP} when {you/s/he} had that repair of an aortic aneurysm?

INTERVIEWER INSTRUCTION:

IF THE SP HAD THE PROCEDURE DONE MULTIPLE TIMES SINCE BASELINE, RECORD THE AGE WHEN THEY FIRST HAD THE PROCEDURE AFTER THEIR ORIGINAL NHANES INTERVIEW.

HARD EDIT:

REPORTED AGE NEEDS TO BE EQUAL TO OR OLDER THAN THE BASELINE AGE.

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

MCQ.430 {Have you/Has SP} ever had a pacemaker implanted or implantable cardioverter defibrillator (ICD) placed?

YES 1

NO 2 (MCQ.440)

REFUSED 7 (MCQ.440)

DON'T KNOW 9 (MCQ.440)

HELP SCREEN:

A pacemaker is a small, battery-operated device that senses when your heart is beating irregularly or too slowly. It sends a signal to your heart that makes your heart beat at the correct pace.

An implantable cardioverter defibrillator, or ICD, monitors heart rhythms. If it senses dangerous rhythms, it delivers shocks. This treatment is called defibrillation. An ICD can help control life-threatening arrhythmias.

MCQ.435 How old {were you/was SP} when {you/s/he} first had this pacemaker or implantable cardioverter defibrillator placed?

INTERVIEWER INSTRUCTION:

IF THE SP HAD THE PROCEDURE DONE MULTIPLE TIMES SINCE BASELINE, RECORD THE AGE WHEN THEY FIRST HAD THE PROCEDURE AFTER THEIR ORIGINAL NHANES INTERVIEW.

HARD EDIT:

REPORTED AGE NEEDS TO BE EQUAL TO OR OLDER THAN THE BASELINE AGE.

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

MCQ.440 {Have you/Has SP} ever had an angioplasty (AN-gee-o-plas-tee) or stenting of a coronary artery with or without placing a coil in the artery to keep it open?

YES 1

NO 2 (MCQ.450)

REFUSED 7 (MCQ.450)

DON'T KNOW 9 (MCQ.450)

HELP SCREEN:

Angioplasty, or stenting of a coronary artery, is a procedure on the coronary arteries. The coronary arteries provide blood to the heart. The procedure to the coronary arteries is done to reduce blockages and improve blood flow to the heart. When angioplasty is performed, a doctor threads a thin tube through a blood vessel in the arm or groin up to the coronary artery. Many people who have this procedure stay overnight in the hospital for 2 or less days but some people do not need to stay overnight.

MCQ.445 How old {were you/was SP} when {you/s/he} first had this angioplasty or stenting of the coronary arteries?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

BOX 4

CHECK ITEM MCQ.446:

IF THE AGE REPORTED IN MCQ.445 IS OLDER THAN THE AGE AT BASELINE, GO TO MCQ.450.

OTHERWISE, CONTINUE.

MCQ.447 {Have you/Has SP} had any other angioplasty or stenting of the coronary arteries since {you were/SP was} {AGE AT BASELINE} years old?

YES 1

NO 2 (MCQ.450)

REFUSED 7 (MCQ.450)

DON'T KNOW 9 (MCQ.450)

MCQ.448 How old {were you/was SP} when {you/s/he} had that angioplasty or stenting of the coronary arteries?

INTERVIEWER INSTRUCTION:

IF THE SP HAD THE PROCEDURE DONE MULTIPLE TIMES SINCE BASELINE, RECORD THE AGE WHEN THEY FIRST HAD THE PROCEDURE AFTER THEIR ORIGINAL NHANES INTERVIEW.

HARD EDIT:

REPORTED AGE NEEDS TO BE EQUAL TO OR OLDER THAN THE BASELINE AGE.

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

MCQ.450 {Have you/Has SP} ever had a procedure to treat blocked arteries in {your/his/her} legs (do not include cosmetic surgery on the legs such as varicose vein stripping)?

YES 1

NO 2 (MCQ.460)

REFUSED 7 (MCQ.460)

DON'T KNOW 9 (MCQ.460)

HELP SCREEN:

When there is a blocked or narrow artery in the leg, a procedure can be done to improve blood flow to the leg. There are several type of procedures that can be done for this problem. Sometimes doctors call these procedures bypass grafting, angioplasty and stent placement, or atherectomy.

MCQ.455 How old {were you/was SP} when {you/s/he} first had this procedure to treat the blocked arteries in {your/his/her} legs?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

BOX 5

CHECK ITEM MCQ.456:

IF THE AGE REPORTED IN MCQ.455 IS OLDER THAN THE AGE AT BASELINE, GO TO MCQ.460.

OTHERWISE, CONTINUE.

MCQ.457 {Have you/Has SP} had any other procedure to treat blocked arteries in {your/his/her} legs since {you were/SP was} {AGE AT BASELINE} years old (do not include cosmetic surgery on the legs such as varicose vein stripping)?

YES 1

NO 2 (MCQ.460)

REFUSED 7 (MCQ.460)

DON'T KNOW 9 (MCQ.460)

MCQ.458 How old {were you/was SP} when {you/s/he} had that procedure to treat the blocked arteries in {your/his/her} legs?

INTERVIEWER INSTRUCTION:

IF THE SP HAD THE PROCEDURE DONE MULTIPLE TIMES SINCE BASELINE, RECORD THE AGE WHEN THEY FIRST HAD THE PROCEDURE AFTER THEIR ORIGINAL NHANES INTERVIEW.

HARD EDIT:

REPORTED AGE NEEDS TO BE EQUAL TO OR OLDER THAN THE BASELINE AGE.

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

MCQ.460 {Have you/Has SP} ever had any other heart or blood vessel surgery?

INTERVIEWER INSTRUCTION:

DO NOT INCLUDE COSMETIC SURGERY, SUCH AS VARICOSE VEIN BLOOD VESSEL SURGERY IN THE LEGS.

YES 1

NO 2 (MCQ.470)

REFUSED 7 (MCQ.470)

DON'T KNOW 9 (MCQ.470)

MCQ.465 How old {were you/was SP} when {you/s/he} first had this other heart or blood vessel surgery?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

BOX 6

CHECK ITEM MCQ.466:

IF THE AGE REPORTED IN MCQ.465 IS OLDER THAN THE AGE AT BASELINE, GO TO MCQ.470.

OTHERWISE, CONTINUE.

MCQ.467 {Have you/Has SP} had any other heart or blood vessel surgery since {you were/SP was} {AGE AT BASELINE} years old?

YES 1

NO 2 (MCQ.470)

REFUSED 7 (MCQ.470)

DON'T KNOW 9 (MCQ.470)

MCQ.468 How old {were you/was SP} when {you/s/he} had that heart or blood vessel surgery?

INTERVIEWER INSTRUCTION:

IF THE SP HAD THE PROCEDURE DONE MULTIPLE TIMES SINCE BASELINE, RECORD THE AGE WHEN THEY FIRST HAD THE PROCEDURE AFTER THEIR ORIGINAL NHANES INTERVIEW.

HARD EDIT:

REPORTED AGE NEEDS TO BE EQUAL TO OR OLDER THAN THE BASELINE AGE.

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

MCQ.470 {Have you/Has SP} ever had a toe amputation?

YES 1

NO 2 (MCQ.480)

REFUSED 7 (MCQ.480)

DON'T KNOW 9 (MCQ.480)

HELP SCREEN:

A toe amputation is a surgery where the toe is removed.

MCQ.475 How old {were you/was SP} when {you/s/he} first had this toe amputation?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

BOX 7

CHECK ITEM MCQ.476:

IF THE AGE REPORTED IN MCQ.475 IS OLDER THAN THE AGE AT BASELINE, GO TO MCQ.480.

OTHERWISE, CONTINUE.

MCQ.477 {Have you/Has SP} had any other toe amputation since {you were/SP was} {AGE AT BASELINE} years old?

YES 1

NO 2 (MCQ.480)

REFUSED 7 (MCQ.480)

DON'T KNOW 9 (MCQ.480)

MCQ.478 How old {were you/was SP} when {you/s/he} had that toe amputation?

INTERVIEWER INSTRUCTION:

IF THE SP HAD THE PROCEDURE DONE MULTIPLE TIMES SINCE BASELINE, RECORD THE AGE WHEN THEY FIRST HAD THE PROCEDURE AFTER THEIR ORIGINAL NHANES INTERVIEW.

HARD EDIT:

REPORTED AGE NEEDS TO BE EQUAL TO OR OLDER THAN THE BASELINE AGE.

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

MCQ.480 {Have you/Has SP} ever had a leg amputation?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HELP SCREEN:

A leg amputation is a surgery where the leg is removed.

MCQ.485 How old {were you/was SP} when {you/s/he} first had this leg amputation?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

MCQ.484 Was this leg amputation below or above {your/his/her} knee?

CAPI INSTRUCTION:

ALLOW UP TO TWO RESPONSES.

BELOW THE LEFT KNEE 1

ABOVE THE LEFT KNEE 2

BELOW THE RIGHT KNEE 3

ABOVE THE RIGHT KNEE 4

REFUSED 7

DON'T KNOW 9

HARD EDIT:

MULTIPLE RESPONSES FOR THE SAME LEG ARE NOT ALLOWED. (RESPONSE COMBINATIONS OF 1 AND 2 OR 3 AND 4 ARE NOT ALLOWED).
REFUSED AND DON’T KNOW RESPONSES CANNOT BE SELECTED IN COMBINATION WITH ANOTHER RESPONSE.

BOX 8

CHECK ITEM MCQ.486:

IF THE AGE REPORTED IN MCQ.485 IS OLDER THAN THE AGE AT BASELINE, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

MCQ.487 {Have you/Has SP} had any other leg amputation since {you were/SP was} {AGE AT BASELINE} years old?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

MCQ.488 How old {were you/was SP} when {you/s/he} had that leg amputation?

INTERVIEWER INSTRUCTION:

IF THE SP HAD THE PROCEDURE DONE MULTIPLE TIMES SINCE BASELINE, RECORD THE AGE WHEN THEY FIRST HAD THE PROCEDURE AFTER THEIR ORIGINAL NHANES INTERVIEW.

HARD EDIT:

REPORTED AGE NEEDS TO BE EQUAL TO OR OLDER THAN THE BASELINE AGE.

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

MCQ.489 Was that leg amputation below or above {your/his/her} knee?

CAPI INSTRUCTION:

ALLOW UP TO TWO RESPONSES.

BELOW THE LEFT KNEE 1

ABOVE THE LEFT KNEE 2

BELOW THE RIGHT KNEE 3

ABOVE THE RIGHT KNEE 4

REFUSED 7

DON'T KNOW 9

HARD EDIT:

MULTIPLE RESPONSES FOR THE SAME LEG ARE NOT ALLOWED. (RESPONSE COMBINATIONS OF 1 AND 2 OR 3 AND 4 ARE NOT ALLOWED).
REFUSED AND DON’T KNOW RESPONSES CANNOT BE SELECTED IN COMBINATION WITH ANOTHER RESPONSE.
IF MCQ.484=2, THEN MCQ.489 CANNOT BE “1” OR “2”
IF MCQ.484=4, THEN MCQ.489 CANNOT BE “3” or “4”.

SOFT EDIT:

IF MCQ.484=1, AND MCQ.489=1, DISPLAY MESSAGE “The selected location is the same as the previous knee amputation, please verify your entry.”
IF MCQ.484=3, AND MCQ.489=3, DISPLAY MESSAGE “The selected location is the same as the previous knee amputation, please verify your entry.”

DIABETES – DIQ

Target Group: SPs 20+

BOX 1

CHECK ITEM DIQ.008:

IF YES (CODE 1) IN DIQ.010 AT BASELINE, GO TO BOX 4.

OTHERWISE, CONTINUE.

DIQ.010 {Other than during pregnancy, {have you/has SP}/{Have you/Has SP}} ever been told by a doctor or other health professional that {you have/{s/he/SP} has} diabetes or sugar diabetes?

CAPI INSTRUCTION:

IF SP IS FEMALE, DISPLAY "OTHER THAN DURING PREGNANCY, {HAVE YOU/HAS SP}".

YES 1

NO 2 (BOX 2)

BORDERLINE OR PREDIABETES 3 (BOX 2)

REFUSED 7 (BOX 2)

DON'T KNOW 9 (BOX 2)

DIQ.040
G/Q

How old {was SP/were you} when a doctor or other health professional first told {you/him/her} that {you/s/he} had diabetes or sugar diabetes?

|___|

ENTER AGE IN YEARS 1

LESS THAN 1 YEAR 2

REFUSED 7

DON'T KNOW 9

|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

BOX 2

CHECK ITEM DIQ.157:

IF YES (CODE 1) IN DIQ.010, GO TO BOX 4.

IF BORDERLINE (CODE 3) IN DIQ.010, OR BORDERLINE (CODE 3) IN DIQ.010 AT BASELINE, OR YES (CODE 1) IN DIQ.160 AT BASELINE, GO TO BOX 3.

OTHERWISE, CONTINUE.

DIQ.160 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/SP has} any of the following: prediabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes or that {your/her/his} blood sugar is higher than normal but not high enough to be called diabetes or sugar diabetes?

HAND CARD DIQ1

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN: PREDIABETES, IMPAIRED FASTING GLUCOSE, IMPAIRED GLUCOSE TOLERANCE, OR BORDERLINE DIABETES OCCURS WHEN BLOOD SUGAR (GLUCOSE) LEVELS ARE HIGHER THAN NORMAL BUT NOT HIGH ENOUGH TO BE DIABETES.

BOX 3

CHECK ITEM DIQ.161:

IF BORDERLINE (CODE 3) IN DIQ.010 OR YES (CODE 1) IN DIQ.160 AT FOLLOW-UP OR AT BASELINE, CONTINUE.

OTHERWISE, GO TO BOX 4.

DIQ.162
G/Q

How old {were you/was SP} when a doctor or other health professional first told {you/him/her} that {you/s/he} had prediabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes or that {your/her/his} blood sugar is higher than normal?

|___|

ENTER AGE IN YEARS 1

LESS THAN 1 YEAR 2

REFUSED 7

DON'T KNOW 9

|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

BOX 4

CHECK ITEM DIQ.047:

IF SP MALE OR YES (CODE 1) IN RHQ.162 AT BASELINE, GO TO DIQ.164.

OTHERWISE, CONTINUE.

RHQ.162 During any pregnancy, {were you/was SP} ever told by a doctor or other health professional that {you/she} had diabetes, sugar diabetes or gestational diabetes? Please do not include diabetes that {you/SP} may have known about before the pregnancy.

YES 1

NO 2

BORDERLINE 3

REFUSED 7

DON’T KNOW 9

HELP SCREEN: Gestational diabetes is a form of diabetes or high blood sugar found in pregnant women.

DIQ.164 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/SP has} peripheral arterial disease (PAD) or peripheral vascular disease (PVD)?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Peripheral vascular disease (PVD) refers to diseases of blood vessels outside the heart and brain. It’s often a narrowing of vessels that carry blood to the legs, arms, stomach or kidneys.

Peripheral arterial disease (PAD) artery disease is a type of PVD. It’s caused by fatty buildups in the inner walls of the arteries. These deposits block normal blood flow.

BOX 5

CHECK ITEM 048:

IF YES (CODE 1) IN MCQ.300c AT BASELINE, GO TO DIQ.050.

OTHERWISE, CONTINUE.

MCQ.300c Including living and deceased, were any of {SP’s/your} close biological that is, blood relatives including father, mother, sisters or brothers, ever told by a health professional that they had diabetes?

HELP SCREEN:

Close biological relatives: Include SP’s parents, full siblings, and children.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DIQ.050 {Is SP/Are you} now taking insulin?

YES 1

NO 2 (BOX 6)

REFUSED 7 (BOX 6)

DON'T KNOW 9 (BOX 6)

HELP SCREEN:

Insulin: A chemical used in the treatment of diabetes. Typically, insulin is administered with a syringe by the patient or through a pump. Insulin may also be taken as a nasal spray and inhaled through the nose.

DIQ.060
G/Q/U

For how long {have you/has SP} been taking insulin?

|___|

ENTER NUMBER (OF MONTHS OR YEARS) 1

LESS THAN 1 MONTH 2 (BOX 6)

REFUSED 7 (BOX 6)

DON'T KNOW 9 (BOX 6)

|___|___|___|

ENTER NUMBER (OF MONTHS OR YEARS)

REFUSED 77777 (BOX 6)

DON'T KNOW 99999 (BOX 6)

ENTER UNIT

|___|

MONTHS 1

YEARS 2

HELP SCREEN:

Insulin: A chemical used in the treatment of diabetes. Typically, insulin is administered with a syringe by the patient or through a pump. Insulin may also be taken as a nasal spray and inhaled through the nose.

BOX 6

CHECK ITEM DIQ.067:

IF YES (CODE 1) OR BORDERLINE (CODE 3) IN DIQ.010 AT FOLLOW-UP OR AT BASELINE, CONTINUE.

IF YES (CODE 1) IN DIQ.160 AT FOLLOW-UP OR AT BASELINE, CONTINUE.

OTHERWISE, GO TO BOX 7.

DIQ.070 {Is SP/Are you} now taking diabetic pills to lower {his/her}/your} blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DIQ.076 {Are you/Is SP} now taking a diabetic medicine other than insulin that {you/s/he} {use/s} a needle to take? The brand names are Byetta (by-ET-a), Bydureon (by-DUR-e-on), Victoza (VIK-toes-a) and Symlin (SYM-lin).

HAND CARD DIQ2

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 7

CHECK ITEM DIQ.227:

IF YES (CODE 1) IN DIQ.010 AT FOLLOW-UP OR AT BASELINE, CONTINUE.

IF BORDERLINE (CODE 3) IN DIQ.010 AT FOLLOW-UP OR AT BASELINE OR YES (CODE 1) IN DIQ.160 AT FOLLOW-UP OR AT BASELINE, GO TO DIQ234.

OTHERWISE, GO TO END OF SECTION

DIQ.232 {Have you/Has SP} ever seen a diabetes nurse educator or dietitian or nutritionist for {your/his/her} diabetes? Do not include doctors or other health professionals.

YES 1 (DIQ.242)

NO 2 (DIQ.242)

REFUSED 7 (DIQ.242)

DON’T KNOW 9 (DIQ.242)

HELP SCREEN: A diabetes nurse educator is a nurse who teaches people with diabetes and who is knowledgeable about the day-to-day aspects of diabetes self-care, such as, use of diabetes medications, checking and controlling blood glucose levels, managing weight through diet and physical activity, and maintaining a healthy pregnancy if diabetes is present.

DIQ.234 {Have you/Has SP} ever seen a diabetes nurse educator or dietitian or nutritionist for {your/his/her} prediabetes or high blood sugar? Do not include doctors or other health professionals.

YES 1 (DIQ.275)

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

DIQ.242 In the past 12 months is there one doctor or other health professional {you usually see/SP usually sees} for {your/his/her} diabetes? Do not include specialists to whom {you have/SP has} been referred such as diabetes educators, dieticians or foot and eye doctors.

YES 1

NO 2 (DIQ.262)

REFUSED 7 (DIQ.262)

DON’T KNOW 9 (DIQ.262)

HELP SCREEN: A diabetes nurse educator is a nurse who teaches people with diabetes and who is knowledgeable about the day-to-day aspects of diabetes self-care, such as, use of diabetes medications, checking and controlling blood glucose levels, managing weight though diet and physical activity, and maintaining a healthy pregnancy if diabetes is present.

DIQ.250 How many times {have you/has SP} seen this doctor or other health professional in the past 12 months?

G/Q

|___|___|___|

ENTER NUMBER OF TIMES

CAPI INSTRUCTION:

HARD EDIT: DO NOT ALLOW 0.

NONE 2

REFUSED 7777

DON'T KNOW 9999

BOX 8

CHECK ITEM DIQ.372:

IF DIQ.250G = 2 (NONE), CONTINUE.

OTHERWISE, GO TO BOX 9.

DIQ.370 INTERVIEWER: YOU HAVE ENTERED “NONE” FOR THE NUMBER OF TIMES IN THE PAST 12 MONTHS THAT THE SP HAS SEEN THEIR USUAL DOCTOR OR OTHER HEALTH PROFESSIONAL. THIS IS AN UNLIKELY RESPONSE. IS THIS CORRECT?

