Download:
pdf |
pdfNational Mental Health Study Field Test,
Supporting Statement
Attachment A-1 – Adult and Adolescent
Questionnaire Specifications
NATIONAL MENTAL HEALTH
STUDY (NMHS): ADULT
INSTRUMENT DRAFT
SPECIFICATIONS
Please see Appendix A for a summary of the content of each National Mental Health
Study (NMHS) Questionnaire module and a high-level overview of changes made to
the module when compared to the source documents originally provided to RTI.
Substance Abuse and Mental Health Services Administration
Center for Behavioral Health Statistics and Quality
Rockville, Maryland
National Institute of Mental Health
Rockville, Maryland
NATIONAL MENTAL HEALTH
STUDY (NMHS): ADULT
INSTRUMENT DRAFT
SPECIFICATIONS
Contract No. HHSS283201300001C
RTI Project No. 0213985.301.002.001
RTI Authors:
RTI Project Director:
Suzanne Triplett
Christine Carr
Rachel A. Caspar
Elizabeth Dean
Mark Edlund
Gretchen McHenry
Brenna Muldavin
Ashley Richards
Leyla Stambaugh
SAMHSA Project Officer:
Peter Tice
NIMH Project Officer:
Lisa Colpe
For questions about this report, please e-mail Peter.Tice@samhsa.hhs.gov.
Prepared for Substance Abuse and Mental Health Services Administration,
Rockville, Maryland, and National Institute of Mental Health, Rockville,
Maryland
Prepared by RTI International, Research Triangle Park, North Carolina
February 27, 2017
Recommended Citation: Center for Behavioral Health Statistics and Quality. (2016). National
Mental Health Study (NMHS): Adult Instrument Draft Specifications (unpublished internal
documentation). Substance Abuse and Mental Health Services Administration; National Institute
of Mental Health, Rockville, MD.
Acknowledgments
This report was prepared for the Substance Abuse and Mental Health Services Administration,
Center for Behavioral Health Statistics and Quality, and the National Institute of Mental Health
by RTI International (a registered trademark and a trade name of Research Triangle Institute).
Contributors to this report at RTI include Kathy Batts, Debbie Bond, Claudia Clark, Laura
James, and Heather Ringeisen.
ii
Table of Contents
Section ...................................................................................................................................... Page
1.
Core Demographics ............................................................................................................ 1
2.
Military Service ................................................................................................................ 10
3.
Beginning ACASI ............................................................................................................. 14
4.
ACASI Tutorial................................................................................................................. 16
5.
Your Health ....................................................................................................................... 19
6.
CIDI Screener ................................................................................................................... 28
7.
Depression......................................................................................................................... 31
8.
Mania ................................................................................................................................ 38
9.
Anxiety and Worry (GAD) ............................................................................................... 42
10.
Social Anxiety ................................................................................................................... 49
11.
Agoraphobia ...................................................................................................................... 53
12.
Panic Disorder ................................................................................................................... 56
13.
Eating Disorders................................................................................................................ 62
14.
Intermittent Explosive Disorder ........................................................................................ 68
15.
Suicidality ......................................................................................................................... 74
16a.
Unusual Experiences ......................................................................................................... 78
17.
Treatment of Emotional Problems .................................................................................... 92
18.
Pharmacoepidemiology................................................................................................... 106
19a.
Trait Fear ......................................................................................................................... 120
19b.
Disinhibition ................................................................................................................... 122
19c.
Personality....................................................................................................................... 124
20.
BPD Screen ..................................................................................................................... 127
22.
Prison .............................................................................................................................. 129
23.
Homelessness .................................................................................................................. 131
24.
Head Injuries ................................................................................................................... 133
25.
Stressful Experiences (Post-Traumatic Stress Disorder) ................................................ 136
26.
Family Medical History (ACE) ...................................................................................... 147
27.
Tobacco, Alcohol, Drugs, and Treatment ....................................................................... 154
28.
Relationships and Social Networks ................................................................................ 170
29.
Childhood Demographics ............................................................................................... 178
Version 4 - February 2017 (Post IRB Approval)
iii
30.
Childhood Experiences ................................................................................................... 182
31.
Employment .................................................................................................................... 186
32.
Household Roster ............................................................................................................ 190
33.
Proxy Information ........................................................................................................... 200
34.
Income............................................................................................................................. 211
35.
Health Insurance ............................................................................................................. 223
36.
Verification ..................................................................................................................... 226
37.
Showcards ....................................................................................................................... 228
Appendix A ................................................................................................................................. 228
Version 4 - February 2017 (Post IRB Approval)
iv
1.
Core Demographics
BEGIN TIME STAMP
NOTE: QUESTIONS DESIGNED TO DETERMINE AGE OF THE RESPONDENT WILL BE
INTERVIEWER ADMINISTERED.
QD_REMINDFI
HAVE YOU READ THE “INTRO TO CAI” IN YOUR SHOWCARD
BOOKLET ALOUD TO THE RESPONDENT?
1
2
YES
NO
QD_INTROCAI
[IF QD_REMINDFI = 2] YOU MUST READ THE “INTRO TO CAI” IN
YOUR SHOWCARD BOOKLET ALOUD TO THE RESPONDENT BEFORE
YOU CONTINUE WITH THE INTERVIEW! DO SO NOW. WHEN YOU ARE
FINISHED, PRESS “1" TO CONTINUE.
QD_AGE1
What is your date of birth?
ENTER MM-DD-YYYY
DOB: ___ [RANGE: 01–12] ___ [RANGE: 01–31] ____ [RANGE: 1900–2015]
DK/REF
DEFINE CALCAGE: CALCAGE = AGE CALCULATED BY "SUBTRACTING" DATE OF
BIRTH FROM DATE OF INTERVIEW.
QD_CONFDOB
[IF QD_AGE1 NE DK OR REF] I have entered your date of birth as
[QD_AGE1]. Is this correct?
1
YES
2
NO
DK/REF
HARD ERROR: [IF QD_CONFDOB = 2] PRESS [ENTER] TO GO BACK AND CORRECT
THE RESPONDENT’S DATE OF BIRTH. [NOTE: DO NOT DEFINE CALCAGE UNTIL
QD_CONFDOB = YES]
QD_CONFIRM
[IF QD_AGE1 NE DK/REF AND QD_CONFDOB NE DK/REF] That would
make you [CALCAGE] years old. Is this correct?
1
YES
2
NO
DK/REF
Version 4 - February 2017 (Post IRB Approval)
1
HARD ERROR: [IF QD_CONFIRM = 2] PRESS [ENTER] TO GO BACK AND CORRECT
THE RESPONDENT’S DATE OF BIRTH.
QD_UNDER13 [IF QD_CONFIRM = 1 OR DK/REF AND CALCAGE < 13] Since you are
[CALCAGE] years old, we cannot interview you for this study. Thank you for your
cooperation.
PRESS [ENTER] TO CONTINUE. [NOTE: PROGRAM SHOULD ROUTE TO
FIEXIT.]
QD_DKREFAGE [IF (CALCAGE IS 13 OR OLDER AND QD_CONFIRM = DK/REF) OR
QD_AGE1 = DK/REF OR QD_CONFDOB = DK/REF] I need your correct age so I
can ask you the right questions. What is your correct age?
______________ AGE [RANGE: 1–110]
DK/REF
IF QD_DKREFAGE NOT (BLANK OR DK/REF), THEN CALCAGE =
QD_DKREFAGE
QD_UNDER13B
[IF QD_DKREFAGE < 13] Since you are [CALCAGE] years old, we cannot
interview you for this study. Thank you for your cooperation.
PRESS [ENTER] TO CONTINUE. [NOTE: PROGRAM SHOULD ROUTE TO
FIEXIT.]
QD_LASTCHANCE [IF QD_DKREFAGE = DK/REF] Since I am not certain what your age is, I
cannot interview you for this study. Thank you for your cooperation.
PRESS [ENTER] TO CONTINUE. [NOTE: PROGRAM SHOULD ROUTE TO
FIEXIT.]
QD_FIPE1 INTERVIEWER: WERE 2 PERSONS SELECTED FOR AN INTERVIEW AT THIS
SDU?
1
2
YES
NO
QD_FIPE2 [IF QD_FIPE1 = 1 AND CURNTAGE = 18 OR OLDER] INTERVIEWER: WAS A 12 17 YEAR OLD CHILD SELECTED FOR AN INTERVIEW AT THIS SDU?
1
2
YES
NO
Version 4 - February 2017 (Post IRB Approval)
2
QD_FIPE3 [IF QD_FIPE2 = 1] INTERVIEWER: IS THIS RESPONDENT THE PARENT OR
LEGAL GUARDIAN OF THE 12 - 17 YEAR OLD CHILD WHO WAS SELECTED FOR
AN INTERVIEW? (VERIFY THIS WITH THE RESPONDENT IF YOU ARE UNSURE.)
1
2
YES
NO
DEFINE CURNTAGE: IF CALCAGE > 12 AND QD_CONFIRM = 1, CURNTAGE =
CALCAGE
IF CALCAGE > 12 AND QD_CONFIRM = DK/REF AND QD_DKREFAGE > 12,
CURNTAGE = QD_DKREFAGE
IF QD_AGE1 = DK/REF AND QD_DKREFAGE > 12, CURNTAGE = QD_DKREFAGE ELSE
RESPONDENT IS INELIGIBLE; ROUTE TO FIEXIT
QD_FIPE4
INTERVIEWER: IN WHAT STATE IS THIS SAMPLE DWELLING UNIT (SDU)
LOCATED?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
THE DISTRICT OF
COLUMBIA (WASHINGTON, DC)
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
Version 4 - February 2017 (Post IRB Approval)
27
28
29
30
31
32
33
34
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
3
QD_FIPE5
INTERVIEWER: THE STATE YOU ENTERED IS [QD_FIPE4 STATE NAME
FILL]. IS THIS CORRECT?
1
2
YES
NO
HARD ERROR: [IF QD_FIPE5 = 2] PRESS [ENTER] TO GO BACK AND CORRECT THE
STATE WHERE YOU ARE CONDUCTING THIS INTERVIEW.
QD01 INTERVIEWER: RECORD RESPONDENT’S SEX:
5
9
QD01a
MALE
FEMALE
INTERVIEWER: YOU HAVE ENTERED THAT THE RESPONDENT IS
[FILL QD01]. IS THIS CORRECT?
1
2
YES
NO
HARD ERROR: [IF QD01a = 2] PRESS [ENTER] TO GO BACK AND CORRECT THE
RESPONDENT’S SEX.
QD03
The first few questions are for statistical purposes only, to help us analyze the results of
the study.
Are you of Hispanic, Latino, or Spanish origin or descent?
1
YES
2
NO
DK/REF
QD05 HAND R SHOWCARD 1.
Which of these groups describes you? Just give me the number or numbers from the
card.
TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR
BETWEEN EACH CATEGORY YOU SELECT.
RESPONDENTS WHO REPORT THEIR RACE AS NATIVE AMERICAN
SHOULD BE INCLUDED IN RESPONSE CATEGORY 1.
1
2
AMERICAN INDIAN OR ALASKA NATIVE
ASIAN
Version 4 - February 2017 (Post IRB Approval)
4
3
4
5
BLACK OR AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
WHITE
DK/REF
QD07
[IF CURNTAGE = 15 OR OLDER] Are you now married, widowed, divorced,
separated, or have you never married?
1
MARRIED
2
WIDOWED
3
DIVORCED
4
SEPARATED
5
HAVE NEVER MARRIED
DK/REF
INTERVIEWER NOTE:
If the respondent is divorced but currently remarried, code as married.
By “divorce” we mean a legal cancellation or annulment of a marriage.
By “separated” we mean legally or informally separating due to marital discord.
QD11 HAND R SHOWCARD 2.
What is the highest grade or year of school you have completed? Just give me the
number from the card.
INCLUDE ANY JUNIOR OR COMMUNITY COLLEGE ATTENDANCE; DO NOT
INCLUDE ATTENDANCE AT TECHNICAL SCHOOLS SUCH AS TRAINING TO
BECOME A MECHANIC OR BEAUTICIAN.
0
1
2
3
4
5
6
7
8
9
10
11
12
NO SCHOOLING COMPLETED
1ST GRADE COMPLETED
2ND GRADE COMPLETED
3RD GRADE COMPLETED
4TH GRADE COMPLETED
5TH GRADE COMPLETED
6TH GRADE COMPLETED
7TH GRADE COMPLETED
8TH GRADE COMPLETED
9TH GRADE COMPLETED
10TH GRADE COMPLETED
11TH GRADE COMPLETED
REGULAR HIGH SCHOOL DIPLOMA
Version 4 - February 2017 (Post IRB Approval)
5
13
14
15
16
17
18
12TH GRADE, NO DIPLOMA
GED CERTIFICATE OF HIGH SCHOOL COMPLETION
SOME COLLEGE CREDIT, BUT NO DEGREE
ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS)
BACHELOR’S DEGREE (FOR EXAMPLE, BA, BS)
MASTER’S DEGREE (FOR EXAMPLE, MA, MS, MENG, M. ED, MSW,
MBA)
19
DOCTORATE DEGREE (FOR EXAMPLE, PHD, EDD)
20
PROFESSIONAL DEGREE BEYOND A BACHELOR’S DEGREE (FOR
EXAMPLE, MD, DDS, DVM, LLB, JD)
DK/REF
QD14
About how tall are you, without shoes?
INTERVIEWER: RECORD FEET ON THIS SCREEN. THEN PRESS ENTER TO
RECORD INCHES ON THE NEXT SCREEN.
______ FEET [RANGE: 2–8]
DK/REF
QD15
[IF QD14 NE DK/RF]
INTERVIEWER: RECORD INCHES ON THIS SCREEN.
______ INCHES [RANGE: 0–11]
DK/REF
QD21
About how much do you weigh?
________ POUNDS [RANGE: 40–850]
DK/REF
QD23
Were you born in the United States?
1
YES
2
NO
DK/REF
QD_DE4_a
[IF QD23 = 2] How old were you when you first came to live in the United States?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
QD24
[IF QD23 = 2] In what country were you born?
1
ARMENIA
Version 4 - February 2017 (Post IRB Approval)
6
2
AUSTRIA
3
AZERBAIJAN
4
CAMBODIA
5
CANADA
6
CHINA
7
CUBA
8
DOMINICAN REPUBLIC
9
ESTONIA
10
EL SALVADOR
11
GEORGIA
12
GERMANY
13
GUATAMALA
14
HUNGARY
15
INDIA
16
IRELAND
17
ITALY
18
KOREA
19
KYRGYZSTAN
20
LATVIA
21
MEXICO
22
PHILIPPINES
23
POLAND
24
RUSSIA
25
SOVIET UNION
26
TAJIKISTAN
27
TURKMENISTAN
28
UKRAINE
29
UZBEKISTAN
30
UNITED KINGDOM
31
VIETNAM
32
OTHER COUNTRY
DK/REF
QD24a
[IF QD24 = 29] INTERVIEWER: RECORD RESPONDENT’S COUNTRY OF
BIRTH
COUNTRY OF BIRTH: _________________ [ALLOW 80 CHARACTERS]
DK/REF
QD25
[IF QD24 NE BLANK OR DK/REF] And what city were you born in?
NON-U.S. CITY OF BIRTH: _______________ [ALLOW 80 CHARACTERS]
DK/REF
QD26
[IF QD23 = 1] In what state were you born?
Version 4 - February 2017 (Post IRB Approval)
7
1
2
3
4
5
6
7
8
9
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
THE DISTRICT OF
COLUMBIA (WASHINGTON, DC)
10
FLORIDA
11
GEORGIA
12
HAWAII
13
IDAHO
14
ILLINOIS
15
INDIANA
16
IOWA
17
KANSAS
18
KENTUCKY
19
LOUISIANA
20
MAINE
21
MARYLAND
22
MASSACHUSETTS
23
MICHIGAN
24
MINNESOTA
25
MISSISSIPPI
26
MISSOURI
DK/REF
QD27
27
28
29
30
31
32
33
34
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
[IF QD26 NE BLANK OR DK/REF] In what city in [QD26] were you born?
CITY OF BIRTH: _____________________ [ALLOW 80 CHARACTERS]
DK/REF
QD_DE7
Did you speak a language other than English at home when you were growing up?
1
YES
2
NO
DK/REF
QD55
How well do you speak English: very well, well, not well, or not at all?
1
2
3
VERY WELL
WELL
NOT WELL
Version 4 - February 2017 (Post IRB Approval)
8
4
NOT AT ALL
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
9
2.
Military Service
BEGIN TIME STAMP
MS1
[IF CURNTAGE = 17 OR OLDER] Have you ever been in the United States Armed
Forces?
1
YES
2
NO
DK/REF
MS2
[IF MS1 = 1 OR DK/REF] Are you currently on active duty in the United States
Armed Forces, are you in a Reserve component, or are you now separated or retired
from the military?
1
ON ACTIVE DUTY IN THE ARMED FORCES
2
IN A RESERVE COMPONENT
3
NOW SEPARATED OR RETIRED FROM THE MILITARY
DK/REF
MS3
[IF MS2 = 1] Are you a member of a Reserve component currently serving full time in
an active duty status?
1
YES
2
NO
DK/REF
MS4
[IF MS2 = 2] Are you currently serving full time in a Reserve component? Full-time
service does not include annual training for the Reserves or National Guard.
1
YES
2
NO
DK/REF
MS5
[IF MS2 = 1] I need to verify what I just entered into the computer. You said you are
currently on active duty in the armed forces. Is this correct?
1
YES
2
NO
DK/REF
HARD ERROR: [IF MS5 = 2 OR DK/REF] INTERVIEWER: PRESS [ENTER] TO GO BACK
AND CORRECT THE RESPONDENT’S CURRENT MILITARY STATUS.
Version 4 - February 2017 (Post IRB Approval)
10
[IF MS5 = 1] People who are currently on active duty in the armed forces are not
eligible to be interviewed in this study. Thank you for your willingness to take part in
this study.
MILTERM2
PRESS [ENTER] TO CONTINUE. [NOTE: PROGRAM SHOULD ROUTE TO
FIEXIT.]
MS6
[IF MS1 = 1 or DK/REF] Have you ever served on active duty in the United States
Armed Forces or Reserve components? Active duty does not include training for the
Reserves or National Guard, but does include activation, for example, for a national
emergency or military conflict.
1
YES
2
NO
DK/REF
MS8
[IF MS6 = 1] How many years or months of active duty service did you complete?
LENGTH OF SERVICE _______ [RANGE 0–65]
DK/REF
SELECT UNIT:
MS8_UNIT
1
YEARS
2
MONTHS
DK/REF
MS9
[IF MS2 = 2 OR 3] How many years or months of Reserve or guard service have you
completed?
LENGTH OF SERVICE _______ [RANGE 0–65]
DK/REF
SELECT UNIT:
MS9_UNIT
1
YEARS
2
MONTHS
DK/REF
MS10
[IF MS2 = 3] What was your rank at the time you separated from the service? Was it
enlisted, noncommissioned officer, warrant officer, or commissioned officer?
[IF MS2 = 2] What is your current rank? Is it enlisted, noncommissioned officer,
warrant officer, or commissioned officer?
1
ENLISTED
Version 4 - February 2017 (Post IRB Approval)
11
2
NONCOMMISSIONED OFFICER
3
WARRANT OFFICER
4
COMMISSIONED OFFICER
DK/REF
MS16
[IF MS6 = 1] HAND R SHOWCARD 3. When did you serve on active duty in the
United States Armed Forces or Reserve components? Just give me the number or
numbers from the card.
TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR
BETWEEN EACH CATEGORY YOU SELECT.
1
2
3
4
5
6
7
8
9
MS12
SEPTEMBER 2001 OR LATER
AUGUST 1990 TO AUGUST 2001 (INCLUDING PERSIAN GULF WAR)
MAY 1975 TO JULY 1990
MARCH 1961 TO APRIL 1975 (VIETNAM ERA)
FEBRUARY 1955 TO FEBRUARY 1961
JULY 1950 TO JANUARY 1955 (KOREAN WAR)
JANUARY 1947 TO JUNE 1950
DECEMBER 1941 TO DECEMBER 1946 (WORLD WAR II)
NOVEMBER 1941 OR EARLIER
[IF MS6 = 1] How many times have you been deployed?
__________ TIMES [RANGE: 0–50]
DK/REF
MS13
[IF MS6 = 1] How many combat or war zone tours have you served?
__________ TOURS [RANGE: 0–50]
DK/REF
MS14
[IF MS12 > 0 AND MS16 = 2] Did you deploy in support of the 1990 to 1991 Gulf
War -- that is, as a part of Desert Shield or Desert Storm?
1
YES
2
NO
DK/REF
MS15
[IF MS12 > 0 AND MS16 = 1 OR 2] Did you deploy in support of Operation Enduring
Freedom, Operation Iraqi Freedom, or Operation New Dawn?
1
YES
2
NO
DK/REF
Version 4 - February 2017 (Post IRB Approval)
12
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
13
3.
Beginning ACASI
BEGIN TIME STAMP
IntroAcasi1 You will do an important part of this interview on your own, using the computer and
headphones.
Before you start, we’ll go through a short practice session so you can learn how to use
this computer and our interview program. Let me quickly point out the keys you will
use. The computerized practice session that follows will go through what each key does
in greater detail.
MOVE COMPUTER SO RESPONDENT CAN SEE THE KEYBOARD AND POINT
OUT THE FOLLOWING:
[POINT TO THE ROW OF FUNCTION KEYS] First, these are the function keys. The
function keys and what they do are labeled for you.
[POINT TO F3] If you don’t know the answer to a question, press F3.
[POINT TO F4] If you don’t want to answer a question, press F4.
PRESS [ENTER] TO CONTINUE.
IntroAcasi3 These next items will help you enter your answers into the computer.
[POINT TO THE ROW OF NUMBER KEYS] These are the number keys.
[POINT TO THE ENTER KEY] The Enter key is here,
[POINT TO THE SPACE BAR] the space bar is here,
[POINT TO THE BACKSPACE KEY] and the Backspace key is here.
[POINT TO THE BOTTOM OF THE SCREEN] The answers that you enter will show
up here at the bottom of the screen.
PRESS [ENTER] TO CONTINUE.
IntroAcasi4 There are a couple of computer features that you will not use.
[POINT TO ON/OFF SWITCH] This button up here turns the machine on and off.
Please do not press it! It will turn the machine off, and we’ll lose the interview.
[POINT TO TOUCHPAD] Also, please do not touch this pad. This might disrupt the
interview.
PRESS [ENTER] TO CONTINUE.
Version 4 - February 2017 (Post IRB Approval)
14
IntroAcasi2 These headphones will allow you to listen while the computer voice reads the interview
questions.
HAND HEADPHONES TO RESPONDENT.
You can adjust the volume here [DEMONSTRATE VOLUME ADJUSTMENT ON
THE HEADPHONE CORD].
Please put on your headphones. When you are ready, let me know.
MOVE COMPUTER SO RESPONDENT CAN USE IT.
ONCE RESPONDENT HAS HEADPHONES ON, PRESS “1" AND [ENTER] SO R
CAN BEGIN PRACTICE SESSION.
HeadPhone
This screen will play while you adjust the volume in your headphones. When you have
adjusted the volume to a level that is comfortable to you, press the large [ENTER] key
on the right side of the keyboard to continue with the practice session. The [ENTER]
key is the one with the symbol on it.
Version 4 - February 2017 (Post IRB Approval)
15
4.
ACASI Tutorial
BEGIN TIME STAMP
INTRO1
Welcome to RTI’s self-interviewing system, which lets you control the interview and
answer in complete privacy.
First, you will learn how to use the system and complete some practice questions. You will learn how
to enter answers and how to back up if you make a mistake and want to change an answer.
Press the large [ENTER] key to move to the next screen.
INTRO2
In this system you can read the questions on the computer screen and hear them read
through the headphones. If you would like to just see the questions on the screen, you
can turn down the volume.
Press [ENTER] to continue.
GOTDOG
You answer questions by putting in the number that is shown next to your answer.
To answer a question, you first press the correct number and then press [ENTER].
Practice Question #1: Do you have a dog?
1
Yes
2
No
DK/REF
EYECOLOR Other questions will have more answers to choose from, and you will pick your
answer from a list.
Practice Question #2: What color are your eyes? Put in the number that best fits you
and press [ENTER].
1
Blue
2
Brown
3
Gray
4
Green
DK/REF
ALLAPPLY
Some questions will let you choose more than one answer. For these questions, you
will use the space bar to separate the answers you type in. Practice this now.
Practice Question #3: What kinds of music do you listen to?
To select more than one kind of music from the list, press the space bar between each
Version 4 - February 2017 (Post IRB Approval)
16
number you type. When you have finished, press [ENTER] to go to the next question.
1
Classical
2
Country
3
Hip Hop
4
Jazz
DK/REF
NUMBER
Other questions will ask you to type in a number instead of choosing a number from a
list.
Practice Question #4: In the past 30 days, on how many days did you eat breakfast?
Type in the number of days you ate breakfast and press [ENTER].
[RANGE: 0–30]
DK/REF
GRID
In some cases there will be more than one question to answer on a screen. For these
questions you will enter your answers one at a time in the order the questions are shown
on the screen.
Practice Question #5: Which kinds of fruit have you eaten in the past 30 days…
GRID1 apples?
GRID2 bananas?
Yes
1
1
No
2
2
DK/REF
BACKUP
If you want to change or see your answer to a previous question, you can back up using
the [F9] key. Each time you press the [F9] key, the computer will go back one
question.
You can tell the computer to repeat a question by pressing [F10]. Try this now.
When you are finished, press [ENTER] to continue.
rangeerr
For some questions, the computer can only accept certain answers. For example, in the
question below, the only numbers the computer will accept are 1 for YES or 2 for NO.
If you try to enter some other number, an instruction box will appear. To correct your
answer, you must press [ENTER] to make the box disappear. You can then answer the
question again.
Version 4 - February 2017 (Post IRB Approval)
17
Try this with the question below. Type a 3 as your answer. Press [ENTER] to remove
the instruction box, then type in a valid answer.
Practice Question #6: Do you have a cat?
1
Yes
2
No
DK/REF
ANYQUES
If you have any questions, please ask your interviewer now. If not, press [ENTER] to
begin. Please answer all of the questions to the best of your abilities.
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
18
5.
Your Health
BEGIN TIME STAMP
B1
In general, would you say your health is:
1
Excellent
2
Very good
3
Good
4
Fair
5
Poor
DK/REF
B2
The following questions are about activities you might do during a typical day. How much, if
at all, does your health now limit you in these activities?
Vigorous activities, such as running, lifting heavy
objects, or participating in strenuous sports
B2b Moderate activities, such as moving a table, pushing a
vacuum cleaner, bowling, or playing golf
B2c Climbing several flights of stairs
B2d Walking several blocks
DK/REF
B2a
B3
Yes,
Limited a
Lot
1
Yes,
Limited
a Little
2
No, Not
Limited
at All
3
1
2
3
1
1
2
2
3
3
During the past 30 days, how often have you had any of the following problems with your
work or other regular activities as a result of your physical health?
Accomplished less than you would like
Were limited in the kind of work or other
activities you could do
B3c Had difficulty performing work or other
activities -- for example, it took extra
effort
DK/REF
B3a
B3b
Version 4 - February 2017 (Post IRB Approval)
All of
the
Time
1
1
Most
of the
Time
2
2
Some
of the
Time
3
3
A
Little
of the
Time
4
4
None
of the
Time
5
5
1
2
3
4
5
19
B4
During the past 30 days, how often have you had any of the following problems with your
work or other regular activities as a result of any problems with emotions, nerves, or
mental health -- such as feeling depressed or anxious?
Accomplished less than you would like
Were limited in the kind of work or other
activities you could do
B4c Didn’t do work or other activities as
carefully as usual
DK/REF
B4a
B4b
B5
All of
the
Time
1
1
Most
of the
Time
2
2
Some
of the
Time
3
3
A
Little
of the
Time
4
4
None
of the
Time
5
5
1
2
3
4
5
During the past 30 days, how much of the time have problems with your physical health or
emotional problems interfered with your social activities -- like visiting with friends or
relatives?
1
All of the time
2
Most of the time
3
Some of the time
4
A little of the time
5
None of the time
DK/REF
B8a
Are you deaf or do you have serious difficulty hearing?
1
Yes
2
No
DK/REF
B8b
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
1
Yes
2
No
DK/REF
B8c
Because of a physical, mental, or emotional condition, do you have serious difficulty
concentrating, remembering, or making decisions?
1
Yes
2
No
DK/REF
Version 4 - February 2017 (Post IRB Approval)
20
B8d
Do you have serious difficulty walking or climbing stairs?
1
Yes
2
No
DK/REF
B8e
Do you have difficulty dressing or bathing?
1
Yes
2
No
DK/REF
B8f
Because of a physical, mental, or emotional condition, do you have difficulty doing errands
alone such as visiting a doctors’ office or shopping?
1
Yes
2
No
DK/REF
B9
Did a health professional ever tell you that you had any type of cancer?
1
Yes
2
No
DK/REF
B9a
[IF B9 = 1] Which type?
B9a1 Non-melanoma skin cancer
B9a2 Breast cancer
B9a3 Lung cancer
B9a4 Prostate cancer
B9a5 Some other type of cancer
DK/REF
Yes
1
1
1
1
1
No
2
2
2
2
2
DEFINE B9A_COUNT (PERFORM EACH TIME MOVE FROM B9A)
B9A_COUNT = 0
IF B9A1 = 1, ADD 1 TO B9A_COUNT.
IF B9A2 = 1, ADD 1 TO B9A_COUNT.
IF B9A3 = 1, ADD 1 TO B9A_COUNT.
IF B9A4 = 1, ADD 1 TO B9A_COUNT.
IF B9A5 = 1, ADD 1 TO B9A_COUNT.
Version 4 - February 2017 (Post IRB Approval)
21
DEFINE B9B_FILL
IF B9A_COUNT > 1, THEN B9B_FILL = “any type of”
IF B9A_COUNT = (1 OR 0), THEN B9B_FILL = “”
B9b
[IF B9 = 1] How old were you when you were first diagnosed with [B9B_FILL] cancer?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE B9C_FILL
IF B9A_COUNT > 1, THEN B9C_FILL = “Are all of your cancers currently cured, are they all in
remission, or is at least one still ongoing?”
IF B9A_COUNT = (1 OR 0), THEN B9C_FILL = “Is your cancer currently cured, in remission, or
still ongoing?”
B9c
[IF B9 = 1] [B9C_FILL]
1
Cured
2
In remission
3
Still ongoing
DK/REF
B10
Did a health professional ever say you had any of the following conditions?
B10a
B10b
B10c
B10d
B10e
B10f
B10g
B10h
B10i
B10j
B10k
DK/REF
B12
Arthritis or rheumatism
Asthma
Any other serious lung disease -- for example, COPD, emphysema,
tuberculosis
Diabetes or high blood sugar
Epilepsy or seizures
HIV infection
High blood pressure
Heart attack or stroke
Any other heart disease
An ulcer in your stomach or intestine
Any other seriously impairing or life-threatening physical illness
Yes
1
1
1
No
2
2
2
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
Do you currently have any of the following health problems?
B12a
B12b
Frequent or very painful back or
neck pain
Frequent or very painful headaches
Version 4 - February 2017 (Post IRB Approval)
Yes
1
No
2
1
2
22
B12c
Some other frequent or very painful
condition that has been going on for
at least 6 months
Yes
1
No
2
DK/REF
B13
Have you ever in your life been told by a professional, or have you personally believed, that
you had any of the following problems?
B13a
B13b
B13c
B13d
B13e
B13f
B13g
B13h
B13i
B13j
B13l
B13m
B13n
DK/REF
B14
Attention-deficit hyperactivity disorder, also known as ADHD
Depression
Panic attacks, also known as anxiety attacks
Phobias, that is, extreme fears of particular situations
Post-traumatic stress disorder, also known as PTSD
Obsessive-compulsive disorder
Generalized anxiety disorder, that is, being very nervous, worried, or anxious
Manic depression, also known as bipolar disorder
Problems with anger control
Schizophrenia or other psychotic disorder
Any other serious emotional problem
Problems with alcohol use
Problems with drug use
Yes
1
1
1
1
1
1
1
1
1
1
1
1
1
No
2
2
2
2
2
2
2
2
2
2
2
2
2
How often in the past 30 days did you have each of the following?
B14a Memory problems
B14c Difficulty concentrating or your
mind going blank
B14d Sleep problems, such as getting to
sleep, staying asleep, waking too
early, or sleeping too much
B14e Feeling tired out, low in energy, or
easily fatigued
B14f Feeling emotionally much higher,
happier, or excitable than usual
Version 4 - February 2017 (Post IRB Approval)
All or
Almost
All of
the
Time
1
1
Most of
the
Time
2
2
Some of
the
Time
3
3
A Little
of the
Time
4
4
None of
the
Time
5
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
23
B14g Being much more hyper or wound
up than usual
B14h Having thoughts race through your
mind so fast you could hardly keep
track of them
DK/REF
B15
Most of
the
Time
2
Some of
the
Time
3
A Little
of the
Time
4
None of
the
Time
5
1
2
3
4
5
How often in the past 30 days did you have each of the following?
B15a Pain in your back, neck, arms, legs,
or joints -- such as your knees or
hips
B15b Headaches
B15c Pain in any other part of the body
B15d Muscle tension
B15e Dizziness
DK/REF
B16
All or
Almost
All of
the
Time
1
All or
Almost
All of
the
Time
1
Most of
the
Time
2
Some of
the
Time
3
A Little
of the
Time
4
None of
the
Time
5
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
How often in the past 30 days did you experience each of the following?
B16a Feeling irritated, annoyed, or grouchy
B16c Feeling that your anger was out of
control
B16d Talking or moving more slowly than
usual
B16e Feeling calm or peaceful
B16f Feeling restless, tense, wound up, or on
edge
B16g Poor appetite or overeating
Version 4 - February 2017 (Post IRB Approval)
All or
Almost
All of
the
Time
1
1
Most of
the
Time
2
2
Some
of the
Time
3
3
A
Little
of the
Time
4
4
None
of the
Time
5
5
1
2
3
4
5
1
1
2
2
3
3
4
4
5
5
1
2
3
4
5
24
DK/REF
B17
[IF B14d = 1, 2, 3, OR 4] You mentioned sleep problems. About how many nights out of 7 in a
typical week do you have problems either getting to sleep, staying asleep, waking too early, or
feeling tired even after a full night’s sleep?
If less than 1 night a week, enter “0.”
__________ NUMBER OF NIGHTS A WEEK [RANGE: 0–7]
DK/REF
B18
[IF B17 = 3, 4, 5, 6, OR 7 OR DK OR REF] How much do your sleep problems interfere with
your daytime functioning?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
B22A [IF B4a NE 5 OR B4b NE 5 OR B4c NE 5] The next questions are about how much your
emotions, nerves, or mental health have caused you to have difficulties in daily activities. In
answering, think of the one month in the past 12 months when your emotions, nerves, or
mental health interfered most with your daily activities.
During that one month when your emotions, nerves, or mental health interfered most with your
daily activities, how much difficulty did you have….
B22Aa remembering to do
things you needed to
do?
B22Ab concentrating on doing
something important
when other things were
going on around you?
B22Ac going out of the house
and getting around on
your own?
Version 4 - February 2017 (Post IRB Approval)
No
Difficulty
1
Mild
Difficulty
2
Moderate
Difficulty
3
Severe
Difficulty
4
Extreme
Difficulty
or Cannot
Do
5
1
2
3
4
5
1
2
3
4
5
25
B22Ad dealing with people
you did not know well?
B22Ae participating in social
activities, like visiting
friends or going to
parties?
B22Af taking care of
household
responsibilities?
B22Ag taking care of your
daily responsibilities at
work or school?
B22Ah getting your daily work
done as quickly as
needed?
DK/REF
No
Difficulty
1
Mild
Difficulty
2
Moderate
Difficulty
3
Severe
Difficulty
4
Extreme
Difficulty
or Cannot
Do
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
B22_WEEK [IF B22Aa = 2–5 OR B22Ab = 2–5 OR B22Ac = 2–5 OR B22Ad = 2–5 OR B22Ae =
2–5 OR B22Af = 2–5 OR B22Ag = 2–5 OR B22Ah = 2–5] During the past 12 months,
about how many weeks did you have any of these difficulties because of your
emotions, nerves, or mental health? If you can’t remember the exact number, just give
your best estimate.
__________ NUMBER OF WEEKS [RANGE: 1–52]
DK/REF
DEFINE B22_DAYS_FILL
IF B22_WEEK = 1, THEN FILL, “that [B22_WEEK] week”
IF B22_WEEK = 2–52, THEN FILL, “those [B22_WEEK] weeks”
B22_DAYS
[IF B22_WEEK = 1–52] During [B22_DAYS_FILL], did you have these kinds of
difficulties every day, most days, or only 1 or 2 days a week?
1
Every day
2
Most days
3
Only 1 or 2 days a week
DK/REF
B22_IMPDYS
[IF B22Aa = 2–5 OR B22Ab = 2–5 OR B22Ac = 2–5 OR B22Ad = 2–5 OR
B22Ae = 2–5 OR B22Af = 2–5 OR B22Ag = 2–5 OR B22Ah = 2–5] About how many
Version 4 - February 2017 (Post IRB Approval)
26
days out of the past 365 were you totally unable to work or carry out your normal
activities because of your emotions, nerves, or mental health?
You can use any number between 0 and 365 to answer.
__________ NUMBER OF DAYS [RANGE: 0–365]
DK/REF
B22B In the past 12 months, how many times have you…
B22Ba been hospitalized overnight for a
physical health problem?
B22Bb been treated in an emergency
department or ER?
B22Bc seen a health care professional as an
outpatient for a physical health
problem?
B22Be been hospitalized or in a rehab center
overnight for alcohol or drug
problems?
DK/REF
Number of Times
If None, Enter “0”
_____
[RANGE: 0–365]
_____
[RANGE: 0–365]
_____
[RANGE: 0–365]
____
[RANGE: 0–365]
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
27
6.
CIDI Screener
The next question is about episodes you might have ever had lasting
several days or longer when you were full of energy, more active than
usual, and your mood was better than usual.
HM1
Yes
1
No
2
1
2
During these episodes, people often talk a lot faster, feel more
outgoing, or feel more self-confident than usual.
Their thoughts often go very quickly and they may have trouble
sitting still.
They often are much happier, hyper, or excitable than usual.
They are sometimes more irritable or quick to take offense than usual.
They sometimes do things during these episodes that are inappropriate
or that they would normally be too embarrassed to do.
With this definition in mind, have you ever in your life had an episode of
this sort lasting several days or longer?
Do not count episodes caused by drinking or using drugs.
[IF HM1 = 1] During one of these episodes, did other people ever notice
or comment that you were much more active or energetic than usual?
HM2
DK/REF
SP1
Was there ever a time in your life -- either as a child or adult -- when you felt very afraid,
anxious, or extremely shy in any of the following social situations?
SP1a Meeting new people
SP1b Going to a party or social gathering
SP1c Going on a date
SP1d Using a bathroom when away from home
SP1e Any other social situation where something embarrassing might happen
DK/REF
Yes
1
1
1
1
1
No
2
2
2
2
2
DEFINE SP1_YCOUNT (PERFORM EACH TIME MOVES FROM SP1E TO SP2)
SET SP1_YCOUNT = 0
IF SP1A = 1, ADD 1 TO SP1_YCOUNT
IF SP1B = 1, ADD 1 TO SP1_YCOUNT
IF SP1C = 1, ADD 1 TO SP1_YCOUNT
IF SP1D = 1, ADD 1 TO SP1_YCOUNT
IF SP1E = 1, ADD 1 TO SP1_YCOUNT
Version 4 - February 2017 (Post IRB Approval)
28
SP2
Was there ever a time in your life when you felt very afraid, anxious, or uncomfortable in any
of the following performance situations?
SP2a Talking to people in authority
SP2b Talking to people you did not know
SP2c Speaking up in a meeting or class
SP2d Giving a speech, acting, or performing in front of an audience
SP2e Any other performance situation where you might be the center of attention
DK/REF
Yes
1
1
1
1
1
No
2
2
2
2
2
DEFINE SP2_YCOUNT (PERFORM EACH TIME MOVES FROM SP2E TO SP3)
SET SP2_YCOUNT = 0
IF SP2A = 1, ADD 1 TO SP2_YCOUNT
IF SP2B = 1, ADD 1 TO SP2_YCOUNT
IF SP2C = 1, ADD 1 TO SP2_YCOUNT
IF SP2D = 1, ADD 1 TO SP2_YCOUNT
IF SP2E = 1, ADD 1 TO SP2_YCOUNT
SC5
SC3
Have you ever in your life felt so frightened of going out of the house
alone, being in a crowd, standing in lines, going over bridges, or travelling
by bus, train, or car that it got in the way of you having a normal life?
The next question is about panic attacks, sometimes called anxiety
attacks. These are sudden, strong feelings of fear or anxiety that are
usually accompanied by physical reactions like a racing heart, shortness of
breath, feeling faint, or feeling sick to your stomach. With this definition
in mind, have you ever in your life had panic attacks?
Yes
1
No
2
1
2
Yes
1
No
2
1
2
1
2
DK/REF
SC6
SC6a
SC7
Have you ever had a time in your life when you had a great deal of
concern about or strongly feared being too fat or overweight?
[IF SC6 = 1] Have you ever had this strong worry or fear at a time when
you actually weighed less than most other people?
The next question is about “eating binges,” where a person eats a large
amount of food during a short period, like 2 hours. By “a large amount,”
we mean eating so much food that it would be like eating two or more
entire meals in one sitting, or eating so much of one particular food -- like
candy or ice cream -- that it would make most people feel sick. With that
definition in mind, have you ever had a time in your life when you went
on eating binges at least once a week for 3 months or longer?
DK/REF
Version 4 - February 2017 (Post IRB Approval)
29
SC8
SC8a
SC8b
Have you ever in your life had attacks of anger when all of a sudden you
lost control and broke or smashed something worth more than a few
dollars?
[IF SC8 NE 1] Have you ever in your life had attacks of anger when all of
a sudden you lost control and hit or tried to hurt someone?