YES 1

NO 2 (DIQ.250)

BOX 9

CHECK ITEM DIQ.379:

IF DIQ.250Q = 100 OR MORE, CONTINUE.

OTHERWISE, GO TO DIQ.262G.

DIQ.380 INTERVIEWER: YOU HAVE ENTERED A VALUE THAT IS OUTSIDE THE EXPECTED RANGE FOR THE NUMBER OF TIMES IN THE PAST 12 MONTHS THAT THE SP HAS SEEN THEIR USUAL DOCTOR OR OTHER HEALTH PROFESSIONAL. THIS IS AN UNLIKELY RESPONSE. IS THIS CORRECT?

YES 1

NO 2 (DIQ.250)

DIQ.262
G/Q/U

In the past 12 months, how often {do you check your/does SP check his/her} blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a doctor or other health professional.

INTERVIEWER INSTRUCTION: DO NOT INCLUDE URINE TESTS.

|___|

ENTER NUMBER OF TIMES 1

NEVER 2 (DIQ.275)

UNABLE TO DO ACTIVITY 3 (DIQ.275)

REFUSED 7 (DIQ.275)

DON'T KNOW 9 (DIQ.275)

|___|___|___|

ENTER NUMBER OF TIMES

REFUSED 7777 (DIQ.275)

DON'T KNOW 9999 (DIQ.275)

ENTER UNIT

|___|

PER DAY 1

PER WEEK 2

PER MONTH 3

PER YEAR 4

CAPI INSTRUCTION:

SOFT EDIT 7 OR MORE PER DAY

SOFT EDIT 30 OR MORE PER WEEK.

DIQ.275 Glycosylated (GLY-CO-SYL-AT-ED) hemoglobin or the “A one C” test measures your average level of blood sugar for the past 3 months, and usually ranges between 5.0 and 13.9. During the past 12 months, has a doctor or other health professional checked {your/SP’s} glycosylated hemoglobin or “A one C”?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN FOR DIQ.010/040:

Diabetes: A glandular disease that impairs the ability of the body to use sugar and causes sugar to appear abnormally in the urine. Common symptoms are persistent thirst and excessive discharge of urine. Do not include gestational diabetes or diabetes that was only present during pregnancy. Also, do not include self-diagnosed diabetes, pre-diabetes or high sugar.

Doctor: The term refers to both medical doctors (M.D.s) and osteopathic physicians (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.

Other Health (Care) Professional: A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, lab technicians, and technicians who administer shots (i.e., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.

VISION – VIQ

Target Group: SPs 20+

VIQ.241 When was the last time {you/SP} had (your/his/her} eyes examined?

LESS THAN 1 MONTH 1

1-12 MONTHS 2

13-24 MONTHS 3

GREATER THAN 2 YEARS 4

NEVER 5 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

VIQ.251 Were {your/SP’s} eyes dilated (drops put in to see the back of the eye)?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VIQ.260 Has an eye doctor ever told {you/SP} that {you have/s/he has} a cataract?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

VIQ.270 Has an eye doctor ever told {you/SP} that {you have/s/he has} glaucoma?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 1

CHECK ITEM VIQ.279:

IF DIQ.010 AT BASELINE OR AT FOLLOW-UP = 1 (YES), CONTINUE.

OTHERWISE, GO TO VIQ.300

VIQ.280 Has an eye doctor ever told {you/SP} that {you have/s/he has} diabetes in the eye or retinopathy (ret-in-op-ath-ee)?

YES 1

NO 2 (VIQ.300)

REFUSED 7 (VIQ.300)

DON’T KNOW 9 (VIQ.300)

VIQ.290 {Have you/Has SP} lost any vision because of diabetic retinopathy?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VIQ.300 Has an eye doctor ever told {you/SP} that {you have/s/he has} macular degeneration?

YES 1

NO 2 (BOX 2)

REFUSED 7 (BOX 2)

DON’T KNOW 9 (BOX 2)

VIQ.311 {Have you/Has SP} lost any vision because of macular degeneration?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2

CHECK ITEM VIQ.319:

IF DIQ.010 AT BASELINE OR AT FOLLOW-UP = 1 (YES), CONTINUE.

OTHERWISE, GO TO END OF SECTION

VIQ.321 Laser surgery to the back of the eye, or retina, is a commonly used treatment for diabetic retinopathy and macular degeneration. {Have you/Has SP} ever had laser surgery to the back of either eye for one of these conditions? [EXPLAIN IF NECESSARY: This does not include “Lasik” surgery to the front of the eye to correct vision.]

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

Neuropathy – PnQ

Target Group: SPs 20+

BOX 1

CHECK ITEM PNQ.001:

IF THIS IS A PROXY INTERVIEW, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE.

PNQ.010 The following questions are about the feeling in your legs and feet. Please answer yes or no based on how your feet and legs typically feel.

Are your legs and/or feet numb?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.020 Do you ever have any burning pain in your legs and/or feet?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.030 Are your feet too sensitive to touch?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.040 Do you get muscle cramps in your legs and/or feet?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.050 Do you ever have any prickling feelings in your legs or feet?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.060 Does it hurt when the bedcovers touch your skin?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.070 When you get into the tub or shower, are you able to tell the hot water from the cold water?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.080 Have you ever had an open sore on your foot?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.090 Has your doctor ever told you that you have diabetic neuropathy?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.100 Do you feel weak all over most of the time?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.110 Are your symptoms worse at night?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.120 Do your legs hurt when you walk?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.130 Are you able to sense your feet when you walk?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PNQ.140 Is the skin on your feet so dry that it cracks open?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

Blood Pressure and Cholesterol – BPQ

Target Group: SPs 20+

BOX 1

CHECK ITEM BPQ.018:

IF YES (CODE 1) IN BPQ.020 AT BASELINE, GO TO BOX 2

OTHERWISE, CONTINUE

BPQ.020 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had hypertension (hy-per-ten-shun), also called high blood pressure?

IF HIGH BLOOD PRESSURE ONLY DURING PREGNANCY, CODE NO.

INTERVIEWER INSTRUCTION: IF SP SAYS “HIGH NORMAL BLOOD PRESSURE”, “BORDERLINE HYPERTENSION” OR “PREHYPERTENSION” CODE NO.

YES 1

NO 2 (BOX 4)

REFUSED 7 (BOX 4)

DON'T KNOW 9 (BOX 4)

HELP SCREEN:

Hypertension (High Blood Pressure): A repeatedly increased blood pressure with the first number 140 or higher and the second number 90 or higher.

BOX 2

CHECK ITEM BPQ.041:

IF YES (CODE 1) IN BPQ.030 AT BASELINE, GO TO BOX 3

OTHERWISE, CONTINUE

BPQ.044 {Were you/Was SP} told {by a doctor or other health professional} on 2 or more different visits that {you/s/he} had hypertension (hy-per-ten-shun), also called high blood pressure?

CAPI INSTRUCTION:

IF YES (CODE 1) IN BPQ.020 AT BASELINE, DISPLAY “by a doctor or other health professional”.

YES 1

NO 2 (BOX 3)

REFUSED 7 (BOX 3)

DON'T KNOW 9 (BOX 3)

BPQ.035
G/Q

How old {were you/was SP} when {you were/he/she was} first told that {you/he/she} had hypertension or high blood pressure?

HARD EDIT: SP AGE CANNOT BE LESS THAN 6.

SOFT EDIT: PLEASE VERIFY THAT SP WAS LESS THAN 11 YEARS OLD.

|___|

ENTER AGE IN YEARS 1

REFUSED 7

DON'T KNOW 9

|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON’T KNOW 999

BOX 3

CHECK ITEM BPQ.071:

IF YES (CODE 1) IN BPQ.040a AT BASELINE, GO TO BPQ.082

OTHERWISE, CONTINUE

BPQ.072 {Because of {your/SP’s} (high blood pressure/hypertension) (hy-per-ten-shun), {have you/has s/he} ever been told to take prescribed medicine?}/{Have you/Has SP} ever been told by a doctor or other health professional to take prescribed medicine for (high blood pressure/hypertension) (hy-per-ten-shun)?}

YES 1

NO 2 (BOX 4)

REFUSED 7 (BOX 4)

DON’T KNOW 9 (BOX 4)

CAPI INSTRUCTION:

IF BPQ.020 = MISSING AND BPQ.044 = MISSING, DISPLAY “{Have you/Has SP} ever been told by a doctor or other health professional to take prescribed medicine for (high blood pressure/hypertension) (hy-per-ten-shun)?”.

OTHERWISE, DISPLAY “Because of {your/SP’s} (high blood pressure/hypertension) (hy-per-ten-shun), {have you/has s/he} ever been told to take prescribed medicine?

HELP SCREEN:

Prescribed Medicine: Prescribed medicines are those ordered by a doctor or other health provider through a written or verbal prescription for a pharmacist to fill. Prescription medicines can also be given by a medical provider directly to a patient to take home, such as free samples.

BPQ.082 {Are you/Is SP} now taking a prescribed medicine for high blood pressure/hypertension?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 4

CHECK ITEM BPQ.081:

IF YES (CODE 1) IN BPQ.080 AT BASELINE, GO TO BOX 5

OTHERWISE, CONTINUE

BPQ.080 {Have you/Has SP} ever been told by a doctor or other health professional that {your/his/her} blood cholesterol level was high?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HELP SCREEN:

Cholesterol: Cholesterol is a type of fat in the bloodstream and is measured with a blood test, usually done in the morning before you’ve eaten. High levels of cholesterol are a major risk factor for heart disease, which leads to heart attack.

BOX 5

CHECK ITEM BPQ.088:

IF YES (CODE 1) IN BPQ.090d AT BASELINE, GO TO BPQ.094

OTHERWISE, CONTINUE

BPQ.090d To lower {your/his/her} blood cholesterol, {have you/has SP} ever been told by a doctor or other health professional to take prescribed medicine?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HELP SCREEN:

BPQ.094 {Are you/Is SP} now taking a prescribed medicine to lower cholesterol?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

CARDIOVASCULAR disease – CdQ

Target Group: SPs 40+

BOX 0

CHECK ITEM CDQ.200:

IF YES (CODE 1) IN CDQ.001 AT BASELINE, GO TO CDQ.002.

OTHERWISE, CONTINUE.

CDQ.001 {Have you/Has SP} ever had any pain or discomfort in {your/her/his} chest?

YES 1

NO 2 (CDQ.010)

REFUSED 7 (CDQ.010)

DON'T KNOW 9 (CDQ.010)

CDQ.002 {Do you/Does she/Does he} get {it/pain or discomfort in your chest} when {you/she/he} {walk/walks} uphill or {hurry/hurries}?

CAPI INSTRUCTION:

IF YES (CODE 1) IN CDQ.001 AT BASELINE, DISPLAY “PAIN OR DISCOMFORT IN YOUR CHEST”.

OTHERWISE, DISPLAY “IT”.

YES 1

NO 2 (CDQ.008)

NEVER WALKS UPHILL OR HURRIES 3

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.003 {Do you/Does she/Does he} get it when {you/she/he} {walk/walks} at an ordinary pace on level ground?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM CDQ.003A:

IF 'YES' (CODE '1') IN CDQ.002 OR CDQ.003, CONTINUE.

OTHERWISE, GO TO CDQ.008.

CDQ.004 What {do you/does she/does he} do if {you/she/he} get it while {you/she/he} are walking? {Do you/Does she/Does he} stop or slow down, or continue at the same pace?

CODE "STOP OR SLOW DOWN" IF SP CARRIES ON AFTER TAKING NITROGLYCERINE.

STOP OR SLOW DOWN 1

CONTINUE AT THE SAME PACE 2 (CDQ.008)

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.005 If {you/she/he} {stand/stands} still, what happens to it? Is the pain or discomfort relieved or not relieved?

RELIEVED 1

NOT RELIEVED 2 (CDQ.008)

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.006 How soon is the pain relieved? Would you say . . .

10 minutes or less or 1

more than 10 minutes? 2 (CDQ.008)

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.009 Please look at this card and show me where the pain or discomfort is located.

CODE ALL THAT APPLY.

PROBE FOR ADDITIONAL AREAS.

HAND CARD CDQ1

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

REFUSED 77

DON'T KNOW 99

CDQ.008 Have {you/she/he} ever had a severe pain across the front of {your/her/his} chest lasting for half an hour or more?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CDQ.010 {Have you/Has SP} had shortness of breath either when hurrying on the level or walking up a slight hill?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

KIDNEY CONDITIONS – KIQ

Target Group: SPs 20+

BOX 1

CHECK ITEM KIQ.021:

IF YES (CODE 1) IN KIQ.022 AT BASELINE, GO TO KIQ.024.

OTHERWISE, CONTINUE.

KIQ.022 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had weak or failing kidneys? Do not include kidney stones, bladder (bladd-er) infections, or incontinence (in‑kon‑ti‑nens).

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Doctor: The term refers to both medical doctors (M.D.s) and osteopathic physicians (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.

Health Care Professionals (Health Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor's assistants, nurse practitioners, nurses, lab technicians, technicians who administer shots (i.e., allergy shots), and who work with a doctor. Also include paramedics, medics, and physical therapists working with or in a doctor's office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.

KIQ.024 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had chronic kidney disease, or CKD?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

KIQ.025 In the past 12 months, {have you/has SP} received dialysis (either hemodialysis (heemo-di-al-i-sis) or peritoneal dialysis (pare-i-ton-nee-al di-al-i-sis))?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

KIQ.410 {Have you/Has SP} ever had a kidney transplant?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

physical activity – PAQ

Target Group: SPs 20+

PAQ.605 Next I am going to ask you about the time {you spend/SP spends} doing different types of physical activity in a typical week.

Think first about the time {you spend/he spends/she spends} doing work. Think of work as the things that {you have/he has/she has} to do such as paid or unpaid work, household chores, and yard work.

Does {your/SP’s} work involve vigorous-intensity activity that causes large increases in breathing or heart rate like carrying or lifting heavy loads, digging or construction work for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.620)

REFUSED 7 (PAQ.620)

DON'T KNOW 9 (PAQ.620)

PAQ.610 In a typical week, on how many days {do you/does SP} do vigorous-intensity activities as part of {your/his/her} work?

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES IN THIS QUESTION.

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.620)

DON'T KNOW 99 (PAQ.620)

PAQ.615 How much time {do you/does SP} spend doing vigorous-intensity activities at work on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when {you do/he does/she does} vigorous-intensity activities during {your/his/her} work.

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.620)

DON'T KNOW 9997 (PAQ.620)

ENTER UNIT

|___|

MINUTES 1

HOURS 2

PAQ.620 Does {your/SP’s} work involve moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking or carrying light loads for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.635)

REFUSED 7 (PAQ.635)

DON'T KNOW 9 (PAQ.635)

PAQ.625 In a typical week, on how many days {do you/does SP} do moderate-intensity activities as part of {your/his/her} work?

PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.635)

DON'T KNOW 99 (PAQ.635)

PAQ.630 How much time {do you/does SP} spend doing moderate-intensity activities at work on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when {you do/he does/she does} moderate-intensity activities during {your/his/her} work.

PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.635)

DON'T KNOW 9999 (PAQ.635)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.635 The next questions exclude the physical activities at work that you have already mentioned. Now I would like to ask you about the usual way {you travel/SP travels} to and from places. For example to work, for shopping, to school.

In a typical week {do you/does SP} walk or use a bicycle for at least 10 minutes continuously to get to and from places?

YES 1

NO 2 (PAQ.650)

REFUSED 7 (PAQ.650)

DON'T KNOW 9 (PAQ.650)

PAQ.640 In a typical week, on how many days {do you/does SP} walk or bicycle for at least 10 minutes continuously to get to and from places?

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.650)

DON'T KNOW 99 (PAQ.650)

PAQ.645 How much time {do you/does SP} spend walking or bicycling for travel on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when {you walk or bicycle/SP walks or bicycles} for travel.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS WALKING OR BICYCLING TO GET TO AND FROM PLACES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.650)

DON'T KNOW 9999 (PAQ.650)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.650 The next questions exclude the work and transportation activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities.

In a typical week {do you/does SP} do any vigorous-intensity sports, fitness, or recreational activities that cause large increases in breathing or heart rate like running or basketball for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.665)

REFUSED 7 (PAQ.665)

DON'T KNOW 9 (PAQ.665)

PAQ.655 In a typical week, on how many days {do you/does SP} do vigorous-intensity sports, fitness or recreational activities?

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.665)

DON'T KNOW 99 (PAQ.665)

PAQ.660
Q/U

How much time {do you/does SP} spend doing vigorous–intensity sports, fitness or recreational activities on a typical day?

PROBE IF NEEDED: Think about a typical day when {you do/SP does} vigorous-intensity sports, fitness or recreational activities.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY RECREATIONAL ACTIVITIES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.665)

DON'T KNOW 9999 (PAQ.665)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.665 In a typical week {do you/does SP} do any moderate-intensity sports, fitness, or recreational activities that cause a small increase in breathing or heart rate such as brisk walking, bicycling, swimming, or golf for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.680)

REFUSED 7 (PAQ.680)

DON'T KNOW 9 (PAQ.680)

PAQ.670 In a typical week, on how many days {do you/does SP} do moderate-intensity sports, fitness or recreational activities?

PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.680)

DON'T KNOW 99 (PAQ.680)

PAQ.675
Q/U

How much time {do you/does SP} spend doing moderate-intensity sports, fitness or recreational activities on a typical day?

PROBE IF NEEDED: Think about a typical day when {you do/SP does} moderate-intensity sports, fitness or recreational activities.

PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY RECREATIONAL ACTIVITIES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.680)

DON'T KNOW 9999 (PAQ.680)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.680
Q/U

The following question is about sitting at work, at home, getting to and from places, or with friends, including time spent sitting at a desk, traveling in a car or bus, reading, playing cards, watching television, or using a computer. Do not include time spent sleeping.

How much time {do you/does SP} usually spend sitting on a typical day?

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777

DON'T KNOW 9999

|___|

ENTER UNIT

MINUTES 1

HOURS 2

SOFT EDIT: 18 HOURS OR MORE AND LESS THAN 3 HOURS.

ERROR MESSAGE: PLEASE VERIFY TIMES OF 18 HOURS OR MORE OR LESS THAN 3 HOURS.

HARD EDIT: 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE LESS THAN 24 HOURS.

DISABILITY - DLQ

Target Group: 20+

DLQ.200 Now I am going to ask you some questions about {your/SP’s} ability to do different activities, and how {you have/SP has} been feeling.

{Do you/Does SP} wear glasses or contact lenses?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DLQ.210 {Do you/Does SP} have difficulty seeing {even if wearing glasses or contact lenses}? Would you say no difficulty, some difficulty, a lot of difficulty, or {you are/s/he is} unable to do this?

no difficulty 1

some difficulty 2

a lot of difficulty 3

unable to do 4

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

IF YES (CODE 1) IN DLQ.200, DISPLAY “even if wearing glasses or contact lenses”

DLQ.220 {Do you/Does SP} use a hearing aid?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DLQ.230 {Do you/Does SP} have difficulty hearing {even if using a hearing aid}? Would you say no difficulty, some difficulty, a lot of difficulty, or {you are/s/he is} unable to do this?