[IF SC8 NE 1 AND SC8a NE 1] Have you ever in your life had attacks of
anger when all of a sudden you lost control and threatened to hit or hurt
someone?
Yes
1
No
2
1
2
1
2
Yes
1
No
2
1
2
1
2
DK/REF
SC9
SC10
SC11
Have you ever in your life felt so afraid of some other specific thing like
heights, bugs, animals, thunder, or blood that you either refused to go near
a situation that would expose you to this feared thing or you became
extremely anxious whenever you were exposed to that thing?
Have you ever in your life had repeated unpleasant thoughts, images, or
urges you couldn’t get out of your head that got in the way of you having
a normal life, such as the idea that things were dirty no matter how much
you washed?
Have you ever in your life had such a strong urge to do something over
and over that it got in the way of you having a normal life, like spending a
great deal of time washing, cleaning, straightening, or saving strange
things (such as nail clippings or old newspapers)?
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
30
7.
Depression
BEGIN TIME STAMP
SECTION DE: DEPRESSION
DEFINE DE1FILL
IF R REPORTED “DEPRESSON” IN B13b (B13b = 1), THEN DE1FILL = “Earlier you reported
having a history of depression. The next questions are about recent feelings of that sort.”
ELSE DE1FILL = “The next questions are about recent feelings of depression and low mood.”
DE1
DE1a
DE1b
DE1c
DE1d
DE1e
[DE1FILL] How often in the past 30 days did you…
feel sad or depressed?
feel empty or hopeless?
feel discouraged about how things were
going in your life?
take little or no interest or pleasure in
things?
feel down on yourself, no good, or
worthless?
All or
Almost
All the
Time
1
1
Most
of the
Time
2
2
Some
of the
Time
3
3
A Little
of the
Time
4
4
None
of the
Time
5
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DK/REF
DEFINE DE1_COUNT
SET DE1_COUNT = 0
IF (DE1a = (1 OR 2)) OR (DE1b = (1 OR 2)) OR (DE1c = (1 OR 2)), ADD 1 TO DE1_COUNT
IF DE1d = (1 OR 2), ADD 1 TO DE1_COUNT
DEFINE PHOLDER1
IF DE_COUNT ≥ 1 THEN PHOLDER1 = 1
ELSE PHOLDER1 = 3
Version 4 - February 2017 (Post IRB Approval)
31
DE2
DE2a
DE2b
DE2c
DE2d
DE2e
DE2f
[IF DE1_COUNT ≥ 1] How often in the past 30 days did you…
All or
Almost
All the
Time
Most
of the
Time
Some
of the
Time
A Little
of the
Time
None
of the
Time
1
2
3
4
5
1
2
3
4
5
1
1
2
2
3
3
4
4
5
5
1
2
3
4
5
1
2
3
4
5
have trouble concentrating or making
day-to-day decisions because of your low
mood?
think a lot about death, either your own,
someone else’s, or death in general?
fear that something awful might happen?
feel that you might lose control?
have psychological distress because of
your depression or low mood?
have depression or low mood that
interfered with your work or personal
life?
DK/REF
DEFINE DE3_COUNT
SET DE3_COUNT = 0
IF DE1a = (1 OR 2), ADD 1 TO DE3_COUNT
IF DE1b = (1 OR 2), ADD 1 TO DE3_COUNT
IF DE1c = (1 OR 2), ADD 1 TO DE3_COUNT
IF DE1d = (1 OR 2), ADD 1 TO DE3_COUNT
IF DE1e= (1 OR 2), ADD 1 TO DE3_COUNT
IF DE2a = (1 OR 2), ADD 1 TO DE3_COUNT
IF DE2b = (1 OR 2), ADD 1 TO DE3_COUNT
IF B14d = (1 or 2), ADD 1 TO DE3_COUNT
IF B14e = (1 or 2), ADD 1 TO DE3_COUNT
IF (B16d = (1 or 2)) OR (B16g = (1 or 2)), ADD 1 TO DE3_COUNT
IF B16f = (1 or 2), ADD 1 TO DE3_COUNT
DEFINE DE3_COUNTA
SET DE3_COUNTA = 0
IF DE2e = (1 OR 2 OR 3), ADD 1 TO DE3_COUNTA
IF DE2f = (1 OR 2 OR 3), ADD 1 TO DE3_COUNTA
DEFINE PHOLDER2
IF DE3_COUNT ≥ 5 OR DE3_COUNTA ≥ 1 THEN PHOLDER2 = 1
ELSE PHOLDER2 = 3
Version 4 - February 2017 (Post IRB Approval)
32
DE3
DE3a
DE3b
DE3c
DE3d
[IF DE3_COUNT < 5 OR DE3_COUNTA < 1] Think of a time lasting 2 weeks or longer in
your life when you had the largest number of problems with depression, low mood, and
related problems, such as feeling empty, helpless, down on yourself, like life is not worth
living, or losing interest in things you used to enjoy. How often during those 2 weeks did
you…
feel sad or depressed?
feel empty or hopeless?
feel discouraged about how things were
going in your life?
take little or no interest or pleasure in
things?
All or
Almost
All the
Time
1
1
Most
of the
Time
2
2
Some
of the
Time
3
3
A Little
of the
Time
4
4
None
of the
Time
5
5
1
2
3
4
5
1
2
3
4
5
DK/REF
DEFINE DE3_COUNTB
SET DE3_COUNTB = 0
IF (DE3a = (1 OR 2)) OR (DE3b = (1 OR 2)) OR (DE3c = (1 OR 2)), ADD 1 TO DE3_COUNTB
IF DE3d = (1 OR 2), ADD 1 TO DE3_COUNTB
DE4_1 [IF DE3_COUNTB ≥ 1] How often during those 2 weeks did you…
DE4a
DE4b
DE4c
DE4d
DE4e
DE4f
DK/REF
feel down on yourself, no good, or
worthless?
have trouble concentrating or making
day-to-day decisions?
think a lot about death, either your own,
someone else’s, or death in general?
have sleep problems, such as getting to
sleep, staying asleep, waking too early, or
sleeping too much?
feel tired out, low in energy, or easily
fatigued?
talk or move more slowly than usual?
Version 4 - February 2017 (Post IRB Approval)
All or
Almost
All the
Time
Most
of the
Time
Some
of the
Time
A Little
of the
Time
None
of the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
33
DE4f_1 [IF DE4f = 1 OR 2] Did other people notice or comment that you were talking or moving
more slowly?
1
Yes
2
No
DK/REF
DE4_2 [IF DE3_COUNTB ≥ 1] How often during those 2 weeks did you…
have a poor appetite or overeat?
have psychological distress because of
your depression or low mood?
feel restless, tense, wound up, or on
edge?
DE4g
DE4h
DE4i
All or
Almost
All the
Time
1
Most
of the
Time
2
Some
of the
Time
3
A Little
of the
Time
4
None
of the
Time
5
1
2
3
4
5
1
2
3
4
5
DK/REF
DE4i_1 [IF DE4i = 1 OR 2] Did other people notice or comment that you were restless or wound up?
1
Yes
2
No
DK/REF
DE4j
[IF DE3_COUNTB ≥ 1] How often during that 2 weeks did depression or low mood interfere
with your work or personal life?
1
All or almost all the time
2
Most of the time
3
Some of the time
4
A little of the time
5
None of the time
DK/REF
DE4k [IF DE4H=(1 OR 2 OR 3 OR 4)] How severe was your psychological distress during those 2
weeks?
1
Mild
2
Moderate
3
Severe
4
Very severe
DK/REF
Version 4 - February 2017 (Post IRB Approval)
34
DE4l [IF DE4j =(1 OR 2 OR 3 OR 4)] How much did your low mood and related problems interfere
with your work or personal life during those two weeks?
1
A little
2
Some
3
A lot
4
Extremely
DK/REF
DEFINE DE4_COUNT
SET DE4_COUNT = 0
IF DE3a = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE3b = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE3c = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE3d = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4a = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4b = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4c = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4d = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4e = (1 OR 2), ADD 1 TO DE4_COUNT
IF (DE4f_1 = 1) OR (DE4i_1 = 1), ADD 1 TO DE4_COUNT
IF DE4g = (1 OR 2), ADD 1 TO DE4_COUNT
DEFINE DE4_COUNTA
SET DE4_COUNTA = 0
IF DE4h = (1 OR 2 OR 3), ADD 1 TO DE4_COUNTA
IF DE4j = (1 OR 2 OR 3), ADD 1 TO DE4_COUNTA
DEFINE DE5_ASK
IF (DE3_COUNT ≥ 5 AND DE3_COUNTA ≥ 1) OR (DE4_COUNT ≥ 5 AND DE4_COUNTA ≥ 1)],
THEN SET DE5_ASK=1.
ELSE, SET DE5_ASK=0.
DE5
[IF DE5_ASK=1] About how old were you the very first time you had an episode lasting 2
weeks or longer when most of the time you had depression or low mood plus some of the
other problems you were just asked about? Your best estimate is fine if you cannot remember
the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DE6
[IF DE5 = (CURNTAGE – 1)] Did that episode start in the past 12 months or more than 12
months ago?
Version 4 - February 2017 (Post IRB Approval)
35
1
IN THE PAST 12 MONTHS
2
MORE THAN 12 MONTHS AGO
DK/REF
DE7
[IF DE5_ASK=1 AND DE5 NE CURNTAGE AND NE (CURNTAGE-1)] During about
how many years in your life did you have at least one episode like this lasting 2 weeks or
longer? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
DE8
[IF DE5 = (CURNTAGE – 1) OR DE7 NE 0] The next question asks about the longest
episode you ever had. What would be the easiest way for you to tell us how long that episode
lasted?
1
Total number of weeks the episode lasted
2
Total number of months the episode lasted
3
Total number of years the episode lasted
DK/REF
DE8W [IF DE8 = (1 OR DK OR REF)] How many weeks was the longest episode you ever had?
_____ NUMBER OF WEEKS [RANGE: 1-104]
DK/REF
DE8M [IF DE8 = 2] How many months was the longest episode you ever had?
_____ NUMBER OF MONTHS [RANGE: 1-48]
DK/REF
DE8Y [IF DE8 = 3] How many years was the longest episode you ever had?
_____ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
DE9
[IF DE5_ASK=1] How much did these episodes ever interfere with your work or personal
life?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
Version 4 - February 2017 (Post IRB Approval)
36
DE10
[IF (DE5_ASK=1] During about how many months in the past 12 months did you have an
episode like this lasting 2 weeks or longer? Your best estimate is fine if you cannot remember
the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
DE11
[IF (DE10 NE OR LESS THAN 1) OR (DE5 NE CURNTAGE) OR (DE5 NE (CURNTAGE
– 1))] About how old were you the most recent time you had an episode like this lasting 2
weeks or longer? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
37
8.
Mania
BEGIN TIME STAMP
DEFINE HM3_FILL
IF B13H=1 THEN HM3_FILL = “Earlier, you reported that you’ve had a problem with manic
depression, also known as bipolar disorder. Manic depression, or bipolar disorder, involves
episodes lasting several days or longer when a person is full of energy, more active than usual,
and the person’s mood is better than usual”
IF HM1 = 1 THEN HM3_FILL = “Earlier, you reported having had an episode lasting several days or
longer when you were full of energy, more active than usual, and your mood was better than
usual.”
HM3 [IF HM1 = 1 ] [HM3_FILL] Think of a typical intense episode of this sort. How often during
that episode did you have each of the following experiences?
HM3a You were happier or more excitable
than usual
HM3b You were much more irritable or
quick to take offense than usual
HM3c You were much more full of
energy, hyper, or wound up than
usual
HM3d You became much more active than
usual at school, work, or home
DK/REF
All or
Almost
All the
Time
Most of
the
Time
Some of
the
Time
A Little
of the
Time
None of
the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE HM3_COUNT (PERFORM EACH TIME MOVES AWAY FROM HM3)
SET HM3_COUNT = 0
IF [HM3A = (1 OR 2 OR 3) OR HM3B = (1 OR 2 OR 3)], ADD 1 TO HM3_COUNT
IF [HM3C = (1 OR 2 OR 3) OR HM3D = (1 OR 2 OR 3)], ADD 1 TO HM3_COUNT
HM4 [IF HM3_COUNT =2] During that episode how often did you…
Version 4 - February 2017 (Post IRB Approval)
38
HM4a find that your thoughts raced
through your mind so fast you
could hardly keep track of them?
HM4b sleep much less than usual and still
not get tired or sleepy?
HM4c talk so much that other people
couldn’t get their say?
HM4d feel extremely self-confident or
optimistic or believe you could do
things you really couldn’t do?
HM4e make bad decisions related to your
feeling happy or overly optimistic
that could have caused problems for
you?
HM4f find it hard to keep your mind on
what you were doing?
HM4g do reckless things like spend too
much money, drive or bike too fast,
or do things that are unsafe?
All or
Almost
All the
Time
Most of
the
Time
Some of
the
Time
A Little
of the
Time
None of
the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DK/REF
HM4h [IF HM3_COUNT ≥ 1] How often did this episode interfere with your school, work, or
personal life?
1
All or almost all the time
2
Most of the time
3
Some of the time
4
A little of the time
5
None of the time
DK/REF
DEFINE HM4_COUNT (PERFORM EACH TIME MOVES AWAY FROM HM4)
SET HM4_COUNT = 0
IF HM3D = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
IF HM4A = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
IF HM4B = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
IF HM4C = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
IF HM4D = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
IF HM4E = (1 OR 2 OR 3) OR HM4G = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
Version 4 - February 2017 (Post IRB Approval)
39
IF HM4F = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
DEFINE HM5_ASK
IF (HM4_COUNT ≥ 3) AND (HM4H = 1 OR 2 OR 3), SET HM5_ASK=1,
ELSE SET HM5_ASK=0.
HM5 [IF HM5_ASK = 1 ] About how old were you the very first time you had an episode like that
lasting several days or longer? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
HM5a [IF ((CURNTAGE – HM5) = 1) AND (HM5 NE DK OR REF) AND (CURNTAGE NE DK
OR REF)] Did it start in the past 12 months or more than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
HM6 [IF ((CURNTAGE – HM5) NE 1) OR (HM5=DK OR REF) OR (CURNTAGE=DK OR REF)]
During about how many years in your life did you have an episode like that lasting several
days or longer? Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
HM7 [IF (HM4_COUNT ≥ 3) AND (H4MH = 1 OR 2 OR 3)] How long was the longest episode
you ever had?
1
3 days or less
2
4–6 days
3
1–2 weeks
4
3–4 weeks
5
More than 4 weeks
DK/REF
HM8 [IF (HM4_COUNT ≥ 3) AND (HM4H = 1 OR 2 OR 3)] How much did these episodes ever
interfere with your school, work, or personal life?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
Version 4 - February 2017 (Post IRB Approval)
40
HM8a [IF (HM4_COUNT ≥ 3) AND (HM4H = 1 OR 2 OR 3)] Were you ever hospitalized as a
result of having an episode?
1
Yes
2
No
DK/REF
HM9 [IF (HM4_COUNT ≥ 3) AND (HM4H = 1 OR 2 OR 3)] During about how many months in
the past 12 months did you have one of these episodes? Your best estimate is fine if you
cannot remember the exact number.
______ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
HM10 [IF HM9 ≥ 1] Did you have one of these episodes at any time in the past 30 days?
1
Yes
2
No
DK/REF
HM11 [IF HM9 = 0 OR DK OR REF] About how old were you the most recent time you had one
of these episodes for several days or longer? Your best estimate is fine if you cannot
remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
41
9.
Anxiety and Worry (GAD)
BEGIN TIME STAMP
DEFINE AW1_FILL
IF B13g = 1 (R REPORTED “ANXIETY DISORDER” IN B13), THEN AW1_FILL = “Earlier, you
reported having a history of anxiety. The next questions are about recent feelings of that sort.”
ELSE AW1_FILL = “The next questions are about recent feelings of anxiety and worry.”
AW1
[AW1_FILL] How often in the past 30 days did you…
AW1a feel anxious or nervous about a
number of activities?
AW1b worry about a number of different
events or activities?
AW1c feel more anxious or worried than
other people in your same situation?
AW1d worry about things that most other
people wouldn’t worry about?
AW1e have trouble stopping yourself from
being anxious or worried?
DK/REF
All or
Almost
All the
Time
Most
of the
Time
Some
of the
Time
A Little
of the
Time
None
of the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE AW1AB_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW1)
SET AW1AB_COUNT = 0
IF AW1A = (1 OR 2 OR 3), ADD 1 TO AW1AB_COUNT
IF AW1B = (1 OR 2 OR 3), ADD 1 TO AW1AB_COUNT
DEFINE AW1CD_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW1)
SET AW1CD_COUNT = 0
IF AW1C = (1 OR 2 OR 3 -), ADD 1 TO AW1CD_COUNT
IF AW1D = (1 OR 2 OR 3 -), ADD 1 TO AW1CD_COUNT
DEFINE AW1E_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW1)
SET AW1E_COUNT = 0
IF AW1E = (1 OR 2 OR 3), ADD 1 TO AW1E_COUNT
Version 4 - February 2017 (Post IRB Approval)
42
DEFINE AW2_ASK (PERFORM EACH TIME MOVES AWAY FROM AW1)
IF [(AW1AB_COUNT ≥ 1) AND (AW1CD_COUNT ≥ 1) AND (AW1E_COUNT ≥ 1), AW2_ASK =
1
ELSE, SET AW2_ASK = 0
AW2
[IF AW2_ASK = 1] How often in the past 30 days did you…
AW2a feel restless, keyed up, or on edge?
AW2b feel tired out, low in energy, or easily
fatigued?
AW2c have difficulty concentrating or your
mind going blank because of your nerves
or worry?
AW2d feel irritated, annoyed, or grouchy?
AW2e have muscle aches or tension caused by
anxiety or worry?
AW2f have difficulty falling or staying asleep or
have restless, unsatisfying sleep because
of your anxiety or worry?
AW2g have psychological distress because of
your anxiety or worry?
AW2h How often during those 30 days did your
anxiety and worry interfere with your
work or personal life?
DK/REF
All or
Almost
All the
Time
1
Most
of the
Time
2
Some
of the
Time
3
A Little
of the
Time
4
None
of the
Time
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE AW2ABCDEF_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW2)
SET AW2ABCDEF_COUNT = 0
IF AW2A = (1 OR 2 OR 3), ADD 1 TO AW2ABCDEF_COUNT
IF AW2B = (1 OR 2 OR 3), ADD 1 TO AW2ABCDEF_COUNT
IF AW2C = (1 OR 2 OR 3), ADD 1 TO AW2ABCDEF_COUNT
IF AW2D = (1 OR 2 OR 3), ADD 1 TO AW2ABCDEF_COUNT
IF AW2E = (1 OR 2 OR 3), ADD 1 TO AW2ABCDEF_COUNT
IF AW2F = (1 OR 2 OR 3), ADD 1 TO AW2ABCDEF_COUNT
DEFINE AW2GH_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW2)
SET AW2GH_COUNT = 0
IF AW2G = (1 OR 2 OR 3), ADD 1 TO AW2GH_COUNT
IF AW2H = (1 OR 2 OR 3), ADD 1 TO AW2GH_COUNT
Version 4 - February 2017 (Post IRB Approval)
43
DEFINE AW3AW4_SKIP (PERFORM EACH TIME MOVE FROM AW2)
SET AW3AW4_SKIP = 0
IF AW2ABCDEF_COUNT ≥ 3 AND AW2GH_COUNT ≥ 1], SET AW3AW4_SKIP = 1
[PROGRAMMER: PLEASE PROGRAM THIS SKIP VARIABLE AND WRITE IT TO THE
DATASET EVEN THOUGH IT’S NOT CURRENTLY USED DOWNSTREAM.]
AW3
Think of a 6-month period in your life when you had the largest number of problems
with anxiety, nerves, or worry. How often during those 6 months did you...
All or
Almost
All the
Time
Most
of the
Time
Some
of the
Time
A Little
of the
Time
None
of the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
AW3a feel anxious or nervous about a number
of activities?
AW3b worry about a number of different events
or activities?
AW3c feel more anxious or worried than other
people in your same situation?
AW3d worry about things that most other people
wouldn’t worry about?
AW3e have trouble stopping yourself from being
anxious or worried?
DK/REF
DEFINE AW3AB_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW3)
SET AW3AB_COUNT = 0
IF AW3A = (1 OR 2 OR 3), ADD 1 TO AW3AB_COUNT
IF AW3B = (1 OR 2 OR 3), ADD 1 TO AW3AB_COUNT
DEFINE AW3CD_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW3)
SET AW3CD_COUNT = 0
IF AW3C = (1 OR 2 OR 3), ADD 1 TO AW3CD_COUNT
IF AW3D = (1 OR 2 OR 3), ADD 1 TO AW3CD_COUNT
DEFINE AW3E_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW3)
SET AW3E_COUNT = 0
IF AW3E = (1 OR 2 OR 3), ADD 1 TO AW3E_COUNT
Version 4 - February 2017 (Post IRB Approval)
44
AW4
[IF (AW3AB_COUNT ≥ 1) AND (AW3CD_COUNT ≥ 1) AND AW3E_COUNT ≥ 1]
How often during those 6 months did you…
AW4a feel restless, keyed up, or on edge?
AW4b feel tired out, low in energy, or easily
fatigued?
AW4c have difficulty concentrating or your
mind going blank because of your nerves
or worry?
AW4d feel irritated, annoyed, or grouchy?
AW4e have muscle aches or tension caused by
anxiety or worry?
AW4f have difficulty falling or staying asleep or
have restless, unsatisfying sleep because
of your anxiety or worry?
AW4g have psychological distress because of
your anxiety or worry?
AW4h How often during those 6 months did
your anxiety and worry interfere with
your work or personal life?
DK/REF
AW4i
All or
Almost
All the
Time
1
Most
of the
Time
2
Some
of the
Time
3
A Little
of the
Time
4
None
of the
Time
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
[IF AW4g = (1 OR 2 OR 3 OR 4)] How severe was your psychological distress during
those 6 months?
1
Mild
2
Moderate
3
Severe
4
Very severe
DK/REF
AW4j
[IF AW4h = (1 OR 2 OR 3 OR 4)] How much did your anxiety and worry interfere
with your work or personal life during those 6 months?
1
Extremely
2
A lot
3
Some
4
A little
DK/REF
DEFINE AW4ABCDEF_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW4)
Version 4 - February 2017 (Post IRB Approval)
45
SET AW4ABCDEF_COUNT = 0
IF AW4A = (1 OR 2 OR 3), ADD 1 TO AW4ABCDEF_COUNT
IF AW4B = (1 OR 2 OR 3), ADD 1 TO AW4ABCDEF_COUNT
IF AW4C = (1 OR 2 OR 3), ADD 1 TO AW4ABCDEF_COUNT
IF AW4D = (1 OR 2 OR 3), ADD 1 TO AW4ABCDEF_COUNT
IF AW4E = (1 OR 2 OR 3), ADD 1 TO AW4ABCDEF_COUNT
IF AW4F = (1 OR 2 OR 3), ADD 1 TO AW4ABCDEF_COUNT
DEFINE AW4GH_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW4)
SET AW4GH_COUNT = 0
IF AW4G = (1 OR 2 OR 3), ADD 1 TO AW4GH_COUNT
IF AW4H = (1 OR 2 OR 3), ADD 1 TO AW4GH_COUNT
DEFINE AW5_ASK (PERFORM EACH TIME MOVES AWAY FROM AW3AW4_SKIP OR
AW4)
IF (AW4ABCDEF_COUNT ≥ 3) AND (AW4GH_COUNT ≥ 1), SET AW5_ASK = 1
ELSE SET AW5_ASK = 0
AW5
[IF AW5_ASK = 1] About how old were you the very first time you had an episode
lasting 6 months or longer when you felt anxious, nervous, or worried and also had
some of the other problems you just reviewed? Your best estimate is fine if you cannot
remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE AW6_ASK (PERFORM EACH TIME MOVES AWAY FROM AW5)
SET AW6_ASK = 0
IF (AW5 NE DK/REF) AND (AW5 = (CURNTAGE-1), SET AW6_ASK = 1
AW6
[IF AW6_ASK = 1] Did that episode start in the past 12 months or more than 12
months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
AW7
[IF AW5_ASK = 1 AND (AW6_ASK = 0 AND (AW5 NE CURNTAGE)) OR (AW6
NE 1)] During about how many years in your life did you have an episode like this
lasting one month or longer? Your best estimate is fine if you cannot remember the
exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
Version 4 - February 2017 (Post IRB Approval)
46
DK/REF
AW8_UNIT [IF AW5_ASK = 1] How long was the longest episode you ever had? Please indicate
whether you’d like to report in months or years.
1
Months
2
Years
DK/REF
AW8_MTHS [IF AW8_UNIT = (1 OR DK OR REF) AND (AW4ABCDEF_COUNT ≥ 3) AND
(AW4GH_COUNT ≥ 1)] How many months long was the longest episode you ever had?
______ MONTHS [RANGE: 1–12]
DK/REF
AW8_YRS
[IF AW8_UNIT = 2 AND (AW4ABCDEF_COUNT ≥ 3) AND (AW4GH_COUNT ≥ 1)]
How many years long was the longest episode you ever had?
______ YEARS [RANGE: 1–CURNTAGE]
DK/REF
DEFINE AW9_FILL
IF (AW1A = (1 OR 2 OR 3) OR AW3A = (1 OR 2 OR 3)) AND (AW1B = (1 OR 2 OR 3) OR AW3B
= (1 OR 2 OR 3)), THEN AW9_FILL = “anxious or worried”
IF (AW1A = (1 OR 2 OR 3) OR AW3A = (1 OR 2 OR 3)) AND (AW1B NE (1 OR 2 OR 3) AND
(AW3B NE (1 OR 2 OR 3)), THEN AW9_FILL = “anxious”
IF (AW1A NE (1 OR 2 OR 3) AND (AW3A NE (1 OR 2 OR 3)) AND (AW1B = (1 OR 2 OR 3) OR
AW3B = (1 OR 2 OR 3)), THEN AW9_FILL = “worried”
AW9
[IF AW5_ASK = 1] During those episodes, about how many days in a typical week
did you feel [AW9_FILL] at least a little of the time?
1
Nearly every day
2
4–5 days a week
3
2–3 days a week
4
1 day a week
5
Less than 1 day a week
DK/REF
AW10
[IF AW5_ASK = 1] How much did these episodes ever interfere with your work or
personal life?
1
2
3
Extremely
A lot
Some
Version 4 - February 2017 (Post IRB Approval)
47
4
A little
5
Not at all
DK/REF
AW11
[IF AW5_ASK = 1] During about how many months in the past 12 months did you
have an episode like this? Your best estimate is fine if you cannot remember the exact
number.
______ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
AW12
[IF AW11 = 0 OR AW11 = DK/REF OR ((AW5 ≤ (CURNTAGE-1) AND (AW5 NE
DK OR REF))] About how old were you the most recent time you had an episode like
this? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
48
10.
Social Anxiety
BEGIN TIME STAMP
DEFINE SP3_FILL
IF SP1_YCOUNT > 0 AND SP2_YCOUNT = 0, THEN SP3_FILL = social
IF SP1_YCOUNT = 0 AND SP2_YCOUNT > 0, THEN SP3_FILL = performance
IF SP1_YCOUNT > 0 AND SP2_YCOUNT > 0, THEN SP3_FILL = social and performance
DEFINE SP3_FILL2
IF SP1_YCOUNT > 0 AND SP2_YCOUNT = 0, THEN SP3_FILL2 = or extremely shy
IF SP1_YCOUNT = 0 AND SP2_YCOUNT > 0, THEN SP3_FILL2 = or uncomfortable
IF SP1_YCOUNT > 0 AND SP2_YCOUNT > 0, THEN SP3_FILL2 = uncomfortable, or extremely
shy
DEFINE SP3_FILL3
IF SP1a = 1 OR SP1b = 1 OR SP1c = 1 OR SP1d = 1, THEN SP3_FILL4 = Another
ELSE, SP3_FILL4 = A
DEFINE SP3_FILL4
IF SP2a = 1 OR SP2b = 1 OR SP2c = 1 OR SP2d = 1, THEN SP3_FILL4 = Another
ELSE, SP3_FILL4 = A
SP3
[IF (SP1_YCOUNT≥ 1 OR SP2_YCOUNT) ≥ 1] Earlier, you mentioned that you have had a
time in your life when you felt very afraid, anxious, [SP3_FILL2] in the following [SP3_FILL]
situations:
[IF SP1a = 1] Meeting new people
[IF SP1b = 1] Going to a party or social gathering
[IF SP1c = 1] Going on a date
[IF SP1d = 1] Using a bathroom when away from home
[IF SP1e = 1] [SP3_FILL3] social situation where something embarrassing might
happen
[IF SP2a = 1] Talking to people in authority
[IF SP2b = 1] Talking to people you did not know
[IF SP2c = 1] Speaking up in a meeting or class
[IF SP2d = 1] Giving a speech, acting, or performing in front of an audience
[IF SP2e = 1] [SP3_FILL4] performance situation where you might be the center of
attention
Think of the time in your life when you had the most intense reactions to [SP3_FILL]
situations. How fearful, upset, or anxious would you get when you were in these situations?
1
2
3
Extremely
Very
Somewhat
Version 4 - February 2017 (Post IRB Approval)
49
4
Only a little
DK/REF
SP4
[IF SP3 = 1 OR 2 OR DK OR REF] Which of the following things were you afraid might
happen in these situations?
SP4a That you might have a panic attack
SP4b That you might do something else embarrassing
SP4c That you might do or say something to offend others
SP4d That people might talk about you or think negative things of you
SP4e That you might be in real physical danger of getting attacked
DK/REF
Yes
1
1
1
1
1
No
2
2
2
2
2
DEFINE SP4_YCOUNT (PERFORM EACH TIME MOVES FROM SP4D TO SP5)
SET SP4_YCOUNT = 0
IF SP4A = 1, ADD 1 TO SP4_YCOUNT
IF SP4B = 1, ADD 1 TO SP4_YCOUNT
IF SP4C = 1, ADD 1 TO SP4_YCOUNT
IF SP4D = 1, ADD 1 TO SP4_YCOUNT
IF SP4E = 1, ADD 1 TO SP4_YCOUNT
SP5
[IF SP4_YCOUNT > 0] Again thinking of the time in your life when you had the most intense
reactions to [SP3_FILL] situations, how often would you get very upset when you were in
these situations?
1
Almost always
2
Most of the time
3
Only some of the time
DK/REF
SP5a [IF SP4_YCOUNT > 0] How often were you much more afraid than most other people would
have been in the same situation?
1
Almost always
2
Most of the time
3
Some of the time
4
A little of the time
5
None of the time
DK/REF
SP6
[IF SP5 = 1 OR 2 OR DK OR REF] During that time in your life, how often did you try to
avoid [SP3_FILL] situations?
Version 4 - February 2017 (Post IRB Approval)
50
1
Whenever you could
2
Most of the time
3
Only some of the time
4
Never
DK/REF
SP7
[IF SP5 = 1 OR 2 OR DK OR REF] How much did your fears or avoidance of these situations
ever interfere with your work, school, or personal life?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
DEFINE SP8_FILL
IF SP1_YCOUNT > 0 AND SP2_YCOUNT = 0, THEN SP8_FILL = extremely shy in social
IF SP1_YCOUNT = 0 AND SP2_YCOUNT > 0, THEN SP8_FILL = very uncomfortable in
performance
IF SP1_YCOUNT > 0 AND SP2_YCOUNT > 0, THEN SP8_FILL = extremely shy or very
uncomfortable in social or performance
SP8
[IF SP5 = 1 OR 2 OR DK OR REF] About how old were you when you first started being
[SP8_FILL] situations?
Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE SP8_YRAGEDIFF
IF SP8 NE DK/REF, THEN SP8_YRAGEDIFF = (CURNTAGE) – SP8
IF SP8 = DK/REF, THEN SP8_YRAGEDIFF = DK/REF
SP9
[IF SP8_YRAGEDIFF = 1] Did it start in the past 12 months or more than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
SP10 [IF SP8_YRAGEDIFF >1 OR SP8 = DK/REF] During about how many years in your life did
you have these reactions?
Your best estimate is fine if you cannot remember the exact number.
Version 4 - February 2017 (Post IRB Approval)
51
_____ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
SP 10B [IF SP10 = 1]
During about how many months in that year would you have gotten very upset if you were in a
situation where you might be unable to escape or get help? Your best estimate is fine if you cannot
remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 1–12]
DK/REF
DEFINE SP11_FILL
IF SP1_YCOUNT > 0 AND SP2_YCOUNT = 0 THEN SP11_FILL = social
IF SP1_YCOUNT = 0 AND SP2_YCOUNT > 0 THEN SP11_FILL = performance
IF SP1_YCOUNT > 0 AND SP2_YCOUNT > 0 THEN SP11_FILL = social or performance
SP11 [IF SP5 = 1 OR 2 OR DK OR REF] About how many months in the past 12 months would
you have had these reactions if you were put in a [SP11_FILL] situation?
Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
SP12 [IF SP11 > 0 AND SP11 < 12] How recently would you have had these reactions -- in the past
30 days or more than 30 days ago?
1
In the past 30 days
2
More than 30 days ago
DK/REF
SP13 [(IF SP11 = 0 OR DK/REF) AND ((SP8_YRAGEDIFF > 1 YEAR) OR (SP8 = DK/REF))]
About how old were you the most recent time you would have had these reactions?
Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
52
11.
Agoraphobia
BEGIN TIME STAMP
AG1
[IF SC5 = 1] Earlier, you reported that you felt so frightened of going out of the house alone,
being in a crowd, standing in lines, going over bridges, or travelling by bus, train, or car that it
got in the way of you having a normal life.
People sometimes fear situations in which escape might be difficult or help might not be
available if they need it. Have you ever had a fear of this sort related to any of the following
situations?
AG1a
AG1b
AG1c
AG1d
AG1e
DK/REF
Standing in line or being in a crowd
Being outside of your home alone
Being in enclosed public spaces like a mall or movie theater
Being in open spaces like a park, on a bridge, or in a parking lot
Riding in a car, bus, airplane, or train
Yes
1
1
1
1
1
No
2
2
2
2
2
DEFINE AGPHOBIA
IF AT LEAST 2 ITEMS IN AG1a – AG1e = 1 THEN AGPHOBIA = 1
ELSE AGPHOBIA = 2
AG2
[IF AGPHOBIA = 1] What did you fear most about these situations?
AG2a
AG2b
AG2c
AG2d
AG2e
DK/REF
AG3
That you might be trapped and unable to escape
That you might have a panic attack and not be able to get help or escape
That you might need to go to the bathroom and end up wetting your pants
That you might have a health problem and be unable to get help
Something else
Yes
1
1
1
1
1
No
2
2
2
2
2
[IF AGPHOBIA = 1] Think of the time in your life when this fear of being unable to escape or
get help was most severe. How fearful, upset, or anxious would you get when you were in that
phobia situation?
1
Extremely
2
Very
3
Somewhat
4
Only a little
DK/REF
Version 4 - February 2017 (Post IRB Approval)
53
AG4
[IF AG3 = 1 OR 2] How often would you get very upset when you were in a situation where
you might be unable to escape or get help?
1
Almost always
2
Most of the time
3
Only some of the time
DK/REF
AG5
[IF AG4 = 1] How often were you much more afraid than most other people would have been
in the same situation?
1
Almost always
2
Most of the time
3
Some of the time
4
A little of the time
5
None of the time
DK/REF
AG6
[IF AG4 = 1] During the time in your life when this fear was most severe, how often did you
try to avoid these kinds of situations?
1
Whenever you could
2
Most of the time
3
Only some of the time
DK/REF
AG7
[IF AG4 = 1] How much did this fear of being unable to escape or get help ever interfere with
your work, school, or personal life?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
AG8
[IF AG4 = 1] About how old were you when this fear started? Your best estimate is fine if you
cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
AG9
[IF AG8 = CURNTAGE – 1] Did it start in the past 12 months or more than 12 months ago?
1
2
In the past 12 months
More than 12 months ago
Version 4 - February 2017 (Post IRB Approval)
54
DK/REF
AG10
[IF AG4 = 1 AND AG8 NE CURNTAGE AND AG8 NE CURNTAGE – 1] During
about how many years in your life did you have this fear? Your best estimate is fine if
you cannot remember the exact number.
_____ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
AG10b
[IF AG10 = 1] About how many months in that year would you have gotten very upset
if you were in a situation where you might be unable to escape or get help? Your best
estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 1–12]
DK/REF
AG11
[IF AG4 = 1] About how many months in the past 12 months would you have gotten
very upset if you were in a situation where you might be unable to escape or get help?
Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
AG12
[IF AG11 = 1–11 OR AG11 = DK OR REF] How recently would you have had that
reaction?
1
In the past 30 days
2
More than 30 days ago
DK/REF
AG13
[IF (CURNTAGE – AG8 > 1) AND (AG11 = 0 OR (AG11 = DK OR REF AND AG12
= 2))] About how old were you the most recent time that you would have become very
upset if you were in that kind of situation? Your best estimate is fine if you cannot
remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
55
12.
Panic Disorder
BEGIN TIME STAMP
L2
[IF SC3 = 1] The next question is about panic attacks, also sometimes called anxiety attacks.
Panic attacks sometimes happen “out of the blue” or for no apparent reason and other times
they occur in situations where a person has a strong fear, such as a fear of snakes or of heights,
or is in real danger, such as in a car accident.
Earlier, you reported having at least one panic or anxiety attack. When have your attacks
occured?
1
2
All of your attacks occurred “out of the blue”
Some of your attacks occurred “out of the blue” and others in situations where you had
a strong fear or were in real danger
3
All of your attacks occurred in situations where you had a strong fear or were in real
danger
DK/REF
L2_DK
[IF L2 = DK] What is your best guess of when your attacks occurred?
1
2
All of your attacks occurred “out of the blue”
Some of your attacks occurred “out of the blue” and others in situations where
you had a strong fear or were in real danger
3
All of your attacks occurred in situations where you had a strong fear or were in
real danger
DK/REF
L2_REF
[IF L2 = REF] The answers that people give us about their panic or anxiety attacks are
important to this study’s success. We know that this information is personal, but
remember your answers will be kept confidential.
Please think again about answering this question: When have your attacks occured?
1
2
All of your attacks occurred “out of the blue”
Some of your attacks occurred “out of the blue” and others in situations where
you had a strong fear or were in real danger
3
All of your attacks occurred in situations where you had a strong fear or were in
real danger
DK/REF
DEFINE L3_FILL
Version 4 - February 2017 (Post IRB Approval)
56
IF L2 = 2 OR L2_DK = 2 OR L2_REF = 2 THEN L3_FILL = that happened out of the blue
ELSE L2_FILL IS BLANK.
L3
[IF (L2 = 1 OR L2 = 2) OR (L2_DK = 1 OR L2_DK = 2) OR (L2_REF = 1 OR L2_REF = 2)]
How many of your attacks [L3_FILL] occurred when you were under the influence of alcohol
or drugs?
1
All
2
Most
3
Some
4
None
DK/REF
L3_DK
[IF L3 = DK] What is your best guess of how many of your attacks [L3_FILL]
occurred when you were under the influence of alcohol or drugs?
1
All
2
Most
3
Some
4
None
DK/REF
L3_REF
[IF L3 = REF] The answers that people give us about their panic or anxiety attacks are
important to this study’s success. We know that this information is personal, but
remember your answers will be kept confidential.
Please think again about answering this question: How many of your attacks
[L3_FILL] occurred when you were under the influence of alcohol or drugs?
1
All
2
Most
3
Some
4
None
DK/REF
L4
[IF ((L2 = 1 OR L2 = 2) OR (L2_DK = 1 OR L2_DK = 2) OR (L2_REF = 1 OR L2_REF = 2))
AND ((L3 = 2 OR 3 OR 4) OR (L3_DK = 2 OR 3 OR 4) OR (L3_REF = 2 OR 3 OR 4))] How
many of your attacks [L3_FILL] started when you were asleep and woke you up from your
sleep?
1
All
2
Most
3
Some
4
None
DK/REF
Version 4 - February 2017 (Post IRB Approval)
57
L4_DK
[IF L4 = DK] What is your best guess of how many of your attacks [L3_FILL] started
when you were asleep and woke you up from your sleep?
1
All
2
Most
3
Some
4
None
DK/REF
L4_REF
[IF L4 = REF] The answers that people give us about their panic or anxiety attacks are
important to this study’s success. We know that this information is personal, but
remember your answers will be kept confidential.
Please think again about answering this question: How many of your attacks
[L3_FILL] started when you were asleep and woke you up from your sleep?
1
All
2
Most
3
Some
4
None
DK/REF
DEFINE L5_ASK
IF ((L2 = 1 OR L2 = 2) OR (L2_DK = 1 OR L2_DK = 2) OR (L2_REF = 1 OR L2_REF = 2))
AND ((L3 = 2 OR 3 OR 4) OR (L3_DK = 2 OR 3 OR 4) OR (L3_REF = 2 OR 3 OR 4)) AND
(L4 = 1 OR 2 OR 3 OR 4) OR (L4_DK = 1 OR 2 OR 3 OR 4) OR (L4_REF = 1 OR 2 OR 3
OR 4)), SET L5_ASK=1
ELSE, SET L5_ASK=0.
L5
[IF L5_ASK=1] What is your best estimate of the total number of panic attacks [L3_FILL] you
have ever had in your life? Your best estimate is fine if you cannot remember the exact
number.
_______ NUMBER OF ATTACKS [RANGE: 0–9,999]
DK/REF
DEFINE L6_FILL
IF L5 = 1 THEN L6_FILL = that attack, did you
IF L5 NE 1 THEN L6_FILL = those attacks, did you usually
L6
[IF L5 > 0] When you had [L6_FILL] have reactions like...
L6a a pounding or racing heart?
L6b sweating?
Version 4 - February 2017 (Post IRB Approval)
Yes
1
1
No
2
2
58
trembling or shaking?
shortness of breath?
feelings of choking?
chest pain or discomfort?
feeling like you might throw up?
feeling dizzy or faint?
chills or heat sensations?
numbness or tingling?
fear of losing control or going crazy?
fear of dying?
feeling like things around you were unreal or like a dream?
feeling like you were “not really there,” like you were watching a movie of
yourself?
DK/REF
L6c
L6d
L6e
L6f
L6g
L6h
L6i
L6j
L6k
L6l
L6m
L6n
Yes
1
1
1
1
1
1
1
1
1
1
1
No
2
2
2
2
2
2
2
2
2
2
2
1
2
DEFINE L6_COUNT
SET L6_COUNT = 0
IF L6a = 1, ADD 1 TO L6_COUNT
IF L6b = 1, ADD 1 TO L6_COUNT
IF L6c = 1, ADD 1 TO L6_COUNT
IF L6d = 1, ADD 1 TO L6_COUNT
IF L6e = 1, ADD 1 TO L6_COUNT
IF L6f = 1, ADD 1 TO L6_COUNT
IF L6g = 1, ADD 1 TO L6_COUNT
IF L6h = 1, ADD 1 TO L6_COUNT
IF L6i = 1, ADD 1 TO L6_COUNT
IF L6j = 1, ADD 1 TO L6_COUNT
IF L6k = 1, ADD 1 TO L6_COUNT
IF L6l = 1, ADD 1 TO L6_COUNT
IF L6m = 1, ADD 1 TO L6_COUNT
IF L6n = 1, ADD 1 TO L6_COUNT
DEFINE L7_FILL
IF L5 = 1 THEN L7_FILL = this attack
IF L5 NE 1 THEN L7_FILL = one of these attacks
L7
[IF L6_COUNT ≥ 4] After having [L7_FILL], have you ever had a time lasting one month or
longer when…
Version 4 - February 2017 (Post IRB Approval)
59
L7a you often worried that you might have another attack or that something
terrible might happen because of the attacks, like an accident, heart attack, or
losing control?
L7b you changed your everyday activities because of fear about having another
attack?
DK/REF
Yes
No
1
2
1
2
DEFINE L8_FILL
IF L5 = 1 THEN L8_FILL = when you had that panic or anxiety attack
IF L5 NE 1 THEN L8_FILL = the very first time you had a panic or anxiety attack
DEFINE BLUE_FILL
IF L2 = 2 OR L2_DK = 2 OR L2_REF = 2 THEN BLUE_FILL = that happened out of the blue
ELSE BLUE_FILL IS BLANK
L8
[IF L6_COUNT ≥ 4 AND (IF L5 > 0 OR L5 = DK/REF)] About how old were you [L8_FILL]
[BLUE_FILL]? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE L9_CKPT:
IF CURNTAGE – L8 = 1, L9_CKPT = 1
IF CURNTAGE = L8, L9_CKPT = 2
IF CURNTAGE – L8 > 1, L9_CKPT = 3
L9
[IF L9_CKPT = 1] Was that in the past 12 months or more than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
L10
[IF L9_CKPT = 2 OR (L5 = 1 & L9 = 1)] Was it in the past 30 days or more than 30 days ago?
1
In the past 30 days
2
More than 30 days ago
DK/REF
L11
[IF (IF L6_COUNT ≥ 4 ) AND ((L9_CKPT = 3 AND L5 NE 1) OR (L9_CKPT = 3 AND L5 >
2))] About how many years in your life did you have at least one panic attack [BLUE_FILL]?
Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
Version 4 - February 2017 (Post IRB Approval)
60
L12
[IF L6_COUNT ≥ 4 AND L5 > 1 AND L9_CKPT < 3] About how many months in the past
12 months did you have at least one panic attack [BLUE_FILL]?
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
L13
[IF L12 = 0] About how old were you the most recent time you had an attack of that sort?
Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
L14
[IF L12 NE 0 OR L12 = DK/REF] About how many days out of the past 30 days did you
have a panic attack?
_____ NUMBER OF DAYS [RANGE: 0–30]
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
61
13.
Eating Disorders
BEGIN TIME STAMP
EA2
[IF SC6 = 1 AND SC6a = 1] The next questions are about your body, including your height
and weight.
What was the lowest body weight you ever purposefully had after the age of 12?
WEIGHT (POUNDS)
DK/REF
EA3FT
[IFSC6 = 1 AND SC6a = 1] How tall were you at that time? First, please type in the number
of feet, then press [ENTER].
FEET [RANGE: 2–8]
DK/REF
EA3IN
[IFSC6 = 1 AND SC6a = 1] Please type in the number of inches and then press [ENTER].
INCH(ES) [RANGE: 0–11]
DK/REF
DEFINE MINWGTFE
IF QD01 = 9 AND EA3FT < 4 AND EA2 < 111, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 4 AND EA3IN ≤ 10 AND EA2 < 111, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 4 AND EA3IN = 11 AND EA2 < 114, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 0 AND EA2 < 116, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 1 AND EA2 < 119, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 2 AND EA2 < 122, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 3 AND EA2 < 125, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 4 AND EA2 < 128, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 5 AND EA2 < 132, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 6 AND EA2 < 135, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 7 AND EA2 < 139, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 8 AND EA2 < 142, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 9 AND EA2 < 145, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 10 AND EA2 < 147, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 11 AND EA2 < 150, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT ≥ 6 AND EA2 < 152, THEN MINWGTFE = 1
ALL ELSE, MINWGTFE = 2
DEFINE MINWGTMA
IF QD01 = 5 AND EA3FT < 5 AND EA2 < 128, THEN MINWGTFE = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN ≤ 2 AND EA2 < 128, THEN MINWGTFE = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 3 AND EA2 < 130, THEN MINWGTMA = 1
Version 4 - February 2017 (Post IRB Approval)
62
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 4 AND EA2 < 133, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 5 AND EA2 < 136, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 6 AND EA2 < 139, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 7 AND EA2 < 143, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 8 AND EA2 < 146, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 9 AND EA2 < 150, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 10 AND EA2 < 153, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 11 AND EA2 < 156, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 6 AND EA3IN = 0 AND EA2 < 160, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 6 AND EA3IN = 1 AND EA2 < 163, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 6 AND EA3IN = 2 AND EA2 < 167, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 6 AND EA3IN = 3 AND EA2 < 172, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 6 AND EA3IN ≥ 4 AND EA2 < 176, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT > 6 AND EA2 < 176, THEN MINWGTMA = 1
ALL ELSE, MINWGTMA = 2
EA6
[IF MINWGTFE OR MINWGTMA = 1] At the time you weighed [EA2] pounds were you
very afraid that you might gain weight?
1
Yes
2
No
DK/REF
EA7
[IF EA6 = 1] Did you do things to keep your weight low, such as dieting or exercising?
1
Yes
2
No
DK/REF
[IF EA7 = 1] Did you feel like you were heavier than you should have been
or heavier than you wanted to be?
EA10b [IF EA7 = 1] Did you think that some parts of your body were too fat?
EA10c [IF EA7 = 1] Did you feel like your self-esteem or confidence depended on
your ability to stay thin or to lose even more weight?
EA10d [IF EA7 = 1] Did anyone tell you that your low weight was bad for your
health?
DK/REF
EA10
Yes
No
1
2
1
2
1
2
1
2
EA16b [IF SC7 = 1] Earlier you reported you have had a time in your life when you went on eating
binges, where you ate a large amount of food during a short period of time. During times when
you ate an unusually large amount of food, did you experience a loss of control or feel like you
couldn’t stop eating or control how much you were eating?
Version 4 - February 2017 (Post IRB Approval)
63
1
Yes
2
No
DK/REF
EA17a [IF SC7 = 1 AND EA16b = 1] During the binges, did you usually eat much
more quickly than usual?
EA17b [IF SC7 = 1 AND EA16b = 1] Did you usually eat until you felt
uncomfortably full?
EA17c [IF SC7 = 1 AND EA16b = 1] Did you usually continue to eat even when
you didn’t feel hungry?
EA17d [IF E SC7 = 1 AND EA16b = 1] Did you usually eat alone because you
were embarrassed by how much you ate?
EA17e [IF SC7 = 1 AND EA16b = 1] Did you feel guilty, very upset with
yourself, or depressed after you binged?
DK/REF
Yes
No
1
2
1
2
1
2
1
2
1
2
DEFINE BINGE
IF SUM (EA17a = 1, EA17b = 1, EA17c = 1, EA17d = 1, EA17e = 1) ≥ 3, THEN BINGE = 1
ALL ELSE, THEN BINGE = 2
[IF BINGE = 1] During episodes of binge eating, were you very afraid that
you would gain weight?
EA17g [IF BINGE = 1] Did you feel like your self-esteem and confidence
depended on your weight or body shape?
EA17h [IF BINGE = 1] Did you worry about the long-term effects of binging on
your health, on your weight, or on your body shape?
EA17i [IF BINGE = 1] Did you often get upset both during and after the binges
that your eating was out of your control?
DK/REF
EA17f
Yes
No
1
2
1
2
1
2
1
2
EA23 [IF SC7 = 1 AND EA16b = 1] Have you ever done any of the following things regularly or
after binges in order to control your weight?
EA23a
EA23b
EA23c
EA23d
EA23e
EA23f
DK/REF
Did you fast by not eating at all or only taking liquids for 8 hours or longer?
[IF SC7 = 1 AND EA16b = 1] Did you take water pills, diuretics, or weight
control medicines?
[IF SC7 = 1 AND EA16b = 1] Did you make yourself vomit?
[IF SC7 = 1 AND EA16b = 1] Did you take laxatives or enemas?
[IF SC7 = 1 AND EA16b = 1] Did you exercise excessively?
[IF SC7 = 1 AND EA16b = 1] Did you chew and then spit out your food?
Version 4 - February 2017 (Post IRB Approval)
Yes
1
No
2
1
2
1
1
1
1
2
2
2
2
64
BULIMIA KEY PHRASES
IF EA23a = 1: “fasted”
IF EA23b = 1: “took water pills, diuretics or weight control medicines”
IF EA23c = 1: “made yourself vomit”
IF EA23d = 1: “took laxatives or enemas”
IF EA23e = 1: “exercised excessively”
IF EA23f = 1: “chewed and then spit out your food”
DEFINE EA25FIL1
IF ONE YES IN EA23 SERIES, THEN EA25FIL1 = BULIMIA KEY PHRASE
IF TWO YESES IN EA23 SERIES, THEN EA25FIL1 = FIRST BULIMA KEY PHRASE, “and”,
THEN SECOND BULIMA KEY PHRASE
IF THREE OR MORE YESES IN EA23 SERIES, THEN EA25FIL1 = BULLETED LIST OF
BULIMA KEY PHRASES
DEFINE EA25FIL2
IF ONE YES IN EA23 SERIES, THEN EA25FIL2 = “this”
IF TWO YESES IN EA23 SERIES, THEN EA25FIL2 = “either of these things”
IF THREE OR MORE YESES IN EA23 SERIES, THEN EA25FIL2 = “any of these things”
EA25_BUL [IF (EA23a OR EA23b OR EA23c OR EA23d OR EA23e OR EA23f) = 1] You
[EA25FILL1]. Have you ever had episodes of binge eating and done [EA25FIL2] at least once
a week for 3 months or longer?
1
Yes
2
No
DK/REF
EA25_BIN [IF BINGE=1 AND EA25_BUL=(2 OR DK OR REF OR MISSING)] Have you ever
had episodes of binge eating at least once a week for 3 months or longer?
1
Yes
2
No
DK/REF
ED3
[IF (EA25_BUL = 1) OR (EA25_BIN = 1)] How old were you the very first time you had you
had an episode of eating like this for 3 months or longer? Your best estimate is fine if you cannot
remember your exact number.
________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
ED3a [IF ED3 = (CURNTAGE – 1)] Did it start in the past 12 months or more than 12 months ago?
1
In the past 12 months
Version 4 - February 2017 (Post IRB Approval)
65
2
More than 12 months ago
DK/REF
ED4
[IF ED3 < (CURNTAGE-1) OR ED3 = DK/REF] During about how many years in your life
did you have episodes of eating like that lasting 3 months or longer? Your best estimate is fine
if you cannot remember the exact number.
_____ NUMBER OF YEARS [RANGE: 1-CURNTAGE]
DK/REF
ED5
[IF (EA25_BUL = 1) OR (EA25_BIN = 1)] How long was the longest episode you ever had?
Your best estimate is fine if you cannot remember the exact number.
1
3–4 months
2
5–6 months
3
7–8 months
4
9–10 months
5
11–12 months
6
13–24 months
7
25 or more months
DK/REF
ED6
[IF (EA25_BUL = 1) OR (EA25_BIN = 1)] How much did these episodes ever interfere with
your school, work, or personal life?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
ED7
[IF ((EA25_BUL = 1) OR (EA25_BIN = 1)) AND ED4 NE 1] In the past 12 months, how
many of these episodes, lasting 3 months or longer, did you have? Your best estimate is fine if
you cannot remember the exact number.
_____ NUMBER OF EPISODES [RANGE: 0–4]
DK/REF
ED8
[IF ED7 NE0 OR DK OR REF AND ED3 NE CURNTAGE] About how old were you the
most recent time you had one of these episodes for 3 months or longer? Your best estimate is
fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
Version 4 - February 2017 (Post IRB Approval)
66
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
67
14.
Intermittent Explosive Disorder
BEGIN TIME STAMP
K1
[IF SC8 = 1 OR SC8a = 1 OR SC8b = 1] Next, we’ll ask about anger attacks. About how many
times in your entire life did you have an anger attack when all of a sudden you lost control
and either yelled a lot about things, had heated arguments, or threatened people? Your best
estimate is fine if you cannot remember the exact number.
_____ NUMBER OF ATTACKS [RANGE: 0–9,900]
DK/REF
DEFINE K2_FILL
IF K1 = 1 THEN K2_FILL = when you had that anger attack
IF K1 > 1 THEN K2_FILL = the very first time you had one of these anger attacks
K2
[IF K1 ≥ 1 AND (K1 NE (DK OR REF))] About how old were you [K2_FILL]? Your best
estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
K3
[IF (K2 = CURNTAGE – 1)] Was that in the past 12 months or more than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
K4
[(K1 = 1 AND (K2 = CURNTAGE OR K3 = 1)] Was it in the past 30 days or more than 30
days ago?
1
In the past 30 days
2
More than 30 days ago
DK/REF
K5
[K1 ≥ 20] Have you ever in your life had 3 or more months in a row when you had at least
two anger attacks each week?
1
Yes
2
No
DK/REF
K6
[IF (K5 = 1) AND (K2 NE CURNTAGE – 1) AND (K2 NE CURNTAGE))] About how old
were you the very first time you had 3 months in a row when you had two or more anger
attacks each week? Your best estimate is fine if you cannot remember the exact age.
Version 4 - February 2017 (Post IRB Approval)
68
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
K7
[IF K5 = 1 AND (K6 = CURNTAGE – 1) OR ((K2 = CURNTAGE – 1) AND (K3 NE 1))]
Did that time start in the past 12 months or more than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
K8
[IF K5=1 AND (K2 NE CURNTAGE) AND ((K2 = CURNTAGE-1) AND (K3 NE 1)) AND
(K6 NE CURNTAGE) AND (K7 = 2)] During about how many years in your life did you have
3 months in a row when you had two or more anger attacks each week? Your best estimate is
fine if you cannot remember the exact number.
________ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
K9
[IF K5 = 1] During about how many months in the past 12 months did you have two or more
anger attacks each week? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
K10
[K5 = 1 AND (K9 = 0 OR DK OR REF) AND (CURNTAGE – K6 NE 1) AND (K6 NE
CURNTAGE)] About how old were you the most recent time you had two or more anger
attacks each week for a month or longer? Your best estimate is fine if you cannot remember
the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
K11
[IF (K1 > 1 AND (K1 NE DK OR REF)) OR (K1 = 1 AND (K2 = CURNTAGE OR K2 =
CURTAGE – 1)) AND ((K3 = 1) AND (K4 = MISSING) AND (K9 = 1-12))] About how
many days in the past 30 days did you have an anger attack? Your best estimate is fine if you
cannot remember the exact number.
_______NUMBER OF DAYS [RANGE: 0–30]
DK/REF
K12
[IF SC8 = 1 OR SC8a = 1 OR SC8b = 1] The next question is about a different kind of anger
attack: one when all of a sudden you lose control and either physically hurt someone, injure an
animal, or break something worth more than a few dollars. About how many times in your
entire life did you have an anger attack like that? Your best estimate is fine if you cannot
remember the exact number.
Version 4 - February 2017 (Post IRB Approval)
69
_____ NUMBER OF ATTACKS [RANGE: 0–9,990]
DK/REF
DEFINE K13_FILL
IF K12 = 1 THEN K13_FILL = when you had that anger attack
IF K12 > 1 THEN K13_FILL = the very first time you had one of these anger attacks
K13
[K12 ≥ 1 AND (K12 NE (DK OR REF))] About how old were you [K13_FILL]? Your best
estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
K14
[IF K13 = CURNTAGE – 1] Was that in the past 12 months or more than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
K15
[(K12 = 1 AND (K13 = CURNTAGE OR K14 = 1)] Was it in the past 30 days or more than 30
days ago?
1
In the past 30 days
2
More than 30 days ago
DK/REF
K16
[K12 ≥ 3 AND (K12 NE DK OR REF)] Have you ever in your life had three or more anger
attacks of this sort in a single year?
1
Yes
2
No
DK/REF
K17
[IF (K16 = 1) AND ((K13 NE CURNTAGE-1) AND (K13 NE CURNTAGE] About how old
were you the very first time you had three or more anger attacks of that sort in a single year?
Your best estimate is fine if you cannot remember the exact age.
_______YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
K18
[IF K16 = 1 AND ((CURNTAGE – K17 = 1) OR (K14 NE 1))] Did that time start in the past
12 months or more than 12 months ago?
1
2
In the past 12 months
More than 12 months ago
Version 4 - February 2017 (Post IRB Approval)
70
DK/REF
K19
[IF K16 = 1 AND (K13 NE CURNTAGE) AND (K14 NE 1) AND (K17 NE CURNTAGE)
AND (K18 = MISSING)] About how many years in your life did you have three or more anger
attacks of that sort in a single year? Your best estimate is fine if you cannot remember the
exact number.
_______NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
K20
[IF (K12 > 2 AND (K12 NE DK OR REF)) OR (K12 = 1 AND (K13 = CURNTAGE OR (K13
= CURTAGE – 1 AND (K14 NE 2 OR DK OR REF)))] During about how many months in the
past 12 months did you have an anger attack of that sort? Your best estimate is fine if you
cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
K21
[(K12 > 2 AND (K12 NE DK OR REF)) AND (K20 = 0 OR DK OR REF) AND (K13 NE
CURNTAGE-1) AND (K13 NE CURNTAGE) AND (K17 NE CURNTAGE-1) AND (K17 NE
CURNTAGE)] About how old were you the most recent time you had an anger attack of that
sort? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
K22
[IF (K12 > 1 OR (K12 = 1 AND (K13 = CURNTAGE OR K13 = CURTAGE-1) AND (K14
NE 2 OR DK OR REF)) AND (K15 = MISSING)) AND K20 ≥ 1] About how many days out
of the past 30 did you have an anger attack of that sort?
_______NUMBER OF DAYS [RANGE: 0–30]
DK/REF
K23
[IF (K1 = 20 OR MORE) OR (K12 = 3 OR MORE)] When you have anger attacks, do you
usually…
K23a get a lot more angry than most people would in the same situation?
K23b feel very sorry or bad about it afterward?
DK/REF
K24
Yes
1
1
No
2
2
[IF K23a AND K23b NE BLANK] How much did your anger attacks ever get you into trouble
or interfere with your work or personal life?
1
2
Extremely
A lot
Version 4 - February 2017 (Post IRB Approval)
71
3
Some
4
A little
5
Not at all
DK/REF
K25
[IF K23a AND K23b NE BLANK] How many of your anger attacks occurred when you had
been drinking, using drugs, or taking medications that caused you to be impulsive, or when you
were having other mental health problems?
1
All
2
Most
3
Some
4
None
DK/REF
K26
[(K1 GTE 150 AND K5 = 1) OR (K12 GTE 150 AND K16 = 1)] Have you ever in your life
had a full year or longer when you had 3 or more anger attacks just about every week in
which you either yelled a lot, had heated arguments, threatened people, broke things, or
physically hurt a person or animal?
1
Yes
2
No
DK/REF
K27
[IF K26 = 1] Think of the one year in your life when these anger attacks were more persistent.
During that year, how often were you irritable or angry in the time between the anger attacks?
1
All or almost all the time
2
Most of the time
3
Some of the time
4
A little of the time
None of the time
DK/REF
K28
[IF K27 = 1 OR 2] During the years you had these persistent anger attacks along with
persistent irritability or anger, where did your anger attacks occur?
K28a.
K28b
K28c
K28d
DK/REF
At home
At work or school
With peers
In the community
Version 4 - February 2017 (Post IRB Approval)
Yes
1
1
1
1
No
2
2
2
2
72
K29
[IF AT LEAST 2 ITEMS IN K28a–K28d = 1] About how old were you the very first time
you had a year of these persistent anger attacks along with persistent irritability or anger? Your
best estimate is fine if you cannot remember the exact age.
_______YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
K30
[IF K29 NE BLANK OR R’S CURRENT AGE] About how many years of that sort did you
have in your life? Your best estimate is fine if you cannot remember the exact number.
_______NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
K31
[IF K29 NE BLANK OR R’S CURRENT AGE] About how old were you the most recent
time you had a year of that sort? If you are currently having a year of that sort, enter your
current age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
73
15.
Suicidality
BEGIN TIME STAMP
SD15
The next few questions are about thoughts of hurting yourself. At the end of this interview,
you will receive a hotline number you can call if you ever feel you need to talk to someone
about mental health issues.
Have you ever seriously thought about killing yourself?
1
Yes
2
No
DK/REF
SD15a
[IF SD15 = 1] How old were you the first time this happened?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SD16
[IF SD15 = 1] Have you seriously thought about killing yourself at any time in the past 12
months?
1
Yes
2
No
DK/REF
SD16a
[IF SD16 = 2 OR DK OR REF] How old were you the last time this experience happened to
you?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SD17
[IF SD15 = 1] Have you ever made a plan for killing yourself?
1
Yes
2
No
DK/REF
SD17a
[IF SD17 = 1] How old were you the first time this happened?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SD18
[IF SD17 = 1] Did you make a plan for killing yourself at any time in the past 12 months?
1
Yes
Version 4 - February 2017 (Post IRB Approval)
74
2
No
DK/REF
SD18a
[IF SD18 = 2 OR DK OR REF] How old were you the last time this experience happened to
you?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SD19
[IF SD15 = 1] Have you ever tried to kill yourself?
1
Yes
2
No
DK/REF
SD19a
[IF SD19 = 1] How many times have you tried to kill yourself in your lifetime?
__________ NUMBER OF TIMES [RANGE: 1-500]
DK/REF
SD21
[IF SD19a NE 1] How old were you the first time?
__________ YEARS OLD [RANGE: 1 – CURNTAGE]
DK/REF
SD22
[IF SD19a NE 1] Which of the three statements below best describes your situation when
you tried to kill yourself the first time?
1
You made a serious attempt to kill yourself and it was only luck that you did not
succeed.
2
You tried to kill yourself but knew that the method was not foolproof.
3
Your attempt was a cry for help, that is, you did not intend to die.
DK/REF
SD23
[IF SD19 = 1] Have you attempted suicide in the past 12 months?
1
Yes
2
No
DK/REF
DEFINE ATTEMPT_FILL
IF SD19a = 1 THEN ATTEMPT_FILL = when
IF SD19a NE 1 THEN ATTEMPT_FILL = the last time
Version 4 - February 2017 (Post IRB Approval)
75
SD23a
[IF SD23 = 2 OR DK OR REF] How old were you [ATTEMPT_FILL] you tried to kill
yourself?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SD24
[IF SD23 = 1] Did it result in an injury or poisoning?
1
Yes
2
No
DK/REF
SD25
[IF SD24 = 1] Did it require medical attention?
1
Yes
2
No
DK/REF
SD26
[IF SD25 = 1] Did it require overnight hospitalization?
1
Yes
2
No
DK/REF
SD27
[IF SD19 = 1] Which of the three statements below best describes your situation when you
tried to kill yourself the last time?
1
You made a serious attempt to kill yourself and it was only luck that you did not
succeed.
2
You tried to kill yourself but knew that the method was not foolproof.
3
Your attempt was a cry for help, that is, you did not intend to die.
DK/REF
DEFINE ATTEMPT_FILL2
IF SD19a = 1 THEN ATTEMPT_FILL = when
IF SD19a NE 1 THEN ATTEMPT_FILL = the last time
SD29
[IF SD23 = 1] Which method did you use [ATTEMPT_FILL2] you tried to kill yourself?
1
2
3
4
5
6
7
Gun
Razor, knife, or other sharp instrument
Overdose of prescription medications
Overdose of over-the-counter medications
Overdose of other drugs, for example, heroin, crack, or alcohol
Poison, for example, carbon monoxide or rat poison
Hanging, strangulation, or suffocation
Version 4 - February 2017 (Post IRB Approval)
76
8
Drowning
9
Jumping from high places
10
Motor vehicle crash
11
Other
DK/REF
SD29OTH
[IF SD29 = 11] Please provide the method you used [ATTEMPT_FILL2] you tried to
kill yourself.
_______________ [ALLOW 60 CHARACTERS]
DK/REF
SD30
Have you ever done something to hurt yourself on purpose, but without wanting to die,
such as cutting yourself, hitting yourself, or burning yourself?
1
Yes
2
No
DK/REF
SD30a
[IF SD30 = 1] How old were you the first time this happened?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SD31
[IF SD30 = 1 AND SD30a NE CURNTAGE] Have you done something to hurt yourself on
purpose, but without wanting to die, at any time in the past 12 months?
1
Yes
2
No
DK/REF
SD31a
[IF SD31 = 2 OR DK OR REF] How old were you the last time you hurt yourself on purpose,
but without wanting to die?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
77
16a.
Unusual Experiences
BEGIN TIME STAMP
PE1
The next questions are about unusual experiences, like seeing visions or hearing voices. As you
answer these questions, please do not include times you had these experiences when you were
feverish, dreaming, half asleep, or under the influence of alcohol or drugs. With these
exclusions in mind, have you ever in your life had any of the following experiences?
Have you ever seen a vision, that is, something other people who were there
could not see? We don’t mean having good eyesight, but rather seeing things
that other people said were not there, like seeing a face, or people, or strange
objects.
Have you ever heard voices that other people could not hear? We don't mean
having good hearing, but rather hearing things that other people said did not
exist, like strange voices coming from inside your head talking to you or
about you, or voices coming out of the air when there was no one around.
Have you ever believed that some mysterious force was inserting strange
thoughts -- that were definitely not your own thoughts -- directly into your
head by means of x-rays or laser beams or other methods?
Have you ever believed that your thoughts were being stolen out of your
mind by some strange force?
Have you ever thought your mind was being taken over by strange forces
with laser beams or other methods that were making you do things you did
not choose to do?
Have you ever thought some strange force was trying to communicate
directly with you by sending special signs or signals that you could
understand but that no one else could understand, such as through the radio or
television?
Have you ever believed there was a plot going on to harm you or have people
follow you that your family and friends did not believe was true?
PE1a
PE1b
PE1c
PE1d
PE1e
PE1f
PE1g
Yes
No
1
2
1
2
1
2
1
2
1
2
1
2
1
2
DK/REF
PE2 [IF PE1a = 1] How old were you the very first time you saw a vision? Remember to report
only times you were not having a fever, not dreaming, not half asleep, and not under the influence of
alcohol or drugs. Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE2a
[IF (CURNTAGE – PE2 = 1)] When was the very first time you saw a vision?
1
In the past 12 months
Version 4 - February 2017 (Post IRB Approval)
78
2
More than 12 months ago
DK/REF
PE3
[IF PE1a = 1] About how many different times in your life did you see a vision? Your best
estimate is fine if you cannot remember the exact number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE4
[IF PE1a = 1 AND (PE2 NE CURNTAGE) AND (PE2a NE 1) AND PE3 NE 1] About how
many different years in your life did you see a vision at least one time? Your best estimate is
fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
DEFINE PE4a_FILL
IF PE3 = 1 THEN PE4a_FILL = “this vision last?”
ELSE PE4a_FILL = “these visions usually last?”
PE4a [IF PE1a = 1] How long did [PE4a_FILL] If it varied, answer for the average duration.
1
Less than 1 minute
2
At least 1 minute but less than 5 minutes
3
At least 5 minutes but less than 30 minutes
4
At least 30 minutes but less than 60 minutes
5
60 minutes or longer
DK/REF
PE5
[IF PE1a = 1 AND PE2a NE 1] Did you see a vision at any time in the past 12 months?
1
Yes
2
No
DK/REF
PE6
[IF PE1a = 1 AND PE5 NE 1] About how old were you the most recent time you saw a
vision? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE PE6a_FILL
IF PE3=1 THEN PE6a_FILL = “this experience”
ELSE PE6a_FILL = “these experiences”
Version 4 - February 2017 (Post IRB Approval)
79
DEFINE PE6b_FILL
IF PE3=1 THEN PE6b_FILL = “it was”
ELSE PE6b_FILL = “they were”
PE6a [IF PE1a = 1 AND PE5 NE 1] When you were having [PE6a_FILL], how convinced were you
that [PE6b_FILL] real rather than your mind playing tricks on you?
1
You strongly believed [PE6b_FILL] real
2
You were unsure if [PE6b_FILL] real
3
You did not believe [PE6b_FILL] real
DK/REF
DEFINE PE6b2_FILL
IF PE3=1 THEN PE6b2_FILL = “was this experience”
ELSE PE6b2_FILL = “were these experiences”
PE6b [IF PE1a = 1 AND PE5 NE 1] How distressing [PE6b2_FILL] to you?
1
Not at all distressing
2
A little
3
Some
4
A lot
5
Extremely distressing
DK/REF
PE7
[IF PE1b = 1] How old were you the very first time you heard voices that other people could
not hear? Remember to report only times you were not having a fever, not dreaming, not half
asleep, and not under the influence of alcohol or drugs. Your best estimate is fine if you cannot
remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE7a
[IF (CURNTAGE – PE7 = 1)] When was the very first time you heard voices that other
people could not hear?
1
In the past 12 months
2
More than 12 months ago
DK/REF
PE8
[IF PE1b = 1] About how many different times in your life did you hear voices? Your best
estimate is fine if you cannot remember the exact number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
Version 4 - February 2017 (Post IRB Approval)
80
PE9
[IF PE1b = 1 AND (PE7 NE CURNTAGE) AND (PE7a NE 1) AND PE8 NE 1] About how
many different years in your life did you hear voices at least one time? Your best estimate is
fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
DEFINE PE9a_FILL
IF PE8 = 1 THEN PE9a_FILL = “this vision last”
ELSE PE9a_FILL = “these visions usually last”
PE9a [IF PE1b = 1] How long did [PE9a_FILL]? If it varied, answer for the most common duration.
1
Less than 1 minute
2
At least 1 minute but less than 5 minutes
3
At least 5 minutes but less than 30 minutes
4
At least 30 minutes but less than 60 minutes
5
60 minutes or longer
DK/REF
PE10 [IF PE1b = 1 AND PE7a NE 1] Did you hear voices at any time in the past 12 months?
1
Yes
2
No
DK/REF
PE11 [IF PE1b = 1 AND PE10 NE 1] About how old were you the most recent time you heard
voices? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE PE11a_FILL
IF PE8 = 1 THEN PE11a_FILL = “this experience”
ELSE PE11a_FILL = “these experiences”
DEFINE PE11a2_FILL
IF PE8 = 1 THEN PE11a2_FILL = “it was”
ELSE PE11a2_FILL = “they were”
PE11a [IF PE1b = 1 AND PE10 NE 1] When you were having [PE11a_FILL], how convinced were
you that [PE11a2_FILL] real rather than your mind playing tricks on you?
1
2
3
You strongly believed [PE11a2_FILL] real
You were unsure if [PE11a2_FILL] real
You did not believe [PE11a2_FILL] real
Version 4 - February 2017 (Post IRB Approval)
81
DK/REF
DEFINE PE11b_FILL
IF PE8 = 1 THEN PE11b_FILL = “was this experience”
ELSE PE11b_FILL = “were these experiences”
PE11b [IF PE1b = 1 AND PE10 NE 1] How distressing [PE11b_FILL] to you?
1
Not at all distressing
2
A little
3
Some
4
A lot
5
Extremely distressing
DK/REF
PE12 [IF PE1c = 1] How old were you the very first time you thought some mysterious force was
inserting strange thoughts into your head? Remember to report only times when you were not
having a fever, not dreaming, not half asleep, and not under the influence of alcohol or drugs.
Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE12a [IF (CURNTAGE – PE12 = 1)] When was the very first time you thought some mysterious
force was inserting strange thoughts into your head?
1
In the past 12 months
2
More than 12 months ago
DK/REF
PE13 [IF PE1c = 1] About how many different times in your life did you think this kind of thought
insertion was happening to you? Your best estimate is fine if you cannot remember the exact
number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE14 [IF PE1c = 1 AND (PE12 NE CURNTAGE) AND (PE12a NE 1) AND PE13 NE 1] About
how many different years in your life did you at least some of the time think you were
experiencing thought insertion? Your best estimate is fine if you cannot remember the exact
number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
Version 4 - February 2017 (Post IRB Approval)
82
PE15 [IF PE1c = 1 AND PE12a NE 1] Did you think you were experiencing thought insertion at any
time in the past 12 months?
1
Yes
2
No
DK/REF
PE16 [IF PE1c = 1 AND PE15 NE 1] About how old were you the most recent time you thought it
was happening? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE16a [IF PE1c = 1] When you were experiencing thought insertion, how convinced were you that it
was real rather than your mind playing tricks on you?
1
You strongly believed it was real
2
You were unsure if it was real
3
You did not believe it was real
DK/REF
DEFINE PE16b_FILL
IF PE13 = 1 THEN PE16b_FILL = “was this experience”
ELSE PE16b_FILL = “were these experiences”
PE16b [IF PE1c = 1] How distressing [PE16b_FILL] to you?
1
Not at all distressing
2
A little
3
Some
4
A lot
5
Extremely distressing
DK/REF
PE17 [IF PE1d = 1] How old were you the very first time you believed that thoughts were being
stolen out of your mind? Remember to report only times you were not having a fever, not
dreaming, not half asleep, and not under the influence of alcohol or drugs. Your best estimate
is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE17a [IF (CURNTAGE – PE17 = 1)] When was the very first time you believed that thoughts were
being stolen out of your mind?
1
In the past 12 months
Version 4 - February 2017 (Post IRB Approval)
83
2
More than 12 months ago
DK/REF
PE18 [IF PE1d = 1] About how many different times in your life did you think thoughts were being
stolen out of your mind? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE19 [IF PE1d = 1 AND (PE17 NE CURNTAGE) AND (PE17a NE 1) AND PE18 NE 1] About
how many different years in your life did you at least one time think this was happening? Your
best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
PE20 [IF PE1d = 1 AND PE17a NE 1] Did you think thoughts were being stolen out of your mind at
any time in the past 12 months?
1
Yes
2
No
DK/REF
PE21 [IF PE1d = 1 AND PE20 NE 1] About how old were you the most recent time you thought
this was happening? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE21a [IF PE1d = 1] When you were experiencing thoughts being stolen out of your mind, how
convinced were you that it was real rather than your mind playing tricks on you?
1
You strongly believed it was real
2
You were unsure if it was real
3
You did not believe it was real
DK/REF
DEFINE PE21b_FILL
IF PE18 = 1 THEN PE21b_FILL = “was this experience”
ELSE PE21b_FILL = “were these experiences”
PE21b [IF PE1d = 1] How distressing [PE21b_FILL] to you?
1
2
3
Not at all distressing
A little
Some
Version 4 - February 2017 (Post IRB Approval)
84
4
A lot
5
Extremely distressing
DK/REF
PE22 [IF PE1e = 1] How old were you the very first time you thought your mind was being taken over
by strange forces making you do things you did not choose to do? Remember to report only times
you were not having a fever, not dreaming, not half asleep, and not under the influence of
alcohol or drugs. Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE22a [IF (CURNTAGE – PE22 = 1)] When was the very first time you thought your mind was
being taken over by strange forces making you do things you did not choose to do?
1
In the past 12 months
2
More than 12 months ago
DK/REF
PE23 [IF PE1e = 1] About how many different times in your life did you think you were
experiencing this mind control? Your best estimate is fine if you cannot remember the exact
number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE24 [IF PE1e = 1 AND (PE22 NE CURNTAGE) AND (PE22a NE 1) AND PE23 NE 1] About
how many different years in your life did you at least one time think you were experiencing
mind control? Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
PE25 [IF PE1e = 1 AND PE22a NE 1] Did you think you were experiencing mind control at any
time in the past 12 months?
1
Yes
2
No
DK/REF
PE26 [IF PE1e = 1 AND PE25 NE 1] About how old were you the most recent time you
experienced mind control? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
Version 4 - February 2017 (Post IRB Approval)
85
PE26a [IF PE1e = 1] When you were experiencing mind control, how convinced were you that it
was real rather than your mind playing tricks on you?
1
You strongly believed it was real
2
You were unsure if it was real
3
You did not believe it was real
DK/REF
DEFINE PE26b_FILL
IF PE23 = 1 THEN PE26b_FILL = “was this experience”
ELSE PE26b_FILL = “were these experiences”
PE26b [IF PE1e = 1] How distressing [PE26b_FILL] to you?
1
Not at all distressing
2
A little
3
Some
4
A lot
5
Extremely distressing
DK/REF
PE27 [IF PE1f = 1] How old were you the very first time you thought a strange force was trying to
send you special signs or signals that no one else could understand? Remember to report only
times you were not having a fever, not dreaming, not half asleep, and not under the influence
of alcohol or drugs. Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 1–CURNTAGE]
DK/REF
PE27a [IF (CURNTAGE – PE27 = 1)] When was the very first time you thought a strange force was
trying to send you special signs or signals that no one else could understand?
1
In the past 12 months
2
More than 12 months ago
DK/REF
PE28 [IF PE1f = 1] About how many different times in your life did you think you were getting
these kinds of special communications? Your best estimate is fine if you cannot remember the
exact number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE29 [IF PE1f = 1 AND (PE27 NE CURNTAGE) AND (PE27a NE 1) AND PE28 NE 1] About
how many different years in your life did you at least one time think you were getting these
Version 4 - February 2017 (Post IRB Approval)
86
kinds of special communications? Your best estimate is fine if you cannot remember the exact
number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
PE30 [IF PE1f = 1 AND PE27a NE 1] Did you think you were getting these kinds of special
communications at any time in the past 12 months?
1
Yes
2
No
DK/REF
PE31 [IF PE1f = 1 AND PE30 NE 1] About how old were you the most recent time you thought
this was happening? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE31a [IF PE1f = 1] When you thought you were getting these kinds of special communications,
how convinced were you that it was real rather than your mind playing tricks on you?
1
You strongly believed it was real
2
You were unsure if it was real
3
You did not believe it was real
DK/REF
DEFINE PE31b_FILL
IF PE28 = 1 THEN PE31b_FILL = “was this experience”
ELSE PE31b_FILL = “were these experiences”
PE31b [IF PE1f = 1] How distressing [PE31b_FILL] to you?
1
Not at all distressing
2
A little
3
Some
4
A lot
5
Extremely distressing
DK/REF
PE32 [IF PE1g = 1] How old were you the very first time you thought there was a plot going on to
harm you or have people follow you? Remember to report only times you were not having a
fever, not dreaming, not half asleep, and not under the influence of alcohol or drugs. Your best
estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
Version 4 - February 2017 (Post IRB Approval)
87
DK/REF
PE32a [IF (CURNTAGE – PE32 = 1)] When was the very first time you thought there was a plot
going on to harm you or have people follow you?
1
In the past 12 months
2
More than 12 months ago
DK/REF
PE33 [IF PE1g = 1] About how many different times in your life did you think you were the victim
of a plot? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE34 [IF PE1g = 1 AND (PE32 NE CURNTAGE) AND (PE32a NE 1) AND PE33 NE 1] About
how many different years in your life did you think you were the victim of a plot? Your best
estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
PE35 [IF PE1g = 1 AND PE32a NE 1] Did you think you were the victim of a plot at any time in the
past 12 months?
1
Yes
2
No
DK/REF
PE36 [IF PE1g = 1 AND PE35 NE 1] About how old were you the most recent time you thought
you were the victim of a plot? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE36a [IF PE1g = 1] When you were experiencing being a victim of a plot, how convinced were you
that it was real rather than your mind playing tricks on you?
1
You strongly believed it was real
2
You were unsure if it was real
3
You did not believe it was real
DK/REF
DEFINE PE36b_FILL
IF PE33 = 1 THEN PE36b_FILL = “was this experience”
ELSE PE26b_FILL = “were these experiences”
Version 4 - February 2017 (Post IRB Approval)
88
PE36b [IF PE1g = 1] How distressing [PE36b_FILL] to you?
1
Not at all distressing
2
A little
3
Some
4
A lot
5
Extremely distressing
DK/REF
DEFINE PE37_FILL
IF PE1a = 1 PE37_FILL = visions
IF PE1b = 1 PE37_FILL = voices
IF PE1c = 1 PE37_FILL = thought insertion
IF PE1d = 1 PE37_FILL = stolen thoughts
IF PE1e = 1 PE37_FILL = mind control
IF PE1f = 1 PE37_FILL = special communications
IF PE1g = 1 PE37_FILL = plots
PE37 [IF AT LEAST 1 YES RESPONSE IN PE1a-g] Have you ever talked to a doctor or mental
health professional for help in dealing with these experiences with [PE37_FILL]?
1
Yes
2
No
DK/REF
DEFINE PE38_FILL
IF ONLY 1 YES IN PE1a-g SERIES PE38_FILL = this experience
ELSE PE38_FILL = these experiences
PE38 [IF AT LEAST 1 YES RESPONSE IN PE1a-g AND PE37=1] What did the doctor say was
causing [PE38_FILL]?
To select more than one answer, press the space bar between each number you type.
1
Schizophrenia or psychosis
2
Manic depression or bipolar disorder
3
Some other mental health problem
4
A physical illness or injury
5
Medication
6
Alcohol or drugs
7
Something else
DK/REF
PE38OT
[IF PE38 = 7] What did the doctor say was causing [PE38_FILL]?