NO DIFFICULTY 1

SOME DIFFICULTY 2

A LOT OF DIFFICULTY 3

UNABLE TO DO 4

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

IF YES (CODE 1) IN DLQ.220, DISPLAY “even if using a hearing aid”

DLQ.240 {Do you/Does SP} have difficulty walking or climbing steps? Would you say no difficulty, some difficulty, a lot of difficulty, or {you are/s/he is} are unable to do this?

no difficulty 1

some difficulty 2

a lot of difficulty 3

unable to do 4

REFUSED 7

DON’T KNOW 9

DLQ.250 Using {your/his/her} usual language, {do you/does SP} have difficulty communicating, for example, understanding or being understood? Would you say no difficulty, some difficulty, a lot of difficulty, or {you are/s/he is} unable to do this?

no difficulty 1

some difficulty 2

a lot of difficulty 3

unable to do 4

REFUSED 7

DON’T KNOW 9

DLQ.260 {Do you/Does SP} have difficulty remembering or concentrating? Would you say no difficulty, some difficulty, a lot of difficulty, or {you are/s/he is} unable to do this?

no difficulty 1

some difficulty 2

a lot of difficulty 3

unable to do 4

REFUSED 7

DON’T KNOW 9

DLQ.270 {Do you/Does SP} have difficulty with self-care, such as washing all over and dressing? Would you say no difficulty, some difficulty, a lot of difficulty, or {you are/s/he is} unable to do this?

no difficulty 1

some difficulty 2

a lot of difficulty 3

unable to do 4

REFUSED 7

DON’T KNOW 9

DLQ.280 {Do you/Does SP} have difficulty raising a 2 liter bottle of water or soda from waist to eye level? Would you say no difficulty, some difficulty, a lot of difficulty, or {you are/s/he is} unable to do this?

no difficulty 1

some difficulty 2

a lot of difficulty 3

unable to do 4

REFUSED 7

DON’T KNOW 9

DLQ.290 {Do you/Does SP} have difficulty using {your/his/her} hands and fingers, such as picking up small objects, for example, a button or pencil, or opening or closing containers or bottles? Would you say no difficulty, some difficulty, a lot of difficulty, or {you are/s/he is} unable to do this?

no difficulty 1

some difficulty 2

a lot of difficulty 3

unable to do 4

REFUSED 7

DON’T KNOW 9

DLQ.300 Because of a physical, mental, or emotional condition, {do you/does SP} have difficulty doing errands alone such as visiting a doctor’s office or shopping? Would you say no difficulty, some difficulty, a lot of difficulty, or {you/SP} {are/is} unable to do this?

no difficulty 1

some difficulty 2

a lot of difficulty 3

Unable to do 4

REFUSED 7

DON’T KNOW 9

DLQ.310 How often {do you/does SP} feel worried, nervous, or anxious? Would you say…

Daily, 1

Weekly, 2

Monthly, 3

A few times a year, or 4

Never? 5 (DLQ.330)

REFUSED………………………………………. 7 (DLQ.330)

DON’T KNOW 9 (DLQ.330)

DLQ.320 Thinking about the last time {you/ SP} felt worried, nervous, or anxious how would {you/s/he} describe the level of these feelings? Would you say…

A little, 1

A lot, or 2

Somewhere in between a little and a lot? 3

REFUSED 7

DON’T KNOW 9

DLQ.330 How often {do you/does SP} feel depressed? Would you say…

Daily, 1

Weekly, 2

Monthly, 3

A few times a year, or 4

Never? 5 (DLQ.350)

REFUSED………………………………………… 7 (DLQ.350)

DON’T KNOW 9 (DLQ.350)

DLQ.340 Thinking about the last time {you/ SP} felt depressed, how depressed did {you/s/he} feel? Would you say…

A little, 1

A lot, or 2

Somewhere in between a little and a lot? 3

REFUSED 7

DON’T KNOW 9

DLQ.350 {Do you/Does SP} have difficulty participating in social activities such as visiting friends, attending clubs and meetings, going to parties? Would you say no difficulty, some difficulty, a lot of difficulty, or {you are/s/he is} unable to do this?

no difficulty 1

some difficulty 2

a lot of difficulty 3

Unable to do 4

REFUSED 7

DON’T KNOW 9

DLQ.360 {Are you/is SP} limited in the kind or amount of work {you/s/he} can do because of a physical, mental, or emotional problem?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

SLEEP DISORDERS – SLQ

Target Group: 20+

SLQ.300 The next set of questions is about {your/SP’s} sleeping habits. The first two questions refer to the times {you get/SP gets} in and out of bed in order to sleep, not including naps.

What time {do you/does SP} usually go to sleep on weekdays or workdays?

|__|__| : |__|__| ENTER AM OR PM

HH MM

INTERVIEWER INSTRUCTION: ENTER TIME AS HH:MM AM OR PM. IF RESPONDENT SAYS TWELVE “MIDNIGHT” CODE AS 12:00 AM.

REFUSED 77777777

DON'T KNOW 99999999

SLQ.310 What time {do you/does SP} usually wake up on weekdays or workdays?

|__|__| : |__|__| ENTER AM OR PM

HH MM

INTERVIEWER INSTRUCTION: ENTER TIME AS HH:MM AM OR PM.

REFUSED 77777777

DON'T KNOW 99999999

CAPI INSTRUCTION:

SOFT EDIT: LESS THAN 4 HOURS OR MORE THAN 12 HOURS OF TOTAL SLEEP. IF SLQ.300 OR 310 IS DK OR RF, DO NOT APPLY SOFT EDIT.

ERROR MESSAGE: PLEASE VERIFY SLEEP TIMES OF LESS THAN 4 HOURS OR MORE THAN 12 HOURS.

SLQ.030 In the past 12 months, how often did {you/SP} snore while {you were/s/he was} sleeping?

INTERVIEWER INSTRUCTION: IF R SAYS “DON’T KNOW”, PROBE IF ANYONE HAS TOLD THEM THAT THEY SNORE.

Never 0

Rarely – 1-2 nights a week 1

Occasionally – 3-4 nights a week 2

Frequently – 5 or more nights a week 3

REFUSED 7

DON’T KNOW 9

SLQ.040 In the past 12 months, how often did {you/SP} snort, gasp, or stop breathing while {you were/s/he was} asleep?

INTERVIEWER INSTRUCTION: IF THE RESPONDENT ASKS “HOW WOULD I KNOW IF I SNORT, GASP OR STOP BREATHING WHEN I AM SLEEPING? PROBE IF ANYONE TOLD THEM THAT THEY DO THIS.

Never 0

Rarely – 1-2 nights a week 1

Occasionally – 3-4 nights a week 2

Frequently – 5 or more nights a week 3

REFUSED 7

DON’T KNOW 9

SLQ.050 {Have you/Has SP} ever told a doctor or other health professional that {you have/s/he has} trouble sleeping?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SLQ.120 In the past month, how often did {you/SP} feel excessively or overly sleepy during the day?

HAND CARD SLQ1

NEVER 0

RARELY – 1 TIME A MONTH 1

SOMETIMES – 2-4 TIMES A MONTH 2

OFTEN – 5-15 TIMES A MONTH 3

ALMOST ALWAYS – 16-30 TIMES A
MONTH 4

REFUSED 7

DON’T KNOW 9

WEIGHT HISTORY – WHQ

Target Group: SPs 20+

WHQ.010
G/F/I/M/C

These next questions ask about {your/SP's} height and weight.

How tall {are you/is SP} without shoes?

|___|

ENTER HEIGHT IN FEET AND INCHES 1

ENTER HEIGHT IN METERS

AND CENTIMETERS 2

REFUSED 7 (WHQ.025)

DON’T KNOW 9 (WHQ.025)

|___|___|

ENTER NUMBER OF FEET

REFUSED 7777 (WHQ.025)

DON’T KNOW 9999 (WHQ.025)

AND

|___|___|

ENTER NUMBER OF INCHES

DON’T KNOW 9999 (WHQ.025)

|___|___|

ENTER NUMBER OF METERS

REFUSED 7777 (WHQ.025)

DON’T KNOW 9999 (WHQ.025)

AND

|___|___|___|

ENTER NUMBER OF CENTIMETERS

DON’T KNOW 9999 (WHQ.025)

WHQ.025/
L/K

How much {do you/does SP} weigh without clothes or shoes? [If {you are/she is} currently pregnant, how much did {you/she} weigh before {your/her} pregnancy?]

RECORD CURRENT WEIGHT. ENTER WEIGHT IN POUNDS OR KILOGRAMS.

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you are/she is} currently pregnant . . .] ONLY IF SP IS FEMALE AND AGE IS 20 THROUGH 59.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (WHQ.053)

DON’T KNOW 9 (WHQ.053)

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777

DON’T KNOW 99999

WHQ.053/
L/K

How much did {you/SP} weigh a year ago? [If {you were/she was} pregnant a year ago, how much did {you/she} weigh before your pregnancy?]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you were/she was} pregnant . . .] ONLY IF SP IS FEMALE AND SP AGE IS 20 THROUGH 60.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7

DON’T KNOW 9

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777

DON’T KNOW 99999

WHQ.030 {Do you/Does SP} consider {your/his/her}self now to be . . . [If {you are/she is} currently pregnant, what did {you/she} consider {your/her}self to be before {you were/she was} pregnant?]

overweight, 1

underweight, or 2

about the right weight? 3

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you are/she is} currently pregnant…] ONLY IF SP IS FEMALE AND AGE IS 20 THROUGH 59.

WHQ.040 Would {you/SP} like to weigh . . .

more, 1

less, or 2

stay about the same? 3

REFUSED 7

DON’T KNOW 9

WHQ.070 During the past 12 months, {have you/has SP} tried to lose weight?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

WHQ.092/
OS

How did {you/SP} try to lose weight?

HAND CARD WHQ1

CODE ALL THAT APPLY

ATE LESS FOOD (AMOUNT) 100

SWITCHED TO FOODS WITH LOWER

CALORIES 110

ATE LESS FAT 120

ATE FEWER CARBOHYDRATES 125

EXERCISED 130

SKIPPED MEALS 140

ATE “DIET” FOODS OR PRODUCTS 150

USED A LIQUID DIET FORMULA SUCH

AS SLIMFAST, OPTIFAST, OR

SHAKEOLOGY 160

JOINED A WEIGHT LOSS PROGRAM

SUCH AS WEIGHT WATCHERS, JENNY

CRAIG, TOPS, OR OVEREATERS

ANONYMOUS 170

FOLLOWED A SPECIAL DIET SUCH AS

DR. ATKINS, SOUTH BEACH, OTHER

HIGH PROTEIN OR LOW

CARBOHYDRATE DIET, CABBAGE

SOUP DIET, ORNISH, NUTRISYSTEM,

BODY-FOR-LIFE, JUICE DIET 300

TOOK DIET PILLS PRESCRIBED BY A

DOCTOR 310

TOOK OTHER PILLS, MEDICINES, HERBS,

OR SUPPLEMENTS NOT NEEDING A

PRESCRIPTION 320

STARTED TO SMOKE OR BEGAN TO

SMOKE AGAIN 325

TOOK LAXATIVES OR VOMITED 330

HAD WEIGHT LOSS SURGERY SUCH AS

GASTRIC BYPASS 335

DRANK A LOT OF WATER 340

ATE MORE FRUITS, VEGETABLES,

SALADS 350

ATE LESS SUGAR, CANDY, SWEETS,

DRANK LESS SODA, DRANK LESS

SUGAR SWEETENED BEVERAGES 360

CHANGED EATING HABITS (DIDN’T EAT

LATE AT NIGHT, ATE SEVERAL SMALL

MEALS A DAY, ATE AT HOME MORE) 370

ATE LESS JUNK FOOD OR FAST FOOD 380

OTHER (SPECIFY) 400

REFUSED 777

DON’T KNOW 999

Cigarette smoking – SMQ

Target Group: SP’s 20+

BOX 1

CHECK ITEM SMQ.021:

IF YES (CODE 1) IN SMQ.020 OR SMQ.022 AT BASELINE, GO TO SMQ.040

OTHERWISE, CONTINUE.

These next questions are about cigarette smoking.

SMQ.022 {Have you/Has SP} smoked at least 100 cigarettes in {your/his/her} entire life? This hand card shows you the products we would like you to include and not include when answering this question.

HAND CARD SMQ1

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

SMQ.030 How old {were you/was SP} when {you/s/he} first started to smoke cigarettes regularly?

G/Q

ENTER AGE 1

NEVER SMOKED CIGARETTES
REGULARLY 2 (SMQ.040)

REFUSED 7 (SMQ.040)

DON’T KNOW 9 (SMQ.040)

|___|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

CAPI INSTRUCTION:

SOFT EDIT: IF THE RESPONDED AGE <13

DISPLAY “UNLIKELY RESPONSE. PLEASE VERIFY.”

HELP SCREEN:

“Regularly” refers to age when started smoking cigarettes on a routine basis as opposed to age when tried first cigarette.

SMQ.040 {Do you/Does SP} now smoke cigarettes . . .

every day, 1 (SMQ.078)

some days, or 2 (SMQ.641)

not at all? 3 (SMQ.050Q/U)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

SMQ.050 How long has it been since {you/SP} quit smoking cigarettes?

Q/U

|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777 (BOX 2)

DON'T KNOW 99999 (BOX 2)

|___|

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 77

DON'T KNOW 99

BOX 2

CHECK ITEM SMQ.053:

IF SMQ.050Q/U >= 1 YEAR (365 DAYS, 52 WEEKS, 12 MONTHS, OR 1 YEAR), CONTINUE.

OTHERWISE, GO TO SMQ.057.

SMQ.055 How old {were you/was SP} when {you/s/he} last smoked cigarettes {regularly}?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

CAPI INSTRUCTION:

DISPLAY “REGULARLY” EXCEPT WHEN SMQ.030 G/Q = 2 (NEVER SMOKED CIGARETTES REGULARLY).

SMQ.057 At that time, about how many cigarettes did {you/SP} usually smoke per day?

1 PACK EQUALS 20 CIGARETTES

IF LESS THAN 1 PER DAY, ENTER 1

IF 95 OR MORE PER DAY, ENTER 95

|___|___|___| (END OF SECTION)

ENTER NUMBER OF CIGARETTES (PER DAY)

REFUSED 7777 (END OF SECTION)

DON'T KNOW 9999 (END OF SECTION)

SMQ.078 How soon after {you/SP} wake{s} up {do you/does s/he} smoke? Would you say . . .

within 5 minutes, 1

from 6 to 30 minutes, 2

from more than 30 minutes to 1 hour, 3

from more than 1 hour to 2 hours, 4

from more than 2 hours to 3 hours, 5

from more than 3 hours to 4 hours, or 6

more than 4 hours? 7

REFUSED 77

DON'T KNOW 99

SMQ.641 During the past 30 days, on how many days did {you/SP} smoke cigarettes?

|___|___|

ENTER NUMBER OF DAYS

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTION:

ALLOW '0' AS AN ENTRY. IF '0' DK OR RF ENTERED, SKIP TO END OF SECTION.

SMQ.650 During the past 30 days, on the days that {you/SP} smoked, how many cigarettes did {you/s/he} smoke per day?

1 PACK EQUALS 20 CIGARETTES

IF LESS THAN 1 PER DAY, ENTER 1

IF 95 OR MORE PER DAY, ENTER 95

|___|___|___|

ENTER NUMBER OF CIGARETTES (PER DAY)

REFUSED 7777

DON'T KNOW 9999

ALCOHOL USE – ALQ

Target Group: SP’s 20+

BOX 1

CHECK ITEM ALQ.099:

IF YES (CODE 1) IN ALQ.101 AT BASELINE, GO TO ALQ.121

OTHERWISE, CONTINUE

ALQ.101 The next questions are about drinking alcoholic beverages. Included are liquor (such as whiskey or gin), beer, wine, wine coolers, and any other type of alcoholic beverage.

In any one year, {have you/has SP} had at least 12 drinks of any type of alcoholic beverage? By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.

HAND CARD ALQ1

YES 1 (ALQ.121)

NO 2

REFUSED 7

DON'T KNOW 9

ALQ.110 In {your/SP’s} entire life, {have you/has he/has she} had at least 12 drinks of any type of alcoholic beverage?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

ALQ.121
Q/U

{The next questions are about drinking alcoholic beverages. Included are liquor (such as whiskey or gin), beer, wine, wine coolers, and any other type of alcoholic beverage.}

In the past 12 months, how often did {you/SP} drink any type of alcoholic beverage? {By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.}

PROBE: How many days per week, per month, or per year did {you/SP} drink?

HAND CARD ALQ1

ENTER '0' FOR NEVER.

HARD EDIT: Range – 1-7 days/week, 1-32 days/month, 1-366 days/year

CAPI INSTRUCTION:

IF QUANTITY CODED ‘0’, GO TO BOX 2

IF ALQ.101 AT BASELINE = 1, DISPLAY “The next questions are about drinking alcoholic beverages. Included are liquor (such as whiskey or gin), beer, wine, wine coolers, and any other type of alcoholic beverage.” AND “By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.”

|___|___|___|

ENTER QUANTITY

REFUSED 777 (BOX 2)

DON'T KNOW 999 (BOX 2)

ENTER UNIT

WEEK 1

MONTH 2

YEAR 3

BOX 2

CHECK ITEM ALQ.125:

IF SP DIDN'T DRINK (CODED '0') IN ALQ.121, GO TO ALQ.170.

OTHERWISE, CONTINUE WITH ALQ.130.

ALQ.130 In the past 12 months, on those days that {you/SP} drank alcoholic beverages, on the average, how many drinks did {you/he/she} have? (By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.)

HAND CARD ALQ1

IF LESS THAN 1 DRINK, ENTER '1'.

IF 95 DRINKS OR MORE, ENTER '95'.

CAPI INSTRUCTION:

SOFT EDIT: IF RESPONSE >=20, THEN DISPLAY “YOU SAID ON THE DAYS THAT YOU DRINK YOU HAVE ON AVERAGE {DISPLAY QUANTITY} DRINKS, IS THAT CORRECT?”

HARD EDIT: If ALQ.101 = 2 or 9, ALQ.130 must be less than 12.

Error Message: “Number of drinks per day cannot be greater than number of drinks in any one year.”

HARD EDIT: Range – 1-95

|___|___|___|

ENTER # OF DRINKS

REFUSED 777

DON'T KNOW 999

ALQ.141
Q/U

In the past 12 months, on how many days did {you/SP} have {DISPLAY NUMBER} or more drinks of any alcoholic beverage?

PROBE: How many days per week, per month, or per year did {you/SP} have {DISPLAY NUMBER} or more drinks in a single day?

ENTER '0' FOR NONE.

CAPI INSTRUCTION:

IF SP = MALE, DISPLAY = 5

IF SP = FEMALE, DISPLAY = 4

CAPI INSTRUCTION: IF QUANTITY CODED ‘0’, GO TO ALQ.170.

HARD EDIT: If ALQ.101 = 2 or 9, ALQ.141 must be less than 3 times per year.

Error Message: “Number of drinks must be less than 3 if SP never had more than 12 drinks per year.”

HARD EDIT: Range – 1-7 days/week, 1-32 days/month, 1-366 days/year

|___|___|___|

ENTER QUANTITY

REFUSED 777 (ALQ.170)

DON'T KNOW 999 (ALQ.170)

|___|

ENTER UNIT

WEEK 1

MONTH 2

YEAR 3

ALQ.170 For this next question I want you to think about the time between {BASELINE YEAR}, when {you were/SP was} {AGE AT BASELINE} years old, and now. Was there ever a time or times since {you were/SP was} {BASELINE AGE} years old when {you/he/she} drank {5 IF MALE, 4 IF FEMALE} or more drinks of any kind of alcoholic beverage almost every day?

CAPI INSTRUCTION:

IF SP = MALE, DISPLAY = 5

IF SP = FEMALE, DISPLAY = 4

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

ALQ.171 Since {you were/SP was} {BASELINE AGE} years old, for about how many years did {you/SP} drink

G/Q {5 if male, 4 if female} or more drinks of any kind of alcoholic beverage almost every day?

CAPI INSTRUCTION:

IF SP = MALE, DISPLAY = 5

IF SP = FEMALE, DISPLAY = 4

|___|

ENTER YEAR 1

LESS THAN 1 YEAR 6

REFUSED 7

DON'T KNOW 9

|___|___|___|

ENTER NUMBER OF YEARS

HARD EDIT: IF RESPONSE =0, ERROR MESSAGE: GO BACK TO PREVIOUS QUESTION AND SELECT LESS THAN 1 YEAR.

HARD EDIT: ALQ.171 MUST BE LESS THAN OR EQUAL TO LENGTH OF FOLLOW-UP PERIOD (CURRENT YEAR MINUS BASELINE YEAR).

ERROR MESSAGE: RESPONSE CANNOT BE GREATER THAN THE NUMBER OF YEARS SINCE BASELINE.

DEMOGRAPHIC INFORMATION – DMQ – SP

Target Group: SPs 20+

DMQ.INTRO Now I have some questions about {you/SP} and {your/his/her} work, and about the people living with {you/him/her}.