Version 4 - February 2017 (Post IRB Approval)
89
______________ [ALLOW 300 CHARACTERS]
DK/REF
PE39 [IF PE38 NE 1] Were you ever prescribed any medications for these problems?
1
Yes
2
No
DK/REF
PE40 [IF PE39=1] Were you ever prescribed any of the following medications for these problems?
PE40a
PE40b
PE40c
PE40d
PE40e
PE40f
PE40g
PE40h
PE40i
PE40j
PE40k
PE40l
PE40m
PE40n
PE40o
PE40p
PE40q
DK/REF
Abilify or Aripiprazole
Saphris or Asenapine
Thorazine or Chlorpromazine
Clozaril or Clozapine
Fluanxol or Flupenthixol
Haldol or Haloperidol
Fanapt or Iloperidone
Loxitane, Loxapac, or Loxapine
Latuda or Lurasidone
Zyprexa or Olanzapine
Invega or Paliperidone
Trilafon, Etrafon, or Perphenazine
Prolixin, Prolixin decanoate, Permitil, Modecate, Fluphenazine, or
Fluphenazine decanoate
Seroquel or Quetiapine
Risperdal or Risperidone
Stelazine or Trifluoperazine
Geodon or Ziprasidone
Yes
1
1
1
1
1
1
1
1
1
1
1
1
No
2
2
2
2
2
2
2
2
2
2
2
2
1
2
1
1
1
1
2
2
2
2
DEFINE PE40_FILL
IF ONLY ONE ITEM IN PE1a - g = 1 THEN PE40_FILL = “this experience”
ELSE PE40_FILL = “these experiences ever”
PE41 [IF AT LEAST 1 YES RESPONSE IN PE1a-g] How much did [PE40_FILL] interfere with
your work or personal life?
1
Not at all
2
A little bit
3
Moderately
4
Quite a bit
5
Extremely
DK/REF
Version 4 - February 2017 (Post IRB Approval)
90
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
91
17.
Treatment of Emotional Problems
BEGIN TIME STAMP
TR1
The next questions are about treatments you might have received for problems with your
emotions, nerves, or mental health. Have you ever in your life stayed overnight or longer in a
hospital to receive treatment for problems with your emotions, nerves, or mental health?
1
Yes
2
No
DK/REF
TR2
[IF TR1 = 1] How many times were you hospitalized for problems with your emotions, nerves,
or mental health? Your best estimate is fine if you cannot remember the exact number.
_______ NUMBER OF TIMES [RANGE: 1–90]
DK/REF
DEFINE TR3_FILL
IF TR2 = 1, THEN TR3_FILL = “when that happened”
ELSE, TR3_FILL = “the first time you were hospitalized for problems with your emotions, nerves, or
mental health”
TR3
[IF TR1 = 1] How old were you [TR3_FILL]?
________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TR4_FILL
IF TR2 = 1, THEN TR4_FILL = “that”
ELSE, TR4_FILL = “your first hospitalization”
TR4
[IF TR3 = (CURNTAGE – 1)] Did [TR4_FILL] start in the past 12 months or more than 12
months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
TR5
[IF TR3 = CURNTAGE OR TR3 = (CURNTAGE – 1)] How many nights in the past 12
months were you in a hospital for problems with your emotions, nerves, or mental health? Your
best estimate is fine if you cannot remember the exact number.
________ NUMBER OF NIGHTS [RANGE: 0–365]
DK/REF
Version 4 - February 2017 (Post IRB Approval)
92
DEFINE B22Bd
SET B22Bd=TR5.
TR6
[IF TR1 = 1 AND (TR5 = DK, REF, OR MISSING)] About how old were you the most
recent time you were in a hospital overnight for problems with your emotions, nerves, or
mental health? Your best estimate is fine if you cannot remember the exact age.
________ YEARS OLD [0–CURNTAGE]
DK/REF
DEFINE TR7_FILL
IF TR1 = 1 AND TR2 = 1, THEN TR7_FILL = “Not counting your hospitalization, did”
IF TR1 = 1 AND TR2 NE 1, THEN TR7_FILL = “Not counting your hospitalizations, did”
ELSE, TR7_FILL = “Did”
TR7
TR7a
TR7b
TR7c
TR7d
TR7e
TR7f
[TR7_FILL] you ever in your life receive counseling or medication from any of the following
sources for problems with your emotions, nerves, or mental health?
A mental health professional? A “mental health professional” includes a
psychiatrist, psychologist, mental health counselor or social worker, and
marriage and family counselor. These professionals can be seen in oneon-one sessions, group sessions, telephone sessions, or computerized
texting sessions.
A general medical doctor, nurse, or other general medical care provider?
A minister, priest, rabbi, or other spiritual advisor?
A Certified Peer Counselor? A “Certified Peer Counselor” is a person
who has experienced mental health issues firsthand and has been trained
to help facilitate mental health recovery in others.
A self-help or support group? A “self-help or support group” is a group
for people with emotional, family, or substance problems that is run by
the people themselves without a mental health professional running the
group.
A computerized or internet-based mental health treatment program? A
“computerized or internet-based mental health treatment program” is a
special type of self-help program where you work through exercises that
give you practice in strategies that can help you improve your mental
health. Sometimes these programs are accompanied by telephone calls or
texting sessions with mental health professionals. When this is the case,
we want you to report both receiving counseling from a mental health
professional and participating in a computerized or internet-based
program.
Yes
No
1
2
1
1
2
2
1
2
1
2
1
2
DK/REF
Version 4 - February 2017 (Post IRB Approval)
93
[IF TR7a = 1] You reported receiving counseling or medication from a mental health
professional. Which did you receive: counseling, medication, or both?
TR8
1
2
3
Only Counseling
Only Medication
Counseling and Medication
DK/REF
DEFINE TR8HLPTYP
IF TR8= 1, THEN, TR8HLPTYP = “counseling”
IF TR8 = 2, THEN TR8HLPTYP = “medication”
IF TR8=3, THEN TR8HLPTYP = “counseling and medication”
IF TR8 = DK/REF, THEN TR8HLPTYP = “counseling or medication”
TR9
[IF TR7a = 1] About how old were you the very first time you received [TR8HLPTYP] from
a mental health professional? Your best estimate is fine if you cannot remember the exact
age.
________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TR10
[IF TR9 = CURNTAGE – 1] Did you start this [TR8HLPTYP] in the past 12 months or more
than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
TR11
[IF TR7A = 1 AND ((TR9 < (CURNTAGE – 1) OR (TR9 = DK OR REF))] During about
how many years of your life did you receive any treatment from a mental health professional?
Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
DEFINE HOSPFILL
IF TR1 = 1, THEN HOSPFILL = “Not counting any hospitalizations, about”
IF TR1 NE 1, THEN HOSPFILL = “About”
TR12
[IF TR7A = 1 AND (TR11 NE 1)] [HOSPFILL] how many treatment sessions with a mental
health professional did you have in the past 12 months, counting face-to-face visits, phone
calls, and texting sessions? Your best estimate is fine if you cannot remember the exact
number.
Version 4 - February 2017 (Post IRB Approval)
94
______ NUMBER OF TREATMENT SESSIONS [RANGE: 0–365]
DK/REF
[IF (TR12 ≥ 1) AND (TR12 NE DK OR REF)] What kind of treatment did you get?
TR13
TR13a
TR13b
TR13c
TR13d
DK/REF
TR14
Face-to-face
Phone call
Texting
Video calling or messaging
Yes
1
1
1
1
No
2
2
2
2
[IF TR7A = 1 AND (TR11 NE 1) AND (TR9 NE CURNTAGE) AND (TR12 = DK, REF,
OR MISSING)] [HOSPFILL] how old were you the most recent time you received
treatment from a mental health professional? Your best estimate is fine if you cannot
remember the exact age.
______ YEARS OLD [RANGE: 0– CURNTAGE]
DK/REF
DEFINE TR15_FILL
IF TR7A = 1, THEN TR15_FILL = “also”
ELSE, TR15_FILL = “”
TR15
[IF TR7B = 1] You [TR15_FILL] reported receiving counseling or medication for problems
with your emotions, nerves, or mental health from a general medical doctor, nurse, or
other general medical care provider. Which did you receive: counseling, medication, or
both?
1
Only Counseling
2
Only Medication
3
Counseling and Medication
DK/REF
DEFINE TR15HLPTYP
IF TR15 = 1, THEN, TR15HLPTYP = “counseling”
IF TR15 = 2, THEN TR15HLPTYP = “medication”
IF TR15 = 3, THEN TR15HLPTYP = “counseling and medication”
IF TR15 = DK/REF, THEN TR15HLPTYP = “counseling or medication”
TR16
[IF TR7B = 1] About how old were you the very first time you received [TR15HLPTYP] for
mental health problems from a general medical care provider? Your best estimate is fine if
you cannot remember the exact age.
Version 4 - February 2017 (Post IRB Approval)
95
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TR17
[IF TR16 = CURNTAGE – 1] Did you start this treatment in the past 12 months or more than
12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
TR18
[IF TR7B = 1 AND ((TR16 < (CURNTAGE – 1) OR (TR16 = DK OR REF))] During about
how many years of your life did you receive this kind of treatment from a general medical
care provider? Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
TR19
[IF TR7B = 1 AND (TR18 NE 1) AND TR18 NE MISSING] About how many treatment
sessions of this sort did you have with a general medical professional in the past 12 months?
Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF TREATMENT SESSIONS [RANGE: 0–365]
DK/REF
TR20
[IF TR7B = 1 AND (TR18 NE 1) AND (TR16 NE CURNTAGE) AND (TR19 = DK OR
REF, OR MISSING)] About how old were you the most recent time you received this kind
of treatment from a general medical professional? Your best estimate is fine if you cannot
remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TR21_FILL
IF TR7A = 1 or TR7B = 1, THEN TR21_FILL = “also”
ELSE, TR21_FILL = “”
TR21
[IF TR7C = 1] You [TR21_FILL] reported receiving counseling for problems with your
emotions, nerves, or mental health from a minister, priest, rabbi, or other spiritual
advisor. About how old were you the very first time you received this kind of counseling?
Your best estimate is fine if you cannot remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TR22
[IF TR21 = CURNTAGE – 1] Did you start this counseling in the past 12 months or more
than 12 months ago?
Version 4 - February 2017 (Post IRB Approval)
96
1
In the past 12 months
2
More than 12 months ago
DK/REF
TR23
[IF TR7C = 1 AND ((TR21 < (CURNTAGE – 1) OR (TR21 = DK OR REF))] During about
how many years of your life did you receive this kind of counseling from a spiritual advisor?
Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
TR24
[IF TR7C = 1 and (TR23 NE 1)] About how many of these counseling sessions with a
spiritual advisor did you have in the past 12 months? Your best estimate is fine if you cannot
remember the exact number.
______ NUMBER OF SESSIONS [RANGE: 0–365]
DK/REF
TR25
[IF TR7C = 1 AND (TR23 NE 1) AND (TR21 NE CURNTAGE) AND (TR24 = DK, REF,
OR MISSING)] About how old were you the most recent time you had one of these sessions
with a spiritual advisor? Your best estimate is fine if you cannot remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TR26_FILL
IF TR7A = 1 OR TR7B = 1 OR TR7C = 1, THEN TR26_FILL = “also”
ELSE, TR26_FILL = “”
TR26
[IF TR7D = 1] You [TR26_FILL] reported receiving counseling for problems with your
emotions, nerves, or mental health from a Certified Peer Counselor. About how old were
you the very first time you received this kind of counseling? Your best estimate is fine if you
cannot remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TR27
[IF TR26 = CURNTAGE – 1] Did you start this counseling in the past 12 months or more
than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
Version 4 - February 2017 (Post IRB Approval)
97
TR28
[IF TR7D = 1 AND ((TR26 < (CURNTAGE – 1) OR (TR26 = DK OR REF))] During about
how many years of your life did you receive this kind of counseling from a Certified Peer
Counselor? Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
TR29
[IF TR7D = 1 AND (TR28 NE (1 OR MISSING))] About how many of these counseling
sessions with a Certified Peer Counselor did you have in the past 12 months? Your best
estimate is fine if you cannot remember the exact number.
______ NUMBER OF SESSIONS [RANGE: 0–365]
DK/REF
TR30
[IF TR7D = 1 AND (TR28 NE (1 OR MISSING)) AND (TR26 NE CURNTAGE) AND
(TR29 = DK OR REF OR MISSING)] About how old were you the most recent time you
had one of these sessions with a Certified Peer Counselor? Your best estimate is fine if you
cannot remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TR31_FILL
IF TR7A = 1 OR TR7B = 1 OR TR7C = 1 OR TR7D = 1, THEN TR31_FILL = “also”
ELSE, TR31_FILL = “”
TR31
[IF TR7E = 1] You [TR31_FILL] reported going to a self-help or support group for
problems with your emotions, nerves, or mental health. About how old were you the very
first time you went to this kind of group? Your best estimate is fine if you cannot remember
the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TR32
[IF TR31 = CUNRTAGE – 1] Did you start going in the past 12 months or more than 12
months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
TR33
[IF TR7E = 1 AND ((TR31 < (CURNTAGE – 1) OR (TR31 = DK OR REF))] During about
how many years of your life did you go to a group of this sort? Your best estimate is fine if
you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
Version 4 - February 2017 (Post IRB Approval)
98
DK/REF
TR34
[IF TR7E = 1 AND (TR33 NE (1 OR MISSING))] About how many meetings did you go to
in the past 12 months? Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF MEETINGS [RANGE: 0–365]
DK/REF
TR35
[IF TR7E = 1 AND (TR33 NE (1 OR MISSING)) AND (TR31 NE CURNTAGE) AND
(TR34 = DK OR REF OR MISSING)] About how old were you the most recent time you
went to a self-help group meeting of this sort? Your best estimate is fine if you cannot
remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TR36_FILL
IF TR7A = 1 OR TR7B = 1 OR TR7C = 1 OR TR7D = 1 OR TR7E = 1, THEN TR36_FILL = “also”
ELSE, TR36_FILL = “”
TR36
[IF TR7F = 1] You [TR36_FILL] reported trying a computerized or internet-based mental
health treatment program. About how old were you the very first time you tried such a
program? Your best estimate is fine if you cannot remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TR37
[IF TR36 = CURNTAGE – 1] Did you start it in the past 12 months or more than 12 months
ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
TR38
[IF TR7f = 1 AND ((TR36 < (CURNTAGE – 1) OR (TR36 = DK OR REF))] During about
how many years of your life did you use a computerized or internet-based mental health
treatment program? Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
TR39
[IF TR7f = 1 AND (TR38 NE (1 OR MISSING))] During about how many days did you
spend time online with this program in the past 12 months? Your best estimate is fine if you
cannot remember the exact number.
______ NUMBER OF DAYS [RANGE: 0–365]
Version 4 - February 2017 (Post IRB Approval)
99
DK/REF
TR40
[IF TR39 ≥ 1] Do you still spend any time working on the computerized treatment program?
Or have you stopped?
1
Still working on the program
2
Stopped
DK/REF
TR41
[IF TR39 = 0 OR TR40 = 2] How important was each of the following reasons for why you
stopped?
TR41a You got better and no longer
need the program
TR41b The program was not helping
TR41c The program took too much
time
DK/REF
TR42
Very
Important
Somewhat
Important
Not Very
Important
Not at All
Important
1
2
3
4
1
2
3
4
1
2
3
4
[TR7F = 1 AND (TR38 NE (1 OR MISSING)) AND (TR36 NE CURNTAGE) AND (TR39
= DK OR REF OR MISSING)] About how old were you the most recent time you spent
time online with a computerized or internet-based mental health treatment program? Your
best estimate is fine if you cannot remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TR43_ASK (PERFORM EACH TIME MOVE TO TR43)
IF TR12 ≥ 1 AND (TR12 NE DK OR REF) AND (TR19 = DK, REF, OR MISSING) AND (TR24 =
DK, REF, OR MISSING) AND (TR29 = DK, REF, OR MISSING) AND (TR34 = DK, REF, OR
MISSING); SET TR43_ASK = 1
ELSE, SET TR43_ASK = 0
DEFINE TR44_ASK (PERFORM EACH TIME MOVE TO TR44)
IF TR19 ≥ 1 AND (TR19 NE DK OR REF) AND (TR12 = DK, REF, OR MISSING) AND (TR24 =
DK, REF, OR MISSING) AND (TR29 = DK, REF, OR MISSING) AND (TR34 = DK, REF, OR
MISSING); SET TR44_ASK = 1
ELSE, SET TR44_ASK = 0
DEFINE TR45_ASK (PERFORM EACH TIME MOVE TO TR45)
IF TR24 ≥ 1 AND (TR24 NE DK OR REF) AND (TR12 = DK, REF, OR MISSING) AND (TR19 =
DK, REF, OR MISSING) AND (TR29 = DK, REF, OR MISSING) AND (TR34 = DK, REF, OR
MISSING); SET TR45_ASK = 1
ELSE, SET TR45_ASK = 0
Version 4 - February 2017 (Post IRB Approval)
100
DEFINE TR46_ASK (PERFORM EACH TIME MOVE TO TR46)
IF TR29 ≥ 1 AND (TR29 NE DK OR REF) AND (TR12 = DK, REF, OR MISSING) AND (TR19 =
DK, REF, OR MISSING) AND (TR24 = DK, REF, OR MISSING) AND (TR34 = DK, REF, OR
MISSING); SET TR46_ASK = 1
ELSE, SET TR46_ASK = 0
DEFINE TR47_ASK (PERFORM EACH TIME MOVE TO TR47)
IF TR34 ≥ 1 AND (TR34 NE DK OR REF) AND (TR12 = DK, REF, OR MISSING) AND (TR19 =
DK, REF, OR MISSING) AND (TR24 = DK, REF, OR MISSING) AND (TR29 = DK, REF, OR
MISSING); SET TR47_ASK = 1
ELSE, SET TR47_ASK = 0
DEFINE TR48_ASK (PERFORM EACH TIME MOVE TO TR48)
IF ((TR12 ≥ 1 AND (TR12 NE DK OR REF)) OR (TR19 ≥ 1 AND (TR19 NE DK OR REF)) AND
((TR24 ≥ 1 AND (TR24 NE DK OR REF)) OR (TR29 ≥ 1 AND (TR29 NE DK OR REF)) AND
(TR34 = DK 0R REF OR MISSING); THEN SET TR48_ASK = 1
ELSE, SET TR48_ASK = 0
DEFINE TR49_ASK (PERFORM EACH TIME MOVE TO TR49)
IF ((TR12 ≥ 1 AND (TR12 NE DK OR REF)) OR (TR19 ≥ 1 AND (TR19 NE DK OR REF)) AND
((TR24 = DK OR REF OR MISSING) AND (TR29 = DK OR REF OR MISSING)) AND (TR34 ≥ 1
AND (TR34 NE DK OR REF)); THEN SET TR49_ASK = 1
ELSE, SET TR49_ASK = 0
DEFINE TR50_ASK (PERFORM EACH TIME MOVE TO TR50)
IF ((TR12 = DK OR REF OR MISSING) AND (TR19 = DK OR REF OR MISSING)) AND ((TR24
≥ 1 AND (TR24 NE DK OR REF)) OR (TR29 ≥ 1 AND (TR = 29 NE DK OR REF)) AND (TR34 ≥ 1
AND (TR34 NE DK OR REF)); THEN SET TR50_ASK = 1
ELSE, SET TR50_ASK = 0
DEFINE TR51_ASK (PERFORM EACH TIME MOVE TO TR51)
IF ((TR12 ≥ 1 AND (TR12 NE DK OR REF)) OR (TR19 ≥ 1 AND (TR19 NE DK OR REF)) AND
((TR24 ≥ 1 AND (TR24 NE DK OR REF)) OR (TR29 ≥ 1 AND (TR29 NE DK OR REF)) AND
(TR34 ≥ 1 AND (TR34 NE DK OR REF)); THEN SET TR51_ASK = 1
ELSE, SET TR51_ASK = 0
TR43
[IF TR43_ASK = 1] Are you still receiving [TR8HLPTYP] from a mental health
professional? Or have you stopped receiving [TR8HLPTYP]?
1
Still receiving [TR8HLPTY]
2
Stopped receiving [TR8HLPTYP]
DK/REF
TR44
[IF TR44_ASK = 1] Are you still in treatment for these problems with a general medical
professional? Or have you stopped receiving treatment?
Version 4 - February 2017 (Post IRB Approval)
101
1
Still in treatment
2
Stopped
DK/REF
TR45
[IF TR45_ASK = 1] Are you still receiving counseling for these problems from a spiritual
advisor? Or have you stopped receiving counseling?
1
Still in counseling
2
Stopped counseling
DK/REF
TR46
[IF TR46_ASK = 1] Are you still receiving counseling from a Certified Peer Counselor? Or
have you stopped receiving counseling?
1
Still in counseling
2
Stopped counseling
DK/REF
TR47
[IF TR47_ASK = 1] Are you still attending self-help group meetings? Or have you stopped?
1
Still attending
2
Stopped attending
DK/REF
TR48
[IF TR48_ASK = 1] Are you still either in treatment or receiving counseling for your mental
health problems? Or have you stopped both treatment and counseling?
1
Still either in treatment or counseling
2
Stopped both treatment and counseling
DK/REF
TR49
[IF TR49_ASK = 1] Are you still either in treatment or in the self-help group? Or have you
stopped both treatment and the self-help group?
1
Still either in treatment or the self-help group
2
Stopped both treatment and the self-help group
DK/REF
TR50
[IF TR50_ASK = 1] Are you still either in counseling or the self-help group? Or have you
stopped both counseling and the self-help group?
1
Still either in counseling or the self-help group
2
Stopped both counseling and the self-help group
DK/REF
Version 4 - February 2017 (Post IRB Approval)
102
TR51
[IF TR51_ASK = 1] Are you still either in treatment, counseling, or the self-help group? Or
have you stopped all of them?
1
Still either in treatment, counseling, or the self-help group
2
Stopped all of them
DK/REF
DEFINE TR52_ASK (PERFORM EACH TIME MOVE TO TR52)
IF TR43 = 2 OR TR44 = 2 OR TR45 = 2 OR TR46 = 2 OR TR47 = 2 OR TR48 = 2 OR TR49 = 2 OR
TR50 = 2 or TR51 = 2, THEN SET TR52_ASK = 1
ELSE, SET TR52_ASK = 0
DEFINE TR52_FILL1 (PERFORM EACH TIME MOVE TO TR52)
IF ((TR12 ≥ 1 AND (TR12 NE DK OR REF)) OR (TR19 ≥ 1 AND (TR19 NE DK OR REF))) OR
((TR24 ≥ 1 AND (TR24 NE DK OR REF)) OR (TR29 ≥ 1 AND (TR29 NE DK OR REF))), THEN
TR52_FILL1 = “treatment”,
ELSE, TR52_FILL1 = “”
DEFINE TR52_FILL3 (PERFORM EACH TIME MOVE TO TR52)
IF (TR34 ≥ 1 AND (TR34 NE DK OR REF)), THEN TR52_FILL3 = “the self-help group”,
ELSE, TR52_FILL3 = “”
DEFINE TR52_FILL2 (PERFORM EACH TIME MOVE TO TR52)
IF TR52_FILL1 = “treatment” AND TR52_FILL3 = “the self-help group”, THEN TR52_FILL2 = “
and ”,
ELSE, TR52_FILL2 = “”
TR52
[IF TR52_ASK = 1] How important was each of the following reasons for why you stopped
[TR52_FILL1][TR52_FILL2][TR52_FILL3]?
TR52a You got better and no longer
needed help
TR52b It was not helping; you were
not getting better
TR52c Financial reasons
TR52d Inconvenience -- for example,
problems with time,
transportation, or scheduling
TR52e Embarrassment or concern
about what people would think
if they knew you were in
treatment
Version 4 - February 2017 (Post IRB Approval)
Very
Important
Somewhat
Important
Not Very
Important
Not at All
Important
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
103
TR52f You preferred to handle the
problem on your own or with
the help of family and friends
DK/REF
1
2
3
4
TR52g [IF TR52_ASK = 1] Was there some other important reason why you stopped
[TR52_FILL1][TR52_FILL2][TR52_FILL3]?
1
Yes
2
No
DK/REF
TR52G_OTH
[IF TR52G = 1] Please briefly describe the other reason why you stopped.
OTHER IMPORTANT REASON:
__________________________________________ [RANGE: 1–100
CHARACTERS]
DK/REF
DEFINE TR53_ASK (PERFORM EACH TIME MOVE TO TR53)
IF (TR12 = DK, REF, OR MISSING) AND (TR19 = DK, REF, OR MISSING) AND (TR24 = DK,
REF, OR MISSING) AND (TR29 = DK, REF, OR MISSING) AND (TR34 = DK, REF, OR
MISSING); SET TR53_ASK = 1
ELSE, SET TR53_ASK = 0
TR53
[TR53_ASK = 1] Was there ever a time in the past 12 months when you felt that you might
need professional help with your emotions, nerves, or mental health?
1
Yes
2
No
DK/REF
TR54
[TR53 = 1] How important was each of the following reasons for why you did not get
treatment?
TR54a The problem got better and you
no longer needed help
TR54b You didn’t know where to go
TR54c You couldn’t find a place that
would see you when you
needed help
TR54d Financial reasons
Version 4 - February 2017 (Post IRB Approval)
Very
Important
Somewhat
Important
Not Very
Important
Not at All
Important
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
104
TR54e Inconvenience -- for example,
problems with time,
transportation, or scheduling
TR54f Embarrassment or concern
about what people would think
if they knew you were in
treatment
TR54g You preferred to handle the
problem on your own or with
the help of family and friends
DK/REF
Very
Important
Somewhat
Important
Not Very
Important
Not at All
Important
1
2
3
4
1
2
3
4
1
2
3
4
TR54h [TR53 = 1] Was there some other important reason why you did not get treatment?
1
Yes
2
No
DK/REF
TR54H_OTH
[IF TR54H = 1] Please briefly describe the other important reason why you did not
get treatment.
__________________________________________ OTHER IMPORTANT
REASON [RANGE: 1–100 CHARACTERS]
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
105
18.
Pharmacoepidemiology
BEGIN TIME STAMP
The next questions are about your use of medicines. In the past 12 months, did you
take any of the following types of prescription medications under the supervision of a
doctor, for your emotions or nerves or mental health?
PH3
PH3a
PH3b
PH3c
PH3d
PH3e
DK/REF
Sleeping pills or other sedatives, such as Ambien or Sonata?
Antidepressant medications, such as Prozac or Zoloft?
Tranquilizers, such as Xanax or Ativan?
Amphetamines or other stimulants, such as Ritalin or dextroamphetamine?
Antipsychotic medications, such as Haldol or Risperdal?
Yes
1
1
1
1
1
No
2
2
2
2
2
DEFINE PH_12MOMEDL
IF (PH3a OR PH3b OR PH3c OR PH3d OR PH3e) = 1 OR DK, THEN PH_12MOMEDL= 1 ALL
ELSE, PH_12MOMEDL= 2
PH4
[IF PH_12MOMEDL= 2] Did you take any other type of prescription medicine in the
past 12 months for problems with your emotions, nerves, mental health, energy,
concentration, sleep, or ability to cope with stress? Include medicines even if you took
them only once.
1
Yes
2
No
DK/REF
DEFINE PH5INTRO_FILL1
IF PH_12MOMEDL = 1, THEN PH5INTRO_FILL1=“in the past 12 months for any of the following
problems: problems with your emotions, nerves, mental health, energy,
concentration, sleep, or ability to cope with stress”
ELSE PH5INTRO_FILL1=“for any of those problems in the past 12 months”
DEFINE PH5INTRO_FILL2
IF PH_12MOMEDL = 1, THEN PH5INTRO_FILL2=“the problems listed above”
ELSE PH5INTRO_FILL2=“any of those problems”
PH5INTRO
[IF PH_12MOMEDL = 1 OR PH4 = 1] Ask your interviewer to show you
SHOWCARD 4.
Version 4 - February 2017 (Post IRB Approval)
106
On this card, each medicine has its own ID number. For each medicine that you
took:
Type the ID number and then press enter.
Include medicines even if you took them only once. You can look at your
prescription bottles if necessary.
If a prescription medicine is not included on Showcard 4, please enter
“990”.
Once you are finished, leave the next field blank and press enter.
Medicine ID
A prescription medicine you took in the past 12 months
for problems with your emotions, nerves, mental
health, energy, concentration, sleep, or ability to cope
with stress:
Another prescription medicine you took for any of
those problems in the past 12 months?
Another?
Another?
Another?
Another?
Another?
Another prescription medicine you took in the past 12
months for problems with your emotions, nerves,
mental health, energy, concentration, sleep, or ability
to cope with stress?
Another?
Another?
Another?
Another?
Another?
Another prescription medicine you took for any of
those problems in the past 12 months?
Another?
Another?
Another?
Another?
Another?
Another?
Version 4 - February 2017 (Post IRB Approval)
107
[RANGE 1 – 175, 990]
DK/REF
PROGRAMMERS: ALLOW UP TO 20 ID NUMBERS BUT HIDE LINES IN
THE GRID UNTIL THE IMMEDIATELY PREVIOUS LINE HAS BEEN FILLED
WITH A VALID ANSWER (IN RANGE).
IF THE RESPONDENT ANSWERS DK/REF, EXIT OUT OF THE QUESTION GRID, BUT SAVE
ANY ANSWERS ALREADY ENTERED INTO THE GRID.
DEFINE MEDFILL1 THROUGH MEDFILL20
FOR EACH CODE ENTERED, CREATE A FILL USING THE CORRESPONDING
MEDICINE NAME, AS SHOWN IN SHOWCARD 4.
FOR CODE 990, USE “a medicine that isn’t on Showcard 4”
IF FEWER THAN 20 CODES ENTERED, CONSIDER THE UNUSED FILLS AS
MISSING.
PH5_CKPT [IF SOME PH5INTRO1 FIELDS ARE IN RANGE (1-175 OR 990)] The computer
recorded that in the past 12 months you used the following prescription medications, for
problems with your emotions, nerves, mental health, energy, concentration, sleep, or ability
to cope with stress:
[PROGRAMMER: VERTICALLY LIST MEDFILL1 THROUGH MEDFILL20, WITH
ONE LINE FOR EACH NON-MISSING MEDFILL.]
Is this list correct?
1
Yes
2
No
DK/REF
HARD ERROR: [IF CKPT = 2] PRESS [ENTER] TO GO BACK TO PH5INTRO, SO THAT
THE RESPONDENT MAY CORRECT THE MEDICINE SELECTED.
Version 4 - February 2017 (Post IRB Approval)
108
SHOWCARD 4 (NOT TO BE INCLUDED IN PROGRAM)
ID#
1
Medicine
Abilify
ID#
66
2
Abilify Maintena
67
Focalin
3
4
5
Adderal
Adderal XR
alprazolam
68
69
70
71
72
Forfivo XL
gabapentin
Gabitril
Geodon
guanfacine
6
Ambien
7
amitriptyline
73
74
Haldol
Haldol decanoate
8
amphetamine
75
9
Anafranil
76
haloperidol
haloperidol
decanoate
10
aripiprazole
11
12
13
armodafinil
Artane
asenapine
14
15
Ativan
atomoxetine
16
Belsomra
17
18
19
20
21
benztropine
Brintellix
Budeprion SR
Budeprion XL
bupropion
Version 4 - February 2017 (Post IRB Approval)
Medicine
fluvoxamine
77
Hetlioz
78
iloperidone
79
Inderal
80
81
82
83
Intuniv
Invega
Invega Sustenna
isocarboxazid
84
Klonopin
85
86
87
Lamictal
lamotrigine
Latuda
88
89
levomilnacipran
Lexapro
ID#
Medicine
120
Phenelzine
121
122
123
124
prazosin
pregabalin
Pristiq
ProCentra
125
Prolixin
126
127
Prolixin decanoate
propranolol
128
129
Provigil
Prozac
130
131
132
133
quetiapine
Quillivant XR
ramelteon
Remeron
134
Restoril
135
136
Risperdal
Risperdal Consta
137
risperidone
138
Ritalin
139
Rozerem
109
ID#
22
23
24
25
26
27
28
29
30
Medicine
BuSpar
buspirone
ID#
90
91
92
93
94
chlordiazepozide
chlorpromazine
Medicine
Saphris
lisdexamfetamine
Lithium
Lithobid
lorazepam
141
Seroquel
142
sertraline
143
Silenor
144
Sonata
145
Strattera
146
suvorexant
147
148
149
150
tasimelteon
Tegretol
temazepam
Tenex
151
Thorazine
152
153
Topamax
topiramate
154
155
tranylcypromine
trazodone
156
trihexyphenidyl
95
96
97
Lunesta
lurasidone
Luvox
98
Lyrica
99
100
Marplan
melatonin
citalopram
clomipramine
clonazepam
clonidine
34
35
36
clozapine
Clozaril
Cogentin
101
37
38
Concerta
Cymbalta
39
Cytomel
40
41
42
Daytrana
Depakene
Depakote
44
45
46
47
ID#
140
carbamazepine
Carbatrol
Catapres
Celexa
31
32
33
43
Medicine
Librium
Depakote sprinkles
Desoxyn
desvenlafaxine
Desyrel
Dexedrine
Version 4 - February 2017 (Post IRB Approval)
Metadate
102
103
methamphetamine
Methylin
104
methylphenidate
105
106
107
Minipress
mirtrazapine
modafinil
108
Nardil
110
ID#
48
dexmethylphenidate
157
Medicine
triiodothyronine
(T3)
49
dextroamphetamine
dextroamphetamine/
amphetamine
158
Trileptal
159
160
Valium
valproic acid
161
venlafaxine
162
163
Viibryd
vilazodone
164
165
166
vortioxetine
Vyvanse
Wellbutrin
167
Xanax
168
169
170
171
zaleplon
Zenzedi
ziprasidone
Zoloft
172
zolpidem
173
Zolpimist
174
175
Zyprexa
Zyprexa Relprevv
50
Medicine
ID#
109
51
Medicine
Neurontin
diazepam
52
divalproex
53
doxepin
54
duloxetine
55
Effexor
56
Elavil
110
111
nortriptyline
Nuvigil
112
olanzapine
57
58
escitalopram
Eskalith
59
60
61
eszopiclone
Evekeo
Fanapt
62
Fetzima
115
63
fluoxetine
116
117
118
oxcarbazepine
paliperidone
paliperidone
palmitate (extended
release injectable)
Pamelor
Parnate
paroxetine
64
65
fluphenazine
fluphenazine decanoate
119
Paxil
Version 4 - February 2017 (Post IRB Approval)
113
114
ID#
111
PH5_OT1 [IF PH5_CKPT=1 AND (LESS THAN 20 CODES ENTERED AT PH5INTRO) AND
(NONE OF THE CODES ENTERED AT PH5INTRO INCLUDE 990)] In the past 12
months have you used any other prescription medicine for problems with your
emotions, nerves, mental health, energy, concentration, sleep, or ability to cope with
stress?
1
Yes
2
No
DK/REF
DEFINE PH5_OT1A_FILL
IF PH5INTRO INCLUDES 990, THEN PH5_OT1A_FILL= “You indicated that you used a
prescription medicine in the past 12 months that doesn’t appear on Showcard 4.”
PH5_OT1A [IF PH5_OT1 = 1 OR (PH5INTRO INCLUDES 990)] [PH5_OT1A_FILL] Please type
in the name of one prescription medicine you have used that doesn’t appear on
Showcard 4.
Please remember that we are only interested in prescription medicines that you have
taken for problems with your emotions, nerves, mental health, energy, concentration,
sleep, or ability to cope with stress.
If you’re not sure how to spell the name of the medicine, just make your best guess.
When you have finished, press the [ENTER] key to go to the next question.
______________
PROGRAMMER: ALLOW 50 CHARACTERS
DK/REF
PROGRAMMER:
IF (PH5_OT1A NE MISSING OR DK OR REF) AND (PH5INTRO INCLUDES 990),
THEN USE PH5_OT1A TEXT TO REPLACE THE FILL TEXT FOR THE FIRST
990 ENTERED.
IF (PH5_OT1A NE MISSING OR DK OR REF) AND (PH5INTRO DID NOT
INCLUDE 990), THEN USE PH5_OT1A TEXT TO POPULATE A PREVIOUSLY
MISSING MEDFILL.
PH5_OT2
[IF PH5_OT1A NE (MISSING OR DK OR REF) AND (LESS THAN 19 CODES
ENTERED AT PH5INTRO)] In the past 12 months have you used any other
Version 4 - February 2017 (Post IRB Approval)
112
prescription medicine, other than those you’ve already reported, for problems with your
emotions, nerves, mental health, energy, concentration, sleep, or ability to cope with
stress?
1
Yes
2
No
DK/REF
PH5_OT2A [IF PH5_OT2=1] Please type in the name of one more prescription medicine you
have used in the past 12 months for problems with your emotions, nerves, mental
health, energy, concentration, sleep, or ability to cope with stress.
Only type in the name of a medicine if you haven’t already reported it in an earlier
question.
When you have finished, press the [ENTER] key to go to the next question.
______________
PROGRAMMER: ALLOW 50 CHARACTERS
DK/REF
PROGRAMMER:
IF (PH5_OT2A NE MISSING OR DK OR REF) AND (PH5INTRO INCLUDED AT
LEAST TWO 990 CODES), THEN USE PH5_OT2A TEXT TO REPLACE THE
FILL TEXT FOR THE SECOND 990 ENTERED.
IF (PH5_OT2A NE MISSING OR DK OR REF) AND (PH5INTRO DID NOT
INCLUDE AT LEAST TWO 990 CODES), THEN USE PH5_OT2A TEXT TO
POPULATE A PREVIOUSLY MISSING MEDFILL.
PH5_OT3
[PH5_OT2A NE (MISSING OR DK OR REF) AND (LESS THAN 18 CODES
ENTERED AT PH5INTRO)] In the past 12 months have you used any other
prescription medicine, other than those you’ve already reported, for problems with your
emotions, nerves, mental health, energy, concentration, sleep, or ability to cope with
stress?
1
Yes
2
No
DK/REF
Version 4 - February 2017 (Post IRB Approval)
113
PH5_OT3A [IF PH5_OT3=1] Please type in the name of one more prescription medicine you
have used in the past 12 months for problems with your emotions, nerves, mental
health, energy, concentration, sleep, or ability to cope with stress.
Only type in the name of a medicine if you haven’t already reported it in an earlier
question.
When you have finished, press the [ENTER] key to go to the next question.
______________
PROGRAMMER: ALLOW 50 CHARACTERS
DK/REF
PROGRAMMER:
IF (PH5_OT3A NE MISSING OR DK OR REF) AND (PH5INTRO INCLUDED AT
LEAST THREE 990 CODES), THEN USE PH5_OT3A TEXT TO REPLACE THE
FILL TEXT FOR THE THIRD 990 ENTERED.
IF (PH5_OT3A NE MISSING OR DK OR REF) AND (PH5INTRO DID NOT
INCLUDE AT LEAST THREE 990 CODES), THEN USE PH5_OT3A TEXT TO
POPULATE ANOTHER MEDFILL.
PH5_OT4
[PH5_OT3A NE (MISSING OR DK OR REF) AND (LESS THAN 17 CODES
ENTERED AT PH5INTRO)] In the past 12 months have you used any other
prescription medicine, other than those you’ve already reported, for problems with your
emotions, nerves, mental health, energy, concentration, sleep, or ability to cope with
stress?
1
Yes
2
No
DK/REF
PH5_OT4A [IF PH5_OT4=1] Please type in the name of one more prescription medicine you
have used in the past 12 months for problems with your emotions, nerves, mental
health, energy, concentration, sleep, or ability to cope with stress.
Only type in the name of a medicine if you haven’t already reported it in an earlier
question.
When you have finished, press the [ENTER] key to go to the next question.
______________
PROGRAMMER: ALLOW 50 CHARACTERS
DK/REF
Version 4 - February 2017 (Post IRB Approval)
114
PROGRAMMER:
IF (PH5_OT4A NE MISSING OR DK OR REF) AND (PH5INTRO INCLUDED AT
LEAST FOUR 990 CODES), THEN USE PH5_OT4A TEXT TO REPLACE THE
FILL TEXT FOR THE FOURTH 990 ENTERED.
IF (PH5_OT4A NE MISSING OR DK OR REF) AND (PH5INTRO DID NOT
INCLUDE AT LEAST FOUR 990 CODES), THEN USE PH5_OT4A TEXT TO
POPULATE ANOTHER MEDFILL.
PH5_OT5
[PH5_OT4A NE (MISSING OR DK OR REF) AND (LESS THAN 16 CODES
ENTERED AT PH5INTRO)] In the past 12 months have you used any other
prescription medicine, other than those you’ve already reported, for problems with your
emotions, nerves, mental health, energy, concentration, sleep, or ability to cope with
stress?
1
Yes
2
No
DK/REF
PH5_OT5A [IF PH5_OT5=1] Please type in the name of one more prescription medicine you
have used in the past 12 months for problems with your emotions, nerves, mental
health, energy, concentration, sleep, or ability to cope with stress.
Only type in the name of a medicine if you haven’t already reported it in an earlier
question.
When you have finished, press the [ENTER] key to go to the next question.
______________
PROGRAMMER: ALLOW 50 CHARACTERS
DK/REF
PROGRAMMER:
IF (PH5_OT5A NE MISSING OR DK OR REF) AND (PH5INTRO INCLUDED AT
LEAST FIVE 990 CODES), THEN USE PH5_OT5A TEXT TO REPLACE THE FILL
TEXT FOR THE FIFTH 990 ENTERED.
IF (PH5_OT5A NE MISSING OR DK OR REF) AND (PH5INTRO DID NOT
INCLUDE AT LEAST FIVE 990 CODES), THEN USE PH5_OT5A TEXT TO
POPULATE ANOTHER MEDFILL.
DEFINE PH_COUNT
SET PH_COUNT= (THE TOTAL NUMBER OF NONMISSING MEDFILL VARIABLES)
Version 4 - February 2017 (Post IRB Approval)
115
DEFINE PH6INTRO_FILL
IF PH_COUNT=1, THEN PH6INTRO_FILL= “the prescription medicine”
IF PH_COUNT>1 AND PH_COUNT<5, THEN PH6INTRO_FILL= “each of the prescription
medicines”
IF PH_COUNT>1 AND PH_COUNT>5, THEN PH6INTRO_FILL= “some of the prescription
medicines”
PH6INTRO. [IF PH_COUNT = OR >1] Next, we’ll ask a couple of questions about
[PH6INTRO_FILL] that you reported taking.