DMQ.380 {Are you/Is SP} now married, widowed, divorced, separated, never married or living with a partner?

MARRIED 1

WIDOWED 2

DIVORCED 3

SEPARATED 4

NEVER MARRIED 5

LIVING WITH PARTNER 6

REFUSED 77

DON'T KNOW 99

OCQ.152 Which of the following {were you/was SP} doing last week . . .

working at a job or business, 1 (DMQ.500)

with a job or business but not at work, 2 (DMQ.500)

looking for work, or 3 (DMQ.500)

not working at a job or business? 4 (OCQ.380)

REFUSED 7 (DMQ.500)

DON'T KNOW 9 (DMQ.500)

OCQ.380 What is the main reason {you/SP} did not work last week?

TAKING CARE OF HOUSE OR FAMILY 1

GOING TO SCHOOL 2

RETIRED 3

UNABLE TO WORK FOR HEALTH
REASONS 4

ON LAYOFF 5

DISABLED 6

OTHER 7

REFUSED 77

DON'T KNOW 99

DMQ.500 Next, I have some questions about {your/SP’s} family. Including {yourself/SP} how many people live in this household? Please do not include anyone who usually lives somewhere else.

|___|___|

NUMBER

DK 99

RF 77

BOX 1

CHECK ITEM DMQ.505:

IF ONLY 1 PERSON IN HOUSEHOLD (CODED 1 IN DMQ.500), GO TO INQ202.

OTHERWISE, CONTINUE.

DMQ.510 Not including {yourself/SP}, what are the names of all of the persons living here? (Please remember not to include anyone who usually lives somewhere else)

PROBE: Any others?

______ _______
FIRST SUFFIX GENDER

DK 9

RF 7

CAPI INSTRUCTIONS: WHEN THE FOCUS IS ON THE “GENDER” FIELD, DISPLAY:

ASK IF NOT OBVIOUS:

Is {NAME} male or female?

MALE 1

FEMALE 2

DK 9

RF 7

CAPI INSTRUCTIONS: AUTOMATICALLY POPULATE THE SP ON THE FIRST LINE OF THE MATRIX.

CAPI INSTRUCTIONS:

ENSURE THAT EACH NAME (COMBINATION OF FIRST AND SUFFIX) IS UNIQUE WITHIN THE HOUSEHOLD. IF A DUPLICATE NAME IS ENTERED, DISPLAY THE FOLLOWING HARD EDIT, “NAMES MUST BE UNIQUE. PERSONS # AND # HAVE IDENTICAL NAMES RECORDED. CORRECT THE ERROR TO CONTINUE.”

DMQ.520 I have {TOTAL # OF PERSONS ENUMERATED} {person/people} living here --

a/b/c

[READ NAMES LISTED BELOW.]

___________ __________
a. FIRST b. SUFFIX c. GENDER

Have I missed anyone else living or staying here?

YES 1 (DMQ.500)

NO 2

DK 9

RF 7

CAPI INSTRUCTIONS:

THE TOTAL COUNT AND LIST OF PERSONS SHOULD INCLUDE THE SP. AS PERSONS ARE ADDED OR DELETED FROM THE HOUSEHOLD COMPOSITION MATRIX, UPDATE THE NUMBER OF PERSONS IN DMQ.500.
A "YES" RESPONSE WILL BRING UP THE HOUSEHOLD COMPOSITION MATRIX. BY CLICKING ON THE “INSERT ROW” BUTTON ON THIS SCREEN, A NEW ROW APPEARS FOR ENTRY OF NAME AND GENDER.
UPON EXITING THE NAME/GENDER SCREEN, RETURN TO DMQ.520.

DMQ.521 Is everyone in this household a member of {your/SP’s} family? By family I mean if they are related to {you/SP} by birth, marriage, or adoption.

YES 1 (BOX 1A)

NO 2

REFUSED 7

DON'T KNOW 9

DMQ.523 Who in this household is a member of {your/SP’s} family? (Again, by family, I mean if they are related to {you/SP} by birth, marriage, or adoption)

PROBE: Anyone else?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL HOUSEHOLD MEMBERS REPORTED IN DMQ.520.

INTERVIEWER INSTRUCTION:

READ NAMES OF ALL HOUSEHOLD MEMBERS TO THE RESPONDENT

SELECT NAME(S) FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

BOX 1A

LOOP 1:

ASK BOX 2 – DMQ.570 AS APPROPRIATE FOR EACH PERSON {P} LISTED BELOW THE SP ON THE HOUSEHOLD MATRIX.

BOX 2

CHECK ITEM DMQ.525:

CHECK GENDER OF THE {PERSON}. IF {PERSON} IS MALE, DISPLAY DMQ.530. IF FEMALE, DISPLAY DMQ.540.

DMQ.530 What is {PERSON's} relationship to {you/SP}?

HAND CARD DMQ1

CAPI DESIGN = RADIO BUTTONS

HUSBAND/SPOUSE  01

PARTNER  02

SON (BIOLOGICAL, SON-IN-LAW,
ADOPTIVE, FOSTER, STEP)  03

SON OF PARTNER  04

GRANDSON  05

FATHER  06

BROTHER  07

GRANDFATHER  08

UNCLE  09

NEPHEW  10

OTHER RELATIVE  11

HOUSEMATE/ROOMMATE  12

ROOMER/BOARDER  13

OTHER/NON RELATED  14

LEGAL GUARDIAN  15

WARD  16

REFUSED  77

DON’T KNOW  99

BOX 3

CHECK ITEM DMQ.535:

GO TO DMQ.545

DMQ.540 What is {PERSON'S} relationship to {you/SP}?

HAND CARD DMQ2

CAPI DESIGN = RADIO BUTTONS

WIFE/SPOUSE  01

PARTNER  02

DAUGHTER (BIOLOGICAL,
DAUGHTER-IN-LAW, ADOPTIVE,
FOSTER, STEP)  03

DAUGHTER OF PARTNER  04

GRANDDAUGHTER  05

MOTHER  06

SISTER  07

GRANDMOTHER  08

AUNT  09

NIECE  10

OTHER RELATIVE  11

HOUSEMATE/ROOMMATE  12

ROOMER/BOARDER  13

OTHER/NON RELATED  14

LEGAL GUARDIAN  15

WARD  16

REFUSED  77

DON’T KNOW  99

BOX 4

CHECK ITEM DMQ.545:

IF {P} RELATIONSHIP IN DMQ.530 or DMQ.540 = SON OR DAUGHTER (CODE 3), CONTINUE.

OTHERWISE, SKIP TO BOX 5.

DMQ.550 Is {PERSON}, {your/SP’s} biological (natural), adoptive, step, foster {son/daughter} or (son/daughter)-in-law?

BIOLOGICAL (NATURAL) {SON/
DAUGHTER} 1

ADOPTIVE {SON/DAUGHTER} 2

STEP {SON/DAUGHTER} 3

FOSTER {SON/DAUGHTER} 4

{SON/DAUGHTER}-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 5

CHECK ITEM DMQ.555:

IF {P} RELATIONSHIP IN DMQ.530 or DMQ.540 = FATHER OR MOTHER (CODE 6), CONTINUE.

OTHERWISE, GO TO BOX 6.

DMQ.560 Is {PERSON}, {your/SP’s} biological (natural), adoptive, step, or foster parent or {mother/father}-in-law?

BIOLOGICAL (NATURAL) PARENT 1

ADOPTIVE PARENT 2

STEP PARENT 3

FOSTER PARENT 4

{MOTHER/FATHER}-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 6

CHECK ITEM DMQ.565:

IF {P} RELATIONSHIP IN DMQ.530 or DMQ.540 = BROTHER OR SISTER (CODE 7), CONTINUE.

OTHERWISE, GO TO BOX 7.

DMQ.570 Is {PERSON}, {your/SP’s} full, half, adoptive, step, or foster {brother/sister} or {brother/sister}-in-law?

FULL {BROTHER/SISTER} 1

HALF {BROTHER/SISTER} 2

ADOPTED {BROTHER/SISTER} 3

STEP {BROTHER/SISTER} 4

FOSTER {BROTHER/SISTER} 5

{BROTHER/SISTER}-IN-LAW 6

REFUSED 7

DON'T KNOW 9

BOX 7

END LOOP 1:

ASK BOX 2 – DMQ.570 AS APPROPRIATE FOR NEXT PERSON {P} LISTED BELOW THE SP ON THE HOUSEHOLD MATRIX.

IF NO NEXT PERSON, GO TO BOX 8.

BOX 8

CHECK ITEM DMQ.575:

IF ALL PERSONS IN HOUSEHOLD ARE RELATED TO (CODES 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) OR HAVE A LEGAL GUARDIAN/WARD RELATIONSHIP WITH THE SP (CODES 15 OR 16) IN DMQ.530 OR DMQ.540), GO TO BOX 11.

OTHERWISE, CONTINUE.

BOX 9

LOOP 2:

ASK DMQ.580 THROUGH DMQ.620 FOR EACH PERSON WHO HAS NOT BEEN IDENTIFIED AS RELATED TO OR HAVING A LEGAL GUARDIAN/WARD RELATIONSHIP WITH THE SP (CODES 12, 13, 14, 77, OR 99 IN DMQ.530 OR DMQ. 540).

DMQ.580 Is {PERSON NOT RELATED TO SP} related to {NAMES OF OTHER FAMILY MEMBERS}?

CAPI INSTRUCTION: NAMES OF OTHER FAMILY MEMBERS ARE THOSE PERSONS WITH RELATIONSHIP CODES 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15, OR 16 IN DMQ.530 or DMQ.540.

YES 1

NO 2 (BOX 10)

REFUSED 7 (BOX 10)

DON'T KNOW 9 (BOX 10)

SOFT EDIT:

2, DISPLAY THE FOLLOWING MESSAGE: “PROBE: This includes if {PERSON NOT RELATED TO SP} is in a partner-type relationship with (this person/any of these persons}.

DMQ.590 Who is {PERSON SELECTED AT DMQ.580} related to? {DISPLAY LIST OF NAMES OF OTHER FAMILY MEMBERS}.

SELECT NAMES OF PERSONS RELATED TO {PERSON SELECTED AT DMQ.580}.

BOX 9A

EMBEDDED LOOP 2A:

ASK BOX 9B THROUGH DMQ.625 FOR EACH PERSON SELECTED IN DMQ.590.

BOX 9B

CHECK ITEM DMQ.595:

CHECK GENDER OF THE PERSON IDENTIFIED AS NOT BEING RELATED TO OR HAVING LEGAL GUARDIAN/WARD RELATIONSHIP WITH THE SP (CODES 12, 13, 77, OR 99 IN DMQ.530 OR DMQ.540). IF {PERSON} IS MALE, DISPLAY DMQ.600. IF FEMALE, DISPLAY DMQ.610.

DMQ.600 What is {PERSON SELECTED IN DMQ.580’S} relationship to {SELECTED NAME IN DMQ.590}?

HAND CARD DMQ3

CAPI DESIGN = RADIO BUTTONS

HUSBAND/SPOUSE  01

PARTNER  02

SON (BIOLOGICAL, SON-IN-LAW,
ADOPTIVE, FOSTER, STEP)  03

SON OF PARTNER  04

GRANDSON  05

FATHER  06

BROTHER  07

GRANDFATHER  08

UNCLE  09

NEPHEW  10

OTHER RELATIVE  11

LEGAL GUARDIAN  15

WARD  16

REFUSED  77

DON’T KNOW  99

BOX 9C

GO TO BOX 9D.

DMQ.610 What is {PERSON SELECTED IN DMQ.580’S} relationship to {SELECTED NAME IN DMQ.590}?

HAND CARD DMQ4

CAPI DESIGN = RADIO BUTTONS

WIFE/SPOUSE  01

PARTNER  02

DAUGHTER (BIOLOGICAL,
DAUGHTER-IN-LAW, ADOPTIVE,
FOSTER, STEP)  03

DAUGHTER OF PARTNER  04

GRANDDAUGHTER  05

MOTHER  06

SISTER  07

GRANDMOTHER  08

AUNT  09

NIECE  10

OTHER RELATIVE  11

LEGAL GUARDIAN  15

WARD  16

REFUSED  77

DON’T KNOW  99

BOX 9D

CHECK ITEM DMQ.615:

IF {P} RELATIONSHIP IN DMQ.600 or DMQ.610 = PARTNER (CODE 2), CONTINUE.

OTHERWISE, GO TO BOX 9E.

DMQ.620 Do {PERSON SELECTED IN DMQ.580} and {SELECTED NAME IN DMQ.590} have a biological or adopted child together?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 9E

CHECK ITEM DMQ.622:

IF THE SP’S SPOUSE OR PARTNER WAS SELECTED IN DMQ.590 AND

{P} RELATIONSHIP IN DMQ.600 OR DMQ.610 = SON OR DAUGHTER (CODE 3), CONTINUE.

OTHERWISE, GO TO BOX 9F.

DMQ.625 Is {PERSON}, {NAME OF SPOUSE/PARTNER’s} biological, adoptive, step, foster child, or (son or daughter)-in-law?

BIOLOGICAL CHILD 1

ADOPTIVE CHILD 2

STEP CHILD 3

FOSTER CHILD 4

(SON/DAUGHTER)-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 9F

END EMBEDDED LOOP 2A:

ASK BOX 9B THROUGH DMQ.625 FOR NEXT PERSON SELECTED IN DMQ.590.

IF NO NEXT PERSON, CONTINUE WITH BOX 10.

BOX 10

END LOOP 2:

ASK DMQ.580 THROUGH DMQ.625 FOR NEXT PERSON WHO HAS NOT BEEN IDENTIFIED AS RELATED TO THE SP.

IF NO NEXT PERSON, CONTINUE WITH BOX 11.

BOX 11

CHECK ITEM DMQ.625:

IF THE SP IS MARRIED (CODED AS 01 IN DMQ.530 OR DMQ.540) OR
LIVING WITH A PARTNER (CODED AS 02 IN DMQ.530 OR DMQ.540)

AND

THE SP HAS A CHILD (CODED AS 03 IN DMQ.530 OR DMQ.540),

CONTINUE.

OTHERWISE GO TO BOX 14.

BOX 12

LOOP 3:

ASK DMQ.630 FOR EACH CHILD OF THE SP (CODED AS 3 IN DMQ.530 OR DMQ.540).

DMQ.630 I recorded that {NAME OF CHILD OF THE SP} is your child. Is {NAME OF CHILD} a biological, or an adoptive child of {NAME OF SPOUSE/PARTNER}?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 13

END LOOP 3:

ASK DMQ.630 FOR NEXT CHILD OF THE SP.

IF NO NEXT CHILD, CONTINUE WITH BOX 14.

BOX 14

CHECK ITEM DMQ.635:

IF THE SP IS MARRIED (CODED AS 01 IN DMQ.530 or DMQ.540) OR LIVING WITH A PARTNER (CODED AS 02 IN DMQ.530 OR DMQ.540)

AND

LIVES WITH A PERSON CODED AS “DAUGHTER/SON OF PARTNER” (CODED AS 04 IN DMQ.530 OR DMQ.540),

CONTINUE

OTHERWISE GO TO BOX 17.

BOX 15

LOOP 4:

ASK DMQ.640 AND DMQ.645 FOR EACH CHILD OF THE SP’S PARTNER (CODED AS 04 IN DMQ.530 OR DMQ.540).

DMQ.640 I recorded that {NAME OF CHILD OF THE SP} is your partner’s child. Is {NAME OF CHILD} a biological, adoptive, step, foster child, (son or daughter)-in-law or a non-relative of {NAME OF SPOUSE/PARTNER’s}?

BIOLOGICAL CHILD 1

ADOPTIVE CHILD 2

STEP CHILD 3

FOSTER CHILD 4 (BOX 16)

(SON/DAUGHTER)-IN-LAW 5

NON RELATIVE 6

REFUSED 7

DON'T KNOW 9

DMQ.645 Is {NAME OF CHILD} a biological, or an adoptive child of yours?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 16

END LOOP 4:

ASK DMQ.640 AND DMQ.645 FOR NEXT CHILD OF THE SP’S PARTNER.

IF NO NEXT CHILD, CONTINUE WITH BOX 17.

BOX 17

ITEM DMQ.650:

CREATE VARIABLE TO DESIGNATE EACH PERSON REPORTED IN HOUSEHOLD COMPOSITION MATRIX AS SP’S FAMILY MEMBER (DMQ.650=1) OR SP’S NON FAMILY MEMBER (DMQ.650=2).

DMQ.650=1, IF:

RELATED BY BIRTH, MARRIAGE OR ADOPTION; STEP CHILDREN, PARENTS OR SIBLINGS ARE INCLUDED: RELATIONSHIP CODES IN (1, 5, 6, 7, 8, 9, 10, 11) IN DMQ.530 OR DMQ.540.
NON-FOSTER CHILD: RELATIONSHIP CODES = 3 IN DMQ.530 OR DMQ.540, AND DMQ.550 ≠ 4.
UNMARRIED PARTNERS WHO HAVE A BIOLOGICAL OR ADOPTIVE CHILD IN COMMON: RELATIONSHIP CODES = 2 IN DMQ.530 OR DMQ.540 AND ((DMQ.630 = 1) OR (DMQ.640 ≠ “BLANK” AND DMQ.640 ≠ 4 AND DMQ.645=1)).
IF UNMARRIED PARTNER WHO WAS DEEMED AS “FAMILY MEMBER” PER ABOVE ITEM 3, ALL HIS/HER OTHER CHILDREN ((DMQ.625 ≠ “BLANK” AND DMQ.625 ≠ 4)) OR ((DMQ.640 ≠ “BLANK” AND DMQ.640 ≠ 4)) WILL BE DEEMED AS FAMILY MEMBER AS WELL.
RELATED TO ANOTHER FAMILY MEMBER: THE PERSON SELECTED IN DMQ.590 HAS BEEN DEEMED AS “FAMILY MEMBER” PER ABOVE ITEMS 1-4 AND ((RELATIONSHIP CODES IN (1, 3, 5, 6, 7, 8, 9, 10, 11) IN DMQ.600 OR DMQ.610) OR (DMQ.620=1)).

OTHERWISE, DMQ.650=2.

INQ.202 This question is about {your/SP’s} {income/combined family income}. When answering this question, please remember that by {income/combined family income}, I mean {your/SP’s} {income/income plus the income of {NAMES OF OTHER FAMILY MEMBERS}} for {LAST CALENDAR YEAR}. Include income from all sources such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me the amount before taxes?

PROBE: Income is important in using the health information we collect. For example, it helps us to learn whether persons in one income group use certain types of medical services or have certain health conditions more or less often than those in another income group.

CAPI INSTRUCTIONS:

 DISPLAY “INCOME” IF ONLY 1 PERSON IN THE FAMILY IN DMQ.500.

 DISPLAY "COMBINED FAMILY INCOME” AND “INCOME PLUS THE INCOME OF {NAMES OF OTHER FAMILY MEMBERS}” IF MORE THAN 1 PERSON IN THE FAMILY IN DMQ.500 AND AT LEAST 1 PERSON IS CODED AS SP FAMILY MEMBER (DMQ.650=1).

 {NAMES OF OTHER FAMILY MEMBERS} INCLUDES: ALL HH MEMBERS WITH DMQ.650=1. SEPARATE NAMES WITH COMMAS. IF MORE THAN ONE NAME, INSERT “AND” BEFORE LAST NAME IN LIST.

$ |___|___|___|___|___|___|___|___|___| (END OF SECTION)

REFUSED 7777777777 (INQ.222)

DON'T KNOW 9999999999 (INQ.222)

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME.

 SCREEN SHOULD READ:

DOUBLE ENTRY OF INCOME REQUIRED.

 IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.

INQ.222 You may not be able to give us an exact figure for {your/SP's/your and NAME’s OF FAMILY MEMBERS} {income/combined family income}, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .

CAPI INSTRUCTIONS:

 DISPLAY “INCOME” IF ONLY 1 PERSON IN THE FAMILY IN DMQ.300.

 DISPLAY "COMBINED FAMILY INCOME” IF MORE THAN 1 PERSON IN THE FAMILY IN DMQ.500 300 AND AT LEAST 1 PERSON IS CODED AS SP FAMILY MEMBER (DMQ.650=1).