NOTE TO PROGRAMMERS:
LOOP THROUGH PH6a THROUGH PH12a FOR EACH MEDICINE PROVIDED IN
PH5INTRO1, PH5INTRO2, PH5_OT1A, PH5_OT2A, OR PH5_OT3A, UP TO A TOTAL OF
5. IF MORE THAN 5 MEDICINES ARE PROVIDED, RANDOMLY SELECT 5 TO LOOP
THROUGH.
BELOW, ‘MEDFILLX’ IS USED TO REPRESENT THE MEDFILL RELEVANT TO THE
CURRENT ITERATION OF THE LOOP. FOR EXAMPLE, IF YOU ARE PASSING
THROUGH THE LOOP FOR THE FIRST TIME, THE ACTUAL MEDFILL REFERENCE
WOULD BE MEDFILL1.
PH6a
[IF (MEDFILLX NE MISSING)]
About how many days out of the past 30 did you take [MEDFILLX]?
DAYS [RANGE: 0–30]
DK/REF
PH7a
[IF MEDFILLX NE MISSING] About how many days out of the past 365 did you take
[MEDFILLX]?
DAYS [RANGE: 0–365]
DK/REF
NOTE TO PROGRAMMERS: AFTER COMPLETING THE PH6a THROUGH PH7a LOOP, LOOP
THROUGH PH15 THROUGH PH23 UP TO THREE TIMES. IF ONE TO THREE MEDICINES
INDICATED IN PH5INTRO1, PH5INTRO2, PH5_OT1A, PH5_OT2A, OR PH5_OT3A, ASK
PH15–PH23 SERIES FOR EACH. IF FOUR OR MORE MEDICINES INDICATED, RANDOMLY
SAMPLE THREE MEDICINES FROM AMONG THE MEDICINES PREVIOUSLY SELECTED
FOR THE PH6a THROUGH PH7a LOOP AND ASK PH15–PH23 SERIES FOR EACH.
Version 4 - February 2017 (Post IRB Approval)
116
DEFINE PH15INTRO_FILL
IF PH_COUNT>3, FILL= “some of”
ELSE, FILL= “each of”
PH15INTRO. [PH_COUNT>1] Now, we’ll ask a few more questions about [PH15INTRO_FILL] the
medicines that you reported taking.
DEFINE PH15_FILL
IF PH_COUNT>1 AND THIS IS THE FIRST ITERATION OF THE LOOP, FILL: “First, let’s talk
about [MEDFILLX].”
IF PH_COUNT>1 AND THIS IS NOT THE FIRST ITERATION OF THE LOOP, FILL: “Now, let’s
talk about [MEDFILLX].”
IF PH_COUNT=1 FILL=“”
PH15
[IF MEDFILLX NE MISSING] [PH15_FILL]
Overall, how effective was [MEDFILLX] in doing the things you expected it to?
1
Very effective
2
Somewhat effective
3
Not very effective
4
Not at all effective
DK/REF
PH16
[IF MEDFILLX NE MISSING] Did you take [MEDFILLX] under the supervision of a
health professional? Or did you take it on your own, that is without a doctor’s prescription
or in any way a doctor did not direct you to use it??
1
With supervision
2
On your own without supervision
DK/REF
PH17
[IF MEDFILLX NE MISSING] Who prescribed the [MEDFILLX] -- a psychiatrist, a
general or family doctor, some other medical doctor, or some other health professional?
1
Psychiatrist
2
General or family doctor
3
Some other doctor
4
Some other health professional
5
No one prescribed the medication
DK/REF
PH18
[IF MEDFILLX NE MISSING] People do not always take their medicine as they are
supposed to. Think of a typical month when you took [MEDFILLX] in the past 12
Version 4 - February 2017 (Post IRB Approval)
117
months. How many days out of 30 did you typically either forget to take it or take less
of it than you were supposed to take?
If you were not supposed to take the [MEDFILLX] regularly or did not take it for a full
month, enter “996.”
___________________ NUMBER OF DAYS [RANGE: 0–30, 996]
DK/REF
PH19
[IF MEDFILLX NE MISSING] Are you still taking [MEDFILLX]?
1
Yes
2
No
DK/REF
PH20
[IF PH19 = 2 AND PH16 = 1] Did the health professional who supervised your use tell
you to stop taking [MEDFILLX]?
1
Yes
2
No
DK/REF
PH21
[IF PH20 = 2] Did the health professional agree with your decision to stop?
1
Yes
2
No
DK/REF
PH22
[IF PH20 = 2] Did you stop taking [MEDFILLX] because you felt so much better that
you no longer needed it? Or did you stop for some other reason?
1
Felt better
2
Other reason
DK/REF
PH23
[IF PH22 = 2] Which of these are reasons why you stopped taking [MEDFILLX]?
Select all that apply from the categories shown below. To select more than one answer
from the list, press the space bar between each number you type. When you have
finished, press the [ENTER] key to go to the next question.
1
2
3
4
5
6
The medicine was not helping
You thought the problem would get better without more medicine
You couldn’t afford to pay for the medicine
You were too embarrassed to continue taking the medicine
You wanted to solve the problem without medications
The medicine caused side effects that made you stop
Version 4 - February 2017 (Post IRB Approval)
118
7
You were afraid that you would get dependent on the medication
8
Someone in your personal life pressured you to stop
9
Any other reason for stopping
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
119
19a.
Trait Fear
BEGIN TIME STAMP
PROGRAMMER: RANDOMIZE RESPONDENT TO RECEIVE EITHER MODULE 19a4 (TRAIT
FEAR) OR MODULE 19b (DISINHIBITION) OR MODULE 19c (PERSONALITY).
TF_INTRO The next section contains statements that different people might use to describe
themselves. Each statement is followed by four choices: True, Somewhat True,
Somewhat False, and False. For each statement, select the choice that describes you
best. There are no right or wrong answers.
TF1
TF2
TF3
TF4
TF5
TF6
TF7
TF8
TF9
TF10
TF11
TF12
TF13
TF14
TF15
You tend to be unsure of yourself
in tough situations.
You like doing physically
dangerous things.
You’re always willing to rush in
where others fear to tread.
You are afraid of a lot of things.
You find it frightening to be in a
strange new place on your own.
You have a great deal of courage.
You stay calm, cool, and collected
in scary situations.
You don’t like walking into new
situations, even when there’s
nothing to fear.
You are very easily frightened.
You gladly do things you’ve never
done before, even if they might be
dangerous.
You sometimes shy away from
crowds of people.
You are fearless.
Major tasks or challenges can seem
overwhelming to you.
You’re afraid of far fewer things
than most people.
It does not disturb you when you
have to do something novel and
unfamiliar.
Version 4 - February 2017 (Post IRB Approval)
True
Somewhat
True
Somewhat
False
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
False
120
TF16
TF17
TF18
TF19
TF20
You stay away from physical
danger as much as you can.
You are never as afraid as most
other people.
It bothers you to be in new
situations where things are
uncertain.
In challenging situations, you love
to be in the “driver’s seat.”
You enjoy doing new things that
other people are afraid to do.
True
Somewhat
True
Somewhat
False
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
False
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
121
19b.
Disinhibition
BEGIN TIME STAMP
PROGRAMMER: RANDOMIZE RESPONDENT TO RECEIVE EITHER MODULE 19a (TRAIT
FEAR) OR MODULE 19b (DISINHIBITION) OR MODULE 19c (PERSONALITY).
DIS1
DIS1a
DIS1b
DIS1c
DIS1d
DIS1e.
DIS1f
DIS1g
DIS1h
DIS1i
DIS1j
DIS1k
DIS1l
DIS1m
DIS1n
DIS1o
DIS1p
DIS1q
DIS1r
The following section contains statements that different people might use to describe
themselves. Each statement is followed by four choices: True, Somewhat True,
Somewhat False, and False. For each statement, select the choice that describes you
best. There are no right or wrong answers.
You often act on immediate needs.
You’ve often missed things you promised
to attend.
Your impulsive decisions have caused
problems with loved ones.
You have missed work without bothering
to call in.
You jump into things without thinking.
You’ve gotten in trouble because you
missed too much school.
You have good control over yourself.
You have taken money from someone’s
purse or wallet without asking.
People often abuse your trust.
You keep appointments you make.
You often get bored quickly and lose
interest.
You have conned people to get money
from them.
You get in trouble for not considering the
consequences of your actions.
You have taken items from a store
without paying for them.
You have a hard time waiting patiently
for things you want.
You have lost a friend because of
irresponsible things you’ve done.
Others have told you they are concerned
about your lack of self-control.
You have robbed someone.
Version 4 - February 2017 (Post IRB Approval)
True
1
Somewhat
True
2
Somewhat
False
3
False
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
1
2
2
3
3
4
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
122
DIS1s
DIS1t
You have had problems at work because
you were irresponsible.
You have stolen something out of a
vehicle.
True
Somewhat
True
Somewhat
False
False
1
2
3
4
1
2
3
4
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
123
19c.
Personality
BEGIN TIME STAMP
PROGRAMMER: RANDOMIZE RESPONDENT TO RECEIVE EITHER MODULE 19a (TRAIT
FEAR) OR MODULE 19b (DISINHIBITION) OR MODULE 19c (PERSONALITY).
PERINTRO This is a list of things different people might say about themselves. We are interested in
how you would describe yourself. Please select the response that best describes you.
People would describe
you as reckless.
PER2 You feel like you act
totally on impulse.
PER3 Even though you
know better, you can’t
stop making rash
decisions.
PER4 You often feel like
nothing you do really
matters.
PER5 Others see you as
irresponsible.
PER6 You’re not good at
planning ahead.
PER7 Your thoughts often
don’t make sense to
others.
PER8 You worry about
almost everything.
PER9 You get emotional
easily, often for very
little reason.
PER10 You fear being alone
in life more than
anything else.
PER11 You get stuck on one
way of doing things,
even when it’s clear it
won’t work.
PER1
Version 4 - February 2017 (Post IRB Approval)
Very
False or
Often
False
Sometimes
or
Somewhat
False
Sometimes
or
Somewhat
True
Very True
or Often
True
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
124
PER12 You have seen things
that weren’t really
there.
PER13 You steer clear of
romantic
relationships.
PER14 You’re not interested
in making friends.
PER15 You get irritated
easily by all sorts of
things.
PER16 You don’t like to get
too close to people.
PER17 It’s no big deal if you
hurt other people’s
feelings.
PER18 You rarely get
enthusiastic about
anything.
PER19 You crave attention.
PER20 You often have to deal
with people who are
less important than
you are.
PER21 You often have
thoughts that make
sense to you but that
other people say are
strange.
PER22 You use people to get
what you want.
PER23 You often “zone out”
and then suddenly
come to and realize
that a lot of time has
passed.
PER24 Things around you
often feel unreal or
more real than usual.
Version 4 - February 2017 (Post IRB Approval)
Very
False or
Often
False
Sometimes
or
Somewhat
False
Sometimes
or
Somewhat
True
Very True
or Often
True
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
125
PER25 It is easy for you to
take advantage of
others.
DK/REF
Very
False or
Often
False
Sometimes
or
Somewhat
False
Sometimes
or
Somewhat
True
Very True
or Often
True
0
1
2
3
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
126
20.
BPD Screen
BEGIN TIME STAMP
BPD
The next items are about your emotions and behaviors.
Yes
No
BPD1
Have any of your closest relationships been troubled by a lot
of arguments or repeated breakups?
1
2
BPD2a
Have you deliberately hurt yourself physically? For example,
have you ever punched yourself, cut yourself, or burned
yourself?
1
2
BPD2b
[IF SD19 NE 1] Have you ever attempted suicide?
1
2
BPD3
Have you had at least two problems with doing things
suddenly or unexpectedly without giving thought to what
might happen? For example, have you had problems with
eating binges, spending sprees, drinking too much, or verbal
outbursts?
1
2
BPD4
Have you been extremely moody?
1
2
BPD5a
Have you felt very angry a lot of the time?
1
2
BPD5b
Have you often acted in an angry or sarcastic manner?
1
2
BPD6
Have you often been distrustful of other people?
1
2
BPD7
Have you frequently felt unreal or as if things around you
were unreal?
1
2
BPD8
Have you often felt empty inside?
1
2
BPD9
Have you often felt that you had no idea of who you are or
that you have no identity?
1
2
BPD10
Have you made desperate efforts to avoid feeling abandoned
or being abandoned? For example, have you repeatedly called
someone to reassure yourself that he or she still cared, begged
them not to leave you, or clung to them physically?
1
2
DK/REF
BPD_COUNT
SET BPD_COUNT=0
IF BPD1=1, THEN ADD 1 TO BPD_COUNT.
IF BPD2A=1 OR BPD2B =1, THEN ADD 1 TO BPD_COUNT.
IF BPD3=1, THEN ADD 1 TO BPD_COUNT.
IF BPD4=1, THEN ADD 1 TO BPD_COUNT.
IF BPD5A=1 OR BPD5B =1, THEN ADD 1 TO BPD_COUNT.
IF BPD6=1, THEN ADD 1 TO BPD_COUNT.
IF BPD7=1, THEN ADD 1 TO BPD_COUNT.
Version 4 - February 2017 (Post IRB Approval)
127
IF BPD8=1, THEN ADD 1 TO BPD_COUNT.
IF BPD9=1, THEN ADD 1 TO BPD_COUNT.
IF BPD10=1, THEN ADD 1 TO BPD_COUNT.
DEFINE BPD_P
IF BPD_COUNT>=7, THEN SET BPD_P=1.
ELSE SET BPD_P=0.
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
128
22.
Prison
BEGIN TIME STAMP
PR1
Next, we’ll ask about encounters with the police or the court system. Not counting
minor traffic violations, have you ever been arrested and booked for breaking a law?
1
Yes
2
No
DK/REF
PR2
[IF PR1 = 1] Not counting minor traffic violations, how many times during the past
12 months have you been arrested and booked for breaking a law?
__________ NUMBER OF TIMES [RANGE: 0–99]
DK/REF
PR3
[IF PR1 = 1] Since the age of 18, were you ever in a jail, prison, or correctional
facility?
1
Yes
2
No
DK/REF
PR4
[IF PR3 = 1] Now think about all the time you have spent in a jail, prison, or
correctional facility since you turned 18. What would be the easiest way for you to give
your answer?
1
Total number of days
2
Total number of weeks
3
Total number of months
4
Total number of years
DK/REF
DEFINE PR4a_FILL
IF PR4 = 1 OR DK OR REF, THEN PR4a_FILL = total number of days
IF PR4 = 2 THEN PR4a_FILL = total number of weeks
IF PR4 = 3 THEN PR4a_FILL = total number of months
IF PR4 = 4 THEN PR4a_FILL = total number of years
PR4a
[IF PR3 = 1] What is the [PR4a_FILL] you were in a jail, prison, or correctional
facility since you turned 18?
______ DURATION [RANGE: 0–999]
DK/REF
Version 4 - February 2017 (Post IRB Approval)
129
PR5
[IF PR3 = 1] Were you in a jail, prison, or correctional facility at any time during the
past 12 months?
1
Yes
2
No
DK/REF
PR6
[IF PR5 = 1] How long altogether were you in one of these facilities during the past 12
months?
1
2
3
4
5
6
PR7
A week or less
More than a week but less than 1 month
At least 1 month but less than 3 months
At least 3 months but less than 6 months
At least 6 months but less than 9 months
More than 9 months
DK/REF
[IF PR1 = 1] Were you on probation at any time during the past 12 months?
1
Yes
2
No
DK/REF
PR8
[IF PR1 = 1] Were you on parole, supervised release, or other conditional release from
prison at any time during the past 12 months?
1
Yes
2
No
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
130
23.
Homelessness
BEGIN TIME STAMP
HOM1
Now we would like to know about whether you have ever been homeless. Have you
ever had a time in your life when you considered yourself homeless?
1
Yes
2
No
DK/REF
HOM2[IF HOM1 = 1] Were you homeless in the last 5 years?
1
Yes
2
No
DK/REF
HOM2a
[IF HOM2 = 1] Were you homeless in the past 12 months?
1
Yes
2
No
DK/REF
HOM345
HOM3
HOM4
HOM5
DK/REF
HOM6
[IF HOM2a = 1] While you were homeless, did you ever sleep in…
a shelter for homeless people or in another temporary residence because
you did not have a place to stay?
a park, in an abandoned building, in the street, or in a train or bus
station?
a friend’s or relative’s home because you were homeless?
Yes
No
1
2
1
2
1
2
[IF HOM1 = 1] Altogether, how much of your life have you been homeless -- would
you say less than a week, more than a week but less than a month, more than a month
but less than a year, or more than a year?
1
Less than a week
2
More than a week but less than a month
3
More than a month but less than a year
4
More than a year
DK/REF
Version 4 - February 2017 (Post IRB Approval)
131
HOM7
[IF HOM2a = 1] Altogether, how much of the past 12 months have you been homeless?
1
Less than a week
2
At least a week but less than 1 month
3
At least 1 month but less than 3 months
4
At least 3 months but less than 6 months
5
At least 6 months but less than 9 months
6
9 months or more
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
132
24.
Head Injuries
BEGIN TIME STAMP
HINJ1
The next questions are about head or neck injuries that you had at any time in your life.
How many times in your life, including childhood and adulthood, did you have a head or
neck injury that…
Number of Times
[RANGE: 0 – 100]
HINJ1b
HINJ1c
HINJ1d
knocked you out, that is, you lost consciousness even if
only for a short time?
didn’t knock you out, but caused you to be dazed or
confused or to “see stars”?
caused you to have a lapse in memory of events, before,
during, or after the injury?
DK/REF
HINJ2 [IF HINJ1d ≥ 1] How many times in your life did you have a head or neck injury that caused
memory loss lasting…
Number of Times
[RANGE: 0 – 100]
HINJ2a
HINJ2b
HINJ2c
DK/REF
less than 30 minutes?
between 30 minutes and 24 hours?
more than 24 hours?
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
133
Eligibility for Part 2 Modules
Part 2 modules will be asked of all respondents who met CRS disorder threshold criteria for any
disorder plus a randomly chosen 25% of those who do not meet CRS threshold criteria for any
disorder. The random selection will take place once for each non-threshold respondent, not separately
for each Part 2 module. That is, a respondent is either administered all Part 2 modules or receive
none of the Part 2 modules.
DEFINE THRSHLD_PART2
IF ANY OF THE FOLLOWING ARE TRUE, THEN SET THRSHLD_PART2=1
Variable
Values
DE5_ASK=1
Disorder
Depression
Plain Language Description
Within the Depression module, the
respondent’s answers to the worst-2weeks symptoms qualified the
respondent to be asked age of onset and
other follow-up questions (DE5
onward).
HM5_ASK=1 Mania
Within Mania, answers qualified the
respondent to be asked age of onset and
other follow-up questions (HM5
onward).
AW5_ASK = Generalized Within the Anxiety and Worry module,
1
Anxiety
the respondent’s answers qualified
him/her to be asked age of onset and
other follow-up questions about anxiety
episodes (AW5 onward).
IF (SP5 = 1
Social
Within Social Anxiety, the
OR 2 OR DK Anxiety
respondent’s answers qualified him/her
OR REF)
to be asked age of onset and other
follow-up questions (SP6 onward).
AG4=1
Agoraphobia Within the Agoraphobia module the
respondent’s answers qualified him/her
to be asked age of onset and other
follow-up questions in the Agoraphobia
module (AG5 onward).
L5_ASK=1
Panic
Within the Panic Disorder module, the
Disroder
respondent’s answers qualified him or
her to be asked age of onset and other
follow-up questions about the
respondent’s attacks (L5 onward).
Version 4 - February 2017 (Post IRB Approval)
134
Variable
Values
EA25=1
Disorder
Eating
Disorders
(K1 ≥ 1 AND
(K1 NE (DK
OR REF)))
OR
(K12 ≥ 1
AND (K12
NE (DK OR
REF)))
Intermittent
Explosive
Disorder
SD15=1
Suicidality
BPD_P=1
BPD Screen
Plain Language Description
Within Eating Disorders, answers
qualified the respondent to be asked
age of onset for eating binges and other
follow-up questions (ED3 onward).
Within Intermittent Explosive
Disorder, answers qualified the
respondent to be asked age of onset and
other follow-up questions, for one or
both kinds of anger attack (nonviolent
or violent).
Within Suicidality, answer qualified
the respondent to be asked age of first
occurance regarding suicidality and
other follow-up questions (SD15aSD29, as applicable)
Within the BPD Screen module, the
respondent gave 7 or more “yes”
answers to current equivalents of the
items that were in the original 10-point
McLean Instrument for BPD.
ELSE, SET THRSHLD_PART2=0.
DEFINE RAND25
RANDOMLY SET RAND25=1 WITH 25% PROBABILITY,
ELSE SET RAND25=0.
DEFINE PART2_SHOW
SET PART2_SHOW=0,
IF THRSHLD_PART2=1, RESET PART2_SHOW=1.
IF THRSHLD_PART2=0 AND RAND25=1, THEN PART2_SHOW=1.
Version 4 - February 2017 (Post IRB Approval)
135
25.
Stressful Experiences (Post-Traumatic Stress Disorder)
BEGIN TIME STAMP
ONLY SHOW THIS MODULE IF PART2_SHOW=1
P1
The next questions are about highly stressful experiences that might have happened to you at
any time in your life. Have you ever had any of the following experiences?
You were threatened or attacked with a knife, gun, baseball bat, bomb, or other
weapon
P1b You were beaten up or physically assaulted
P1c You were sexually assaulted or raped
P1d You had combat experience in a war zone or region of terror
P1e You were kidnapped or held hostage
P1f You had a life-threatening illness or injury
P1g You were in a serious motor vehicle accident
P1h You had some other serious accident at home, work, or during recreational
activity
P1i You were in a life-threatening natural disaster, like a hurricane or earthquake
P1j You were in a life-threatening manmade disaster, like a fire, explosion, or toxic
chemical exposure
P1k You had some other experience that put you at serious risk of injury or death
P1l You witnessed a serious assault, murder, or suicide
P1m You witnessed a serious accidental injury or death
P1n You witnessed any other highly stressful situation where people were in pain,
suffering, dying, or dead
P1o You caused someone else to have serious suffering, injury, or death
P1p A close friend or relative experienced sudden violent death
P1q A close friend or relative experienced accidental death
P1r A close friend or relative had any other experience that put them at serious risk
of injury or death
DK/REF
P1a
Yes
No
1
2
1
1
1
1
1
1
2
2
2
2
2
2
1
2
1
2
1
2
1
1
1
2
2
2
1
2
1
1
1
2
2
2
1
2
DEFINE P2_FILL
IF P1a = 1 AND P1b NE 1 THEN P2_FILL = threatened or attacked with a weapon
IF P1a NE 1 and P1b = 1 THEN P2_FILL = beaten up
IF P1a = 1 AND P1b = 1 THEN P2_FILL = threatened or attacked with a weapon or beaten up
P2
[IF P1a = 1 OR P1b = 1] How many times in your life were you [P2_FILL]?
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
Version 4 - February 2017 (Post IRB Approval)
136
DEFINE P3_FILL
IF P2 = 1 THEN P3_FILL = when
ELSE P3_FILL = the first time
P3
[IF P2 NE 0 OR BLANK] How old were you [P3_FILL] you were [P2_FILL]?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P4
[IF P1c = 1] How many times in your life were you sexually assaulted or raped?
_____ NUMBER OF TIMES [RANGE: 0–100]
DK/REF
DEFINE P5_FILL
IF P4 = 1 THEN P5_FILL = when
ELSE P5_FILL = the first time
P5
[IF P4 NE 0 OR BLANK] How old were you [P5_FILL] you were sexually assaulted or raped?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P6
[IF P1d = 1] How old were you when you first had combat experience?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P7a
[IF P1d = 1] Now think about the amount of time you were in a combat zone or region of
terror. Would it be easiest for you to provide this time in the number of months or the number
of years?
1
Number of months
2
Number of years
DK/REF
DEFINE P7_FILL
IF P7a = 1 OR DK/REF THEN P7_FILL = months
IF P7a = 2 THEN P7_FILL = years
P7b
[IF P1d = 1] How many [P7_FILL] were you in a combat zone or region of terror?
_____ [P7_FILL] [RANGE: 0–999]
DK/REF
P8
[IF P1e = 1] How old were you when you were first kidnapped?
Version 4 - February 2017 (Post IRB Approval)
137
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P9a
[IF P1e = 1] Now think about the amount of time you were in captivity. Would it be easiest for
you to provide this time in the number of days, months, or years?
1
Number of days
2
Number of months
3
Number of years
DK/REF
DEFINE P9_FILL
IF P9a = 1 OR DK/REF THEN P9_FILL = days
IF P9a = 2 THEN P9_FILL = months
IF P9a = 3 THEN P9_FILL = years
P9b
[IF P1e = 1] How many [P9_FILL] were you in captivity?
_____ [P9_FILL] [RANGE: 0–999]
DK/REF
P10
[IF P1f = 1] How many times in your life have you had a life-threatening illness or injury?
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
DEFINE P11_FILL
IF P10 = 1 THEN P11_FILL = when
ELSE P11_FILL = the first time
P11
[IF P10 NE 0 OR BLANK] How old were you [P11_FILL] you had a life-threatening illness or
injury?
____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE P12_FILL
IF P1g = 1 OR P1h = 1 THEN P12_FILL = serious accident
IF P1i = 1 OR P1j = 1 THEN P12_FILL = life-threatening natural or manmade disaster
IF (P1g = 1 OR P1h = 1) AND (P1i = 1 OR P1j = 1) THEN P12_FILL = serious accident or lifethreatening natural or manmade disaster
P12
[IF P1g = 1 OR P1h = 1 OR P1i = 1 OR P1j = 1] How many times in your life have you been
in a [P12_FILL]?
Version 4 - February 2017 (Post IRB Approval)
138
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
DEFINE P13_FILL
IF P12 = 1 THEN P13_FILL = when
ELSE P13_FILL = the first time
P13
[IF P12 NE 0 OR BLANK] How old were you [P13_FILL] you were in a [P12_FILL]?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE P14_FILL
IF P1a = 1 OR P1b = 1 OR P1c = 1 OR P1d = 1 OR P1e = 1 OR P1f = 1 OR P1g = 1 OR P1h = 1 OR
P1i = 1 OR P1j = 1 THEN P14_FILL = any other
ELSE P14_FILL = an
P14
[IF P1k = 1] How many times in your life have you had [P14_FILL] experience that put you at
serious risk of injury or death?
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
DEFINE P15_FILL
IF P14 = 1 THEN P15_FILL = when
ELSE P15_FILL = the first time
P15
[IF P14 NE 0 OR BLANK] How old were you [P15_FILL] you had [P14_FILL] experience
that put you at serious risk of injury or death?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P16
[IF P1l = 1 OR P1m = 1 OR P1n = 1] How many times in your life have you witnessed a
serious assault, injury, death, or other highly stressful experience?
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
DEFINE P17_FILL
IF P16 = 1 THEN P17_FILL = when
ELSE P17_FILL = the first time
P17
[IF P16 NE 0 OR BLANK] How old were you [P17_FILL] you witnessed a serious assault,
injury, death, or other highly stressful experience?
Version 4 - February 2017 (Post IRB Approval)
139
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P18
[IF P1o = 1] How many times in your life have you done something that caused serious injury,
death, or suffering to someone else?
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
DEFINE P19_FILL
IF P18 = 1 THEN P19_FILL = when
ELSE P19_FILL = the first time
P19
[IF P18 NE 0 OR BLANK] How old were you [P19_FILL] you did something that caused
serious injury, death, or suffering to someone else?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE P20_FILL
IF P1p = 1 AND P1q NE 1 AND P1r NE 1 THEN P20_FILL = a sudden violent death
IF P1p NE1 AND P1q = 1 AND P1r NE 1 THEN P20_FILL = an accidental death
IF P1p NE 1 AND P1q NE 1 AND P1r = 1 THEN P20_FILL = an experience that put them at serious
risk of injury or death
IF P1p = 1 AND P1q = 1 AND P1r NE 1 THEN P20_FILL = a sudden violent death or an accidental
death
IF P1p = 1 AND P1q NE 1 AND P1r = 1 THEN P20_FILL = a sudden violent death or any other
experience that put them at serious risk of injury or death
IF P1p NE 1 AND Pq1 = 1 AND P1r = 1 THEN P20_FILL = an accidental death or any other
experience that put them at serious risk of injury or death
IF P1p = 1 AND P1q = 1 AND P1r = 1 THEN P20_FILL = a sudden violent death, an accidental
death, or any other experience that put them at serious risk of injury or death
P20
[IF P1p = 1 OR P1q = 1 OR P1r = 1] How many times in your life has one of your close
friends or relatives experienced [P20_FILL]?
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
DEFINE P21_FILL
IF P20 = 1 THEN P21_FILL = when
ELSE P21_FILL = the first time
P21
[IF P20 NE 0 OR BLANK] How old were you [P21_FILL] one of your close friends or
relatives experienced [P20_FILL]?
Version 4 - February 2017 (Post IRB Approval)
140
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P22
[IF P1a=1 OR P1b=1 OR P1c=1 OR P1d=1 OR P1e=1 OR P1f=1 OR P1g=1 OR P1h=1 OR
P1i=1 OR P1j=1 OR P1k=1 OR P1l=1 OR P1m=1 OR P1n=1 OR P1o=1 OR P1p=1 OR
P1q=1 OR P1r=1] Highly stressful experiences can cause upsetting reactions that often last for
months or even years after the experiences occur. In the past 30 days, how much were you
bothered by…
P22a repeated, disturbing, and
unwanted memories of a
highly stressful experience?
P22b strong physical reactions when
something reminded you of a
highly stressful experience, for
example, heart pounding,
trouble breathing, or sweating?
P22c avoiding memories, thoughts,
or feelings related to a highly
stressful experience?
P22d avoiding external reminders of
a highly stressful experience,
for example, people, places,
conversations, activities,
objects, or situations?
P22e difficulty concentrating?
P22f feeling jumpy or easily
startled?
P22g serious psychological distress
because of your reactions to a
highly stressful experience?
P22h interference with your work or
personal life because of your
reactions to a highly stressful
experience?
DK/REF
P23
Extremely
Quite
a Bit
Moderately
A Little
Bit
Not at
All
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
[IF P1a=1 OR P1b=1 OR P1c=1 OR P1d=1 OR P1e=1 OR P1f=1 OR P1g=1 OR P1h=1 OR
P1i=1 OR P1j=1 OR P1k=1 OR P1l=1 OR P1m=1 OR P1n=1 OR P1o=1 OR P1p=1 OR
P1q=1 OR P1r=1] Think of a month in your life when you had the largest number of
Version 4 - February 2017 (Post IRB Approval)
141
reactions like these to a highly stressful experience. During that month, how much were you
bothered by…
P23a repeated, disturbing, and
unwanted memories of a
stressful experience?
P23b having strong physical
reactions when something
reminded you of a stressful
experience, like heart
pounding, trouble breathing, or
sweating?
P23c avoiding memories, thoughts,
or feelings related to a highly
stressful experience?
P23d avoiding external reminders of
a stressful experience, like
people, places, or activities
that reminded you of an
experience?
P23e having difficulty
concentrating?
P23f feeling jumpy or easily
startled?
DK/REF
Extremely
Quite
a Bit
Moderately
A Little
Bit
Not at
All
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE P24LOGIC
IF 2 OR MORE IN THE P23 SERIES = 1, 2, OR 3 THEN P24LOGIC = 1
ELSE P24LOGIC = 0
P24
[IF P24LOGIC = 1] Still thinking about that same month in your life when you had the largest
number of reactions to a highly stressful experience, how much were you bothered by…
P24a repeated, disturbing dreams of
a stressful experience?
P24b suddenly feeling or acting as if
a stressful experience were
happening again, like you
were actually back there
reliving it?
Version 4 - February 2017 (Post IRB Approval)
Extremely
Quite
a Bit
Moderately
A Little
Bit
Not at
All
1
2
3
4
5
1
2
3
4
5
142
P24c feeling very upset when
something reminded you of a
stressful experience?
P24d trouble falling or staying
asleep?
P24e feeling irritable, having angry
outbursts, or acting
aggressively?
P24f taking too many risks or doing
things that could cause you
harm?
P24g being “super-alert” or
watchful or on guard?
P24h having amnesia or trouble
remembering important parts
of a stressful experience?
P24i blaming yourself or someone
else for a stressful experience
or what happened after it?
P24j having strong negative beliefs
about yourself, other people,
or the world, like thoughts that
you are bad, that no one can
be trusted, or that the world is
completely dangerous?
P24k having strong negative
feelings such as fear, horror,
anger, guilt, or shame?
P24l losing interest in activities that
you used to enjoy?
P24m feeling distant or cut off from
other people?
P24n having trouble experiencing
positive feelings, like being
unable to have loving feelings
for people close to you, or
feeling emotionally numb?
DK/REF
Extremely
Quite
a Bit
Moderately
A Little
Bit
Not at
All
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE P25LOGIC
IF ALL OF THE FOLLOWING CONDITIONS ARE MET:
P23a < 4 OR P23b < 4 OR P24a < 4 OR P24b < 4 OR P24c < 4
P23c < 4 OR P23d < 4
Version 4 - February 2017 (Post IRB Approval)
143
2 OR MORE OF P24h-P24n < 4
2 OR MORE OF P23e, P23f, P24d, P24e, P24f, P24g < 4
THEN P25LOGIC = 1
ELSE P25LOGIC = 0
P24o [IF P25LOGIC = 1] You mentioned being bothered by a number of reactions. How much
psychological distress did these reactions cause?
1
None
2
Mild
3
Moderate
4
Severe
5
Very severe
DK/REF
P25
[IF P25LOGIC = 1] About how old were you the very first time you had a month or longer
when you had reactions like these to a highly stressful experience? Your best estimate is fine if
you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE P26 LOGIC
IF CURNTAGE – P25 = 1 THEN P26LOGIC = 0
IF CURNTAGE = P25 THEN P26LOGIC = 0
ELSE P26LOGIC = 1
P26
[IF (P25LOGIC = 1) AND (P26LOGIC = 1)] About how many years in your life have you had
at least one month when you had reactions like these? Your best estimate is fine if you cannot
remember the exact number.
_______NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
P27
[IF P25LOGIC = 1] During about how many months in the past 12 months have you had
reactions like these? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
P28
[IF P27 < 1 OR P27 = DK/REF] About how old were you the most recent time you had a
month of that sort? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
Version 4 - February 2017 (Post IRB Approval)
144
P29
[IF P25LOGIC = 1] How much did these reactions ever interfere with your work or personal
life?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
P30
Have you had any of the following stressful life events in the past 12 months?
P30_1
P30_2
P30_3
P30_4
P30_5
P30_6
P30_7
P30_8
P30_9
P30_10
P30_11
P30_12
P30_13
P30_14
P30_15
P30_16
DK/REF
Serious illness or injury
Separation, divorce, or other serious romantic breakup
Breakup or falling out with a close friend or relative
Betrayal by someone close to you
Job loss
Any other major financial crisis
A break-in or burglary of your home, car, or workplace
You were the victim of a mugging or armed robbery
[IF P1b NE 2] You were physically assaulted
[IF P1c NE 2] You were sexually assaulted or raped
You got into serious trouble with the police (e.g., arrested)
You got into serious legal trouble (e.g., an audit, a lawsuit)
Someone very close to you died
Someone very close to you had a life-threatening illness or injury
Someone very close to you had some other serious life crisis
Something else
Yes
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
No
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
P30a [IF P30_16 = 1] Please type in a brief description of any other stressful life events you have
had in the past 12 months.
______________________________[ALLOW 50 CHARACTERS]
P31
On a 0-to-10 scale where 0 means “No Stress” and 10 means “Very Severe Stress,” how much
stress do you currently have in each of the following areas of your life?
Version 4 - February 2017 (Post IRB Approval)
145
P31a Your financial
situation
P31b Your career
P31c Your health
P31d Your love life
P31e Your relationships
with close family
and friends
P31f The health of your
loved ones
P31g Other problems
experienced by your
loved ones
P31h Problems getting
along with people at
work and in your
community
P31i Your life overall
DK/REF
P32
No
Stress
0
1
Mild
2
0
1
0
0
0
Very
Severe
Stress
10
3
Moderate
4
5
6
Severe
7
8
9
2
3
4
5
6
7
8
9
10
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
7
7
7
8
8
8
9
9
9
10
10
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
People differ a lot in how they handle stress. How would you rate your ability to handle stress
in each of the following ways?
P32a Your ability to keep calm and
think of the right thing to do in a
crisis
P32b Your ability to manage stress
P32c Your ability to try new
approaches if old ones don’t work
P32d Your ability to get along with
people when you have to
P32e Your ability to keep your sense of
humor in tense situations
DK/REF
Excellent
Very Good
Good
Fair
Poor
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
146
26.
Family Medical History (ACE)
BEGIN TIME STAMP
ONLY SHOW THIS MODULE IF PART2_SHOW=1
FMIN
These next questions are about your biological mother. Are you able to answer
questions about your biological mother?
1
Yes
2
No
DK/REF
FM2a
[IF FMIN = 1] Is your biological mother still living?
1
Yes
2
No
DK/REF
FM2b
[IF FM2a = 2] How old was your mother at the time of her death?
__________ YEARS OLD [RANGE: 0–100]
DK/REF
FM2
[IF FM2a = 1 OR DK OR REF] What is your biological mother’s current age?
__________ YEARS OLD [RANGE: 0–100]
DK/REF
FM3
[IF FMIN = 1] What was the last grade or year of school your biological mother
completed?
0
1
2
3
4
5
6
7
8
9
10
11
No schooling completed
1st grade completed
2nd grade completed
3rd grade completed
4th grade completed
5th grade completed
6th grade completed
7th grade completed
8th grade completed
9th grade completed
10th grade completed
11th grade completed
Version 4 - February 2017 (Post IRB Approval)
147
12
13
14
15
16
17
18
19
20
Regular high school diploma
12th grade, no diploma
GED certificate of high school completion
Some college credit, but no degree
Associate’s degree, for example, AA or AS
Bachelor’s degree, for example, BA or BS
Master’s degree, for example, MA, MS, MENG, M. ED, MSW, or MBA
Doctorate degree, for example, PHD or EDD
Professional degree beyond a bachelor’s degree, for example, MD, DDS, DVM,
LLB, or JD
DK/REF
DEFINE FM4_FILL
IF FM2a = 1 OR DK OR REF, THEN FM4_FILL = “currently has or has ever had”
IF FM2a = 2, THEN FM4_FILL = “ever had”
FM4
FM4a
FM4b
FM4c
FM4d
FM4e
DK/REF
FMIN2
[IF FMIN = 1] Please indicate whether your biological mother [FM4_FILL] any of the
following conditions.
Autism spectrum disorder, including Asperger’s
Bipolar disorder, also known as manic depression
An anxiety disorder such as phobia, panic disorder, generalized anxiety
disorder, post-traumatic stress disorder, or any other anxiety disorder
Depression
Schizophrenia
Yes
1
1
No
2
2
1
2
1
1
2
2
These next questions are about your biological father. Are you able to answer
questions about your biological father?
1
Yes
2
No
DK/REF
FM5a
[IF FMIN2 = 1] Is your biological father still living?
1
Yes
2
No
DK/REF
FM5b
[IF FM5a = 2] How old was your father at the time of his death?
__________ YEARS OLD [RANGE: 0–100]
Version 4 - February 2017 (Post IRB Approval)
148
DK/REF
FM6
[IF FM5a = 1 OR DK OR REF] What is your biological father’s current age?
__________ YEARS OLD [RANGE 1–100]
DK/REF
FM7
[IF FMIN2 = 1] What was the last grade or year of school your biological father
completed?
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
No schooling completed
1st grade completed
2nd grade completed
3rd grade completed
4th grade completed
5th grade completed
6th grade completed
7th grade completed
8th grade completed
9th grade completed
10th grade completed
11th grade completed
Regular high school diploma
12th grade, no diploma
GED certificate of high school completion
Some college credit, but no degree
Associate’s degree, for example, AA or AS
Bachelor’s degree, for example, BA or BS
Master’s degree, for example, MA, MS, MENG, M. ED, MSW or MBA
Doctorate degree, for example, PHD or EDD
Professional degree beyond a bachelor’s degree, for example, MD, DDS, DVM,
LLB or JD
DK/REF
DEFINE FM8_FILL
IF FM5a = 1 OR DK OR REF, THEN FM8_FILL = “currently has or has ever had”
IF FM5a = 2, THEN FM8_FILL = “ever had”
FM8
FM8a
FM8b
FM8c
[IF FMIN2 = 1] Please indicate whether your biological father [FM8_FILL] any of the
following conditions.
Autism spectrum disorder, including Asperger’s
Bipolar disorder, also known as manic depression
An anxiety disorder such as phobia, panic disorder, generalized anxiety
disorder, post-traumatic stress disorder, or any other anxiety disorder
Version 4 - February 2017 (Post IRB Approval)
Yes
1
1
No
2
2
1
2
149
FM8d
FM8e
DK/REF
FM9
Depression
Schizophrenia
Yes
1
1
No
2
2
The next questions are about any siblings you may have. For these questions, please
think about siblings who are alive as well as those who are no longer living.
Do you have, or have you ever had, any siblings?
1
Yes
2
No
DK/REF
FM9a
[IF FM9 = 1] How many of your siblings are full siblings?
A full sibling is a brother or sister who has the same biological mother and biological
father as you.
_________ [RANGE: 0 – 25]
DK/REF
FM9b
[IF FM9 = 1] How many of your siblings are half siblings?
A half sibling is a brother or sister with whom you share one biological parent.
________ [RANGE: 0 – 25]
DK/REF
DEFINE FULLSIB
IF FM9a > 0 THEN FULLSIB = FM9a
ELSE FULLSIB = BLANK
DEFINE HALFSIB
IF FM9b > 0 THEN HALFSIB = FM9b
ELSE HALFSIB = BLANK
FM10
[IF FULLSIB NE BLANK AND HALFSIB NE BLANK] Please indicate whether any of
your full or half siblings currently have or have ever had any of the following conditions.