 DISPLAY "your and {NAME’s OF OTHER FAMILY MEMBERS}" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY AND AT LEAST 1 PERSON IS CODED AS SP FAMILY MEMBER (DMQ.650=1). {NAME’s OF OTHER FAMILY MEMBERS} INCLUDES: ALL HH MEMBERS WITH DMQ.650=1. SEPARATE NAMES WITH COMMAS. IF MORE THAN ONE NAME, INSERT “AND” BEFORE LAST NAME IN LIST.

$20,000 or more, or 1

less than $20,000? 2

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

INQ.232
a/b

Of these income groups, can you tell me which letter best represents {your/SP’s}/you and NAME’s OF FAMILY MEMBERS} {income/combined family income} in {LAST CALENDAR YEAR}?

HAND CARD {INQ1 AND INQ2}

ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED FAMILY INCOME.

CAPI INSTRUCTIONS:

 DISPLAY “INCOME” IF ONLY 1 PERSON IN THE FAMILY IN DMQ.300.

 DISPLAY "COMBINED FAMILY INCOME” IF MORE THAN 1 PERSON IN THE FAMILY IN DMQ.500 AND AT LEAST 1 PERSON IS SP’s FAMILY MEMBER (DMQ.650=1).

 DISPLAY "YOUR" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY AND AT LEAST 1 PERSON IS SP’s FAMILY MEMBER (DMQ.650=1). {NAME’s OF OTHER FAMILY MEMBERS} INCLUDES: ALL HH MEMBERS WITH DMQ.650=1. SEPARATE NAMES WITH COMMAS. IF MORE THAN ONE NAME, INSERT “AND” BEFORE LAST NAME IN LIST.

 IF $20,000 OR MORE, DISPLAY HAND CARD INQ1.

 IF LESS THAN $20,000, DISPLAY HAND CARD INQ2.

|___|___|

REFUSED 77

DON'T KNOW 99

HELP SCREEN FOR OCQ.380:

Taking Care of House or Family: Doing any type of work around the house, such as cleaning, cooking, maintaining the yard, caring for children or family, etc.

Going to School: Attending any type of public or private educational establishment both in and out of the regular school system.

Retired: Respondent defined.

Unable to Work for Health Reasons: Respondent defined.

On Layoff: Is when a person is waiting to be called back to a job from which they were temporarily laid-off or furloughed. Layoffs can be due to slack work, plant retooling or remodeling, inventory taking, and the like. Do not consider a person who was not working because of a labor dispute at his or her place of employment as being in layoff.

Disabled: Respondent defined.

Work (Working): Paid work for wages, salary, commission, tips, or pay "in kind." Examples of pay in kind include meals, living quarters, or supplies provided in place of wages. This definition of employment includes work in the person's own business, professional practice, or farm, paid leaves of absence (including vacations and illnesses), work without pay in a family business or farm run by a relative, exchange work or share work on a farm, and work as a civilian employee of the Department of Defense or the National Guard. This definition excludes unpaid volunteer work (such as for a church or charity), unpaid leaves of absences, temporary layoffs (such as a strike), and work around the house.

HELP SCREEN FOR DMQ.530, DMQ.540, DMQ.600, DMQ.610:

Stepchild: A child is referred to as the stepchild, stepdaughter or stepson of their biological parent's new spouse, and that person is the stepparent, stepfather or stepmother of the child.

Stepparent: A stepfather is the husband of one's mother and not one's biological father. A stepmother is the wife of one's father and not one's biological mother.

Son/Daughter of Partner: Including the partner’s biological, adoptive, step, and foster child, and the partner’s son- or daughter-in-law.

HEALTH INSURANCE – HIQ

Target Group: SP’s 20+

HIQ.011 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.

{Are you/Is SP} covered by health insurance or some other kind of health care plan?

YES 1

NO 2 (BOX 1)

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

HIQ.031 What kind of health insurance or health care coverage {do you/does SP} have? Include those that pay for only one type of service (nursing home care, accidents, or dental care). Exclude private plans that only provide extra cash while hospitalized. If {you have/s/he has} more than one kind of health insurance, tell me all plans that {you have/s/he has}.

CODE ALL THAT APPLY

HAND CARD HIQ1

CAPI INSTRUCTION:

DO NOT ALLOW MORE THAN ONE ANSWER WHEN 40 (NO COVERAGE OF ANY TYPE) IS CODED.

PRIVATE HEALTH INSURANCE 14

MEDICARE 15

MEDI-GAP 16

MEDICAID ({DISPLAY STATE PLAN NAME}) 17

SCHIP (CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM) 18

MILITARY HEALTH CARE (TRICARE/VA/CHAMP-VA) 19

INDIAN HEALTH SERVICE 20

STATE-SPONSORED HEALTH PLAN ({DISPLAY STATE

PLAN NAME}) 21

OTHER GOVERNMENT PROGRAM 22

SINGLE SERVICE PLAN (E.G., DENTAL, VISION,

PRESCRIPTIONS) 23

NO COVERAGE OF ANY TYPE 40

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

SOFT EDIT: IF SP AGE LESS THAN 18 AND HIQ.031 = 15 (MEDICARE) DISPLAY ERROR MESSAGE, “PLEASE VERIFY THAT CHILD SP HAS MEDICARE. Only disabled children or children with kidney failure can get Medicare. Children who have Medicare are almost always also receiving Social Security or SSI and have Medicaid.”

SOFT EDIT: IF SP AGE EQUAL TO OR GREATER THAN 20 AND LESS THAN 65 AND HIQ.031 – 15 (MEDICARE) DISPLAY ERROR MESSAGE, “PLEASE VERIFY THAT SP AGE 20-64 HAS MEDICARE. Only disabled adults or adults with kidney failure under 65 years old can have Medicare. They are almost always receiving disability checks from Social Security or SSI.”

HARD EDIT: IF HIQ.031 = 16 (MEDI-GAP) AND 15 (MEDICARE) IS NOT SELECTED, DISPLAY ERROR MESSAGE, “Medi-Gap refers to Medicare Supplemental Insurance. You must have Medicare to be eligible to purchase Medi-Gap. PLEASE VERIFY IF SP HAS MEDI-GAP AND, IF YES, IF HE/SHE HAS Medicare.”

{CAPI DISPLAYS ONE QUESTION FOR CORRECTION}

HIQ.031

BOX 1

CHECK ITEM HIQ.063:

IF AGE => 65 AND HIQ.031 = 14,16-99 OR EMPTY, CONTINUE.
IF AGE = BIRTH+ AND HIQ.031 = CODE 15, GO TO HIQ.502.
OTHERWISE, GO TO END OF SECTION.

HIQ.260 {Do you/Does SP} have Medicare? This is a health insurance program that virtually all persons 65 and older are eligible for. A card is automatically mailed to you shortly before your 65th birthday, it looks like this.

SHOW HAND CARD HIQ2 OF MEDICARE CARD

YES 1

NO 2 (END OF SECTION0

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

HIQ.502 May I please see {your/SP's} Medicare card to record the Health Insurance Claim Number?

This number is needed to allow Medicare records of the Center for Medicare and Medicaid Services to be easily and accurately located and identified for statistical or research purposes. We may also need to link it with other records in order to re-contact {you/SP}. Providing the Health Insurance Claim Number is voluntary and collected under the authority of the Public Health Service Act. Whether the number is given or not, there will be no effect on {your/his/her} benefits. This number will be held confidential. [The Public Health Service Act is Title 42, United States Code, Section 242K.]

CAPI INSTRUCTION:

REQUIRE DOUBLE ENTRY OF NUMBER.

ALLOW UP TO 11 CHARACTERS (LETTERS OR NUMBERS)

|___|___|___|___|___|___|___|___|___|___|___|

ENTER CLAIM NUMBER

REFUSED 77777777777 (END OF SECTION)

DON'T KNOW 99999999999 (END OF SECTION)

HIQ.105 INTERVIEWER: ENTER 1 RESPONSE

CARD AVAILABLE 1

CARD NOT AVAILABLE 2

HELP SCREEN FOR HIQ.011:

Health Insurance: Health benefits coverage which provides persons with health-related benefits. Coverage may include the following; hospitalization, major medical, surgical, prescriptions, dental, and vision.

Medicare: A Federal health insurance program for people 65 or older and for certain persons under 65 with long-term disabilities. Almost all Social Security recipients are covered by Medicare. It is run by the Center for Medicare and Medicaid Services of the U.S., Department of Health and Human Services.

Medicare consists of two parts, A and B:

Part A is called the Hospital Insurance Program. It helps pay for inpatient care in a hospital or in a skilled nursing facility, for home health care, and for hospice care. It is available to nearly everyone 65 or older.

Persons who are eligible for either Social Security or Railroad Retirement benefits are not required to pay a monthly premium for Part A of Medicare. However, anyone who is 65 or over and does not qualify for Social Security or Railroad Retirement benefits may pay premiums directly to Social Security to obtain Part A coverage.

Part B is called the Supplementary Medical Insurance Program. It is a voluntary plan that builds upon the hospital insurance protection provided by the basic plan. It helps pay for the doctor and surgeon services, outpatient hospital services, durable medical equipment, and a number of other medical services and supplies that are not already covered under Part A of Medicare.

If a person elects this additional insurance, the monthly premium is deducted from his/her Social Security.

Medicaid: Refers to a medical assistance program that provides health care coverage to low-income and disabled persons. The Medicaid program is a joint federal-state program which is administered by the states.

HELP SCREEN FOR HIQ.031:

Private Health Insurance Plan: Any type of health insurance, including HMOs, that is not a public program. Private health insurance plans may be provided in part or full by a person's employer or union, or may be purchased directly by an individual.

Private Health Insurance Plan through a State or Local Government Program or Community Program: A type of health insurance for which state or local government or community effort pays for part or all of the cost of a private insurance plan, such as Blue Cross/Blue Shield. The individual may also contribute to the cost of the health insurance and may receive a card such as a Blue Cross/Blue Shield card. A community program or effort may include a variety of mechanisms to achieve health insurance for persons who would otherwise be uninsured. An example would be a private company giving a grant to an HMO to pay for health insurance coverage.

Medicare consists of two parts, A and B:

If a person elects this additional insurance, the monthly premium is deducted from his/her Social Security.

Medi-Gap: Refers to private health insurance purchased to supplement Medicare. Medi-Gap will be treated as a private health insurance plan in the detailed questions about health insurance.

CHIP (Children's Health Insurance Program, also called SCHIP): A joint federal and state program, administered by each state, that offers health care coverage to low-income, uninsured children. This law was passed in 1997. In some states, CHIP programs have distinct names.

Military Health Care/VA: Refers to health care available to active duty personnel and their dependents, in addition, the VA provides medical assistance to veterans of the Armed Forces, particularly those with service-connected ailments.

CHAMPUS/TRICARE/CHAMP-VA: CHAMPUS (Comprehensive Health and Medical Plan for the Uniformed Services) provides health care in private facilities for dependents of military personnel on active duty or retired for reasons other than disability. TRICARE is the "managed care" version of CHAMPUS. CHAMP-VA (Comprehensive Health and Medical Plan of the Veterans Administration) provides health care for the spouse, dependents, or survivors of a veteran who has a total, permanent service-connected disability.

Indian Health Service: The federal health care program for Native Americans.

State-Sponsored Health Plan: Any other health care coverage run by a specific state, including public assistance programs other than "Medicaid" that pay for health care.

Other Government Program: A catch-all category for any public program providing health care coverage other than those programs in specific categories.

Single Service Plan (SSP): Health insurance coverage paid for by an individual that provides for only one type of service or treatment for a specific condition. These plans are usually bought to supplement a more comprehensive health insurance plan. Examples of SSPs are dental care, vision care, prescriptions, nursing home care, hospice care, accidents, catastrophic care, cancer treatment, AIDS care, and/or hospitalization.

HELP SCREEN FOR HIQ.502:

Medicare consists of two parts, A and B:

If a person elects this additional insurance, the monthly premium is deducted from his/her Social Security

Aspirin and Prescription Medication Use - RXQ Part 1

Target Group: SPs 20+

RXQ.616 These next questions are about medications {you/SP} may be taking.

Doctors and other health care providers sometimes recommend that {you/SP} take low-dose aspirin each day to prevent heart attacks, strokes or cancer.

{Are you/Is SP} now taking a low-dose aspirin each day or every other day?

YES 1

NO 2 (RXQ.620)

REFUSED 7 (RXQ.620)

DON'T KNOW 9 (RXQ.620)

RXQ.618 Please look at this hand card. Can you tell me why {you take/SP takes} aspirin?

HAND CARD RXQ1

CODE ALL THAT APPLY.

TO REDUCE THE CHANCE OF A HEART
ATTACK 1 (RXQ.032)

TO REDUCE THE CHANCE OF A STROKE 2 (RXQ.032)

TO REDUCE THE CHANCE OF CANCER 3 (RXQ.032)

TO RELIEVE PAIN 4 (RXQ.032)

OTHER………………………………………….. 5 (RXQ.032)

REFUSED 7 (RXQ.032)

DON'T KNOW 9 (RXQ.032)

RXQ.620 {Do you/Does SP} have a health problem or condition that makes taking aspirin unsafe for {you/him/her}?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

RXQ.032 In the past 30 days, {have you/has SP} used or taken medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. Do not include prescription vitamins or minerals.

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN FOR RXQ.032:

Prescription Medication: Prescription medications are those ordered by a physician or other authorized medical professional through a written or verbal prescription for a pharmacist to fill. Prescription medications may also be given by a medical professional directly to a patient to take home, such as free samples.

Prescription medications do not include:

- Medication administered to the patient during the event in the office as part of the treatment (such as an antibiotic shot for an infection, a flu shot, or an oral medication) unless a separate bill for the medication is received;

- Diaphragms and IUD’s (Intra-Uterine Devices); or

- Some state laws require prescriptions for over the counter medications. Sometimes physicians write prescriptions for over the counter medications, such as aspirin. Consider any medication a prescription medication if the respondent reports it as prescribed. If it is an over the counter medication, however, the prescription must be a written prescription to be filled by a pharmacist, not just a written or oral instruction. If in doubt, probe whether the patient got a written prescription to fill at a pharmacy.

Past Month: The past 30 days. From yesterday, 30 days back.

HOSPITALIZATIONS - HVQ

Target Group: SP’s 20+

BOX 1

CHECK ITEM HVQ.001:

IF ANY OF MCQ.197b-q = 1, GO TO HVQ.020.

OTHERWISE, CONTINUE

HVQ.010 For these next questions I would like you to think back over the time since {your/SP’s} original health interview in the NHANES mobile exam center in {BASELINE YEAR} and now, that is in the last {YEARS ELAPSED} years.

Since {you were/SP was} {AGE AT BASELINE} years old {have you/has SP} stayed overnight in the hospital? Please include overnight stays for any medical problems, surgeries, and procedures. Do not include stays for uncomplicated childbirth or overnight visits to the emergency room.

YES 1 (HVQ.020)

NO 2

REFUSED 7 (BOX 9)

DON’T KNOW 9

BOX 2

CHECK ITEM HVQ.013:

IF ANY OF MCQ.407, MCQ.417, MCQ.427, MCQ.447, MCQ.457, MCQ.467, MCQ.477, MCQ.487 CODED “1”, CONTINUE;

ELSE IF AGE REPORTED IN ANY OF MCQ.405, MCQ.415, MCQ.425, MCQ.435, MCQ.445, MCQ.455, MCQ.465, MCQ.475, MCQ.485 IS OLDER THAN BASELINE AGE, CONTINUE;

OTHERWISE, GO TO BOX 9.

HVQ.015 Earlier in this interview you reported that {you/SP} had the following procedures since {you were/s/he was} {AGE AT BASELINE} years old:

{LIST PROCEDURES}

{Have you/Has SP} stayed overnight in the hospital for {this procedure/any of these procedures}?

YES 1

NO 2 (BOX 9)

REFUSED 7 (BOX 9)

DON’T KNOW 9 (BOX 9)

CAPI INSTRUCTION:

DISPLAY THE PROCEDURES AS A LIST WITH EACH PROCEDURE DISPLAYED ON A SEPARATE LINE:

IF AGE REPORTED IN MCQ.405 IS OLDER THAN BASELINE AGE, OR MCQ.407 IS YES (CODE 1), DISPLAY “coronary bypass surgery, a graft, CABG or bypass procedure”
IF AGE REPORTED IN MCQ.415 IS OLDER THAN BASELINE AGE, OR MCQ.417 IS YES (CODE 1), DISPLAY “surgery on the arteries in the neck”
IF AGE REPORTED IN MCQ.425 IS OLDER THAN BASELINE AGE, OR MCQ.427 IS YES (CODE 1), DISPLAY “repair of an aortic aneurysm”
IF AGE REPORTED IN MCQ.435 IS OLDER THAN BASELINE AGE, DISPLAY “a pacemaker or implantable cardioverter defibrillator (ICD) placed”
IF AGE REPORTED IN MCQ.445 IS OLDER THAN BASELINE AGE, OR MCQ.447 IS YES (CODE 1), DISPLAY “angioplasty or stenting of the coronary arteries”
IF AGE REPORTED IN MCQ.455 IS OLDER THAN BASELINE AGE, OR MCQ.457 IS YES (CODE 1), DISPLAY “procedure to treat the blocked arteries in the legs”
IF AGE REPORTED IN MCQ.465 IS OLDER THAN BASELINE AGE, OR MCQ.467 IS YES (CODE 1), DISPLAY “other heart or blood vessel surgery”
IF AGE REPORTED IN MCQ.475 IS OLDER THAN BASELINE AGE, OR MCQ.477 IS YES (CODE 1), DISPLAY “toe amputation”
IF AGE REPORTED IN MCQ.485 IS OLDER THAN BASELINE AGE, OR MCQ.487 IS YES (CODE 1), DISPLAY “leg amputation”

IF ONLY A SINGLE PROCEDURE, DISPLAY “this procedure”, OTHERWISE, DISPLAY “any of these procedures”.

HVQ.020 {For these next questions I would like you to think back over the time since {your/SP’s} original health interview in the NHANES mobile exam center in {BASELINE YEAR} and now, that is in the last {YEARS ELAPSED} years.}

{We will/Next we will} ask you for the names of hospitals where {you/SP} stayed overnight {since {you were/SP was} {AGE AT BASELINE} years old}. We would like to contact hospitals you tell us about to ask them for information on the reasons for hospitalization and surgeries performed.

Before we contact the hospitals, we will ask you to sign a document giving authorization for the hospital to give us {your/SP’s} information. Your participation is voluntary.⁰

Do we have permission to obtain {your/SP’s} hospital information?

CAPI INSTRUCTION:

IF ANY OF MCQ.197b-q = 1, DISPLAY “For these next questions I would like you to think back over the time since {your/SP’s} original health interview in the NHANES mobile exam center in {BASELINE YEAR} and now, that is in the last {YEARS ELAPSED} years.}”, “We will”, and “{since {you were/SP was} {AGE AT BASELINE} years old”
Otherwise, DISPLAY “Next we will”

YES 1

NO 2 (BOX 9)

HVQ.025 Please tell me the names of all the hospitals where {you/SP} stayed overnight since {you were/SP was} {AGE AT BASELINE} years old. Include stays for any medical problems, surgeries, and procedures, but do not include stays for uncomplicated childbirth or overnight visits to the emergency room.

PROBE: Any other hospitals?

HOSPITAL NAME

REFUSED 7 (BOX 9)

DON’T KNOW 9 (BOX 9)

CAPI INSTRUCTION:

ALLOW INTERVIEWER TO ENTER EACH HOSPITAL NAME ON A SEPARATE LINE IN A TABLE DISPLAYED AT THE BOTTOM OF THE SCREEN.

BOX 3

CHECK ITEM HVQ.027:

IF ANY OF MCQ.197b-q = 1, CONTINUE WITH HVQ.030.

OTHERWISE, GO TO BOX 4.

HVQ.030 Earlier in this interview you reported that {you/SP} had an overnight hospital stay for:

{LIST CONDITIONS}

Have you told me the names of all the hospitals where {you/SP} stayed for (this/these) condition(s) since {you were/SP was} {AGE AT BASELINE} years old?