[IF FULLSIB = 1 AND HALFSIB = BLANK] Please indicate whether your full sibling
currently has or has ever had any of the following conditions.
[IF FULLSIB > 1 AND HALFSIB = BLANK] Please indicate whether any of your full
siblings currently have or have ever had any of the following conditions.
Version 4 - February 2017 (Post IRB Approval)
150
[IF FULLSIB = BLANK and HALFSIB = 1] Please indicate whether your half sibling
currently has or has ever had any of the following conditions.
[IF FULLSIB = BLANK and HALFSIB > 1] Please indicate whether any of your half
siblings currently have or have ever had any of the following conditions.
FM10a
FM10b
FM10c
FM10d
FM10e
DK/REF
FM11
Autism spectrum disorder, including Asperger’s
Bipolar disorder, also known as manic depression
An anxiety disorder such as phobia, panic disorder, generalized
anxiety disorder, post-traumatic stress disorder, or any other
anxiety disorder
Depression
Schizophrenia
Yes
1
1
No
2
2
1
2
1
1
2
2
[IF (FULLSIB ≥ 1 AND HALFSIB ≥ 1) AND FM10a = 1] You reported having a sibling
with autism spectrum disorder. Is it a full sibling, half sibling, or both that currently has or
has ever had autism spectrum disorder?
1 [IF FULLSIB = 1, FILL: “Full sibling”] [IF FULLSIB > 1, FILL: “Full sibling or
siblings”]
2 [IF HALFSIB = 1, FILL: “Half sibling” [IF HALFSIB > 1, FILL: “Half sibling or
siblings”]
3 Both full and half siblings
DK/REF
FM12
[IF (FULLSIB ≥ 1 AND HALFSIB ≥ 1) AND FM10b = 1] You reported having a sibling
with bipolar disorder, also known as manic depression. Is it a full sibling, half sibling, or
both that currently has or has ever had bipolar disorder?
1 [IF FULLSIB = 1, FILL: “Full sibling”] [IF FULLSIB > 1, FILL: “Full sibling or
siblings”]
2 [IF HALFSIB = 1, FILL: “Half sibling” [IF HALFSIB > 1, FILL: “Half sibling or
siblings”]
3 Both full and half siblings
DK/REF
FM13
[IF (FULLSIB≥ 1 AND HALFSIB ≥ 1) AND FM10c = 1] You reported having a sibling
with an anxiety disorder, such as phobia, panic disorder, generalized anxiety disorder, or
post-traumatic stress disorder.
Version 4 - February 2017 (Post IRB Approval)
151
Is it a full sibling, half sibling, or both that currently has or has ever had an anxiety
disorder?
1 [IF FULLSIB = 1, FILL: “Full sibling”] [IF FULLSIB > 1, FILL: “Full sibling or
siblings”]
2 [IF HALFSIB = 1, FILL: “Half sibling” [IF HALFSIB > 1, FILL: “Half sibling or
siblings”]
3 Both full and half siblings
DK/REF
FM14
[IF (FULLSIB ≥ 1 AND HALFSIB ≥ 1) AND FM10d = 1] You reported having a sibling
with depression.
Is it a full sibling, half sibling, or both that currently has or has ever had depression?
1 [IF FULLSIB = 1, FILL: “Full sibling”] [IF FULLSIB > 1, FILL: “Full sibling or
siblings”]
2 [IF HALFSIB = 1, FILL: “Half sibling” [IF HALFSIB > 1, FILL: “Half sibling or
siblings”]
3 Both full and half siblings
DK/REF
FM15
[IF (FULLSIB ≥ 1 AND HALFSIB ≥ 1) AND FM10e = 1] You reported having a sibling
with schizophrenia.
Is it a full sibling, half sibling, or both that currently has or has ever had schizophrenia?
1 [IF FULLSIB = 1, FILL: “Full sibling”] [IF FULLSIB > 1, FILL: “Full sibling or
siblings”]
2 [IF HALFSIB = 1, FILL: “Half sibling” [IF HALFSIB > 1, FILL: “Half sibling or
siblings”]
3 Both full and half siblings
DK/REF
FM16
Next we would like to ask your opinion about how likely you think various events
might be. For each question, we’d like for you to give a number from 0 to 100, where
"0" means you think there is absolutely no chance, and "100" means that you think the
event is absolutely sure to happen. You can choose any number from 0 to 100. The
larger the number, the more likely you think it is that the event will happen. The
smaller the number, the less likely you think it is that the event will happen.
[IF CURNTAGE < 75] On the scale from 0 to 100, what is the percent chance that you
will live to the age of 75 or older?
____________ [RANGE: 0–100]
Version 4 - February 2017 (Post IRB Approval)
152
DK/REF
FM17
[IF B13b = 2 AND (DE3_COUNT < 5 AND DE3_COUNTA < 1) AND
(DE4_COUNT < 5 AND DE4_COUNTA < 1)] On the scale from 0 to 100, what is the
percent chance that you will become seriously depressed in your lifetime?
____________ [RANGE: 0–100]
DK/REF
FM18
On a different topic, there have been a lot of national and world events and changes
over the past 90 or so years— -- say, from about 1930 right up until today. Please use
the keyboard to type one or two such events or changes that seem to you to have been
especially important. When you are finished, press [ENTER] to continue.
_______________________ [LIMIT TO 150 CHARACTERS]
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
153
27.
Tobacco, Alcohol, Drugs, and Treatment
BEGIN TIME STAMP
ONLY SHOW THIS MODULE IF PART2_SHOW=1
TAD1 The next questions are about your use of tobacco, alcohol, and drugs.. Have you ever in your
life used any of the following substances, even if it was only one time?
Yes
TAD1a
TAD1c
TAD1f
TAD1g
TAD1h
TAD1i
TAD1j
No
A cigarette, cigar, pipe, snuff, or smokeless tobacco?
A drink of alcohol, such as beer, wine, wine cooler,
shot of liquor, or mixed drink?
Marijuana or hashish?
Any other kind of illegal drug, such as cocaine,
ecstasy, speed, LSD, or poppers?
A prescription stimulant, such as Adderall,
amphetamines, or diet pills, on your own, that is
without a doctor’s prescription or in any way a doctor
did not direct you to use it?
A prescription tranquilizer or muscle relaxer, such as
Ativan, Valium, or sedatives, such as Ambien, on your
own?
A prescription pain reliever, such as Codeine or
OxyContin, on your own?
DK/REF
TAD2
[IF TAD1a = 1] About how old were you the very first time you smoked a cigarette, cigar,
or pipe, or used snuff, or smokeless tobacco?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD3
[IF TAD1a = 1] In the past 12 months, how often did you use any tobacco product, such as
a cigarette, cigar, pipe, snuff, or smokeless tobacco?
1 4-7 days a week
2 2-3 days a week
3 2-4 days a month
4 Monthly or less
5 Haven’t Used in Past 12 Months
DK/REF
Version 4 - February 2017 (Post IRB Approval)
154
TAD4 [IF TAD3 NE 5] On the days you used tobacco products in the past 12 months, about how
many cigarettes, cigars, pipes, dips, or chews did you usually have per day?
_____ NUMBER PER DAY [RANGE: 1–70]
DK/REF
TAD5 [IF TAD1a = 1] Have you ever used tobacco products at least once a week for a full 12
months?
1 Yes
2 No
DK/REF
TAD6 [IF TAD5 = 1] About how old were you the very first time you used tobacco products at
least once a week for a full 12 months?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD7 [IF TAD1c = 1] About how old were you when you had your first drink of alcohol, such as
beer, wine, a wine cooler, a shot of liquor, or a mixed drink?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD8 [IF TAD1c = 1] In the past 12 months, how often did you have at least 1 drink of alcohol?
1
4-7 days a week
2
2-3 days a week
3
2-4 days a month
4
Monthly or less
5
Never
DK/RE
TAD9 [IF TAD8 NE 5] On the days you used alcohol in the past 12 months, about how many
drinks did you usually have per day?
_____ NUMBER OF DRINKS PER DAY [RANGE: 1–50]
DK/REF
TAD10 [IF TAD1c = 1] Have you ever drank alcohol at least once a month for a full year?
1 Yes
2 No
DK/REF
Version 4 - February 2017 (Post IRB Approval)
155
TAD11 [IF TAD10 = 1] About how old were you the very first time you drank alcohol at least once a
month for a full year?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD12 [IF TAD1c = 1] Have you ever had [IF QD01 = 5 FILL: five; IF QD01 = 9 FILL: four] or
more drinks of alcohol on the same day?
1 Yes
2 No
DK/REF
TAD13 [IF TAD12 = 1] About how old were you the very first time you had [IF QD01 = 5 FILL:
five; IF QD01 = 9 FILL: four] or more drinks of alcohol on the same day?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD14 [IF TAD1f = 1] About how old were you the very first time you used marijuana or hashish?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD15 [IF TAD1f = 1] In the past 12 months, how often did you use marijuana or hashish….
1
4-7 days a week
2
2-3 days a week
3
2-4 days a month
4
Monthly or less
5
Never
DK/REF
TAD16 [IF TAD1g = 1] About how old were you the very first time you used any other kind of
illegal drug, such as cocaine, ecstasy, speed, LSD, or poppers?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD17 [IF TAD1g = 1] In the past 12 months, how often did you use any other kind of illegal drug?
1
2
3
4
4-7 days a week
2-3 days a week
2-4 days a month
Monthly or less
Version 4 - February 2017 (Post IRB Approval)
156
5
Never
DK/REF
TAD18 [IF TAD1h = 1] About how old were you the very first time you used a prescription
stimulant, such as Adderall, amphetamines, or diet pills, on your own, that is without a
doctor’s prescription or in any way a doctor did not direct you to use it?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD19 [IF TAD1h = 1] In the past 12 months, how often did you use a prescription stimulant on
your own?
1
4-7 days a week
2
2-3 days a week
3
2-4 days a month
4
Monthly or less
5
Never
DK/REF
TAD20 [IF TAD1i = 1] About how old were you the very first time you used a prescription
tranquilizer or muscle relaxer, such as Ativan, Valium, or sedatives, such as Ambien, on your
own?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD21 [IF TAD1i = 1] In the past 12 months, how often did you use a prescription tranquilizer,
muscle relaxer or sedative on your own?
1
4-7 days a week
2
2-3 days a week
3
2-4 days a month
4
Monthly or less
5
Never
DK/REF
TAD22 [IF TAD1j = 1] About how old were you the very first time you used a prescription pain
reliever, such as Codeine or OxyContin, on your own?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD23 [IF TAD1j = 1] In the past 12 months, how often did you use a prescription pain reliever on
your own?
Version 4 - February 2017 (Post IRB Approval)
157
1
4-7 days a week
2
2-3 days a week
3
2-4 days a month
4
Monthly or less
5
Never
DK/REF
TAD24 [IF TAD1c = 1] Think of the time in your life when you used the most alcohol. During that
time, how often did you drink?
1
4–7 days a week
2
2–3 days a week
3
2–4 days a month
4
Monthly or less
DK/REF
TAD25 [IF TAD1c = 1 ] On the days you used alcohol during that time in your life, about how many
drinks did you usually have per day?
_____ NUMBER OF DRINKS PER DAY [RANGE: 1–50]
DK/REF
TAD26 [IF (TAD8 = 1) OR (TAD8 = 2 AND TAD9 ≥ 2) OR (TAD8 = 3 AND TAD9 ≥ 3) OR
(TAD8 = 4 AND TAD9 ≥ 5) OR (TAD12 = 1) OR (TAD24 = 1) OR (TAD24 = 2 AND
TAD25 ≥ 2) OR (TAD24 = 3 AND TAD25 ≥ 3) OR (TAD24 = 4 AND TAD25 ≥ 5)] In
answering the next questions, think of the one year in your life when your use of alcohol
interfered most with your life. During that year, how often did you have each of the following
problems?
TAD26a Your drinking or being hung over
interfered with your
responsibilities at school, home,
or work?
TAD26b You continued drinking even
when it caused problems with
your family, friends, neighbors, or
co-workers?
TAD26c You were under the influence in
hazardous situations, like when
driving or operating a machine?
Version 4 - February 2017 (Post IRB Approval)
4-7
Days a
Week
2-3
Days a
Week
2-4
Days a
Month
Monthly
or Less
Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
158
TAD26d You either drank more or spent
more time drinking than you
intended when you started?
TAD26e You greatly reduced important
activities with family, friends, or
at work because of your drinking?
DK/REF
4-7
Days a
Week
2-3
Days a
Week
2-4
Days a
Month
Monthly
or Less
Never
1
2
3
4
5
1
2
3
4
5
DEFINE TAD26_COUNT
SET TAD26_COUNT = 0
IF TAD26a = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD26_COUNT
IF TAD26b = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD26_COUNT
IF TAD26c = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD26_COUNT
IF TAD26d = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD26_COUNT
IF TAD26e = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD26_COUNT
DEFINE TAD27RAND = random number between 0.00–1.00
TAD27 [IF TAD26_COUNT ≥ 1 OR (TAD26_COUNT = 0 AND TAD27RAND ≤ 0.10)] Still
thinking about the one year in your life when your use of alcohol interfered most with your
life, how often during that year did you have each of these other problems?
TAD27a You tried to cut down or control
your drinking but were unable to
do so?
TAD27b You spent a great deal of time
drinking or recovering from
drinking?
TAD27c You had such a strong desire or
craving to drink that you couldn’t
think of anything else?
TAD27d You continued to drink even when
it caused physical or emotional
health problems?
Version 4 - February 2017 (Post IRB Approval)
4-7
Days a
Week
2-3
Days a
Week
2-4
Days a
Month
Monthly
or Less
Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
159
TAD27e You developed alcohol tolerance,
that is, either the same amount no
longer had the same effect or you
needed to drink a lot more to get
the same effect?
TAD27f You experienced withdrawal
symptoms like fatigue, headaches,
diarrhea, the shakes, or emotional
problems when you tried to cut
down your drinking?
TAD27g You continued to drink in order to
avoid having withdrawal
symptoms?
DK/REF
4-7
Days a
Week
2-3
Days a
Week
2-4
Days a
Month
Monthly
or Less
Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE TAD28_COUNT
SET TAD28_COUNT = 0
IF TAD26a = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD26b = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD26c = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD26d = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD26e = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27a = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27b = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27c = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27d = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27e = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27f = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27g = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
DEFINE TAD28_FILL
IF TAD28_COUNT = 2 THEN TAD28_FILL = “these problems”
ELSE TAD28_FILL = “at least two of these problems”
TAD28
[IF TAD28_COUNT ≥ 2] You reported [TAD28_COUNT] problems associated with your
alcohol use. About how old were you the very first time you had [TAD28_FILL] in the
same year? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
Version 4 - February 2017 (Post IRB Approval)
160
TAD29
[IF TAD28 = (CURNTAGE – 1)] Did that start in the past 12 months or more than 12
months ago?
1 In the past 12 months
2 More than 12 months ago
DK/REF
TAD30
[IF (TAD28_COUNT ≥ 2) AND TAD28 NE CURNTAGE AND NE (CURNTAGE – 1)]
About how many years in your life did you have [TAD28_FILL] in the same year? Your
best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF YEARS [RANGE: 1–(CURNTAGE – 2)]
DK/REF
TAD31
[IF TAD28_COUNT ≥ 2] During about how many months in the past 12 months did you
have these problems? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
TAD32
[(TAD28_COUNT ≥ 2) AND TAD31 NE 1–12] About how old were you the most recent
time you had [TAD28_FILL] in the same year? Your best estimate is fine if you cannot
remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TAD33A_FILL
IF TAD1f OR TAD1g OR TAD1h OR TAD1i OR TAD1j = 1 THEN TAD33A_FILL = “also”
ELSE TAD33A_FILL = “”
DEFINE TAD33B_FILL
IF TAD1f = 1, TAD33B_FILL: “marijuana or hashish (and/,)”
IF TAD1g = 1, TAD33B_FILL: “other illegal drugs (and/,)”
IF TAD1h = 1, TAD33B_FILL: “prescription stimulants (and/,)”
IF TAD1i = 1, TAD33B_FILL: “prescription tranquilizers (and/,)”
IF TAD1j = 1, TAD33B_FILL: “prescription pain relievers”
DEFINE TAD33C_FILL
IF TAD1f = 1 AND TAD1g-TAD1j = 2 OR DK OR REF, TAD33C_FILL: “marijuana or hashish”
IF TAD1h = 1 AND TAD1f AND TAD1g AND TAD1i AND TAD1j = 2 OR DK OR REF,
TAD33C_FILL: “prescription stimulant”
IF TAD1i = 1 AND TAD1f AND TAD1g AND TAD1h AND TAD1j = 2 OR DK OR REF,
TAD33C_FILL: “prescription tranquilizer”
IF TAD1j = 1 AND TAD1f AND TAD1g AND TAD1h AND TAD1i = 2 OR DK OR REF,
TAD33C_FILL: “prescription pain reliever”
Version 4 - February 2017 (Post IRB Approval)
161
ELSE TAD33C_FILL: drug
TAD33
[IF TAD1f OR TAD1g OR TAD1h OR TAD1i OR TAD1j = 1] You [TAD33A_FILL]
reported using [TAD33B_FILL]. In answering the next questions, think of the one year in
your life when your [TAD33C_FILL] use interfered most with your life. During that year,
how often did you have each of the following problems?
TAD33a Your [TAD33C_FILL] use or
being under the influence
interfered with your
responsibilities at school, home,
or work?
TAD33b You continued to use even when
it caused problems with your
family, friends, neighbors, or coworkers?
TAD33c You were under the influence in
hazardous situations, like when
driving or operating a machine?
TAD33d You either used more or spent
more time using than you
intended when you started?
TAD33e You greatly reduced important
activities with family, friends, or
at work because of your use?
DK/REF
4-7
Days a
Week
2-3
Days a
Week
2-4
Days a
Month
Monthly
or Less
Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE TAD33_COUNT
SET TAD33_COUNT = 0
IF TAD33a = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD33_COUNT
IF TAD33b = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD33_COUNT
IF TAD33c = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD33_COUNT
IF TAD33d = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD33_COUNT
IF TAD33e = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD33_COUNT
DEFINE TAD34RAND = random number between 0.00–1.00
TAD34
[IF TAD33_COUNT ≥ 1 OR (TAD33_COUNT = 0 AND TAD34RAND ≤ 0.10] Still
thinking about the one year in your life when your [TAD33C_FILL] use interfered most
with your life, how often during that year did you have each of these other problems?
Version 4 - February 2017 (Post IRB Approval)
162
TAD34a You tried to cut down or control
your use but were unable to do
so?
TAD34b You spent a great deal of time
using or recovering from use?
TAD34c You had such a strong desire or
craving to use that you couldn’t
think of anything else?
TAD34d You continued to use even when it
caused physical or emotional
health problems?
TAD34e You experienced
[TAD33C_FILL] tolerance, that
is, either the same amount no
longer had the same effect or you
needed to use a lot more to get the
same effect?
TAD34f You experienced withdrawal
symptoms like trouble sleeping,
emotional problems, restlessness,
sweating or nausea when you tried
to cut down your use?
TAD34g You continued to use in order to
avoid having withdrawal
symptoms?
DK/REF
4-7
Days a
Week
2-3
Days a
Week
2-4
Days a
Month
Monthly
or Less
Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE TAD35_COUNT
SET TAD35_COUNT = 0
IF TAD33a = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD33b = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD33c = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD33d = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD33e = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34a = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34b = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34c = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34d = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34e = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34f = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34g = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
Version 4 - February 2017 (Post IRB Approval)
163
DEFINE TAD35_FILL
IF TAD35_COUNT = 2 THEN TAD35_FILL = “these problems”
IF TAD35_COUNT > 2 THEN TAD35_FILL = “at least two of these problems”
TAD35
[IF TAD35_COUNT ≥ 2] You reported [TAD35_COUNT] problems associated with your
drug use. About how old were you the very first time you had [TAD35_FILL] in the same
year? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TAD36
[IF TAD35 = (CURNTAGE – 1)] Did that episode start in the past 12 months or more than
12 months ago?
1 In the past 12 months
2 More than 12 months ago
DK/REF
TAD37
[IF (TAD35_COUNT ≥ 2) AND TAD35 NE CURNTAGE AND (TAD35 NE
(CURNTAGE – 1))] About how many years in your life did you have [TAD35_FILL] in the
same year? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF YEARS [RANGE: 1–(CURNTAGE – 2)]
DK/REF
TAD38
[IF TAD35_COUNT ≥ 2] During about how many months out of the past 12 did you have
these problems? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
TAD39
[IF (TAD35_COUNT ≥ 2) AND TAD38 NE (1–12)] About how old were you the most
recent time you had these problems because of your drug use? Your best estimate is fine if
you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TAD40_FILL
IF TAD28_COUNT ≥ 2 AND TAD35_COUNT ≥ 2 THEN TAD40_FILL = “alcohol or drug use”
IF TAD28_COUNT ≥ 2 AND TAD35_COUNT < 2 THEN TAD40_FILL = “alcohol use”
IF TAD28_COUNT < 2 AND TAD35_COUNT ≥ 2 THEN TAD40_FILL = “drug use”
TAD40
[IF ((TAD28_COUNT ≥ 2) OR (TAD35_COUNT ≥ 2) ] The next questions are about
treatment.
Version 4 - February 2017 (Post IRB Approval)
164
Have you ever in your life stayed overnight or longer in a substance abuse treatment center or
hospital to receive treatment for problems with [TAD40_FILL]?
1 Yes
2 No
DK/REF
TAD41
[IF TAD40 = 1] How many times were you hospitalized for problems with [TAD40_FILL]?
Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF TIMES [RANGE: 1–100]
DK/REF
DEFINE TAD42_FILL
IF TAD41 = 1 THEN TAD42_FILL = “when that happened?”
ELSE TAD42_FILL = “the first time you were hospitalized for those problems?”
TAD42
[IF TAD40=1] How old were you [TAD42_FILL]?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TAD43_FILL
IF TAD41 = 1 THEN TAD43_FILL = “that”
ELSE TAD43_FILL = “your first hospitalization”
TAD43
[IF TAD42 = (CURNTAGE – 1)] Did [TAD43_FILL] start in the past 12 months or more
than 12 months ago?
1 In the past 12 months
2 More than 12 months ago
DK/REF
TAD44
[IF TAD40 =1] How many nights in the past 12 months were you in a hospital for problems
with [TAD40_FILL]? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF NIGHTS IN A HOSPITAL [RANGE: 0–365]
DK/REF
TAD45
[IF TAD44 < 1 OR TAD42 NE CURNTAGE] About how old were you the most recent
time you were in a hospital overnight for problems with [TAD40_FILL]? Your best
estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 1–(CURNTAGE – 1)]
DK/REF
Version 4 - February 2017 (Post IRB Approval)
165
DEFINE TAD46_FILL
IF TAD40 = 1 AND TAD41 = 1 TAD46_FILL: “Not counting the time when you were hospitalized,
have”
IF TAD40 = 1 AND TAD41 NE 1 TAD46_FILL: “Not counting times when you were hospitalized,
have”
ELSE TAD46_FILL: “Have”
TAD46
[IF (TAD28_COUNT ≥ 2) OR (TAD35_COUNT ≥ 2)] People can receive treatment for
problems with [TAD40_FILL] by attending a self-help group, participating in a 12-step
program, receiving professional counseling, or taking medication.
[TAD46_FILL] you ever in your life received any of these kinds of treatment for problems
with [TAD40_FILL]?
1 Yes
2 No
DK/REF
TAD47
[IF TAD46 = 1] About how old were you the very first time you received this treatment?
Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TAD48
[IF TAD47 = (CURNTAGE-1)] Did you start that treatment in the past 12 months or more
than 12 months ago?
1 In the past 12 months
2 More than 12 months ago
DK/REF
TAD49
[IF TAD46 = 1 AND (TAD47 NE CURNTAGE) AND (TAD48 NE1)] During about how
many years in your life did you receive treatment for problems with [TAD40_FILL] at least
once? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF YEARS [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TAD50_FILL
IF TAD40 = 1 AND TAD41 = 1, TAD50_FILL: “Not counting time when you were hospitalized,
about”
IF TAD40 = 1 AND TAD41 NE 1, TAD50_FILL: “Not counting times when you were hospitalized,
about”
ELSE TAD50_FILL: “About”
Version 4 - February 2017 (Post IRB Approval)
166
TAD50
[IF TAD46 = 1 AND ((TAD47 NE CURNTAGE) OR IF ((TAD49 NE 1) AND (TAD47
NE (CURNTAGE – 2 OR MORE)) AND ((TAD31 NE (1–12)) OR (TAD38 NE (1–12)))]
A person can have a treatment session with a professional counselor by visiting face-toface, talking over the telephone, or by exchanging text messages. A person can also have a
treatment session by attending a self-help group or by participating in a 12-step program.
[TAD50_FILL] how many treatment sessions, for problems with [TAD40_FILL], did you
have in the past 12 months?
Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF TREATMENT SESSIONS [RANGE: 1–1000]
DK/REF
TAD51
[TAD49 < 1] About how old were you the most recent time you received treatment? Your
best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TAD52
[IF TAD50 ≥ 1] Are you still in treatment? Or have you stopped treatment?
1 Still in treatment
2 Stopped treatment
DK/REF
TAD53
[IF TAD52 = 2] How important was each of the following reasons for why you stopped
treatment?
TAD53a You got better and no longer
needed help
TAD53b It was not helping; you were
not getting better
TAD53c Financial reasons
TAD53d Inconvenience, such as
problems with time,
transportation, or scheduling
TAD53e Embarrassment or concern
about what people would
think if they knew you were in
treatment
Version 4 - February 2017 (Post IRB Approval)
Very
Important
Somewhat
Important
Not Very
Important
Not at All
Important
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
167
TAD53f You preferred to handle the
problem on your own or with
the help of family and friends
TAD53g Some other important reason
DK/REF
TAD53OT
Very
Important
Somewhat
Important
Not Very
Important
Not at All
Important
1
2
3
4
1
2
3
4
[IF TAD53g = 1 OR 2] What was the other important reason you stopped treatment?
_________________ [ALLOW 200 CHARACTERS]
DK/REF
TAD54
[IF TAD40 = (2 OR DK OR REF) OR TAD46 = (2 OR DK OR REF) OR TAD48 = (2 OR
DK OR REF)] Was there ever a time in the past 12 months when you felt that you might
need treatment for your [TAD40_FILL]?
1 Yes
2 No
DK/REF
TAD55
[IF TAD54 = 1] How important was each of the following reasons for why you did not get
treatment?
TAD55a The problem got better and
you no longer needed help
TAD55b You didn’t know where to go
TAD55c You couldn’t find a place that
would see you when you
needed help
TAD55d Financial reasons
TAD55e Inconvenience, such as
problems with time,
transportation, or scheduling
TAD55f Embarrassment or concern
about what people would
think if they knew you were in
treatment
TAD55g You preferred to handle the
problem on your own or with
the help of family and friends
TAD55h Some other important reason
DK/REF
Version 4 - February 2017 (Post IRB Approval)
Very
Important
Somewhat
Important
Not Very
Important
Not at All
Important
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
168
TAD55OT
[IF TAD55h = 1 OR 2] What was the other important reason you did not get treatment?
_________________ [ALLOW 200 CHARACTERS]
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
169
28.
Relationships and Social Networks
BEGIN TIME STAMP
ONLY SHOW THIS MODULE IF PART2_SHOW=1
U1A
The next questions are about how you describe yourself.
Which of the following best represents how you think of yourself?
1
Lesbian or gay
2
Straight, that is, not lesbian or gay
3
Bisexual
4
Something else
DK/REF
U1B
What sex were you assigned at birth, on your original birth certificate?
1
Male
2
Female
DK/REF
U1C
How do you describe yourself?
1
Male
2
Female
3
Transgender
4
Do not identify as female, male, or transgender
DK/REF
U4x
[IF QD07 = 1 OR 2 OR 3 OR 4] Earlier, you mentioned that you are now [FILL QD07]. How
old were you when you first got married?
__________ YEARS OLD [RANGE: 10 - CURNTAGE]
DK/REF
U4y
[IF QD07 = 1] How long have you been married?
__________ YEARS [RANGE: 0–90]
DK/REF
U9
[IF QD07 NE 1] Next, we’ll ask about your relationships with other people.
Version 4 - February 2017 (Post IRB Approval)
170
Are you currently living with someone in a marriage-like relationship?
1
Yes
2
No
DK/REF
U10
[IF U9 = 2] Which of the following best describes your current dating situation?
1
Engaged to be married
2
Cohabitating or living together
3
Steadily dating one person, but not engaged
4
Dating one or more people, but not in one steady relationship
5
Not currently dating
DK/REF
DEFINE U11_FILL
IF QD07 = 1, THEN U11_FILL = spouse
IF U10 = 1, THEN U11_FILL = fiancé
ELSE U11_FILL = partner
U11
[IF (QD07 = 1) OR (U9 = 1) OR (U10 = 1 OR 2)] What is the sex of your [U11_FILL]?
1
Male
2
Female
3
Transgender
DK/REF
U12
[IF QD07 NE 1 AND U10 = 1 OR 2] How many years have you been in a steady relationship
with your [U11_FILL]? If less than one year, enter “0”.
__________ YEARS [RANGE: 0–CURNTAGE]
DK/REF
DEFINE U13_FILL
IF QD07 = 1, THEN U13_FILL = Counting your spouse, how
ELSE U13_FILL = How
U13
[U13_FILL] many people have you had sexual intercourse with in the past 12 months?
__________ NUMBER OF PEOPLE [RANGE: 0–300]
DK/REF
U14A [IF QD07 = 1 OR U9 = 1 OR U10 = 1 OR 2] Please think about your [U11_FILL] when
answering the next questions.
Version 4 - February 2017 (Post IRB Approval)
171
A Lot
Some
A Little
Not at
All
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
U14A1 How much does your [U11_FILL] really care
about you?
U14A2 How much does your [U11_FILL] understand the
way you feel about things?
U14A3 How much can you rely on your [U11_FILL] for
help if you have a serious problem?
U14A4 How much can you open up to your [U11_FILL]
if you need to talk about your worries?
DK/REF
U14B [IF QD07 = 1 OR U9 = 1 OR U10 = 1 OR 2] Please think about your [U11_FILL] when
answering the next questions.
U14B1 How often does your [U11_FILL] make too
many demands on you?
U14B2 How often does your [U11_FILL] criticize
you?
U14B3 How often does your [U11_FILL] let you
down when you are counting on them?
U14B4 How often does your [U11_FILL] get on
your nerves?
DK/REF
U15
Often
Sometimes
Rarely
Never
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
How many biological children have you had?
If you have no biological children, please enter 0.
__________ NUMBER OF CHILDREN [RANGE: 0–25]
DK/REF
DEFINE U16_FILL
IF U15 = 2, THEN U16_FILL = older
IF U15 > 2, THEN U16_FILL = oldest
ELSE, U16_FILL = BLANK
U16
[IF U15 > 0] How old is your [U16_FILL] biological child? If your child is less than 1 year
old, enter “0”.
__________ YEARS OLD [RANGE: 0–80]
DK/REF
DEFINE U17_FILL
Version 4 - February 2017 (Post IRB Approval)
172
IF U15 = 2, THEN U17_FILL = younger
IF U15 > 2, THEN U17_FILL = youngest
ELSE, U17_FILL = BLANK
U17
[IF U15 > 1] How old is your [U17_FILL] biological child? If your child is less than 1 year
old, enter “0”.
__________ YEARS OLD [RANGE: 0–80]
DK/REF
U18
How many step-children or adoptive children do you have? If none, enter “0”.
__________ NUMBER OF CHILDREN [RANGE: 0–25]
DK/REF
DEFINE U19_FILL
IF U18 = 2, THEN U19_FILL = older
IF U18 > 2, THEN U19_FILL = oldest
ELSE, U19_FILL = BLANK
U19
[IF U18 > 0] How old is your [U19_FILL] step or adoptive child? If your child is less than 1
year old, enter “0”.
__________ YEARS OLD [RANGE: 0–80]
DK/REF
DEFINE U20_FILL
IF U18 = 2, THEN U20_FILL = younger
IF U18 > 2, THEN U20_FILL = youngest
ELSE, U20_FILL = BLANK
U20
[IF U18 > 1] How old is your [U20_FILL] step or adoptive child? If your child is less than 1
year old, enter “0”.
__________ YEARS OLD [RANGE: 0–80]
DK/REF
DEFINE U21_FILL
IF QD07 = 1, THEN U21_FILL = is your spouse
IF U9 = 1, THEN U21_FILL = is your partner
IF U10 = 1, THEN U21_FILL = is your fiancé
IF U10 = 2, THEN U21_FILL = is your partner
ELSE, THEN U21_FILL = are any of your sexual partners
U21
[IF U1B = 1 AND U13 > 0] As far as you know, [U21_FILL] currently pregnant?
Version 4 - February 2017 (Post IRB Approval)
173
1
Yes
2
No
DK/REF
U22
[IF U1B = 2 AND U13 > 0 AND CURNTAGE < 55] As far as you know, are you currently
pregnant?
1
Yes
2
No
DK/REF
SN1
The next few questions are about your social life.
How often do you talk on the phone, chat online, or get together with friends or relatives?
1
Most every day
2
A few times a week
3
A few times a month
4
Once a month
5
Less than once a month
6
Never
DK/REF
SN2
[IF SN1 = 1 OR 2 OR 3 OR 4] How many friends and relatives do you talk to on the phone,
chat with online, or get together with at least once a month?
__________ NUMBER OF FRIENDS AND RELATIVES [RANGE: 1–95]
DK/REF
SN2a
How often do you attend meetings of religious, fraternal, social, or recreation groups you
belong to?
1
Several times a week
2
1–2 times a week
3
Several times a month
4
1–2 times a month
5
Less than once a month
6
Never
DK/REF
SN2r This next question is about the role that religious beliefs may play in your life. Please indicate
whether you strongly disagree, disagree, agree, or strongly agree.
Your religious beliefs are a very important part of your life.
1
Strongly Disagree
Version 4 - February 2017 (Post IRB Approval)
174
2
Disagree
3
Agree
4
Strongly Agree
DK/REF
SN3
How much could you rely on people in your personal life for support and comfort if you had
a serious personal problem?
1
A lot
2
Some
3
A little
4
Not at all
DK/REF
SN4
[IF SN3 = 1 OR 2] How many people could you rely on in this way?
__________ NUMBER OF PEOPLE [RANGE: 1–95]
DK/REF
SN6
How often do the people in your personal life make too many demands on you?
1
Often
2
Sometimes
3
Rarely
4
Never
DK/REF
SN7
How often do the people in your personal life argue with you or say things that make you
feel bad about yourself?
1
Often
2
Sometimes
3
Rarely
4
Never
DK/REF
SN8
SN8a
How well do the following statements describe you?
Exactly
Like Me
A Lot
Like Me
Somewhat
Like Me
A Little
Like Me
Not at All
Like Me
1
2
3
4
5
The people in my
personal life would be
happier without me
Version 4 - February 2017 (Post IRB Approval)
175
SN8b
SN8c
SN8d
Exactly
Like Me
A Lot
Like Me
Somewhat
Like Me
A Little
Like Me
Not at All
Like Me
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
I am a burden to the
people in my personal
life
I feel like I belong
The people in my
personal life need me
and would be much
worse off if I was not
around
DK/REF
SN10
The next questions are about using the internet for social networking and playing
games with other people.
SN10a Do you use the internet for playing games with other people?
SN10b Do you use the internet for social networking with other people?
DK/REF
SN11
Yes
1
1
No
2
2
[IF SN10a = 1] How often do you play online games with other people? Include any type of
online game you play with other people, such as website games, console games, and mobile
apps.
1
Less than once a day
2
Once a day
3
Several times a day
4
Many times a day
5
Constantly
DK/REF
SN12
[IF SN10b = 1] How often do you use social networking apps or sites like Facebook,
Snapchat, Instagram, and Twitter?
1
Less than once a day
2
Once a day
3
Several times a day
4
Many times a day
6
Constantly
DK/REF
SN14
[IF SN10a = 1 OR IF SN10b = 1] How many new friends, if any, have you made online?
Version 4 - February 2017 (Post IRB Approval)
176
1
None
2
One
3
2–5
4
More than 5
DK/REF
SN15
[IF SN10a = 1 OR IF SN10b = 1] When you use social networking apps or play games
with others online, do you ever . . .
SN15a feel more relaxed and happy?
SN15b feel more angry and frustrated?
DK/REF
Yes, a Lot
1
1
Yes, a Little
2
2
No
3
3
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
177
29.
Childhood Demographics
BEGIN TIME STAMP
ONLY SHOW THIS MODULE IF PART2_SHOW=1
Now we have some questions about your childhood.
Q_DE2
Press [ENTER] to continue.
Q_DE20_11
Were you raised mostly in a large city, suburbs of a large city, a small city, a town or
village, or in a rural area?
1
Large city
2
Suburbs of a large city
3
Small city
4
Town or village
5
Rural area
DK/REF
Q_DE20_12
How many times while you were growing up did you move to a totally new
neighborhood or town?
_____________ TIMES [RANGE: 0–50]
DK/REF
Q_DE20_5
[IF ADQ11 > 0] The following questions are about specific educational experiences
during different periods of your life. How many different schools did you attend up to
the end of high school?
_____________ SCHOOLS [RANGE: 1–36]
DK/REF
Q15b
[IF QD11 > 0] How well did you do in math compared to other children in your class?
1
Much better
2
Better
3
About the same
4
Worse
5
Much worse
6
Did not have other children in your class
DK/REF
Q15c
[IF QD11 > 0] How well did you do in reading and writing, like spelling and grammar,
compared to other children in your class?
Version 4 - February 2017 (Post IRB Approval)
178
1
Much better
2
Better
3
About the same
4
Worse
5
Much worse
6
Did not have other children in your class
DK/REF
Q16
[IF QD11 > 0] In elementary school, did any teachers, principals, or school psychologists
tell you or your parents that you had a problem with learning any of the following usual
school subjects?
Q16a Reading
Q16b Writing
Q16c Mathematics or arithmetic
Q16d Speaking or language
DK/REF
Yes
1
1
1
1
No
2
2
2
2
DEFINE Q16_COUNT
SET Q16_COUNT=0
IF Q16a=1, ADD 1 TO Q16_COUNT
IF Q16b=1, ADD 1 TO Q16_COUNT
IF Q16c=1, ADD 1 TO Q16_COUNT
IF Q16d=1, ADD 1 TO Q16_COUNT
DEFINE Q16_FILL
IF Q16_COUNT=1, THEN SET Q16_FILL=“this learning problem”
IF Q16_COUNT>1, THEN SET Q16_FILL=“these learning problems”
Q17
[IF Q16a OR Q16b OR Q16c OR Q16d = 1] Because of [Q16_FILL], did you receive any of
the following at any time?
Q17a Special education testing to help understand the problem
Q17b Special or different classes provided by the school, because of the problem
Q17c Individual tutoring or counseling arranged by the school
Q17d Private tutoring arranged at home
Q17e A request to see a medical doctor or psychologist about this problem
Q17f A request to change to a different school
DK/REF
Version 4 - February 2017 (Post IRB Approval)
Yes
1
1
1
1
1
1
No
2
2
2
2
2
2
179
Q17g
[IF Q17f = 1] Did you actually change schools because of [Q16_FILL]?
1
Yes
2
No
DK/REF
Q18
[IF QD11 ≥ 8] When you were in middle school, junior high, or high school, were you or
your parents ever told by a professional that you had any of the following problems?
Q18a Mental or emotional problems
Q18b Dyslexia
Q18c Attention Deficit Hyperactivity Disorder, also called ADHD
Q18d Another learning disorder
DK/REF
Q18e
Yes
1
1
1
1
No
2
2
2
2
[IF Q18d = 1] What other learning disorder were you or your parents told by a professional
that you had?
_______________ LEARNING DISORDER [LIMIT TO 150 CHARACTERS]
DK/REF
Q19
[IF QD11 ≥ 8] The next questions are about things you may have done in high school. By
high school, we mean public or private high school and homeschooling for grades 9 through
12. Did you take special courses or classes in high school to better prepare you for college?
1
Yes
2
No
3
I did not attend high school
DK/REF
Q20
[IF QD11 ≥ 8 AND Q19 NE 3] Did you take courses or classes in high school that were
intended to prepare you for a job after high school? This is also called vocational training.
1
Yes
2
No
DK/REF
Q21
[IF QD11 ≥ 8 AND Q19 NE 3] Did your high school ever monitor your attendance more
often than most students’ because they felt you were absent more than usual?
1
Yes
2
No
DK/REF
Version 4 - February 2017 (Post IRB Approval)
180
Q25
[IF QD11 ≥ 8 AND Q19 NE 3] Approximately how many school clubs or organizations
were you involved with during high school?
1
0
2
1–5
3
6–9
4
10–19
5
20 or more
DK/REF
Q26
[IF QD11 ≥ 8 AND Q19 NE 3] During middle school, junior high, or high school, did you
regularly participate in any kind of organized sport, such as basketball, swimming, tennis,
gymnastics, or snow sports?
1
Yes
2
No
DK/REF
Q26a
[IF Q26 = 1] In how many of your middle school, junior high or high school years did you
participate in some kind of organized sport?
________ YEARS [RANGE: 1–8]
DK/REF
Q29
In the past year, how often have you taken part in activities that are vigorous or
moderately energetic, such as running, working out, swimming, walking, dancing, or
tennis?
1
Every day
2
More than once a week
3
Once a week
4
One to three times a month
5
Hardly ever or never
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
181
30.
Childhood Experiences
[ONLY SHOW THIS MODULE IF PART2_SHOW=1.]
BEGIN TIME STAMP
X1
Next, we’ll ask about some experiences you may have had growing up. Which of the
following experiences did you have before age 18?
X1a Did your mother or father die before you were 18?
X1b Did your parents separate or divorce before you were 18?
X1c Did either parent attempt or commit suicide?
X1d Was either parent in prison or jail for 6 months or longer?
X1e Did either parent, or person who raised you, have a mental illness?
X1f Did either parent, or person who raised you, have an alcohol or drug problem?
X1g Were you sent to a juvenile detention center?
DK/REF
X2
NUMBER OF YEARS
________ [RANGE: 0–17]
________ [RANGE: 0–17]
________ [RANGE: 0–17]
How often did you do each of the following things before age 18?
Very Often
X3a [IF CURNTAGE > 30] Bully or
threaten other kids
X3b Start fights
X3c Run away from home and stay
away overnight
X3d Lie or “con” other people
X3e Set fires
X3f Stay out very late, long after you
were supposed to be home
X3g Skip school
DK/REF
X4
No
2
2
2
2
2
2
2
How many years out of the first 17 of your life did you live…
X2a with your biological mother?
X2b with your biological father?
X2c in a foster home?
DK/REF
X3
Yes
1
1
1
1
1
1
1
Often Sometimes Rarely Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
1
2
2
3
3
4
4
5
5
1
2
3
4
5
1
2
3
4
5
How often did you do each of the following things before age 18?
X4a Argue or “talk back” to adults
Version 4 - February 2017 (Post IRB Approval)
Very Often
1
Often
2
Sometimes Rarely Never
3
4
5
182
X4b Disobey rules at home, school,
or work
X4c Refuse to follow directions from
adults like your parents, teacher,
or boss
X4d Blame others for your mistakes
or bad behavior
X4e Do mean things to “pay people
back” for things they did that
you didn’t like
DK/REF
X5
Often
Sometimes Rarely Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
How often did you have each of the following experiences before age 18?
X5a Your family was on welfare
X5b You were homeless
X5c You had to do chores too hard or
dangerous for someone your age
X5d You didn’t have anyone who
would take care of you or protect
you
X5e Nobody ensured you had
adequate food or clothing or
medical care
X5f Someone touched you or made
you touch them in a sexual way
against your will
X5g You were sexually abused at
home
X5h [IF CURNTAGE > 30] You were
beaten up or terrorized by bullies
at school or in the neighborhood
DK/REF
X6
Very Often
Very Often
1
1
Often Sometimes Rarely Never
2
3
4
5
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
How often did you have each of the following experiences before age 18?
Very Often
X6a Someone in your family hit you
so hard that it left bruises or
marks
X6b You were physically abused at
home
Version 4 - February 2017 (Post IRB Approval)
Often Sometimes Rarely Never
1
2
3
4
5
1
2
3
4
5
183
Very Often
X6c You felt that someone in your
family hated you
X6d You were emotionally abused at
home
X6e People in your family said hurtful
or insulting things to you
X6f Someone in your family made
you feel important
X6g You felt loved and cared for
X6h Your family was a source of
strength and support
DK/REF
X7
Often Sometimes Rarely Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
[IF CURNTAGE = 18–30] The next questions ask about bullying. Bullying is when one or
more people tease, threaten, spread rumors about, hit, shove, or hurt another person over and
over again. It is not bullying when two people of about the same strength or power argue or
fight or tease each other in a friendly way.
With that definition in mind, have you ever in your life been bullied?
1
Yes
2
No
DK/REF
X8
[IF X7 = 1] During the past 12 months, have you been bullied?
1
Yes
2
No
DK/REF
X9
[IF CURNTAGE = 18–30] Have you ever in your life bullied someone?
1
Yes
2
No
DK/REF
X10
[IF X9 = 1] During the past 12 months, have you bullied someone?
1
Yes
2
No
DK/REF
Version 4 - February 2017 (Post IRB Approval)
184
X11
[IF CURNTAGE = 18–30] Electronic bullying is when someone bullies you through texting,
instant messaging, e-mail, chat rooms, or websites. Have you ever in your life been
electronically bullied?
1
Yes
2
No
DK/REF
X12
[IF X11 = 1] During the past 12 months, have you been electronically bullied?
1
Yes
2
No
DK/REF
X13
[IF CURTAGE = 18–30] Have you ever in your life bullied someone electronically?
1
Yes
2
No
DK/REF
X14
[IF X13 = 1] During the past 12 months, have you bullied someone electronically?
1
Yes
2
No
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
185
31.
Employment
BEGIN TIME STAMP
E1
The next few questions are about employment status. Which of the following were you doing
last week?
1
Working for pay at a job or business
2
With a job or business but not at work, such as on vacation or leave
3
Looking for work
4
Working, but not for pay, at a family-owned job or business
5
Not working at a job or business and not looking for work
DK/REF
DEFINE E2_FILL
IF E1 = 2, THEN E2_FILL = work last week
IF E1 = 5, THEN E2_FILL = have a job or business last week
E2
[IF E1 = 2 OR 5] What is the main reason you did not [E2_FILL]?
1
Taking care of house or family
2
Going to school
3
Retired
4
On a planned vacation from work
5
On family or maternity leave
6
Temporarily unable to work for health reasons
7
Have job/contract and off-season
8
On layoff
9
Disabled
10
Other
DK/REF
DEFINE E3_FILL
IF E1 = 1 OR 4, THEN E3_FILL = did you work last week at all jobs or businesses
IF E2 = 4 OR 5 OR 6 OR 7, THEN E3_FILL = do you usually work at all jobs or businesses
DEFINE E3_ASK
IF (E1 = 1 OR 4) OR (E2 = 4 OR 5 OR 6 OR 7), then E3_ASK=1,
ELSE E3_ASK=0.
E3
[IF E3_ASK=1] How many hours [E3_FILL]?
__________ NUMBER OF HOURS [RANGE: 1–168]
Version 4 - February 2017 (Post IRB Approval)
186
DK/REF
E3_SFTCK [IF E3 = 95 – 168] [FILL: E3] is an unusually high number. Is it correct that you
worked [E3] hours last week?
1
Yes
2
No
DK/REF
E3_2 [IF E3_SFTCK = 2 OR DK] How many hours [E3_FILL]?
_________ NUMBER OF HOURS [RANGE: 1 – 168]
DK/REF
E4
[IF E3 = 1 – 34 OR DK OR REF] Do you usually work 35 hours or more per week in total at
all jobs or businesses?
1
Yes
2
No
DK/REF
E5
Did you work for pay at any time in [4 DIGIT LAST FULL CALENDAR YEAR]?
1
Yes
2
No
DK/REF
DEFINE E_EMPLY
IF (E1 = 1 OR 2 OR 4) AND (E2=4 OR 5 OR 6 OR 7), THEN E_EMPLY=1,
ELSE E_EMPLY=0.
QD37 [IF E_EMPLY=1] During the past 12 months, was there ever a time when you did not have at
least one job or business?
1
Yes
2
No
DK/REF
QD38 [IF QD37 = 1] In how many weeks during the past 12 months did you not have at least one job
or business?
__________ NUMBER OF WEEKS WITHOUT A JOB OR BUSINESS [RANGE: 0–52]
DK/REF
IF QD38 = 0, HARD ERROR TEXT SHOULD READ: If less than 1 week, enter 1.
Version 4 - February 2017 (Post IRB Approval)
187
[IF E3_ASK=0 AND (E5 = 2 OR DK OR REF)] In what year did you last work at a job
or business? If you have never worked for pay, enter 9991.
QD39a
PROGRAMMER: ADD “YYYY” NEXT TO THE ENTRY FIELD IN THE TOOL BAR.
____________ YEAR LAST WORKED
DK/REF
PROGRAMMER: DO NOT ALLOW BLANKS IN QD39a.
[IF QD39a > SYSTEM YEAR] HARD ERROR: The year that the computer recorded
is [YEAR FROM QD39a]. Press [ENTER] to close this box and then enter the correct
year.
[IF QD39a < (SYSTEM YEAR – CURRENT AGE)] HARD ERROR: The year the
computer recorded is earlier than your birth date. Press [ENTER] to close this box and
then double-check the year.
QD39b
[IF QD39a = SYSTEM YEAR OR (SYSTEM YEAR – 1)] In what month in [YEAR
FROM QD39a] did you last work at a job or business?
1
January
2
February
3
March
4
April
5
May
6
June
7
July
8
August
9
September
10
October
11
November
12
December
DK/REF
QD40 [IF E_EMPLY=1] During the past 30 days, that is, from [DATEFILL] up to and including
today, how many whole days of work did you miss because you were sick or injured? Please
do not include days you missed because you stayed home with a sick child or other family
member.
__________ NUMBER OF DAYS [RANGE: 0–30]
DK/REF
QD41 [IF E_EMPLY=1] During the past 30 days, that is, from [DATEFILL] up to and including
today, how many whole days of work did you miss because you just didn’t want to be there?
Version 4 - February 2017 (Post IRB Approval)
188
Please do not include days you missed because of a planned vacation or days that you stayed
home with a sick child or other family member.
__________ NUMBER OF DAYS [RANGE: 0–30]
DK/REF
PENTER1
Thank you for your help with this part of the interview. When you leave this screen,
the responses you entered into the computer will be locked and can no longer be seen
by you, the interviewer, or anyone else who uses this computer. When you are ready,
please press 1 and [ENTER] to complete this part of the interview and lock your
responses.
[ONCE 1 IS ENTERED FOR PENTER1, NO ONE CAN RE-ENTER THE ACASI PORTION
OF THE INTERVIEW.]
ENDAUDIO
Your responses have been locked. Please tell your interviewer that you are finished.
INTERVIEWER: ENTER THE 3-LETTER CODE TO MOVE TO THE NEXT SECTION.
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
189
32.
Household Roster
BEGIN TIME STAMP
HR_INTRODM2
For the next questions, I will read the question out loud, you can tell me your
answer, and I will enter it into the computer.
PRESS [ENTER] TO CONTINUE.
HR1
Altogether, how many people live here now, including yourself? Please include
anyone who (has lived/will live) here for most of (January, February, and
March/April, May, and June/July, August, and September/October,
November, and December).
NUMBER IN HOUSEHOLD:
DK/REF
[RANGE: 1–25]
INTERVIEWER: If you are interviewing in a transient shelter, enter “1”. If you
are interviewing in a group quarters unit that was listed by room, enter the
number of people living in the room.
IF HR1 = 1 OR DK/REF, SKIP TO FIRST QUESTION FOLLOWING HH
ROSTER, OTHERWISE CONTINUE.
DEFINE GRID WITH ROWS EQUAL TO HR1. EACH COLUMN OF THE
GRID IS A QUESTION AS SPEC’D BELOW.
PERAGEYR
[IF HR1 = 2–25] Now I need some additional information about each person
who lives here. Let’s start with the oldest. How old was he or she on his or her
last birthday? (WORDING FOR ADDITIONAL CYCLES: How old was the
next oldest person on his or her last birthday?)
INTERVIEWER: FOR CHILDREN LESS THAN 24 MONTHS (2 YEARS),
ENTER “1”. YOU WILL BE PROMPTED FOR THE AGE IN MONTHS ON
THE NEXT SCREEN.
AGE IN WHOLE YEARS:
DK/REF
CHAGEMON
[RANGE: 1–110]
[IF PERAGEYR = 1] ENTER THE AGE IN WHOLE MONTHS FOR THIS
HOUSEHOLD MEMBER. FOR BABIES UNDER 1 MONTH OLD, ENTER
1.
AGE IN MONTHS:
DK/REF
Version 4 - February 2017 (Post IRB Approval)
[RANGE: 1–23]
190
CHMONSEX
[IF CHAGEMON = 1–23] Is the [CHAGEMON FILL]-month-old child a
male or a female?
5
MALE
9
FEMALE
DK/REF
CHYRSEX
[IF CHAGEMON = DK/REF] Is this child a male or female?
5
MALE
9
FEMALE
DK/REF
PERYRSEX
[IF PERAGEYR = 2–110] Is the [PERAGEYR FILL]-year-old person male or
female?
5
MALE
9
FEMALE
DK/REF
PERSEX
[IF PERAGEYR = DK/REF] Is this person a male or a female?
5
MALE
9
FEMALE
DK/REF
MRELATON
[IF CHMONSEX OR CHYRSEX OR PERYRSEX OR PERSEX = 5]
[IF QD01 = 5] IF IT IS CLEAR THAT RESPONDENT IS TALKING ABOUT
HIMSELF: ASK “Is that you?” IF YES, ENTER “1” for “SELF”.
IF RESPONDENT IS NOT TALKING ABOUT SELF HAND R SHOWCARD
5. Please look at this card, and tell me which category best describes his
relationship to you.
1
2
3
4
5
6
7
8
9
10
11
SELF
HUSBAND
SON (INCLUDES STEP, FOSTER, ADOPTIVE)
SON-IN-LAW
BROTHER (INCLUDES HALF, STEP, FOSTER, ADOPTIVE)
BROTHER-IN-LAW
FATHER (INCLUDES STEP, FOSTER, ADOPTIVE)
FATHER-IN-LAW
UNCLE
NEPHEW
GRANDFATHER
Version 4 - February 2017 (Post IRB Approval)
191
12
GRANDSON
13
COUSIN
14
EX-HUSBAND
15
UNMARRIED PARTNER
16
HOUSEMATE OR ROOMMATE
17
TENANT, BOARDER, OR EXCHANGE STUDENT
18
OTHER RELATIVE
19
OTHER NONRELATIVE
DK/REF
[R SEX] IF MRELATON = 1 AND QD01 = 9, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT IS MALE. EARLIER,
YOU RECORDED THE RESPONDENT’S SEX AS FEMALE. CONFIRM THE RESPONDENT’S
SEX, AND CORRECT THE ANSWER THAT WAS ENTERED INCORRECTLY.
CREATE ERROR BOX SO IT ALLOWS R TO GO TO EITHER ANSWER TO FIX IT.
[R AGE] IF MRELATON = 1 AND PERAGEYR DOES NOT EQUAL CURNTAGE, DISPLAY
ERROR BOX THAT SAYS: INTERVIEWER: YOU HAVE RECORDED THAT THE
RESPONDENT IS [FILL PERAGEYR]. EARLIER, THE RESPONDENT’S AGE WAS ENTERED
AS [FILL CURNTAGE]. PLEASE CONFIRM THE RESPONDENT’S AGE. IF YOU NEED TO
CORRECT THE AGE OR RELATIONSHIP GIVEN IN THE ROSTER, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWER YOU ENTERED IN THE
ROSTER IS CORRECT, HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
[NOTE: FI SHOULD ONLY BE ALLOWED TO CHANGE PERAGEYR AND MRELATON.]
SUPPMAGE
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
YOU HAVE CHOSEN TO SUPPRESS THIS ERROR.
ALLOW 200 CHARACTERS.
[GRANDPARENT YOUNGER THAN R] IF MRELATON = 11 AND PERAGEYR DOES NOT
EQUAL DK OR REF AND IS = OR < CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S GRANDFATHER IS
THE SAME AGE AS OR YOUNGER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH
THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPGDAD
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
Version 4 - February 2017 (Post IRB Approval)
192
[GRANDCHILD OLDER THAN R] IF MRELATON = 12 AND PERAGEYR DOES NOT
EQUAL DK OR REF AND IS = OR > CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S GRANDSON IS THE
SAME AGE AS OR OLDER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH THE
RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION
NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT
“SUPPRESS” AND PRESS [ENTER].
SUPPGSON
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[SPOUSE/PARTNER < 16] IF MRELATON = 2 OR 15 OR 14 AND PERAGEYR = OR < 16,
DISPLAY ERROR BOX THAT SAYS: INTERVIEWER: YOU HAVE RECORDED THAT THE
RESPONDENT’S SPOUSE, EX-SPOUSE OR PARTNER IS 16 YEARS OLD OR YOUNGER.
PLEASE VERIFY THIS WITH THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY,
HIGHLIGHT THAT QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE
CORRECT AS IS, HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPHUS
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[IN-LAW < 16] IF MRELATON = 8 OR 4 AND PERAGEYR = OR < 16, DISPLAY ERROR BOX
THAT SAYS: INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S
[MRELATON] IS 16 YEARS OLD OR YOUNGER. PLEASE VERIFY THIS WITH THE
RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION
NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT
“SUPPRESS” AND PRESS [ENTER].
SUPPMIL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[SON IN-LAW OLDER THAN R] IF MRELATON = 4 AND PERAGEYR DOES NOT EQUAL
DK OR REF AND IS = OR > CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S SON-IN-LAW IS THE
SAME AGE AS OR OLDER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH THE
RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION
Version 4 - February 2017 (Post IRB Approval)
193
NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT
“SUPPRESS” AND PRESS [ENTER].
SUPPSIL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[FATHER IN-LAW YOUNGER THAN R] IF MRELATON = 8 AND PERAGEYR DOES NOT
EQUAL DK OR REF AND IS = OR < CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S FATHER-IN-LAW IS
THE SAME AGE AS OR YOUNGER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH
THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPPIL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
BTWNTYPE
[IF QD_AGE1 = AGE OF THIS HOUSEHOLD MEMBER AND
MRELATON=5] Is he your identical twin, fraternal twin, or neither?
1
IDENTICAL TWIN
2
FRATERNAL TWIN
3
NEITHER
DK/REF
FRELATON
[IF CHMONSEX OR CHYRSEX OR PERYRSEX OR PERSEX = 9] IF QD01
= 9] IF IT IS CLEAR THAT RESPONDENT IS TALKING ABOUT
HERSELF: ASK “Is that you?” IF YES, ENTER “1” for “SELF”.
IF RESPONDENT IS NOT TALKING ABOUT SELF: HAND R
SHOWCARD 6. Please look at this card and tell me which category best
describes her relationship to you.
1
2
3
4
5
6
7
SELF
WIFE
DAUGHTER (INCLUDES STEP, FOSTER, ADOPTIVE)
DAUGHTER-IN-LAW
SISTER (INCLUDES HALF, STEP, FOSTER, ADOPTIVE)
SISTER-IN-LAW
MOTHER (INCLUDES STEP, FOSTER, ADOPTIVE)
Version 4 - February 2017 (Post IRB Approval)
194
8
MOTHER-IN-LAW
9
AUNT
10
NIECE
11
GRANDMOTHER
12
GRANDDAUGHTER
13
COUSIN
14
EX-WIFE
15
UNMARRIED PARTNER
16
HOUSEMATE OR ROOMMATE
17
TENANT, BOARDER, OR EXCHANGE STUDENT
18
OTHER RELATIVE
19
OTHER NONRELATIVE
DK/REF
[R SEX] IF FRELATON = 1 AND QD01 = 5, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT IS FEMALE. EARLIER,
YOU RECORDED THE RESPONDENT’S SEX AS MALE. CONFIRM THE RESPONDENT’S
SEX, AND CORRECT THE ANSWER THAT WAS ENTERED INCORRECTLY.
CREATE ERROR BOX SO IT ALLOWS R TO GO TO EITHER ANSWER TO FIX IT.
[R AGE] IF FRELATON = 1 AND PERAGEYR DOES NOT EQUAL CURNTAGE, DISPLAY
ERROR BOX THAT SAYS: INTERVIEWER: YOU HAVE RECORDED THAT THE
RESPONDENT IS [FILL PERAGEYR]. EARLIER, THE RESPONDENT’S AGE WAS ENTERED
AS [FILL CURNTAGE]. PLEASE CONFIRM THE RESPONDENT’S AGE. IF YOU NEED TO
CORRECT THE AGE OR RELATIONSHIP GIVEN IN THE ROSTER, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWER YOU ENTERED IN THE
ROSTER IS CORRECT, HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
[NOTE: FI SHOULD ONLY BE ALLOWED TO CHANGE PERAGEYR AND FRELATON.]
SUPPFAGE
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
YOU HAVE CHOSEN TO SUPPRESS THIS ERROR.
ALLOW 200 CHARACTERS.
[GRANDPARENT YOUNGER THAN R] IF FRELATON = 11 AND PERAGEYR DOES NOT
EQUAL DK OR REF AND IS = OR < CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S GRANDMOTHER IS
THE SAME AGE AS OR YOUNGER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH
THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
Version 4 - February 2017 (Post IRB Approval)
195
SUPPGMOM
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[GRANDCHILD OLDER THAN R] IF FRELATON = 12 AND PERAGEYR DOES NOT EQUAL
DK OR REF AND IS = OR > CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S GRANDDAUGHTER
IS THE SAME AGE AS OR OLDER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH
THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPGDAU
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[SPOUSE/PARTNER < 16] IF FRELATON = 2 OR 15 OR 14 AND PERAGEYR = OR < 16,
DISPLAY ERROR BOX THAT SAYS: INTERVIEWER: YOU HAVE RECORDED THAT THE
RESPONDENT’S SPOUSE, EX-SPOUSE, OR PARTNER IS 16 YEARS OLD OR YOUNGER.
PLEASE VERIFY THIS WITH THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY,
HIGHLIGHT THAT QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE
CORRECT AS IS, HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPWIF
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[IN-LAW < 16] IF FRELATON = 8 OR 4 AND PERAGEYR = OR < 16, DISPLAY ERROR BOX
THAT SAYS: INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S
[FRELATON] IS 16 YEARS OLD OR YOUNGER. PLEASE VERIFY THIS WITH THE
RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION
NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT
“SUPPRESS” AND PRESS [ENTER].
SUPPFIL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
Version 4 - February 2017 (Post IRB Approval)
196
[DAUGHTER IN-LAW OLDER THAN R] IF FRELATON = 4 AND PERAGEYR DOES NOT
EQUAL DK OR REF AND IS = OR > CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S DAUGHTER-IN-LAW
IS THE SAME AGE AS OR OLDER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH
THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPDIL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[MOTHER IN-LAW YOUNGER THAN R] IF FRELATON = 8 AND PERAGEYR DOES NOT
EQUAL DK OR REF AND IS = OR < CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S MOTHER-IN-LAW IS
THE SAME AGE AS OR YOUNGER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH
THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPGIL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
FTWNTYPE
[IF QD_AGE1 = AGE OF THIS HOUSEHOLD MEMBER AND
FRELATON=5] Is she your identical twin, fraternal twin, or neither?
1
IDENTICAL TWIN
2
FRATERNAL TWIN
3
NEITHER
DK/REF
MBRSELCT
[IF QD_FIPE1 = 1 AND MRELATON NE 1 AND FRELATON NE 1 AND
PERAGEYR = (12 OR OLDER OR DK/REF) AND MBRSELCT NE 1 FOR A
PREVIOUS ROSTER MEMBER] WAS THIS HOUSEHOLD MEMBER
ALSO SELECTED TO BE INTERVIEWED? (IF YOU ARE UNSURE,
ATTEMPT TO VERIFY WITH THIS RESPONDENT.)
1
YES
2
NO
DK/REF
Version 4 - February 2017 (Post IRB Approval)
197
RETURN TO PERAGEYR AND CYCLE THROUGH THE QUESTIONS FOR THE NEXT
HOUSEHOLD MEMBER. CONTINUE CYCLES UNTIL THE NUMBER OF CYCLES = THE
NUMBER REPORTED IN HR1.
[OTHER HH MEMBER SELECTED FOR INTERVIEW] IF QD_FIPE1 = 1 AND MBRSELCT
= 2 FOR ALL HOUSEHOLD MEMBERS, DISPLAY ERROR BOX: INTERVIEWER: EARLIER,
YOU RECORDED THAT TWO PEOPLE WERE SELECTED AT THIS HOUSEHOLD. THE
HOUSEHOLD ROSTER DOES NOT SHOW ANYONE LISTED AS THE SECOND
RESPONDENT. PLEASE VERIFY THE NUMBER OF PEOPLE SELECTED AT THIS
HOUSEHOLD, AND FIX THE APPROPRIATE ANSWER. IF YOU NEED TO CORRECT AN
ENTRY, HIGHLIGHT THAT QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS
ARE CORRECT AS IS, HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
PROGRAMMER: ONLY ALLOW EDITING OF MBRSELCT.
SUPPHHME
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
YOU HAVE CHOSEN TO SUPPRESS THIS ERROR.
ALLOW 200 CHARACTERS.
[MORE THAN 1 SELF] NOTE TO PROGRAMMERS: ONCE MRELATON OR FRELATON = 1,
PLEASE IMPLEMENT A HARD ERROR TO OCCUR IF THE FI ATTEMPTS TO ENTER A “1"
FOR EITHER OF THESE VARIABLES FOR SUBSEQUENT HOUSEHOLD MEMBERS. THE
MESSAGE BOX SHOULD READ: INTERVIEWER: YOU HAVE ALREADY RECORDED
“SELF” AS THE RELATIONSHIP FOR ANOTHER MEMBER OF THIS HOUSEHOLD. “SELF”
CAN ONLY BE CODED FOR ONE MEMBER OF THIS HOUSEHOLD. REVIEW YOUR
ENTRIES, AND CORRECT THE APPROPRIATE RELATIONSHIPS AS NECESSARY.
[MORE THAN 1 SPOUSE/PARTNER] NOTE TO PROGRAMMERS: ONCE MRELATON OR
FRELATON = 2 OR 15, PLEASE IMPLEMENT A HARD ERROR TO OCCUR IF THE FI
ATTEMPTS TO ENTER A “2” OR “15” FOR EITHER OF THESE VARIABLES FOR
SUBSEQUENT HOUSEHOLD MEMBERS. THE MESSAGE BOX SHOULD READ:
INTERVIEWER: YOU HAVE RECORDED THAT THIS IS THE RESPONDENT’S
[WIFE/HUSBAND/UNMARRIED PARTNER]. EARLIER, YOU ENTERED THAT THE
RESPONDENT ALREADY HAS [A/AN] [WIFE/HUSBAND/UNMARRIED PARTNER]. IF YOU
NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION NUMBER AND PRESS
[ENTER]. IF THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT “SUPPRESS” AND PRESS
[ENTER].
SUPPMULT
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
Version 4 - February 2017 (Post IRB Approval)
198
[16-YEAR-OLD R MARRIED/COHABITATING] IF CURNTAGE = OR < 16, AND ANY
FRELATON OR MRELATON = 2 OR 14 OR 15, DISPLAY ERROR BOX: INTERVIEWER: YOU
HAVE ENTERED THAT THE [CURNTAGE]-YEAR-OLD RESPONDENT HAS BEEN MARRIED
OR COHABITATING. PLEASE VERIFY THIS WITH THE RESPONDENT. IF YOU NEED TO
CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION NUMBER AND PRESS [ENTER]. IF
THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPRMC
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[16-YEAR-OLD R HAS IN-LAW] IF CURNTAGE = OR < 16, AND ANY FRELATON OR
MRELATON = 8 OR 4, DISPLAY ERROR BOX: INTERVIEWER: YOU HAVE ENTERED THAT
THE [CURNTAGE]-YEAR-OLD RESPONDENT HAS AN IN-LAW. PLEASE VERIFY THIS
WITH THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPRINL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[GRANDPARENT/GRANDCHILD AND R LESS THAN 30 YEARS APART] IF FRELATON
OR MRELATON = (12 OR 11) AND PERAGEYR NE DK/REF AND IS 0–29 YEARS > OR <
CURNTAGE, DISPLAY ERROR BOX THAT SAYS: INTERVIEWER: YOU HAVE RECORDED
THAT THE RESPONDENT’S [GRANDPARENT/GRANDCHILD] IS LESS THAN 30 YEARS
[OLDER/YOUNGER] THAN THE RESPONDENT. PLEASE VERIFY THIS WITH THE
RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION
NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT
“SUPPRESS” AND PRESS [ENTER].
SUPPGR30
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
199
33.
Proxy Information
BEGIN TIME STAMP
PROXYINT The next questions are about your health insurance coverage and the kinds and amounts
of income that you [IF FAMILY MEMBERS IN ROSTER THEN FILL “and your
family”] receive. This information will help in planning health care services and
finding ways to lower costs of care.
PRESS “1” AND [ENTER] TO CONTINUE.
FAMLY
IF HR1 = 1, SKIP TO HI_1
IF MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN
HOUSEHOLD, SKIP TO HI_1.
DEFINE FAMILY RELATIONSHIP FILLS
IF EXACTLY 1 IN ROSTER = (MRELATON = 2), FILL = “husband”
IF MORE THAN 1 IN ROSTER = (MRELATON = 2), FILL = “husbands”
IF EXACTLY 1 IN ROSTER = (MRELATON = 3), FILL = “son”
IF MORE THAN 1 IN ROSTER = (MRELATON = 3 AND), FILL = “sons”
IF EXACTLY 1 IN ROSTER = (MRELATON = 4), FILL = “son-in-law”
IF MORE THAN 1 IN ROSTER = (MRELATON = 4), FILL = “sons-in-law”
IF EXACTLY 1 IN ROSTER = (MRELATON = 5), FILL = “brother”
IF MORE THAN 1 IN ROSTER = (MRELATON = 5), FILL = “brothers”
IF EXACTLY 1 IN ROSTER = (MRELATON = 6), FILL = “brother-in-law”
IF MORE THAN 1 IN ROSTER = (MRELATON = 6), FILL = “brothers-in-law”
IF EXACTLY 1 IN ROSTER = (MRELATON = 7), FILL = “father”
IF MORE THAN 1 IN ROSTER = (MRELATON = 7), FILL = “fathers”
IF EXACTLY 1 IN ROSTER = (MRELATON = 8), FILL = “father-in-law”
IF MORE THAN 1 IN ROSTER = (MRELATON = 8), FILL = “fathers-in-law”
IF EXACTLY 1 IN ROSTER = (MRELATON = 9), FILL = “uncle”
IF MORE THAN 1 IN ROSTER = (MRELATON = 9), FILL = “uncles”
IF EXACTLY 1 IN ROSTER = (MRELATON = 10), FILL = “nephew”
IF MORE THAN 1 IN ROSTER = (MRELATON = 10), FILL = “nephews”
Version 4 - February 2017 (Post IRB Approval)
200
IF EXACTLY 1 IN ROSTER = (MRELATON = 11), FILL = “grandfather”
IF MORE THAN 1 IN ROSTER = (MRELATON = 11), FILL = “grandfathers”
IF EXACTLY 1 IN ROSTER = (MRELATON = 12), FILL = “grandson”
IF MORE THAN 1 IN ROSTER = (MRELATON = 12), FILL = “grandsons”
IF EXACTLY 1 IN ROSTER = (MRELATON = 13), FILL = “male cousin”
IF MORE THAN 1 IN ROSTER = (MRELATON = 13), FILL = “male cousins”
IF EXACTLY 1 IN ROSTER = (MRELATON = 14), FILL = “ex-husband”
IF MORE THAN 1 IN ROSTER = (MRELATON = 14), FILL = “ex-husbands”
IF EXACTLY 1 IN ROSTER = (MRELATON = 15 OR FRELATON = 15), FILL = “partner”
IF MORE THAN 1 IN ROSTER = (MRELATON = 15 OR FRELATON = 15), FILL = “partners”
IF EXACTLY 1 IN ROSTER = (MRELATON = 18), FILL = “other male relative”
IF MORE THAN 1 IN ROSTER = (MRELATON = 18), FILL = “other male relatives”
IF EXACTLY 1 IN ROSTER = (FRELATON = 2), FILL = “wife”
IF MORE THAN 1 IN ROSTER = (FRELATON = 2), FILL = “wives”
IF EXACTLY 1 IN ROSTER = (FRELATON = 3), FILL = “daughter”
IF MORE THAN 1 IN ROSTER = (FRELATON = 3), FILL = “daughters”
IF EXACTLY 1 IN ROSTER = (FRELATON = 4), FILL = “daughter-in-law”
IF MORE THAN 1 IN ROSTER = (FRELATON = 4), FILL = “daughters-in-law”
IF EXACTLY 1 IN ROSTER = (FRELATON = 5), FILL = “sister”
IF MORE THAN 1 IN ROSTER = (FRELATON = 5), FILL = “sisters”
IF EXACTLY 1 IN ROSTER = (FRELATON = 6), FILL = “sister-in-law”
IF MORE THAN 1 IN ROSTER = (FRELATON = 6), FILL = “sisters-in-law”
IF EXACTLY 1 IN ROSTER = (FRELATON = 7), FILL = “mother”
IF MORE THAN 1 IN ROSTER = (FRELATON = 7), FILL = “mothers”
IF EXACTLY 1 IN ROSTER = (FRELATON = 8), FILL = “mother-in-law”
IF MORE THAN 1 IN ROSTER = (FRELATON = 8), FILL = “mothers-in-law”
IF EXACTLY 1 IN ROSTER = (FRELATON = 9), FILL = “aunt”
IF MORE THAN 1 IN ROSTER = (FRELATON = 9), FILL = “aunts”
IF EXACTLY 1 IN ROSTER = (FRELATON = 10), FILL = “niece”
IF MORE THAN 1 IN ROSTER = (FRELATON = 10), FILL = “nieces”
IF EXACTLY 1 IN ROSTER = (FRELATON = 11), FILL = “grandmother”
Version 4 - February 2017 (Post IRB Approval)
201
IF MORE THAN 1 IN ROSTER = (FRELATON = 11), FILL = “grandmothers”
IF EXACTLY 1 IN ROSTER = (FRELATON = 12), FILL = “granddaughter”
IF MORE THAN 1 IN ROSTER = (FRELATON = 12), FILL = “granddaughters”
IF EXACTLY 1 IN ROSTER = (FRELATON = 13), FILL = “female cousin”
IF MORE THAN 1 IN ROSTER = (FRELATON = 13), FILL = “female cousins”
IF EXACTLY 1 IN ROSTER = (FRELATON = 14), FILL = “ex-wife”
IF MORE THAN 1 IN ROSTER = (FRELATON = 14), FILL = “ex-wives”
IF EXACTLY 1 IN ROSTER = (FRELATON = 18), FILL = “other female relative”
IF MORE THAN 1 IN ROSTER = (FRELATON = 18), FILL = “other female relatives”
[NOTE TO PROGRAMMERS: FAMILY RELATIONSHIP FILLS should be taken from the roster.
They should appear in lowercase and be separated by commas. In QP01, INTROINC, and INTROFI1,
the last FAMILY RELATIONSHIP FILL should be preceded by the word “and”. In all other
situations, the last FAMILY RELATIONSHIP FILL should be preceded by the word “or”. For
example, if a respondent has a father and a husband listed in the roster, INTROINC should read,
“These next questions are about the kinds and amounts of income received by your family living here,
including you, your father, and your husband.”]
HR2
[IF HR1 > 1 AND RESPONDENT IS ONLY FAMILY MEMBER 18 OR OLDER
AND ALL PERAGEYR NE DK/REF, SKIP TO HI_1]
[IF ROSTER HAS MORE THAN 1 ADULT FAMILY MEMBER LISTED AND ALL
PERAGEYR NE DK/REF] {FILL ONLY ADULT FAMILY MEMBERS
(PERAGEYR > 17) IN THIS QUESTION} I have listed as adult family members who
live here: your [FAMILY RELATIONSHIP FILLS]. Do you think one of these people
would be better able to give me the correct information about your health insurance
coverage and the kinds of income you and your family receive?
[IF ROSTER HAS ONLY 1 ADULT FAMILY MEMBER LISTED] {FILL ONLY
ADULT FAMILY MEMBERS (PERAGEYR > 17) IN THIS QUESTION} Do you
think your [FAMILY RELATIONSHIP FILL] would be better able to give me the
correct information about your health insurance coverage and the kinds of income you
and your family receive?
[IF ROSTER HAS NO FAMILY MEMBER OTHER THAN THE RESPONDENT
LISTED AS 18 OR OLDER, BUT THERE IS AT LEAST 1 DK OR REF ENTERED
FOR ANY PERAGEYR OR THERE IS MORE THAN 1 ADULT LISTED AND AT
LEAST 1 DK/REF ENTERED FOR ANY PERAGEYR] Is there anyone else who lives
here who is 18 or older who would be better able to give me the correct information
about your health insurance coverage and the kinds of income you and your family
receive?
Version 4 - February 2017 (Post IRB Approval)
202
1
2
YES
NO [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
DK/REF [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
HR3
[IF HR2 = 1 AND MORE THAN 1 ADULT FAMILY MEMBER IN ROSTER] (Who
is the person you think can help us get the correct information for these questions?)
ENTER RELATIONSHIP OF PERSON WHO CAN BETTER ANSWER THESE
QUESTIONS.
[IF HR2 = 1 AND ONLY 1 ADULT FAMILY MEMBER IN ROSTER]
INTERVIEWER: ENTER “1”.
[FILL 1–9 WITH AGES AND RELATIONSHIPS FROM THE FIRST NINE ADULT
FAMILY MEMBERS OF THE HOUSEHOLD ROSTER, I.E., “father”. FILL
UNUSED LINES WITH “DO NOT USE”, AND MAKE THEM INVALID. IF
PERAGEYR = DK/REF AND MRELATON = 7, 8, OR 11 OR FRELATON = 7, 8,
OR 11, DISPLAY MRELATON/FRELATON IN HR3]
1
[ROSTER FILL]
2
[ROSTER FILL]
3
[ROSTER FILL]
4
[ROSTER FILL]
5
[ROSTER FILL]
6
[ROSTER FILL]
7
[ROSTER FILL]
8
[ROSTER FILL]
9
[ROSTER FILL]
10
OTHER ADULT RELATIVE
DK/REF
HR4
[IF HR2 = 1] (Is your [HR3 FILL] available right now?)
1
2
YES
NO [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
DK/REF [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
HR5
[IF HR4 = 1] (Would you ask your [HR3 FILL] to join us to help with these last
questions about health insurance and income?)
1
2
YES
NO [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
Version 4 - February 2017 (Post IRB Approval)
203
DK/REF [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
HASJOIN
[IF HR5 = 1] HAS THE PERSON’S [HR3 FILL] JOINED R?
1
2
YES [ACTIVATE PROXYFILL AS “SAMPLE MEMBER/SAMPLE
MEMBER’S” FOR REMAINING QUESTIONS]
NO [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
IF HASJOIN = 1, GO TOPROXY.
IF HASJOIN NE 1, GO TO DEFINE SAMPLE MEMBER.
HR6
[IF (HR4 = 2 OR DK/REF OR HR5 = 2 OR DK/REF OR HASJOIN = 2) AND
ADULTFAMRELCOUNT > 1] Is there any other adult family member available who
might be able to answer these questions?
1
YES
2
NO
DK/REF
IF HR6 = YES THEN RETURN TO HR3.
PROGRAMMER NOTE: IF HR2 = 2 OR DK/REF OR HR3 = 2 OR DR/REF OR HR4 = 2 OR
DK/REF OR HR5 = 2 OR DK/REF OR HASJOIN = 2 OR HRP4 = 2 OR DK/REF, THEN
ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING QUESTIONS.
DEFINE SAMPLE MEMBER
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLEMEMBER = “you”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER = “your husband”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER = “your father”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER = “your father-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER = “your brother”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER = “your brother-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER = “your son”
Version 4 - February 2017 (Post IRB Approval)
204
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER = “your son-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER = “your nephew”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER = “your uncle”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER = “your grandson”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER = “your grandfather”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “cousin” (FRELATON = 13 or MRELATON = 13),
SAMPLE MEMBER = “your cousin”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER = “your ex-husband”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER = “your partner”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER = “your relative”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER = “your husband”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER = “your mother”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER = “your mother-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER = “your sister”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER = “your sister-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER = “your daughter”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER = “your daughter-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER = “your niece”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER = “your aunt”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER = “your granddaughter”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER = “your grandmother”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “cousin” (MRELATON = 13 or FRELATON = 13),
SAMPLE MEMBER = “your cousin”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER = “your ex-wife”
Version 4 - February 2017 (Post IRB Approval)
205
IF QD01 = 9 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER = “your partner”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER = “your relative”
DEFINE SAMPLE MEMBER POSS
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLE MEMBER POSS = “your”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER POSS = “your husband’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER POSS = “your father’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER POSS = “your father-in-law’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER POSS = “your brother’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER POSS = “your brother-in-law’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER POSS = “your son’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER POSS = “your son-in-law’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER POSS = “your nephew’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER POSS = “your uncle’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER POSS = “your grandson’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER POSS = “your grandfather’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “cousin” (FRELATON = 13 or MRELATON = 13),
SAMPLE MEMBER = “your cousin’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER = “your ex-husband’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER POSS = “your partner’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER POSS = “your relative’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER POSS = “your wife’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER POSS = “your mother’s”
Version 4 - February 2017 (Post IRB Approval)
206
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER POSS = “your mother-in-law’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER POSS = “your sister’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER POSS = “your sister-in-law’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER POSS = “your daughter’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER POSS = “your daughter-in-law’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER POSS = “your niece’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER POSS = “your aunt”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER POSS = “your granddaughter’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER POSS = “your grandmother’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “cousin” (MRELATON = 13 or FRELATON = 13),
SAMPLE MEMBER = “your cousin”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER = “your ex-wife’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER POSS = “your partner’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER POSS = “your relative’s”
DEFINE SAMPLE MEMBER A
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLE MEMBER A = “Are you”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER A = “Is your husband”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER A = “Is your father”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER A = “Is your father-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER A = “Is your brother”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER A = “Is your brother-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER A = “Is your son”
Version 4 - February 2017 (Post IRB Approval)
207
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER A = “Is your son-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “niece”
(FRELATON = 9, SAMPLE MEMBER A = “Is your nephew”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER A = “Is your uncle”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER A = “Is your grandson”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER A = “Is your grandfather”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “cousin” (FRELATON = 13 or MRELATON = 13),
SAMPLE MEMBER = “Is your cousin”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER = “Is your ex-husband”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER A = “Is your partner”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER A = “Is your relative”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER A = “Is your wife”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER A = “Is your mother”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER A = “Is your mother-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER A = “Is your sister”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER A = “Is your sister-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER A = “Is your daughter”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER A = “Is your daughter-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER A = “Is your niece”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER A = “Is your aunt”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER A = “Is your granddaughter”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER A = “Is your grandmother”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “cousin” (MRELATON = 13 or FRELATON = 13),
SAMPLE MEMBER = “Is your cousin”
Version 4 - February 2017 (Post IRB Approval)
208
IF QD01 = 9 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER = “Is your ex-wife”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER A = “Is your partner”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER A = “Is your relative”
DEFINE SAMPLE MEMBER B
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLE MEMBER B = “you are”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER B = “your husband is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER B = “your father is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER B = “your father-in-law is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER B = “your brother is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER B = “your brother-in-law is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER B = “your son is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER B = “your son-in-law is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER B = “your nephew is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER B = “your uncle is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER B = “your grandson is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER B = “your grandfather is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “cousin” (FRELATON = 13 or MRELATON = 13),
SAMPLE MEMBER = “your cousin is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER = “your ex-husband is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER B = “your partner is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER B = “your relative is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER B = “your wife is”
Version 4 - February 2017 (Post IRB Approval)
209
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER B = “your mother is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER B = “your mother-in-law is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER B = “your sister is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER B = “your sister-in-law is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER B = “your daughter is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER B = “your daughter-in-law is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER B = “your niece is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER B = “your aunt is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER B = “your granddaughter is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER B = “your grandmother is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “cousin” (MRELATON = 13 or FRELATON = 13),
SAMPLE MEMBER = “your cousin is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER = “your ex-wife is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER B = “your partner is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER B = “your relative is”
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
210
34.