ADD HOSPITALS 1

CONTINUE 2

CAPI INSTRUCTIONS:

DISPLAY THE CONDITIONS REPORTED IN MCQ.197b-q AS A LIST WITH EACH CONDITION DISPLAYED ON A SEPARATE LINE:

IF MCQ.197b IS YES (CODE 1), DISPLAY “congestive heart failure”
IF MCQ.197c IS YES (CODE 1), DISPLAY “coronary heart disease”
IF MCQ.197d IS YES (CODE 1), DISPLAY “angina pectoris”
IF MCQ.197e IS YES (CODE 1), DISPLAY “a heart attack”
IF MCQ.197f IS YES (CODE 1), DISPLAY “a stroke”
IF MCQ.197p IS YES (CODE 1), DISPLAY “asthma”
IF MCQ.197q IS YES (CODE 1), DISPLAY “COPD, emphysema or chronic bronchitis

DISPLAY THE TABLE WITH THE HOSPITAL NAMES COLLECTED IN HVQ.025 AT THE BOTTOM OF THE SCREEN. IF HVQ.030 CODED “1”, ALLOW THE INTERVIEWER TO INSERT ROWS AND ENTER ADDITIONAL HOSPITAL NAMES.

BOX 4

CHECK ITEM HVQ.035:

IF HVQ.015 = 1, GO TO HVQ.050;

ELSE IF HVQ.010 = MISSING AND (ANY OF MCQ.407, MCQ.417, MCQ.427, MCQ.447, MCQ.457, MCQ.467, MCQ.477, MCQ.487 IS CODED “1”), CONTINUE;

ELSE IF AGE REPORTED IN ANY OF MCQ.405, MCQ.415, MCQ.425, MCQ.435, MCQ.445, MCQ.455, MCQ.465, MCQ.475, MCQ.485 IS OLDER THAN BASELINE AGE AND HVQ.010 = MISSING, CONTINUE;

OTHERWISE, GO TO HVQ.060.

HVQ.040 Earlier in this interview you reported that {you/SP} had the following procedures since {you were/s/he was} {AGE AT BASELINE} years old:

{LIST PROCEDURES}

{Have you/Has SP} stayed overnight in the hospital for {this procedure/any of these procedures}?

YES 1

NO 2 (HVQ.060)

REFUSED 7 (HVQ.060)

DON’T KNOW 9 (HVQ.060)

CAPI INSTRUCTION:

DISPLAY THE PROCEDURES AS A LIST WITH EACH PROCEDURE DISPLAYED ON A SEPARATE LINE:

IF AGE REPORTED IN MCQ.405 IS OLDER THAN BASELINE AGE, OR MCQ.407 IS YES (CODE 1), DISPLAY “coronary bypass surgery, a graft, CABG or bypass procedure”
IF AGE REPORTED IN MCQ.415 IS OLDER THAN BASELINE AGE, OR MCQ.417 IS YES (CODE 1), DISPLAY “surgery on the arteries in the neck”
IF AGE REPORTED IN MCQ.425 IS OLDER THAN BASELINE AGE, OR MCQ.427 IS YES (CODE 1), DISPLAY “repair of an aortic aneurysm”
IF AGE REPORTED IN MCQ.435 IS OLDER THAN BASELINE AGE, DISPLAY “a pacemaker or implantable cardioverter defibrillator (ICD) placed”
IF AGE REPORTED IN MCQ.445 IS OLDER THAN BASELINE AGE, OR MCQ.447 IS YES (CODE 1), DISPLAY “angioplasty or stenting of the coronary arteries”
IF AGE REPORTED IN MCQ.455 IS OLDER THAN BASELINE AGE, OR MCQ.457 IS YES (CODE 1), DISPLAY “procedure to treat the blocked arteries in the legs”
IF AGE REPORTED IN MCQ.465 IS OLDER THAN BASELINE AGE, OR MCQ.467 IS YES (CODE 1), DISPLAY “other heart or blood vessel surgery”
IF AGE REPORTED IN MCQ.475 IS OLDER THAN BASELINE AGE, OR MCQ.477 IS YES (CODE 1), DISPLAY “toe amputation”
IF AGE REPORTED IN MCQ.485 IS OLDER THAN BASELINE AGE, OR MCQ.487 IS YES (CODE 1), DISPLAY “leg amputation”

IF ONLY A SINGLE PROCEDURE, DISPLAY “this procedure”. OTHERWISE, display “any of these procedures”.

HVQ.050 Have you included the hospitals where {you/SP} stayed for {this procedure/these procedures/the following procedure(s)}?

{LIST PROCEDURES}

ADD HOSPITALS 1

CONTINUE 2

CAPI INSTRUCTIONS:

DISPLAY THE TABLE WITH THE HOSPITAL NAMES COLLECTED IN HVQ.025 AND HVQ.030 AT THE BOTTOM OF THE SCREEN. IF HVQ.050 CODED “1”, ALLOW THE INTERVIEWER TO INSERT ROWS AND ENTER ADDITIONAL HOSPITAL NAMES.

CAPI INSTRUCTION:

IF HVQ.015 ≠ 1, NO PROCEDURE LIST NEEDED.

IF ONLY A SINGLE PROCEDURE DISPLAYED IN HVQ.040, DISPLAY “this procedure”, OTHERWISE, DISPLAY “these procedures”

ELSE IF HVQ.015 = 1, DISPLAY “the following procedure(s)” AND DISPLAY THE PROCEDURES AS A LIST WITH EACH PROCEDURE DISPLAYED ON A SEPARATE LINE:

IF AGE REPORTED IN MCQ.405 IS OLDER THAN BASELINE AGE, OR MCQ.407 IS YES (CODE 1), DISPLAY “coronary bypass surgery, a graft, CABG or bypass procedure”
IF AGE REPORTED IN MCQ.415 IS OLDER THAN BASELINE AGE, OR MCQ.417 IS YES (CODE 1), DISPLAY “surgery on the arteries in the neck”
IF AGE REPORTED IN MCQ.425 IS OLDER THAN BASELINE AGE, OR MCQ.427 IS YES (CODE 1), DISPLAY “repair of an aortic aneurysm”
IF AGE REPORTED IN MCQ.435 IS OLDER THAN BASELINE AGE, DISPLAY “a pacemaker or implantable cardioverter defibrillator (ICD) placed”
IF AGE REPORTED IN MCQ.445 IS OLDER THAN BASELINE AGE, OR MCQ.447 IS YES (CODE 1), DISPLAY “angioplasty or stenting of the coronary arteries”
IF AGE REPORTED IN MCQ.455 IS OLDER THAN BASELINE AGE, OR MCQ.457 IS YES (CODE 1), DISPLAY “procedure to treat the blocked arteries in the legs”
IF AGE REPORTED IN MCQ.465 IS OLDER THAN BASELINE AGE, OR MCQ.467 IS YES (CODE 1), DISPLAY “other heart or blood vessel surgery”
IF AGE REPORTED IN MCQ.475 IS OLDER THAN BASELINE AGE, OR MCQ.477 IS YES (CODE 1), DISPLAY “toe amputation”
IF AGE REPORTED IN MCQ.485 IS OLDER THAN BASELINE AGE, OR MCQ.487 IS YES (CODE 1), DISPLAY “leg amputation”

HVQ.060 I have listed the following hospitals.

REVIEW LIST OF HOSPITALS.

{Have you/Has SP} stayed overnight at any other hospitals since {you were/she/he was} {AGE AT BASELINE} years old? Do not include stays for uncomplicated childbirth or overnight visits to the emergency room.

ADD ANY ADDITIONAL HOSPITALS. SELECT CONTINUE WHEN THERE ARE NO MORE HOSPITALS TO ADD.

CONTINUE 1

CAPI INSTRUCTIONS:

DISPLAY THE TABLE WITH THE HOSPITAL NAMES AT THE BOTTOM OF THE SCREEN. ALLOW THE INTERVIEWER TO INSERT ROWS AND ENTER ADDITIONAL HOSPITAL NAMES.

BOX 5

LOOP 1:

ASK HVQ.070 AND HVQ.080 FOR EACH OF THE HOSPITALS IN THE TABLE.

HVQ.070 I have a directory to look up contact information for the hospitals you’ve told me about. I’ll confirm the hospital address with you to make sure I’ve selected the correct hospital.

INTERVIEWER INSTRUCTION:

USE THE TAB KEY TO MOVE TO THE “PROVIDER LOOKUP” FIELD AND PRESS THE SPACE BAR TO START THE HOSPITAL SEARCH
ENTER THE NAME OF THE HOSPITAL AND USE THE UP AND DOWN ARROWS TO HIGHLIGHT THE CORRECT ROW
CONFIRM THE ADDRESS (STREET, CITY, AND STATE) AND SELECT THE HOSPITAL

IF HOSPITAL NOT ON LIST – PRESS BS TO DELETE ENTRY.
TYPE “**”.
PRESS ENTER TO SELECT

CAPI INSTRUCTION:

DISPLAY THE TABLE WITH THE NAMES OF THE HOSPITAL ENTERED BY THE INTERVIEWER IN THE FIRST COLUMN. LIST EACH HOSPITAL ON A SEPARATE ROW.
ALLOW THE INTERVIEWER TO USE THE TAB KEY TO MOVE TO THE SECOND COLUMN AND PRESS THE SPACE BAR TO ACTIVATE THE HOSPITAL PROVIDER LOOK UP.
DISPLAY HOSPITAL PROVIDER LOOK UP AS A POP-UP SCREEN WITH COLUMNS FOR HOSPITAL NAME, STREET ADDRESS, CITY, AND STATE, ZIP CODE, PHONE NUMBER, TAXONOMY.
ALLOW INTERVIEWER TO TYPE THE HOSPITAL NAME IN THE SEARCH FIELD TO ACTIVATE TRIGRAM SEARCH. DISPLAY POTENTIAL MATCHES AND ALLOW INTERVIEWER TO USE THE UP AND DOWN ARROWS TO HIGHLIGHT THE CORRECT ROW.
THE LOOK UP IS A SUBSET OF RECORDS FROM THE NPI PROVIDER DIRECTORY. SELECT THE SUBSET OF HOSPITALS WITH AN Entity type code of “2, Organization” and ANY OF the “Healthcare provider taxomony codeS” LISTED BELOW designated as the primary taxonomy. DISPLAY THE DESCRIPTIVE TEXT, NOT THE ASSOCIATED CODE, IN THE LOOK UP.

Chronic disease hospital (281P00000X)
General acute care hospital (282N00000X)
Military hospital (286500000X)
Psychiatric hospital (283Q00000X)
Rehabilitation hospital (283X00000X)

SAVE THE DIRECTORY HOSPITAL NAME, ADDRESS, CITY, STATE, ZP CODE AND PHONE NUMBER. ALSO SAVE THE NPI PROVIDER ID, BUT DO NOT DISPLAY IT IN THE TABLE.

HVQ.080 I was not able to find that hospital in my directory. What is the hospital name, street address, city, state, zip

a/b/c/d/e/f code and phone number? I can wait if you need to find any records you may have with that information.

HOSPITAL NAME: [____________________________]

STREET ADDRESS: [____________________________]

CITY: [____________________________]

STATE: [____________________________]

ZIP CODE: [____________________________]

PHONE NUMBER: [____________________________]

CAPI INSTRUCTION:

HOSPITAL NAME, CITY AND STATE ARE REQUIRED FIELDS. ALLOW STREET ADDRESS, ZIP CODE AND PHONE NUMBER TO BE LEFT BLANK.

BOX 6

END LOOP 1

ASK HVQ.070 AND HVQ.080 FOR EACH HOSPITAL IN THE TABLE.

IF NO MORE HOSPITALS, CONTINUE.

BOX 7

LOOP 2

ASK HVQ.090 - HVQ.100 FOR EACH HOSPITAL IN THE TABLE.

HVQ.090 In what month and year did {you/SP} stay overnight at {HOSPITAL NAME}?

M/Y If {you have/SP has} had more than one hospital stay at {HOSPITAL NAME} since {you were/SP was}

a/b/c {AGE AT BASELINE} years old, we would like you to think about {your/his/her} three most recent overnight stays.

INTERVIEWER INSTRUCTION:

RECORD MONTH OF ADMISSION IF ADMISSION AND DISCHARGE MONTHS DIFFER.
PROBE FOR UP TO 3 MOST RECENT STAYS IF R REPORTS MULTIPLE STAYS AT THE SAME HOSPITAL.

|___|___|

ENTER NUMBER (MONTH)

REFUSED 77

DON'T KNOW 99

|___|___|___|___|

ENTER NUMBER (YEAR)

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTIONS:

DISPLAY A TABLE WITH THE NAME OF THE HOSPITAL IN THE FIRST COLUMN. COLUMNS 2-4 WILL BE POPULATED WITH THE ADMISSION MONTH AND YEAR AND THE REASON FOR THE STAY AS THEY ARE COLLECTED IN HVQ.090 – HVQ.100. DISPLAY INFORMATION ON ALL HOSPITAL STAYS IN A SINGLE GRID.
ALLOW THE INTERVIEWER TO COLLECT INFORMATION ON UP TO 3 SEPARATE ADMISSIONS FOR EACH HOSPITAL. INCLUDE A FUNCTION SO IF MULTIPLE STAYS OCCURRED AT THE SAME HOSPITAL, THE INTERVIEWER CAN CLICK AND HAVE THE HOSPITAL INFORMATION AUTOMATICALLY COPY TO A NEW ROW BELOW.

HVQ.100 Please look at this card and tell me the main reason for {your/his/her} stay at {HOSPITAL NAME} in

a/b/c {MONTH IN HVQ.090} {YEAR IN HVQ.090}.

HAND CARD HVQ1

INTERVIEWER INSTRUCTION:

SELECT ONE MAIN REASON FOR EACH HOSPITAL STAY.

ARTHRITIS 1

ASTHMA 2

COMPLICATION OF DEVICE, IMPLANT, OR GRAFT 3

COMPLICATIONS DUE TO PREGNANCY AND CHILDBIRTH 4

COPD, EMPHYSEMA, CHRONIC BRONCHITIS 5

DEPRESSION, OTHER MOOD DISORDER 6

HEART DISEASE (FOR EXAMPLE, ABNORMAL OR IRREGULAR
HEARTBEAT, ANGINA, CONGESTIVE HEART FAILURE,
CORONARY HEART DISEASE, HEART ATTACK, MYOCARDIAL
INFARCTION) 7

NECK OR BACK PAIN; DISC, SPINE OR BACK PROBLEMS 8

PNEUMONIA 9

SEPSIS, SEPTICEMIA 10

STROKE 11

URINARY TRACT INFECTION 12

OTHER REASON 13

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTIONS:

SORT THE TABLE WITH ADMISSIONS LISTED IN REVERSE CHRONOLOGIAL ORDER WITHIN EACH HOSPITAL.
DISPLAY RESPONSE OPTIONS AS A DROP DOWN LIST.

BOX 8

END LOOP 2

ASK HVQ.090 - HVQ.100 FOR EACH HOSPITAL IN THE TABLE.

IF THERE ARE NO MORE HOSPITALS, CONTINUE.

HVQ.120 I’d like to review the information I have recorded to make sure it’s complete. I have listed the following hospital stays:

REVIEW THE INFORMATION IN THE TABLE WITH THE SP AND MAKE ANY CORRECTIONS.

Have I missed any overnight hospital stays {you/SP} had since {you were/SP was} {AGE AT BASELINE} years old? Please include overnight stays for any medical problems, surgeries, and procedures, but do not include stays for uncomplicated childbirth or overnight visits to the emergency room.

INFORMATION CORRECT 1

UPDATES NEEDED 2

CAPI INSTRUCTION:

DISPLAY A TABLE LISTING EACH OF THE HOSPITAL STAYS IN HVQ.090 – HVQ.110, WITH EACH HOSPITALIZATION LISTED ON A SEPARATE LINE.
DISPLAY THE FOLLOWING FIELDS:

HOSPITAL NAME, CITY, STATE
MONTH AND YEAR OF HOSPITALIZATION
REASON FOR HOSPITALIZATION

ALLOW INTERVIEWER TO HIGHLIGHT A ROW AND MAKE EDITS TO INDIVIDUAL FIELDS OR DELETE AN ENTIRE ROW.
ALLOW INTERVIEWER TO ADD MISSING HOSPITAL STAYS, LOOPING BACK THROUGH HVQ.090-HVQ.110 TO COLLECT THE INFORMATION.

HVQ.130 Before I ask you to sign the form authorizing the hospital(s) to give us information about {your/SP’s} hospital stays, is there a name or names besides {DISPLAY FIRST, MIDDLE, LAST NAME, AND SUFFIX FROM DMQ.044, DMQ.048, DMQ.062, AND DMQ.068).under which {your/SP’s} hospital records may be filed?

YES 1

NO 2 (HVQ.150)

REFUSED 7 (HVQ.150)

DON’T KNOW 9 (HVQ.150)

HVQ.140 What is that name?

INTERVIEWER INSTRUCTION:

PROBE FOR ALL ALTERNATE NAMES AND VERIFY SPELLING.

Alternate Name #1:

FIRST NAME: [____________________________]

MIDDLE NAME: [____________________________]

LAST NAME: [____________________________]

SUFFIX: [____________________________]

Alternate Name #2:

FIRST NAME: [____________________________]

MIDDLE NAME: [____________________________]

LAST NAME: [____________________________]

SUFFIX: [____________________________]

Alternate Name #3:

FIRST NAME: [____________________________]

MIDDLE NAME: [____________________________]

LAST NAME: [____________________________]

SUFFIX: [____________________________]

REFUSED 7---7

DON’T KNOW 9---9

HVQ.150 Now I will ask you to sign a form for each hospital you have just told me about to give your permission for us to request your medical records. Here is some more information about the records check [HAND SP A COPY OF “ABOUT THE REQUEST FOR HOSPITAL RECORDS”]. Please take a few minutes to review it.

INTERVIEWER INSTRUCTION:

REFER TO JOB AID HVQ1, REVIEW KEY POINTS OF THE INFORMATION SHEET WITH RESPONDENT.

ANSWER ANY RESPONDENT QUESTIONS

OBTAIN A SEPARATE SIGNED HIPAA AUTHORIZATION FORM FOR EACH HOSPITAL LISTED IN THE TABLE.

CAPI INSTRUCTION:

DISPLAY FIRST, MIDDLE, LAST NAME AND SUFFIX FROM DMQ.044, DMQ.048, DMQ.062, AND DMQ.068 AS LEFT HEADER AND ANY ALTERNATE NAMES COLLECTED IN HVQ.140 ON SEPARATE LINES BELOW.
DISPLAY DATE OF BIRTH FROM DMQ.010 AS LEFT HEADER BELOW SP NAMES.
EXTRACT LIST OF HOSPITALS FROM TABLE IN HVQ.120 AND DISPLAY SEPARATE COLUMNS FOR HOSPITAL NAME, STREET ADDRESS, CITY, STATE. LIST EACH HOSPITAL ON A SEPARATE LINE.
INCLUDE COLUMN TITLED “FORM SIGNED” WITH DROP DOWN OPTIONS TO SELECT “YES” OR “NO” FOR EACH HOSPITAL.

JOB AID HVQ1 HIPAA Authorization Form Talking Points

We are collecting medical records so we can obtain more information about your hospital stays, such as discharge diagnoses and procedures that were done. By collecting the records we hope to learn more about certain medical problems.
The information in your hospital records will supplement the interview and exam data collected in NHANES.
We will only contact the hospitals you give us permission to contact. We will give the hospitals your name, sex, and date of birth to obtain your records but no other information.
By contacting them, hospital staff will know you participated in NHANES. By law they will not be able to use this knowledge to obtain additional information about you through the NHANES data files.
Signing the authorization forms(s) is voluntary and you will not lose any benefits by saying no.

ANSWER ANY QUESTIONS THE SP HAS, THEN PROCEED WITH OBTAINING SIGNED HIPAA FORMS.

BOX 9

CHECK ITEM HVQ.155:

IF SP MALE, GO TO END OF SECTION.

IF SP FEMALE AND >= 56 YEARS OLD, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

HVQ.160 When we asked you to tell us about {your/SP’s} overnight hospital stays, we said not to include uncomplicated pregnancies. Now we would like to ask you about overnight stays for uncomplicated pregnancies. How many times since {BASELINE YEAR} when {you were/SP was} {AGE AT BASELINE} years old {have you/has SP} stayed overnight in the hospital for an uncomplicated pregnancy?

|___|___|

ENTER NUMBER OF TIMES

NONE 00

REFUSED 77

DON'T KNOW 99

contact information – maq

Target Group: SP’s 20+

MAQ.021 Please give me your complete mailing address. We may use this to contact you in the future. Your mailing address is:

CRITICAL INFORMATION – CHECK CAREFULLY.

MAKE CORRECTIONS AS NEEDED.

__________ __________ ________________________ _______________ ___________

a. STREET # b. DIR PRE c. STREET NAME d. STREET TYPE e. DIR POST

f. UNIT TYPE

APT 1

BLDG 2

BSMT 3

DEPT 4

FL 5

FRNT 6

HNGR 7

KEY 8

LBBY 9

LOT 10

LOWR 11

OFC 12

PH 13

PIER 14

REAR 15

RM 16

SIDE 17

SLIP 18

SPC 19

STE 20

STOP 21

TRLR 22

UNIT 23

UPPR 24

BOX 25

DORM 26

POBOX 27

OTHER 99

UNKNOWN 999

__________ ________ ________ ________ ________

g. UNIT # h. CITY i. STATE j. ZIP1 k. ZIP 2

CAPI INSTRUCTION:

DISPLAY THE MOST RECENT MAILING ADDRESS INFORMATION. ENTRY SHOULD APPEAR IN ALL CAPS.
ALLOW INTERVIEWER TO MAKE EDITS TO INDIVIDUAL FIELDS OR TO CLEAR ENTIRE MAILING ADDRESS AND ENTER NEW ADDRESS.
DISPLAY STREET #, DIR PRE, STREET NAME, STREET TYPE, DIR POST ON ONE SCREEN.
DISPLAY UNIT TYPE ON SECOND SCREEN.
DISPLAY UNIT NO, CITY, STATE, ZIP1, ZIP2 ON THIRD SCREEN.

MAQ.040 I have recorded . . .

{DISPLAY ADDRESS ENTERED IN MAQ.021 IN UPPER CASE}

Is that correct?

YES 1

NO 2 (MAQ.021)

MAQ.090 INTERVIEWER INSTRUCTION:

SPECIFY LANGUAGE IN WHICH HARD COPY MATERIALS SHOULD BE MAILED.

ENGLISH 1

SPANISH 2

VIETNAMESE 3

KOREAN 4

CHINESE (TRADITIONAL SCRIPT) 5

CHINESE (SIMPLIFIED SCRIPT) 6

MAQ.100 Please give me {your/SP’s} home telephone number in case my office wants to check my work.

G/Q

CAPI INSTRUCTION:

ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE CHECK MESSAGE IF NOT 10 DIGITS.

ENTER HOME TELEPHONE NUMBER 1

NO HOME TELEPHONE 2

REFUSED 7

DON’T KNOW 9

|__|__|__|__|__|__|__|__|__|__|

MAQ.110 Is there another number where {you/SP} can be reached?

G/Q

CAPI INSTRUCTION:

ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE ERROR IF NOT 10 DIGITS.

YES 1

NO 2 (BOX 4)

REFUSED 7 (BOX 4)

DON’T KNOW 9 (BOX 4)

|__|__|__|__|__|__|__|__|__|__|

ENTER ANOTHER PHONE NUMBER

MAQ.115 I have recorded . . .

{DISPLAY PHONE ENTERED IN MAQ.110 AS (XXX) XXX-XXXX}

Is that correct?

YES 1

NO 2 (MAQ.110)

MAQ.120 Where is that phone located?

WORK 1

RELATIVE’S HOME 2

NEIGHBOR’S HOME 3

CELL PHONE 4

OTHER 5

REFUSED 7

DON’T KNOW 9

BOX 4

CHECK ITEM MAQ.140N:

IF MAQ.120 = 4, GO TO MAQ.200.

IF MAQ.120 NOT EQUAL TO 4, CONTINUE.

MAQ.150 Do you have a cell phone?

YES 1

NO 2 (MAQ.200)

REFUSED 7 (MAQ.200)

DON’T KNOW 9 (MAQ.200)

MAQ.180 What is your cell phone number?

CAPI INSTRUCTION:

ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE ERROR IF NOT 10 DIGITS.

|__|__|__|__|__|__|__|__|__|__|

REFUSED 7 (MAQ.200)

DON’T KNOW 9 (MAQ.200)

MAQ.185 I have recorded . . .

{DISPLAY PHONE ENTERED IN MAQ.180 AS (XXX) XXX-XXXX}

Is that correct?

YES 1

NO 2 (MAQ.180)

MAQ.200 Do you have an e-mail account?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

MAQ.210 What is your e-mail address?

a/b

_____________________ _____________________________

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

CAPI INSTRUCTION:

ALLOW 64 CHARACTERS TO THE LEFT OF THE @ SYMBOL TO BE STORED IN MAQ210a.

ALLOW 190 CHARACTERS TO THE RIGHT OF THE @ SYMBOL TO BE STORED IN MAQ210b.

HARD EDITS:

IF THERE’S SPACES IN THE EMAIL ADDRESS, DISPLAY “EMAIL ADDRESS DOES NOT ALLOW SPACES.”
IF EMAIL ADDRESS IS MISSING THE @ SYMBOL, DISPLAY “EMAIL ADDRESS IS MISSING THE @ SYMBOL - PLEASE GO BACK AND CORRECT.”
IF TEXT IS MISSING TO THE LEFT OR RIGHT OF THE @ SYMBOL, DISPLAY “PART OF THE EMAIL ADDRESS IS MISSING - PLEASE GO BACK AND CORRECT.”

MAQ.220 I have recorded . . .

{DISPLAY E-MAIL ADDRESS ENTERED IN MAQ.210}

Is that correct?

YES 1

NO 2 (MAQ.210)

TRACKING AND TRACING – TTq

Target Group: SP’s 20+

TTQ.005 The National Center for Health Statistics may wish to contact you again to obtain additional health related information. Please give me the names, addresses, and telephone numbers of 2 relatives or friends who would know where you could be reached in case we have trouble reaching you. (Please give me the names of persons not currently living in the household.)

PRESS F6 IF RESPONDENT REFUSES {ALL/SECOND} CONTACT INFORMATION

PRESS F5 IF RESPONDENT DOESN'T KNOW {ANY/SECOND} CONTACT INFORMATION

PRESS ENTER TO ADD {FIRST/SECOND} CONTACT INFORMATION

REFUSED 777777 (TTQ.050)

DON'T KNOW 999999 (TTQ.050)

HELP SCREEN:

Household: The entire group of persons who live in one dwelling unit. It may be several persons living together or one person living alone. It includes the study participant and any of their relatives, as well as roomers, employees, and other non-related persons.

Relative: All common relationships that occur through blood (grandfather, daughter), marriage (wife, stepson), or adoption (adopted son or daughter). Include foster relationships and guardian/ward relationships. Also refers to extended relationships by legal marriage. For example, a man and woman are married. The woman's cousin's husband would also be counted as a "relative" of the man.

BOX 1

LOOP 1:

ASK TTQ.010 - TTQ.040 FOR 2 CONTACT PERSONS.

TTQ.010 REFERRING TO PERSON {1/2}

VERIFY SPELLING.

ENTER FIRST NAME

REFUSED 7----7

DON'T KNOW 9----9

PROBE FOR MIDDLE NAME IF NOT REPORTED

ENTER "NMN" FOR NO MIDDLE NAME

ENTER MIDDLE NAME

REFUSED 7----7

DON'T KNOW 9----9

ENTER LAST NAME

REFUSED 7----7

DON'T KNOW 9----9

TTQ.020 REFERRING TO PERSON {1/2}

What is this person's address? [If there is more than one address, please give us the address used most often.]

ENCOURAGE RESPONDENT TO USE PHONE BOOK OR OTHER DOCUMENTATION IF AVAILABLE.

______________________ ___________________________ _____________________

a. ENTER STREET NUMBER b. ENTER STREET NAME c. ENTER APARTMENT NUMBER

REFUSED 7777777777 REFUSED 7----7 REFUSED 77777777

DON'T KNOW 9999999999 DON'T KNOW 9----9 DON'T KNOW 99999999

_____________________ |____|____| |___|____|____|____|____|

d. ENTER TOWN OR e. ENTER 2 LETTER f. ENTER POSTAL CODE

CITY NAME STATE ABBREVIATION TO OR ZIP CODE

TO START THE LOOKUP.

SELECT STATE FROM CAPI STATE LIST.

PRESS ENTER TO ACCEPT SELECTION.

REFUSED 7----7 REFUSED 777777 REFUSED 77777777777

DON'T KNOW 9----9 DON'T KNOW 999999 DON'T KNOW 99999999999

CAPI INSTRUCTION:

DISPLAY FIPS STATE LIST. INTERVIEWER SHOULD ONLY BE ABLE TO SELECT 1 STATE FROM THE LIST. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS.

SAVE STATE LOOKUP NAME AS TTQ.020g AND STATE FIPS LOOKUP CODE AS TTQ.020h.

ALLOW TTQ.020c (APARTMENT NUMBER) TO BE BLANK.

TTQ.030 REFERRING TO PERSON {1/2}

What is this person's telephone number, beginning with the area code?

REPEAT AREA CODE

REPEAT PHONE NUMBER

REPEAT EXTENSION

|___|___|___| |___|___|___| - |___|___|___|___| |___|___|___|___|

a. ENTER AREA CODE b. ENTER TELEPHONE NUMBER c. ENTER EXTENSION

NO PHONE 666 (TTQ.040) REFUSED 7777777777 REFUSED 777777

REFUSED 777777 (TTQ.040) DON'T KNOW 9999999999 DON'T KNOW 999999

DON'T KNOW 999999 (TTQ.040)

CAPI: ALLOW TTQ.030c (PHONE EXTENSION) TO BE BLANK.

TTQ.040 REFERRING TO PERSON {1/2}

What is the relationship of this contact person to you?

SPOUSE/EX-SPOUSE NOT LIVING IN HH 1

UNMARRIED PARTNER NOT LIVING IN HH 2

CHILD 3

GRANDCHILD 4

PARENT (MOTHER OR FATHER) 5

BROTHER OR SISTER 6

GRANDPARENT 7

OTHER RELATIVE 8

LEGAL GUARDIAN 9

FRIEND 10

CO-WORKER 11

NEIGHBOR 12

OTHER 13

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

Spouse (Husband/Wife): Persons who are legally married or have a common-law marriage.

Unmarried Partner: Persons who share living quarters because they have a close, personal relationship, but are not legally married (i.e., unmarried couples living together as if they were married).

Child: Male or female child through birth or adoption, regardless of age. Also include stepchildren, foster children and sons/daughters-in-law. Do not include an unmarried partner's children. A stepchild is one's spouse's male or female child by a previous relationship. A foster child is not one's biological child, but lives with one's family as one's son or daughter. A son/daughter-in-law is the spouse of one's child.

Grandchild: A child of one’s daughter or son.

Parent: Include a person’s biological, adoptive, step or foster mother or father, as well as his/her mother or father-in-law.

Mother: One's female parent, including biological, adoptive, step and foster mothers and mothers-in-law. A stepmother is the spouse of one's biological or adoptive father. A foster mother is the mother in one's foster family.

Father: One's male parent, including biological, adoptive, step, and foster fathers and fathers-in-law. A stepfather is the spouse of one's biological or adoptive mother. A foster father is the father in one's foster family.

Brother: Includes biological, adoptive, step, foster and half-brothers, and brothers-in-law. A brother is one's male sibling who shares both of the same biological or adoptive parents. A stepbrother is one's stepparent's son by a previous relationship. A half-brother is one's male sibling who shares one of the same biological or adoptive parents. A brother-in-law is one's sister's husband. A foster brother is the foster son of one or both of one's parents or the son of one's foster parent(s).

Sister: A sister includes biological, adoptive, step, foster, half-sisters and sisters-in-law. A sister is one's female sibling who shares both of the same biological or adoptive parents. A stepsister is one's stepparent's daughter by a previous relationship. A half-sister is one's female sibling who shares one of the same biological or adoptive parents. A sister-in-law is one's brother's wife. A foster sister is the foster daughter of one or both of one's parents or the daughter of one's foster parent(s).

Grandfather: The male parent of one's mother or father.

Grandmother: The female parent of one's mother or father.

Legal Guardian: A person appointed to take charge of the affairs of a minor, or of a person not capable of managing his/her own affairs.

BOX 2

END LOOP 1:

ASK TTQ.010 - TTQ.040 FOR SECOND CONTACT PERSON.

IF SECOND CONTACT PERSON INFORMATION COLLECTED, GO TO TTQ.050.

TTQ.050 This is the end of the health interview. Thank you very much for your cooperation.

SIASTATS SET QUESTIONNAIRE INSTRUMENT STATUS

COMPLETE 1 (END)

PARTIAL 2

NOT DONE 3

CAPI INSTRUCTION:

SET TO COMPLETE IF ALL ELIGIBLE ITEMS IN QUESTIONNAIRE HAVE A RESPONSE.

SET TO PARTIAL IF AT LEAST ONE ELIGIBLE ITEM IN QUESTIONNAIRE HAS NO RESPONSE.

SET TO NOT DONE IF NO ELIGIBLE ITEMS IN QUESTIONNAIRE HAVE A RESPONSE.

SIACMT REASON FOR PARTIAL OR NOT DONE

SP REFUSAL 2 (END)

NO TIME 3 (END)

COMMUNICATION PROBLEM. 5 (END)

EQUIPMENT FAILURE 6 (END)

SP ILL/EMERGENCY 7 (END)

INTERRUPTED 14 (END)

LANGUAGE BARRIER 122 (END)

OTHER, SPECIFY 99 (END)

PRESCRIPTION MEDICATION USE – RXQ Part 2

Target Group: SPs 20+

BOX 1

CHECK ITEM RXQ.620:

THIS INSTRUMENT WILL ONLY BE ACTIVATED IN BFOS IF RXQ.032 = 1 IN THE SP QUESTIONNAIRE.

RXAMODE INTERVIEWER: SELECT INTERVIEW MODE:

IN PERSON 1

PHONE 2 (BOX 5)

RXA.020 INTERVIEWER: DO YOU WANT TO ADMINISTER THE PRESCRIPTION DRUG QUESTIONNAIRE NOW?

YES 1

NO 2 (BOX 5)

BOX 2

CHECK ITEM RXQ.625:

IF SP INTERVIEW CONDUCTED WITH PROXY (RIQ.002=2), CONTINUE.

OTHERWISE, GO TO BOX 3.

RXQPROXY INTERVIEWER OBSERVATION:

IS THE PROXY A DIFFERENT PERSON THAN THE PROXY FOR OTHER COMPONENTS CONDUCTED WITH THIS SP?

YES 1

NO 2 (BOX 3)

RIQ.231 CAPI INSTRUCTION: BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING.

The computer is now recording our conversation.

Do I have your permission to continue recording?

YES 1 (RXQ.231)

NO 2 (RXQ.231)

CAPI INSTRUCTION: IF RIQ.231 = 2/NO, STOP RECORDING.

BOX 3

CHECK ITEM RXQ.630:

IF SP REFUSED AUDIO RECORDING PREVIOUSLY (RIQ.201 = 2 OR RIQ.231 = 2 IN ANY INSTRUMENT), GO TO RXQ.231.

OTHERWISE, CONTINUE.

RIQ.201 CAPI INSTRUCTION: BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING.

A reminder that the system is now recording our conversation. Do I have your permission to continue recording?

YES 1

NO 2

CAPI INSTRUCTION: IF RIQ.201 = 2/NO, STOP RECORDING.

RXQ.231 Now I would like to talk about prescription medication {you have/SP has} used in the past 30 days. Again, these are products prescribed by a health professional such as a doctor or dentist.

[First I will record some information about the medication, then I will ask you some questions about it.]

INTERVIEWER INSTRUCTION:

REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF PRESCRIPTION MEDICATIONS USED.

“DO NOT INCLUDE PRESCRIPTION DIETARY SUPPLEMENTS”

ENTER MEDICATION NAME

REFUSED 7---7

DON’T KNOW 9---9

CAPI INSTRUCTION:

IF THE ONLY PRESCRIPTION MEDICATION IS DON’T KNOW OR REFUSED, GO TO END OF SECTION.

SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.

TEXT SHOULD BE OPTIONAL, “[ ]”S, AFTER THE FIRST TIME.

RXQ.240 PRESS BS TO START THE LOOKUP.

SELECT MEDICATION

FROM LIST.

IF MEDICATION NOT

ON LIST – PRESS BS

TO DELETE ENTRY.

TYPE ‘**’.

PRESS ENTER TO SELECT

CAPI INSTRUCTION:

DISPLAY CAPI MEDICATION PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.231 BY TYPING IN “**”. THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.

INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME AN UNLIMITED NUMBER OF TIMES. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 1.

ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:

DRUG TYPE {3}

GENERIC NAME {60}

THERAPEUTIC CLASS CODE {6}

GENERIC FLAG {1}

THERE IS NO NEED TO DISPLAY THIS INFORMATION.

RXQ.251 INTERVIEWER: ENTER 1 RESPONSE

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS A LEFT HEADER.

CONTAINER SEEN 1

CONTAINER NOT SEEN 2

ONLY PHARMACY PRINT OUT SEEN 3

RXQ.260 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?

Q/U

CAPI INSTRUCTION:

RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 7777777

DON’T KNOW 9999999

|___|

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

RXQ.290 What is the main reason for which {you use/SP uses} {PRODUCT NAME}?

REFUSED 7---7

DON’T KNOW 9---9

RXQ.294 CHECK CONTAINERS. ARE THERE ANY OTHER PRESCRIPTION MEDICATIONS?

OR ASK RESPONDENT:

[Are there any other prescription medications that {you/SP} used in the past 30 days?]

YES 1

NO 2

REFUSED 77

DON’T KNOW 99

BOX 4

CHECK ITEM RXQ.299:

ASK RXQ.231 - RXQ.294 FOR NEXT MEDICATION (CODE 1 IN RXQ.294). IF NO NEXT MEDICATION (CODE 2 IN RXQ.294), GO TO RXASTATS.

BOX 5

CHECK ITEM RXQ.635:

IF RXAMODE = 2/PHONE, EXIT THE INSTRUMENT AND DISCARD THE RECORD. QUESTIONNAIRE STATUS WILL NOT BE SET.

ELSE IF RXA.020 = 2/NO, EXIT THE INSTRUMENT AND DISCARD THE RECORD. QUESTIONNAIRE STATUS WILL NOT BE SET.

OTHERWISE, CONTINUE.

RXASTATS SET PRESCRIPTION QUESTIONNAIRE STATUS

COMPLETE 1 (END)

PARTIAL 2

NOT DONE 3

CAPI INSTRUCTION:

SET TO COMPLETE IF ALL ELIGIBLE ITEMS IN QUESTIONNAIRE HAVE A RESPONSE.

SET TO PARTIAL IF AT LEAST ONE ELIGIBLE ITEM IN QUESTIONNAIRE HAS NO RESPONSE.

SET TO NOT DONE IF NO ELIGIBLE ITEMS IN QUESTIONNAIRE HAVE A RESPONSE.

RXACMT REASON FOR PARTIAL OR NOT DONE

SP REFUSAL 2 (END)

NO TIME 3 (END)

COMMUNICATION PROBLEM. 5 (END)

EQUIPMENT FAILURE 6 (END)

SP ILL/EMERGENCY 7 (END)

INTERRUPTED 14 (END)

LANGUAGE BARRIER 122 (END)

OTHER, SPECIFY_________________ 99 (END)

HELP SCREEN FOR RXQ.231:

Prescription Medication: Prescription medications are those ordered by a physician or other authorized medical professional through a written or verbal prescription for a pharmacist to fill. Prescription medications may also be given by a medical professional directly to a patient to take home, such as free samples.

Prescription medications do not include:

- Diaphragms and IUD’s (Intra-Uterine Devices); or

Past Month: The past 30 days. From yesterday, 30 days back.

HELP SCREEN FOR RXQ.294:

Prescription medications do not include:

- Diaphragms and IUD’s (Intra-Uterine Devices); or

Home Examination Data Collection

The core exam components planned for the NHANES Longitudinal Study are:

Body Measurements
Blood Pressure
Peripheral Neuropathy Assessment
Capillary Blood Collection
Home Urine Collection (A self-collection of urine sample occurred after the home visit, see Attachment 3c for details)

BODY MEASUREMENTS (WEIGHT AND WAIST CIRCUMFERENCE)

Objectives:

The nationally representative cohort data on measured weight and waist circumference can be used to identify, monitor, and clarify the longitudinal impact of early onset of metabolic risk (including a large waistline) and other risk factors on the development of obesity and chronic conditions such as hypertension and diabetes.

The specific objective of including the body measurement component in the feasibility study is to evaluate the operational feasibility within the context of the home environment for the following items: 1) using Tanita scale to collect weight data with the Health Measures at Home Study⁰ protocol; and 2) using the protocol developed in the NHANES Waist Circumference Measurement Methodology Study⁰ to obtain self-measured waist circumference.

Protocol:

Weight:

In the home, participants will wear their own clothing for weight measurement. Before weight, the Health Representative will ask participants to remove their shoes, and remove any items from their pockets (see suggested scripts below). The participant will be asked to stand in the center of the scale platform facing the examiner, hands at sides, and looking straight ahead. The Health Representative manually enters the weight value twice into the computer.

Waist Circumference:

Following the weight measurement, the Health Representative will give a brief explanation (see suggested scripts below) and a demonstration of doing a self-measured waist circumference using a Gulick II Plus tape. The participant will be asked to put the tape measure around the waist at the level of the umbilicus to obtain a self-measured waist circumference. The Health Representative will verify the measurement and manually enter the waist circumference value twice into the computer.

Both weight and waist circumference will be measured over clothing. The Health Representative will record whether heavy street clothes such as a coat or jeans were wore by the participant during the exam.

Suggested Scripts:

Body Measurement

“We are now going to conduct the Body Measurement part of the home exam. I am going to measure your weight first and then ask you to measure your waist. I will explain each of the procedures as I conduct the measurements. Do you have any questions?”

Weight:

“I will take your weight. Please remove your shoes and empty your pockets. Please step on the scale with your hands at your sides looking straight ahead.”

Waist Circumference:

“Next, I will measure your waist. First I will ask you to wrap the tape around your waist like a belt at the level of your belly button. I will coach you how to apply the tape correctly. I will ask you to make the corrections by yourself and then take the measurement.”

Time Allotment:

5 minutes

Eligibility:

All participants in the feasibility study

Exclusion Criteria:

Persons over 440 pounds (maximum capacity of the weight scale) are excluded from the weight measurement.
Persons who refuse to remove their shoes are excluded from the weight measurement.
Persons in a wheelchair are excluded from the weight and waist measurements.
Pregnant women are excluded from the waist measurement.

Justification for Using Vulnerable Populations:

There is no reason to exclude mentally impaired individuals, or persons with functional difficulties because there is no contraindication if they can understand and follow exam instructions.

Risks to Subjects:

There is no more than minimal risk to the participants.

Report of Findings:

Measured values for weight (in pounds) and waist circumference (in inches) will be reported to all participants who complete the test.

A “weight statement” (Table 1) based on the participant’s baseline height and BMI categories will also be included in the report for all non-pregnant participants who complete the weight measurement.

In addition, a gender-specific waist circumference statement (Table 2) will be included in the report for participants with BMI ≥ 18.5 kg/m². The statement is based on the 1998 guidelines from NIH’s National Heart, Lung and Blood Institute (http://www.nhlbi.nih.gov/health-pro/guidelines/current/obesity-guidelines/e_textbook/txgd/4142.htm). The guidelines specify the increased health risk associated with large waist circumference among persons in the normal weight, overweight, and obese BMI categories. A similar risk does not apply to underweight individuals (BMI < 18.5 kg/m²), therefore, the statement will not be included for this subgroup of participants.

Table 1. Weight Statement

Based on your baseline height, your weight is:

Body mass index Statement ___ __

< 18.5 below the range of a healthy weight, and you may be underweight.

18.5 – < 25.0 within the range of a healthy weight.

≥ 25.0 – < 30.0 above the range of a healthy weight, and you may be overweight.

≥ 30.0 above the range of a healthy weight, and you may be obese.

(The system will select and display the correct statement from above categories based on the test result)

Table 2. Waist Circumference Statement
Gender	Statement
Male	For men, a waist circumference greater than 40 inches is associated with an increased risk of health problems such as type 2 diabetes, high blood pressure, and cardiovascular disease. This is based on guidelines from the National Heart, Lung and Blood Institute, NIH, 1998.
Female	For women, a waist circumference greater than 35 inches is associated with an increased risk of health problems such as type 2 diabetes, high blood pressure, and cardiovascular disease. This is based on guidelines from the National Heart, Lung and Blood Institute, NIH, 1998.

Blood Pressure

Objectives:

Hypertension, or high blood pressure, is a common medical condition that is a major risk factor for cardiovascular, cerebrovascular, and renovascular morbidity and mortality. Standardized blood pressure measurements will be used to monitor the incidence and control of hypertension.

The specific objective of including blood pressure measurements in the feasibility study is to assess the operational feasibility of using the Omron device to collect blood pressure data with the Health Measures at Home Study⁰ protocol in the home environment.

Protocol:

The Health Representative will explain the blood pressure measurement (see suggested scripts below) and ask pre-examination questions. The participant will be in a seated position, facing forward, with their back supported, legs uncrossed, and feet flat on the floor. The forearm will be supported on a stable surface at heart level. The cuff size will be selected based on the mid-arm circumference calculated from a gender-specific regression equation.⁰ The Omron HEM-907 XL digital BP monitor will be used to obtain blood pressure and pulse readings.

The Health Representative will apply the appropriate blood pressure cuff, position the participant’s arm, start the exam after an initial 5‑minute wait period, and obtain three measurements with 30-second rest intervals between each of the blood pressure readings. The results will be manually entered twice into the computer by the Health Representative.

Suggested Scripts and Talking Points:

For this part of the visit, I will take your blood pressure and pulse with this monitor.
The monitor will take 3 blood pressure readings and there will be a 30-second resting period between the readings.
When the machine inflates the cuff, it may feel tight and you will feel some pressure.
While the machine is taking your blood pressure, I ask that you not talk or move and I will not talk either. Talking and moving can change your blood pressure.
Before taking your blood pressure reading, there is going to be a 5-minute resting period. I would like for you to sit down comfortably and quietly for those 5 minutes.
I will give you your results at the end of the visit.
Before we get started, do you have any questions? Thank you.

Time Allotment:

15 minutes.

Eligibility:

All participants in the feasibility study.

Exclusion Criteria:

Presence of the following on both arms: rashes, gauze dressings, casts, edema, paralysis, tubes, open sores or wounds, withered arms, arteriovenous shunts or fistula.
Largest cuff size does not fit around the arm

Justification for Using Vulnerable Populations:

There is no reason to exclude pregnant women, or mentally impaired individuals because there is no contraindication if they can understand and follow exam instructions.

Risks:

Minimal risk. Transient discomfort during blood pressure measurement.

Report of Findings:

Blood pressure

	Your Measurements	Normal
Systolic Blood Pressure	mm Hg	<120
Diastolic Blood Pressure	mm Hg	< 80

Your blood pressure on <insert date> was within the normal range. We suggested you see your doctor within the next year to have your blood pressure rechecked.
Your blood pressure on <insert date> was above normal and in the pre-hypertension range. We suggested you see your doctor within the next six months to have your blood pressure rechecked.
Your blood pressure on <insert date> was high. We suggested you see your doctor within the next two months to have your blood pressure rechecked.
Your blood pressure on <insert date> was very high. We suggested you see your doctor within next two weeks to have your blood pressure rechecked.
Your blood pressure on <insert date> was severely high. We strongly encouraged at that time that you see a medical provider on that day to have your high blood pressure evaluated.

Items #1 to #4 are from the seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; NIH Publication, 2003. Item #5 is based on a recommendation from the American Heart Association.

(The system will select the correct statement from above categories based on the test result)

PERIPHERAL NEUROPATHY ASSESSMENT

Objectives:

Peripheral neuropathy (PN) is characterized by numbness, reduction or loss of temperature and pain sensation, tingling, and muscle weakness and atrophy. PN may be associated with decreased physical activity and increased disability among older adults. Many risk factors have been associated with PN, including 1) demographic characteristics (especially male gender and older age); 2) health-related factors such as diabetes, vitamin deficiencies (especially vitamin B), infection (including Lyme disease, shingles, Epstein-Barr virus, hepatitis C, and HIV), and kidney, liver and thyroid disorders; and 3) exposure to excess alcohol use or environmental toxins. Analysis of the NHANES 1999-2000 data found that 14.8% of adults over 40 years of age had PN. The prevalence was 13% among those without diabetes and 28% among those with diabetes. The prevalence of PN increased with age and was higher among race/ethnicity minorities compared to non-Hispanic whites. Reduced sensation can lead to a number of complications such as burns from not feeling hot water, unnoticed trauma leading to foot ulcers and serious infections, and ultimately amputation.

Nationally representative PN data from the follow-up study can be used to identify, monitor, and clarify the longitudinal association between PN and established or novel risk factors, including: 1) diabetes onset, management, and progression; 2) toxin exposures either from alcohol abuse or environmental chemicals; and 3) modifiable nutritional deficiencies. Nationally representative PN data can also be used to identify and monitor the impact of PN on physical activity and disability.

The specific objectives of including the PN exam in the feasibility study is to evaluate the operational feasibility of: 1) using the Monofilament Test Protocol from the Michigan Neuropathy Screening Instrument to assess the touch-pressure sensation of participants examined in the home environment; and 2) training Health Representatives with no or little health background to administer this type of health exam in the home setting.

Protocol:

The Health Representative will explain and demonstrate the monofilament test before beginning the test (see suggested scripts below). The participants will be in the sitting position with shoes and socks removed, and eyes closed during the testing. Both feet will be tested.

During the exam, the Health Representative will use a standard monofilament (5.07 Semmes-Weinstein nylon monofilament mounted on a plastic handle, delivering approximately a 10-gram filament force) to touch the dorsum (top) of the big toe, midway between the nail fold and the distal interphalangeal joint (Figure 1). The participant will be asked to respond “yes” whenever he/she feels the filament on the big toe. Eight or more correct responses out of 10 applications to the big toe is considered “normal” or “present”. One to seven correct responses is “reduced” and no correct answer is “absent” monofilament perception. Reduced or absent monofilament perception will suggest neuropathy.

Figure 1. Placing the monofilament to touch the dorsum of the big toe

Suggested Scripts and Talking Points:

Next I want to test the feeling or sense of touch on your big toe(s). To do this test, I will ask you to close your eyes during the test and I will use this small filament to apply pressure to your big toe(s). It is not sharp and will not break the skin.

[Show SP the filament and touch SP’s arm with the filament so the SP will know what to expect]

First, I will demonstrate on your arm before we begin the test.

[Demonstrate the procedure on the SP’s arm]

Please close your eyes now. Say “yes” when you feel the filament.
Do you understand what I have explained about the test?
Do you have any questions?

[Be sure the SP understands the test before starting. Repeat the explanation if necessary]

Let’s begin the test. With your eyes closed, I want you to say “yes” each time you feel the filament on your big toe.

Time Allotment:

5 minutes.

Eligibility:

All participants in the feasibility study.

Exclusion Criteria:

Persons with a bilateral big toe amputation.
Local medical conditions such as a cast, ulcer, or dressing on both feet that would prevent access to the dorsum of toe and interfere with the testing.

Justification for Using Vulnerable Populations:

There is no reason to exclude pregnant women, mentally impaired individuals, or persons with functional difficulties because there is no contraindication if they can follow exam instructions.

Risks:

There is no known risk to the participants.

Report of Findings:

Foot sensation

General statement:

For participants with same sensation category for both feet:

The sensory examination tested your ability to feel a filament pressed on the big toes of your feet. The examination showed that you have {normal/reduced/absent} sensation in both of your feet.

For participants with different sensation categories between the two feet:

The sensory examination tested your ability to feel a filament pressed on the big toes of your feet. The examination showed that you have {normal/reduced/absent} sensation in your right foot, and {normal/reduced/absent} sensation in your left foot.

For persons with reduced or absent sensation, the following statement will be included as well:

Having reduced or absent sensation may be an indication of a medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.

If one of the big toes has been amputated, the statement for that limb will be suppressed.

If the big toe test site on a foot was not able to be tested and received a ‘Could Not Obtain’ response, the statement below will be printed:

We were not able to collect enough information to report results on you {right/left} foot.

See table below for detailed programming instructions in filling the statement:

		Left foot
		≥8 correct responses	1-7 correct responses	0 correct responses	Count Not Obtain
Right foot	≥8 correct responses	The examination showed that you have normal sensation in both of your feet.	The examination showed that you have normal sensation in your right foot, and reduced sensation in your left foot. Having reduced or absent sensations may be an indication of a chronic medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.	The examination showed that you have normal sensation in your right foot, and absent sensation in your left foot. Having reduced or absent sensations may be an indication of a chronic medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.	The examination showed that you have normal sensation in your right foot. We were not able to collect enough information to report results on your left foot.
	1-7 correct responses	The examination showed that you have reduced sensation in your right foot, and normal sensation in your left foot. Having reduced or absent sensations may be an indication of a chronic medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.	The examination showed that you have reduced sensation in both of your feet. Having reduced or absent sensations may be an indication of a chronic medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.	The examination showed that you have reduced sensation in your right foot, and absent sensation in your left foot. Having reduced or absent sensations may be an indication of a chronic medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.	The examination showed that you have reduced sensation in your right foot. We were not able to collect enough information to report results on your left foot. Having reduced or absent sensations may be an indication of a chronic medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.
	0 correct responses	The examination showed that you have absent sensation in your right foot, and normal sensation in your left foot. Having reduced or absent sensations may be an indication of a chronic medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.	The examination showed that you have absent sensation in your right foot, and reduced sensation in your left foot. Having reduced or absent sensations may be an indication of a chronic medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.	The examination showed that you have absent sensation in both of your feet. Having reduced or absent sensations may be an indication of a chronic medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.	The examination showed that you have absent sensation in your right foot. We were not able to collect enough information to report results on your left foot. Having reduced or absent sensations may be an indication of a chronic medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.
	Count Not Obtain	The examination showed that you have normal sensation in your left foot. We were not able to collect enough information to report results on your right foot.	The examination showed that you have reduced sensation in your left foot. We were not able to collect enough information to report results on your right foot. Having reduced or absent sensations may be an indication of a chronic medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.	The examination showed that you have absent sensation in your left foot. We were not able to collect enough information to report results on your right foot. Having reduced or absent sensations may be an indication of a chronic medical problem such as diabetes, vitamin deficiencies, or infection. We suggest you follow up with your medical provider for these findings.	We were not able to collect enough information to report results on either of your feet.

CAPILLARY BLOOD COLLECTION

Objectives:

A capillary puncture is performed to obtain laboratory results that provide objective measures of biomarker data to assess various health conditions and nutritional status. Inclusion of a capillary blood collection in the feasibility study will help us assess participants’ willingness in providing a blood sample in a home environment for a longitudinal study.

Collected blood samples will be tested for hemoglobin A1c also referred to as glycohemoglobin. Hemoglobin A1c is an indicator for the risk of diabetes mellitus, a large, growing, and costly public health problem in the United States, which disproportionately affects racial and ethnic minorities. Reporting hemoglobin A1c results back to the participants will provide added benefit for their participation in the study.

Protocol:

Methods

10 uL of capillary whole blood obtained via a finger-stick with a sterile lancet.

Suggested Scripts and Talking Points:

I will use this small sterile lancet to collect a few drops of blood from your fingertip.
The procedure to collect the blood is very simple and quick, and causes minimal discomfort.
I will use your {middle/ring} finger for the fingerstick.
First I’m going to clean your finger with alcohol and wait for it to dry.
You may experience a little pain and soreness with the fingerstick.
If we do not get enough blood from the first finger stick, I may have to do a second one.
Your blood sample will be tested for Hemoglobin A1c.
You will receive your test results in the mail in several weeks.

Time Allotment:

Range 5 - 10 minutes.

Health Measures:

Laboratory test result for hemoglobin A1c.

Eligibility:

All participants in the feasibility study.

Exclusion Criteria:

Hemophilia

Information obtained by the phlebotomist at baseline will be used to identify hemophilia. For those who have missing data or responded as “don’t know” or “refused” at baseline, a question “Do you have hemophilia?” will be asked prior to the blood taken. Participants who answered “yes”, “don’t know”, or “refused” will be excluded.

Receiving cancer chemotherapy within the past four week

A question “Have you received cancer chemotherapy in the past four weeks?” will be asked prior to the blood taken. Participants who answered “yes”, “don’t know”, or “refused” will be excluded.

None of the index, middle, or ring fingers in either hand is available for a capillary puncture, for example:

Missing all these six fingers,
All these six fingers are callused or having open sore, wound, gauze dressing, or rash,
Both hands wear casts, shunts (a semi-permanent draining tube), or splints,
Both hands are swollen, withered, or paralyzed,
Both arms or hands have intravenous catheters (IV) or other medical devices attached.

Justification for Using Vulnerable Populations:

There is no reason to exclude pregnant women, mentally impaired individuals, or persons with functional difficulties because there is no contraindication if they can understand and follow the instructions.

Risks:

The following are known risks associated with capillary puncture:

Hematoma;
Swelling, tenderness and inflammation at the site;
Persistent bleeding; and
Vasovagal response—dizziness, sweating, coldness of skin, numbness and tingling of hands and feet, nausea, vomiting, possible visual disturbance, syncope and injury fall from fainting.

Steps to Minimize Risk:

After the capillary puncture, the Health Representative will apply a piece of gauze, using slight pressure, to the puncture site until the bleeding has completely stopped. A bandage will be applied to puncture site. If bleeding continues, keep direct pressure on the site for 5 minutes or more, then apply a bandage. If the participant experiences symptoms of vasovagal responses, the Health Representative will advise him/her to lie down and have his/her legs elevated.

Rare Adverse Effects:

Infection.

Special Precautions:

Sterile equipment issued with all participants.

Report of Findings:

Laboratory Blood Test	Result	Units	Flag	Reference Range
Hemoglobin A1c		%	High/Blank	< 6.5

The reference range for hemoglobin A1c is < 6.5%. The Flag field will display “High” if the values equal to or greater than 6.5. The field will be blank if the value is below 6.5%.

In addition to the flag, for persons with an abnormal hemoglobin A1c value (i.e., ≥ 6.5%), the sentence “We reviewed your test results from your examination on <insert date>, and found that some values were abnormal and require your immediate attention” will also be included in the cover letter of their final report of findings (See Appendix 7-2 in Attachment 7).

0 “Yes” indicates the question items in the section came from baseline NHANES questionnaire. Some minor modifications may have been made to adapt to the follow-up study setting. Input on probing relative time frame (i.e., time since baseline) were sought from NCHS’ Collaborating Center for Questionnaire Design and Evaluation Research.

“No” indicates the question items in the section were not collected in the baseline. See column “Source” for the source of the questions

0 Note: More detailed information on HIPAA authorization will be provided to the participants when the authorization form is presented to the participant to obtain the signature – see HVQ.150.

0 Gindi R, Zipf G, Galinsky A, Miller I, Nwankwo T, Terry A. Comparison of In-Home Collection of Physical Measurements and Bio-specimens with Collection in a Standardized Setting: the Health Measures at Home Study. Vital Health Stat 2. 2014 Apr;(164):1-16.

0 Waist Circumference Measurement Methodology Study - NHANES 2016: NCHS Protocol #2011-17 National Health and Nutrition Examination Survey Amendment #60.

0 Nwankwo T, Ostchega Y, Zhang G, Hughes JP. Validation of predicting equations for mid-arm circumference measurements in adults: National Health and Nutrition Examination Survey, 2001-2012. Blood Press Monit. 2015 Jun;20(3):157-63.

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File Created	2021-01-22