Income
BEGIN TIME STAMP
INC1
[IF NO FAMILY MEMBERS IN ROSTER] These next questions are about the kinds
and amounts of income that you receive.
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] These next
questions are about the kinds and amounts of income received by you and your
[FAMILY RELATIONSHIP FILL].
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] These next questions
are about the kinds and amounts of income received by [SAMPLE MEMBER] and you.
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN NE 1]
These next questions are about the kinds and amounts of income received by your
family living here, including you, your [FAMILY RELATIONSHIP FILLS].
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN = 1] These
next questions are about the kinds and amounts of income received by [SAMPLE
MEMBER] and [IF QD01 = 5 FILL his, QD01 = 9 FILL her] family living here,
including you, [IF QD01 = 5 FILL his, QD01 = 9 FILL her] [FAMILY
RELATIONSHIP FILLS]. [PROGRAMMER NOTE: THE PROXY SHOULD NOT
APPEAR IN [FAMILY RELATIONSHIP FILLS]. ALSO, USE “other” AS A
MODIFIER TO THE FAMILY RELATIONSHIP FILL WHEN THE
RELATIONSHIP TYPE IS EQUAL TO PROXY RELATIONSHIP TYPE AND ONE
OF THESE RELATIONSHIP TYPES IS STILL IN THE LIST. PLEASE PRECEDE
EACH RELATIONSHIP WITH “HIS/HER”. ]
[IF HASJOIN NE 1] These questions refer to the calendar year [CURRENT YEAR –
1] rather than to the past 12 months that were referred to in some earlier questions. The
calendar year [CURRENT YEAR – 1] would be from January 1st, [CURRENT YEAR
– 1], through December 31st, [CURRENT YEAR – 1].
INC2
Social Security or Railroad Retirement payments are paid by the U.S. Government to
persons who are retired, severely disabled, or are dependents or survivors of workers.
[IF NO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1], did you
receive Social Security or Railroad Retirement payments?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] In [CURRENT
YEAR – 1], did you or your [FAMILY RELATIONSHIP FILL] receive Social
Security or Railroad Retirement payments?
Version 4 - February 2017 (Post IRB Approval)
211
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] In [CURRENT
YEAR – 1], did [SAMPLE MEMBER] or you receive Social Security or Railroad
Retirement payments?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1],
did [SAMPLE MEMBER] or any of these same family members receive Social
Security or Railroad Retirement payments?
1
YES
2
NO
DK/REF
INC3
Supplemental Security Income or SSI is a program administered by a government
agency that makes assistance payments to people with low income who are aged, blind,
or disabled. This is not the same as Social Security.
[IF NO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1], did you
receive Supplemental Security Income or SSI?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] In [CURRENT
YEAR – 1], did you or your [FAMILY RELATIONSHIP FILL] receive Supplemental
Security Income or SSI?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] In [CURRENT
YEAR – 1], did [SAMPLE MEMBER] or you receive Supplemental Security Income
or SSI?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1],
did [SAMPLE MEMBER] or any of these same family members receive Supplemental
Security Income or SSI?
1
YES
2
NO
DK/REF
INC3a
The Supplemental Nutrition Assistance Program, or SNAP, formerly known as food
stamps, provides assistance for buying food. A special card is issued which can be used
to buy food in grocery stores. SNAP does not include WIC or free or reduced school
lunches.
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1 [IF NO FAMILY
MEMBERS IN ROSTER] In [CURRENT YEAR – 1], did you receive SNAP benefits?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] In [CURRENT
YEAR – 1], did you or your [FAMILY RELATIONSHIP FILL] receive SNAP
benefits?
Version 4 - February 2017 (Post IRB Approval)
212
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] In [CURRENT
YEAR – 1], did [SAMPLE MEMBER] or you receive SNAP benefits?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1],
did [SAMPLE MEMBER] or any of these same family members receive SNAP
benefits?
1
YES
2
NO
DK/REF
DEFINE CONDITION_FILL
IF QD_FIPE4 = 1 THEN CONDITION_FILL = the Family Assistance Program (FAP)
IF QD_FIPE4 = 2 THEN CONDITION_FILL = the Alaska Temporary Assistance Program (ATAP)
IF QD_FIPE4 = 3 THEN CONDITION_FILL = Cash Assistance (CA)
IF QD_FIPE4 = 4 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 5 THEN CONDITION_FILL = California Work Opportunity and Responsibility to
Kids (CalWorks)
IF QD_FIPE4 = 6 THEN CONDITION_FILL = Colorado Works
IF QD_FIPE4 = 7 THEN CONDITION_FILL = Temporary Family Assistance (TFA)
IF QD_FIPE4 = 8 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 9 THEN CONDITION_FILL = Temporary Cash Assistance for Needy Families
(TANF)
IF QD_FIPE4 = 10 THEN CONDITION_FILL =Temporary Assistance for Needy Families (TANF)
Maintenance of Effort (MOE)
IF QD_FIPE4 = 11 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 12 THEN CONDITION_FILL = Temporary Assistance to Needy Families (TANF)
or Temporary Assistance to Other Needy Families (TAONF)
IF QD_FIPE4 = 13 THEN CONDITION_FILL = Temporary Assistance for Families in Idaho (TAFI)
IF QD_FIPE4 = 14 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 15 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 16 THEN CONDITION_FILL = the Family Investment Program (FIP)
IF QD_FIPE4 = 17 THEN CONDITION_FILL = Cash Assistance
IF QD_FIPE4 = 18 THEN CONDITION_FILL = the Kentucky Transitional Assistance Program
(KTAP)
IF QD_FIPE4 = 19 THEN CONDITION_FILL = The Family Independence Temporary Assistance
Program (FITAP)
IF QD_FIPE4 = 20 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
or Additional Support for People in Retraining and Employment (ASPIRE)
IF QD_FIPE4 = 21 THEN CONDITION_FILL = The Family Investment Program (FIP) or
Temporary Cash Assistance (TCA)
IF QD_FIPE4 = 22 THEN CONDITION_FILL = Transitional Aid to Families with Dependent
Children (TAFDC)
IF QD_FIPE4 = 23 THEN CONDITION_FILL = the Family Independence Program (FIP)
IF QD_FIPE4 = 24 THEN CONDITION_FILL = the Minnesota Family Investment Program (MFIP)
Version 4 - February 2017 (Post IRB Approval)
213
IF QD_FIPE4 = 25 THEN CONDITION_FILL = Temporary Assistance to Needy Families (TANF)
IF QD_FIPE4 = 26 THEN CONDITION_FILL = Temporary Assistance
IF QD_FIPE4 = 27 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 28 THEN CONDITION_FILL = Aid to Dependent Children (ADC)
IF QD_FIPE4 = 29 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 30 THEN CONDITION_FILL = Financial Assistance to Needy Families
IF QD_FIPE4 = 31 THEN CONDITION_FILL = Work First New Jersey (WFNJ)
IF QD_FIPE4 = 32 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF),
or NMWorks
IF QD_FIPE4 = 33 THEN CONDITION_FILL = Family Assistance (FA)
IF QD_FIPE4 = 34 THEN CONDITION_FILL = Work First
IF QD_FIPE4 = 35 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
or Job Opportunities and Basic Skills (JOBS)
IF QD_FIPE4 = 36 THEN CONDITION_FILL = Ohio Works First (OWF) or Temporary Assistance
for Needy Families (TANF)
IF QD_FIPE4 = 37 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 38 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 39 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF),
Cash Assistance, or Moving to Independence
IF QD_FIPE4 = 40 THEN CONDITION_FILL = Rhode Island Works (RI Works)
IF QD_FIPE4 = 41 THEN CONDITION_FILL = Family Independence (FI)
IF QD_FIPE4 = 42 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 43 THEN CONDITION_FILL = Families First
IF QD_FIPE4 = 44 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 45 THEN CONDITION_FILL = the Family Employment Program (FEP)
IF QD_FIPE4 = 46 THEN CONDITION_FILL = Reach Up
IF QD_FIPE4 = 47 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 48 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
or WorkFirst
IF QD_FIPE4 = 49 THEN CONDITION_FILL = West Virginia Works (WV Works)
IF QD_FIPE4 = 50 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 51 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
ELSE CONDITION_FILL = BLANK
INC4
[IF NO FAMILY MEMBERS IN ROSTER] At any time during [CURRENT YEAR –
1], even for one month, did you receive any cash assistance from a state or [IF
QD_FIPE4 = 2, THEN “borough”] [IF QD_FIPE4 = 19 THEN “parish”] [IF
QD_FIPE4 NE 2 OR 19 THEN “county”] welfare program such as
[CONDITION_FILL]?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] At any time during
[CURRENT YEAR – 1], even for one month, did you or your [FAMILY
RELATIONSHIP FILL] receive any cash assistance from a state or [IF QD_FIPE4 = 2
THEN “borough”] [IF QD_FIPE4 = 19 THEN “parish”] [IF QD_FIPE4 NE 2 OR 19
THEN “county”] welfare program such as [CONDITION_FILL]?
Version 4 - February 2017 (Post IRB Approval)
214
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] At any time during
[CURRENT YEAR – 1], even for one month, did [SAMPLE MEMBER] or you
receive any cash assistance from a state or [IF QD_FIPE4 = 2 THEN “borough”] [IF
QD_FIPE4 = 19 THEN “parish”] [IF QD_FIPE4 NE 2 OR 19 THEN “county”] welfare
program such as [CONDITION_FILL]?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] At any time during
[CURRENT YEAR – 1], even for one month, did [SAMPLE MEMBER] or any of
these same family members receive any cash assistance from a state or [IF QD_FIPE4
= 2 THEN “borough”] [IF QD_FIPE4 = 19 THEN “parish”] [IF QD_FIPE4 NE 2 OR
19 THEN “county”] welfare program such as [CONDITION_FILL]?
1
YES
2
NO
DK/REF
INC5
[IF NO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1], because of
low income, did you receive any other kind of non-monetary welfare or public
assistance, such as help with getting a job, placement in education or job training
programs, or help with transportation, child care, or housing?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] In [CURRENT
YEAR – 1], because of low income, did you or your [FAMILY RELATIONSHIP
FILL] receive any other kind of non-monetary welfare or public assistance, such as
help with getting a job, placement in education or job training programs, or help with
transportation, child care, or housing?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] In [CURRENT
YEAR – 1], because of low income, did [SAMPLE MEMBER] or you receive any
other kind of non-monetary welfare or public assistance, such as help with getting a
job, placement in education or job training programs, or help with transportation, child
care, or housing?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1],
because of low income, did [SAMPLE MEMBER] or any of these same family
members receive any other kind of non-monetary welfare or public assistance, such as
help with getting a job, placement in education or job training programs, or help with
transportation, child care, or housing?
1
YES
2
NO
DK/REF
Version 4 - February 2017 (Post IRB Approval)
215
INC6
[IF (INC4 = 1 OR INC5 = 1) AND INC3a = 2]
[IF NO FAMILY MEMBERS IN ROSTER] For how many months in [CURRENT
YEAR – 1] did you receive any type of welfare or public assistance?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] For how many
months in [CURRENT YEAR – 1] did you or your [FAMILY RELATIONSHIP FILL]
receive any type of welfare or public assistance?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] For how many
months in [CURRENT YEAR – 1] did [SAMPLE MEMBER] or you receive any type
of welfare or public assistance?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] For how many months in
[CURRENT YEAR – 1] did [SAMPLE MEMBER] or any other family member living
here receive any type of welfare or public assistance?
[ALL] Please include:
• Cash assistance from a state or [IF QD_FIPE4 = 2 THEN “borough”] [IF QD_FIPE4
= 19 THEN “parish”] [IF QD_FIPE4 NE 2 OR 19 THEN “county”] welfare program
such as [CONDITION_FILL]
• Any other kind of non-monetary welfare or public assistance
__________ NUMBER OF MONTHS RECEIVED ASSISTANCE [RANGE: 1–12]
DK/REF
INC7
[IF (INC4 = 1 OR INC5 = 1) AND INC3a = (1, DK, OR REF)]
[IF NO FAMILY MEMBERS IN ROSTER] For how many months in [CURRENT
YEAR – 1] did you receive any type of welfare or public assistance, not including
SNAP benefits?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] For how many
months in [CURRENT YEAR – 1] did you or your [FAMILY RELATIONSHIP FILL]
receive any type of welfare or public assistance, not including SNAP benefits?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] For how many
months in [CURRENT YEAR – 1] did [SAMPLE MEMBER] or you receive any type
of welfare or public assistance, not including SNAP benefits?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] For how many months in
[CURRENT YEAR – 1] did [SAMPLE MEMBER] or any other family member living
here receive any type of welfare or public assistance, not including SNAP benefits?
[ALL] Please include:
Version 4 - February 2017 (Post IRB Approval)
216
• Cash assistance from a state or [IF QD_FIPE4 = 2 THEN “borough”] [IF QD_FIPE4
= 19 THEN “parish”] [IF QD_FIPE4 NE 2 OR 19 THEN “county”] welfare program
such as [CONDITION_FILL]
• Any other kind of non-monetary welfare or public assistance
__________ NUMBER OF MONTHS RECEIVED ASSISTANCE [RANGE: 1–12]
DK/REF
INC7A
HAND R SHOWCARD 7 Here is a list of some other sources of income. When you
answer the next questions, please consider these income sources as well as those asked
about in earlier questions.
Income earned at a job or business
Retirement, disability, or survivor pension
Unemployment or worker's compensation
Veteran's administration payments
Child support
Alimony
Interest income
Dividends from stocks or mutual funds
Income from rental properties, royalties, estates or trusts
INC8
[IF NO FAMILY MEMBERS IN ROSTER] Before taxes and other deductions, was
your total personal income from all sources during [CURRENT YEAR – 1] more or
less than 20,000 dollars?
[IF AT LEAST ONE FAMILY MEMBER IN ROSTER] Now we are going to ask
about [SAMPLE MEMBER POSS] own personal income. Before taxes and other
deductions, was [SAMPLE MEMBER POSS] total personal income from all sources
during [CURRENT YEAR – 1] more or less than 20,000 dollars?
1
$20,000 OR MORE
2
LESS THAN $20,000
DK/REF
INC8A
[IF INC8 = DK OR REF] Income data are important in analyzing the health
information we collect. For example, the information helps us to learn whether persons
in one income group use certain types of medical care services or have conditions more
or less often than those in another group.
Before taxes and other deductions, was [SAMPLE MEMBER POSS] total personal
income from all sources during [CURRENT YEAR – 1] more or less than 20,000
dollars?
1
$20,000 OR MORE
2
LESS THAN $20,000
DK/REF
Version 4 - February 2017 (Post IRB Approval)
217
INC9
[IF INC8 = 2 OR IF INC8A = 2] HAND R SHOWCARD 8 Of these income groups,
which category best represents [SAMPLE MEMBER POSS] total personal income
during [CURRENT YEAR – 1]?
(Income data are important in analyzing the health information we collect. For
example, the information helps us to learn whether people in one income group use
certain types of medical care services or have conditions more or less often than those
in another group.)
1
LESS THAN $1,000
2
$1,000–$1,999
3
$2,000–$2,999
4
$3,000–$3,999
5
$4,000–$4,999
6
$5,000–$5,999
7
$6,000–$6,999
8
$7,000–$7,999
9
$8,000–$8,999
10
$9,000–$9,999
11
$10,000–$10,999
12
$11,000–$11,999
13
$12,000–$12,999
14
$13,000–$13,999
15
$14,000–$14,999
16
$15,000–$15,999
17
$16,000–$16,999
18
$17,000–$17,999
19
$18,000–$18,999
20
$19,000–$19,999
DK/REF
INC9A
[IF INC9 = DK OR REF] Income data are important in analyzing the health
information we collect. For example, the information helps us to learn whether persons
in one income group use certain types of medical care services or have conditions more
or less often than those in another group.
Of these income groups, which category best represents [SAMPLE MEMBER POSS]
total personal income during [CURRENT YEAR – 1]?
1
2
3
4
5
LESS THAN $1,000
$1,000–$1,999
$2,000–$2,999
$3,000–$3,999
$4,000–$4,999
Version 4 - February 2017 (Post IRB Approval)
218
6
$5,000–$5,999
7
$6,000–$6,999
8
$7,000–$7,999
9
$8,000–$8,999
10
$9,000–$9,999
11
$10,000–$10,999
12
$11,000–$11,999
13
$12,000–$12,999
14
$13,000–$13,999
15
$14,000–$14,999
16
$15,000–$15,999
17
$16,000–$16,999
18
$17,000–$17,999
19
$18,000–$18,999
20
$19,000–$19,999
DK/REF
INC10
[IF INC8 = 1 OR IF INC8A = 1] HAND R SHOWCARD 9 Of these income groups,
which category best represents [SAMPLE MEMBER POSS] total personal income
during [CURRENT YEAR – 1]?
(Income data are important in analyzing the health information we collect. For
example, the information helps us to learn whether people in one income group use
certain types of medical care services or have conditions more or less often than those
in another group.)
21
$20,000–$24,999
22
$25,000–$29,999
23
$30,000–$34,999
24
$35,000–$39,999
25
$40,000–$44,999
26
$45,000–$49,999
27
$50,000–$74,999
28
$75,000–$99,999
29
$100,000–$149,999
30
$150,000 OR MORE
DK/REF
INC10A
[IF INC10 = DK OR REF] Income data are important in analyzing the health
information we collect. For example, the information helps us to learn whether persons
in one income group use certain types of medical care services or have conditions more
or less often than those in another group.)
Of these income groups, which category best represents [SAMPLE MEMBER POSS]
total personal income during [CURRENT YEAR – 1]?
Version 4 - February 2017 (Post IRB Approval)
219
21
$20,000–$24,999
22
$25,000–$29,999
23
$30,000–$34,999
24
$35,000–$39,999
25
$40,000–$44,999
26
$45,000–$49,999
27
$50,000–$74,999
28
$75,000–$99,999
29
$100,000–$149,999
30
$150,000 OR MORE
DK/REF
INC11
[IF MORE THAN ONE FAMILY MEMBER IN ROSTER AND IF INC10 NE 30 OR
INC10A NE 30]
Next, we would like to know about the total family income from all sources during
[CURRENT YEAR – 1] before taxes and other deductions.
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] We would like you
to combine everyone’s income -- that is, yours and that of your [FAMILY
RELATIONSHIP FILL].
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] We would like you
to combine everyone’s income -- that is, [SAMPLE MEMBER POSS] and yours.
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN NE 1] We
would like you to combine everyone’s income -- that is, yours and that of your
[FAMILY RELATIONSHIP FILLS].
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN = 1] We
would like you to combine everyone’s income -- that is, yours, [SAMPLE MEMBER
POSS] and that of [IF QD01 = 5 FILL his, QD01 = 9 FILL her] [FAMILY
RELATIONSHIP FILLS] living here. [PROGRAMMER NOTE: THE PROXY
SHOULD NOT APPEAR IN [FAMILY RELATIONSHIP FILLS]. ALSO, USE
“other” AS A MODIFIER TO THE FAMILY RELATIONSHIP FILL WHEN THE
RELATIONSHIP TYPE IS EQUAL TO PROXY RELATIONSHIP TYPE AND ONE
OF THESE RELATIONSHIP TYPES IS STILL IN THE LIST.]
Please include all of the sources of income that we just talked about.
INC12
[IF MORE THAN ONE FAMILY MEMBER IN ROSTER AND (INC8 NE 1 OR
INC8A NE 1)] Before taxes and other deductions, was the total combined family
income during [CURRENT YEAR – 1] more or less than 20,000 dollars?
1
2
$20,000 OR MORE
LESS THAN $20,000
Version 4 - February 2017 (Post IRB Approval)
220
DK/REF
INC13
[IF INC12 = 2] HAND R SHOWCARD 8
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] Of these income
groups, which category best represents your total combined family income during
[CURRENT YEAR – 1] -- that is, yours and that of your [FAMILY RELATIONSHIP
FILL].
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] Of these income
groups, which category best represents your total combined family income during
[CURRENT YEAR – 1] -- that is, your [SAMPLE MEMBER POSS] and yours.
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN NE 1] Of
these income groups, which category best represents your total combined family
income during [CURRENT YEAR – 1] -- that is, yours and that of your
[RELATIONSHIP FILLS].
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN = 1] Of
these income groups, which category best represents your total combined family
income during [CURRENT YEAR – 1] -- that is, yours, [SAMPLE MEMBER POSS],
and that of [IF QD01 = 5 FILL his, QD01 = 9 FILL her] [FAMILY RELATIONSHIP
FILLS] living here? [PROGRAMMER NOTE: THE PROXY SHOULD NOT
APPEAR IN [FAMILY RELATIONSHIP FILLS]. ALSO, USE “other” AS A
MODIFIER TO THE FAMILY RELATIONSHIP FILL WHEN THE
RELATIONSHIP TYPE IS EQUAL TO PROXY RELATIONSHIP TYPE AND ONE
OF THESE RELATIONSHIP TYPES IS STILL IN THE LIST.]
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
LESS THAN $1,000
$1,000–$1,999
$2,000–$2,999
$3,000–$3,999
$4,000–$4,999
$5,000–$5,999
$6,000–$6,999
$7,000–$7,999
$8,000–$8,999
$9,000–$9,999
$10,000–$10,999
$11,000–$11,999
$12,000–$12,999
$13,000–$13,999
$14,000–$14,999
$15,000–$15,999
$16,000–$16,999
$17,000–$17,999
Version 4 - February 2017 (Post IRB Approval)
221
19
$18,000–$18,999
20
$19,000–$19,999
DK/REF
INC14
[IF (INC12 = 1 OR INC8 = 1 OR INC8A = 1) AND INC10 NE 30 OR INC10A NE 30]
HAND R SHOWCARD 9
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] Of these income
groups, which category best represents your total combined family income during
[CURRENT YEAR – 1] -- that is, yours and that of your [FAMILY RELATIONSHIP
FILL]?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] Of these income
groups, which category best represents your total combined family income during
[CURRENT YEAR – 1] -- that is, [SAMPLE MEMBER POSS] and yours?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN NE 1] Of
these income groups, which category best represents your total combined family
income during [CURRENT YEAR – 1] -- that is, yours and that of your [FAMILY
RELATIONSHIP FILLS]?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN = 1] Of
these income groups, which category best represents your total combined family
income during [CURRENT YEAR – 1] -- that is, yours, [SAMPLE MEMBER POSS],
and that of [IF QD01 = 5 FILL his, QD01 = 9 FILL her] [FAMILY RELATIONSHIP
FILLS] living here? [PROGRAMMER NOTE: THE PROXY SHOULD NOT
APPEAR IN [FAMILY RELATIONSHIP FILLS]. ALSO, USE “other” AS A
MODIFIER TO THE FAMILY RELATIONSHIP FILL WHEN THE
RELATIONSHIP TYPE IS EQUAL TO PROXY RELATIONSHIP TYPE AND ONE
OF THESE RELATIONSHIP TYPES IS STILL IN THE LIST.]
19
$20,000–$24,999
20
$25,000–$29,999
21
$30,000–$34,999
22
$35,000–$39,999
23
$40,000–$44,999
24
$45,000–$49,999
25
$50,000–$74,999
26
$75,000–$99,999
27
$100,000–$149,999
28
$150,000 OR MORE
DK/REF
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
222
35.
Health Insurance
BEGIN TIME STAMP
TOPROXY
[IF HASJOIN = 1] WHEN [HR3 FILL] HAS JOINED YOU:
The next questions are about [SAMPLE MEMBER POSS] health insurance coverage.
PRESS [ENTER] TO CONTINUE.
DEFINE H1_FILL
IF HASJOIN NE 1, THEN H1_FILL = The next questions are about health insurance.
ELSE HI_FILL = “’”
HI_1 [H1_FILL] 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.
[SAMPLE MEMBER A] covered by any kind of health insurance or some other kind of health
care plan?
1
YES
2
NO
DK/REF
DEFINE HI_2FILL
IF HASJOIN = 1, THEN HI_2FILL = does [SAMPLE MEMBER]
ELSE HI_2FILL = do you
HI_2 [IF HI_1 = 1 OR DK OR REF] What kind of health insurance or health care coverage
[HI_2FILL] have? Include those that pay for only one type of service, such as nursing home
care, accidents, or dental care. Exclude private plans that only provide extra cash while
hospitalized.
TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR BETWEEN
EACH CATEGORY YOU SELECT.
1
2
3
4
5
6
7
8
Private health insurance
Medicare
Medi-Gap
Medicaid
SCHIP, also known as CHIP or Children's Health Insurance Program
Military health care, such as TRICARE, VA, or CHAMP-VA
Indian Health Service
State-sponsored health plan
Version 4 - February 2017 (Post IRB Approval)
223
9
Other government program
10
Single service plan, such as dental, vision, or prescriptions
11
No coverage of any type
DK/REF
DEFINE HI_3FILL
IF HASJOIN = 1, THEN HI_3FILL = [SAMPLE MEMBER]
ELSE HI_3FILL = you
HI_3 [IF HI_1 = 2 OR HI_2 = 11] About how long has it been since [HI_3FILL] last had health care
coverage?
1
6 months or less
2
More than 6 months, but less than 1 year
3
1 year
4
More than 1 year, but less than 3 years
5
3 years or more
6
Never had coverage
DK/REF
DEFINE WEREWAS
IF HR1 = 1 OR HASJOIN = BLANK OR 2 THEN WEREWAS = “were you”
ELSE WEREWAS = “was SAMPLE MEMBER”
HI14
[HI_3 = (1 OR 2 OR DK OR REF)] During the past 12 months, that is from [DATE FILL]
through today, about how many months [FILL WEREWAS] without any kind of health
insurance or coverage?
__________ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
GPS1
Finally, we are also interested in collecting GPS coordinates from this location. This
information will only be used for data quality and verification purposes. Do I have your
permission to collect this information?
1
2
YES
NO
DK/REF
[NOTE TO FI: IF CONSENT IS GIVEN, RECORD GPS ON TABLET ONCE YOU
ARE OUTSIDE OF THE HOME]
Version 4 - February 2017 (Post IRB Approval)
224
GPS2
[IF GPS1 = 2 OR DK OR REF] GPS coordinates will provide the latitude and
longitude of this address or location on a map. A researcher will use this information
only to verify that I conducted this interview at the correct address. Your name and
interview responses will be stored separately from the coordinates. May I collect the
GPS coordinates?
1
2
YES
NO
DK/REF
[NOTE TO FI: IF CONSENT IS GIVEN, RECORD GPS ON TABLET ONCE YOU
ARE OUTSIDE OF THE HOME]
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
225
36. Verification
BEGIN TIME STAMP
CASEID
OPEN QC FORM ON TABLET. ENTER CASEID TO OPEN NEW QC FORM.
ENTER THE CASE ID FOR THIS INTERVIEW IN THE CAI. BE SURE TO
INCLUDE A OR B AT THE END OF THE CASE ID.
TOALLR3I It is important that I do my job correctly; therefore, my supervisors will be checking on
my work. Would you help me by giving me your phone number? I will enter it into this
tablet.
This information is kept separate from the responses that were entered so they will still
be completely private.
PRESS [ENTER] TO CONTINUE.
PHONE
May I please have your phone number?
ENTER 10 DIGIT PHONE NUMBER INTO TABLET AND PRESS ENTER. IF R
REFUSES, MARK “REFUSED” ON TABLET AND PRESS ENTER.
ADDRESS
May I please confirm your current address?
CONFIRM PREFILLED ADDRESS FROM TABLET.
INCENT01
HAND RESPONDENT $40 CASH.
MARK THE APPROPRIATE “CASH ACCEPTANCE” BOX ON THE INTERVIEW
INCENTIVE RECEIPT.
SIGN AND DATE INTERVIEW INCENTIVE RECEIPT AND GIVE TOP COPY TO
RESPONDENT.
I have signed this form to indicate that I have given you $40 for this interview. At the
bottom of this form, we have included national hotline numbers that you can call if you
ever feel you need to talk to someone about mental health or drug use issues.
IF NOT DONE EARLIER, GIVE ADULT RESPONDENT OR
PARENT/GUARDIAN OF YOUTH THE Q&A BROCHURE AND SAY:
For more details on the National Mental Health Study, this brochure includes answers
to common questions, website addresses, and other information.
Version 4 - February 2017 (Post IRB Approval)
226
PRESS [ENTER] TO CONTINUE.
THANKR2
Thank you for your time.
[ALL CASES] BE SURE YOU HAVE YOUR SHOWCARD BOOKLET, YUBIKEY,
AND INCENTIVE RECEIPT COPIES.
[ALL CASES] PRESS [ENTER] TO CONTINUE.
FIEXIT
END OF INTERVIEW REACHED.
PRESS 1 TO EXIT.
END TIME STAMP
Version 4 - February 2017 (Post IRB Approval)
227
37. Showcards
SHOWCARD 1
1
AMERICAN INDIAN OR ALASKA NATIVE
2
ASIAN
3
BLACK OR AFRICAN AMERICAN
4
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
5
WHITE
Version 4 - February 2017 (Post IRB Approval)
228
SHOWCARD 2
0
NO SCHOOLING COMPLETED
1
1ST GRADE COMPLETED
2
2ND GRADE COMPLETED
3
3RD GRADE COMPLETED
4
4TH GRADE COMPLETED
5
5TH GRADE COMPLETED
6
6TH GRADE COMPLETED
7
7TH GRADE COMPLETED
8
8TH GRADE COMPLETED
9
9TH GRADE COMPLETED
10
10TH GRADE COMPLETED
11
11TH GRADE COMPLETED
12
REGULAR HIGH SCHOOL DIPLOMA
13
12TH GRADE, NO DIPLOMA
14
GED CERTIFICATE OF HIGH SCHOOL
COMPLETION
15
SOME COLLEGE CREDIT, BUT NO DEGREE
16
ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS)
17
BACHELOR’S DEGREE (FOR EXAMPLE, BA, BS)
18
MASTER’S DEGREE (FOR EXAMPLE, MA, MS,
MENG, M. ED, MSW, MBA)
19
DOCTORATE DEGREE (FOR EXAMPLE, PHD, EDD)
20
PROFESSIONAL DEGREE BEYOND A BACHELOR’S
DEGREE (FOR EXAMPLE, MD, DDS, DVM, LLB, JD)
Version 4 - February 2017 (Post IRB Approval)
229
SHOWCARD 3
1
SEPTEMBER 2001 OR LATER
2
AUGUST 1990 TO AUGUST 2001 (INCLUDING
PERSIAN GULF WAR)
3
MAY 1975 TO JULY 1990
4
MARCH 1961 TO APRIL 1975 (VIETNAM ERA)
5
FEBRUARY 1955 TO FEBRUARY 1961
6
JULY 1950 TO JANUARY 1955 (KOREAN
WAR)
7
JANUARY 1947 TO JUNE 1950
8
DECEMBER 1941 TO DECEMBER 1946
(WORLD WAR II)
9
NOVEMBER 1941 OR EARLIER
Version 4 - February 2017 (Post IRB Approval)
230
SHOWCARD 4
1
2
3
4
5
6
7
--------
ABILIFY
ABILIFY MAINTENA
ADDERAL
ADDERAL XR
ALPRAZOLAM
AMBIEN
AMITRIPTYLINE
8 -- AMPHETAMINE
9 -- ANAFRANIL
10 -- ARIPIPRAZOLE
11 -- ARMODAFINIL
12 -- ARTANE
13 -- ASENAPINE
14 -- ATIVAN
15
16
17
18
-----
ATOMOXETINE
BELSOMRA
BENZTROPINE
BRINTELLIX
19 -- BUDEPRION SR
20 -- BUDEPRION XL
21 -- BUPROPION
22
23
24
25
26
27
28
29
---------
BUSPAR
BUSPIRONE
CARBAMAZEPINE
CARBATROL
CATAPRES
CELEXA
CHLORDIAZEPOZIDE
CHLORPROMAZINE
Version 4 - February 2017 (Post IRB Approval)
30
31
32
33
34
35
36
--------
CITALOPRAM
CLOMIPRAMINE
CLONAZEPAM
CLONIDINE
CLOZAPINE
CLOZARIL
COGENTIN
37 -- CONCERTA
38-- CYMBALTA
39 -- CYTOMEL
40 -- DAYTRANA
41 -- DEPAKENE
42 -- DEPAKOTE
43 -- DEPAKOTE
SPRINKLES
44 -- DESOXYN
45 -- DESVENLAFAXINE
46 -- DESYREL
47 -- DEXEDRINE
48 -DEXMETHYLPHENIDATE
49 -DEXTROAMPHETAMINE
50 -DEXTROAMPHETAMINE/
AMPHETAMINE
51 -- DIAZEPAM
52 -- DIVALPROEX
53 -- DOXEPIN
54 -- DULOXETINE
55 -- EFFEXOR
56 -- ELAVIL
57 -- ESCITALOPRAM
58 -- ESKALITH
59
60
61
62
63
64
65
--------
66
67
68
69
70
71
72
ESZOPICLONE
EVEKEO
FANAPT
FETZIMA
FLUOXETINE
FLUPHENAZINE
FLUPHENAZINE
DECANOATE
-- FLUVOXAMINE
-- FOCALIN
-- FORFIVO XL
-- GABAPENTIN
-- GABITRIL
-- GEODON
-- GUANFACINE
73
74
75
76
-----
HALDOL
HALDOL DECANOATE
HALOPERIDOL
HALOPERIDOL
DECANOATE
77 -- HETLIOZ
78 -- ILOPERIDONE
79 -- INDERAL
80
81
82
83
84
85
86
87
---------
INTUNIV
INVEGA
INVEGA SUSTENNA
ISOCARBOXAZID
KLONOPIN
LAMICTAL
LAMOTRIGINE
LATUDA
231
88
89
90
91
92
93
94
95
96
97
-----------
LEVOMILNACIPRAN
LEXAPRO
LIBRIUM
LISDEXAMFETAMINE
LITHIUM
LITHOBID
LORAZEPAM
LUNESTA
LURASIDONE
LUVOX
98 -- LYRICA
99 -- MARPLAN
PARNATE
PAROXETINE
PAXIL
PHENELZINE
PRAZOSIN
PREGABALIN
PRISTIQ
PROCENTRA
PROLIXIN
PROLIXIN
DECANOATE
127 -- PROPRANOLOL
128 -- PROVIGIL
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
-----------------
MELATONIN
METADATE
METHAMPHETAMINE
METHYLIN
METHYLPHENIDATE
MINIPRESS
MIRTRAZAPINE
MODAFINIL
NARDIL
NEURONTIN
NORTRIPTYLINE
NUVIGIL
OLANZAPINE
OXCARBAZEPINE
PALIPERIDONE
PALIPERIDONE
PALMITATE
117
118
119
120
121
122
123
124
125
126
-----------
146
147
148
149
150
151
152
153
154
155
-----------------
156 -- TRIHEXYPHENIDYL
157 -- TRIIODOTHYRONINE
(T3)
158 -- TRILEPTAL
159 -- VALIUM
160 -- VALPROIC ACID
161 -- VENLAFAXINE
162 -- VIIBRYD
163 -- VILAZODONE
164 -- VORTIOXETINE
165 -- VYVANSE
166 -- WELLBUTRIN
167 -- XANAX
168 -- ZALEPLON
169 -- ZENZEDI
170 -- ZIPRASIDONE
171 -- ZOLOFT
172 -- ZOLPIDEM
173 -- ZOLPIMIST
PROZAC
QUETIAPINE
QUILLIVANT XR
RAMELTEON
REMERON
RESTORIL
RISPERDAL
RISPERDAL CONSTA
RISPERIDONE
RITALIN
ROZEREM
SAPHRIS
SEROQUEL
SERTRALINE
SILENOR
SONATA
-----------
SUVOREXANT
TASIMELTEON
TEGRETOL
TEMAZEPAM.
TENEX
THORAZINE
TOPAMAX
TOPIRAMATE
TRANYLCYPROMINE
TRAZODONE
(EXTENDED RELEASE
INJECTABLE)
116 -- PAMELOR
145 -- STRATTERA
174 -- ZYPREXA
175 -- ZYPREXA
RELPREVV
Version 4 - February 2017 (Post IRB Approval)
232
SHOWCARD 5
1
SELF
2
HUSBAND
3
SON (INCLUDES STEP, FOSTER, ADOPTIVE)
4
SON-IN-LAW
5
BROTHER (INCLUDES HALF, STEP, FOSTER,
ADOPTIVE)
6
BROTHER-IN-LAW
7
FATHER (INCLUDES STEP, FOSTER,
ADOPTIVE)
8
FATHER-IN-LAW
9
UNCLE
10
NEPHEW
11
GRANDFATHER
12
GRANDSON
13
COUSIN
14
EX-HUSBAND
15
UNMARRIED PARTNER
16
HOUSEMATE OR ROOMMATE
17
TENANT, BOARDER, OR EXCHANGE STUDENT
18
OTHER RELATIVE
19
OTHER NON-RELATIVE
Version 4 - February 2017 (Post IRB Approval)
233
SHOWCARD 6
1
SELF
2
WIFE
3
DAUGHTER (INCLUDES STEP, FOSTER,
ADOPTIVE)
4
DAUGHTER-IN-LAW
5
SISTER (INCLUDES HALF, STEP, FOSTER,
ADOPTIVE)
6
SISTER-IN-LAW
7
MOTHER (INCLUDES STEP, FOSTER,
ADOPTIVE)
8
MOTHER-IN-LAW
9
AUNT
10
NIECE
11
GRANDMOTHER
12
GRANDDAUGHTER
13
COUSIN
14
EX-WIFE
15
UNMARRIED PARTNER
16
HOUSEMATE OR ROOMMATE
17
TENANT, BOARDER, OR EXCHANGE STUDENT
18
OTHER RELATIVE
19
OTHER NON-RELATIVE
Version 4 - February 2017 (Post IRB Approval)
234
SHOWCARD 7
INCOME EARNED AT A JOB OR BUSINESS
RETIREMENT, DISABILITY, OR SURVIVOR PENSION
UNEMPLOYMENT OR WORKER’S COMPENSATION
VETERAN’S ADMINISTRATION PAYMENTS
CHILD SUPPORT
ALIMONY
INTEREST INCOME
DIVIDENDS FROM STOCKS OR MUTUAL FUNDS
INCOME FROM RENTAL PROPERTIES, ROYALTIES,
ESTATES OR TRUSTS
Version 4 - February 2017 (Post IRB Approval)
235
SHOWCARD 8
1
LESS THAN $1,000
2
$1,000 - $1,999
3
$2,000 - $2,999
4
$3,000 - $3,999
5
$4,000 - $4,999
6
$5,000 - $5,999
7
$6,000 - $6,999
8
$7,000 - $7,999
9
$8,000 - $8,999
10
$9,000 - $9,999
11
$10,000 - $10,999
12
$11,000 - $11,999
13
$12,000 - $12,999
14
$13,000 - $13,999
15
$14,000 - $14,999
16
$15,000 - $15,999
17
$16,000 - $16,999
18
$17,000 - $17,999
19
$18,000 - $18,999
20
$19,000 - $19,999
Version 4 - February 2017 (Post IRB Approval)
236
SHOWCARD 9
21
$20,000 - $24,999
22
$25,000 - $29,999
23
$30,000 - $34,999
24
$35,000 - $39,999
25
$40,000 - $44,999
26
$45,000 - $49,999
27
$50,000 - $74,999
28
$75,000 - $99,999
29
$100,000 - $149,999
30
$150,000 OR MORE
Version 4 – February 2017 (Post IRB Approval)
237
Appendix A
Summary of Module Content
Version 4 – February 2017 (Post IRB Approval)
238
Introduction
This document briefly summarizes the content of each National Mental Health Study (NMHS) Adult
Instrument module, provides a high-level overview of the changes made to the module when compared
with the source material provided from the Substance Abuse and Mental Health Services Administration
(SAMHSA) and the National Institute of Mental Health (NIMH), and includes some topics the reader
may wish to consider in reviewing the instrument.
Changes
All modules were revised as follows.
•
Inclusion Logic. Checkpoint (CKPT) and “GO TO” logic instructions were translated
to question-by-question inclusion logic. This logic, which appears at the beginning of a
question, indicates which respondents should be asked each question. If no inclusion
logic appears in the specifications, the question will be asked of all adult respondents.
•
Logic-Processing Variables. Where logic is complicated, it has been divided into
smaller units, each with its own variable name. Programmers and instrument testers
will use these variables to help ensure the instrument functions as intended. However,
respondents will not see the processing variables or their associated logic.
•
ACASI Adaptations. Most modules will be administered via audio computer-assisted
self-interviewing (ACASI). Where needed, items were revised to enable the automated
system to appropriately read text aloud.
•
– Removed parentheses and instead used other methods for setting text apart.
– Removed italicization.
– Removed underlining used to indicate text that should be emphasized and replaced
with bolding.
– Converted abbreviations to full words.
– Integrated most showcard booklet references into on-screen text.
– Revised language that suggested the question was being read to the respondent by
an interviewer (e.g., “Now I’d like to ask you about…” to “These next questions are
about…”).
Ranges. Wherever a question asks for an open-ended numerical answer, a specified
range is documented within which the respondents’ answers must fall in order to be
considered valid by the system. When a respondent enters a response outside the
allowable range, the system will generate a message alerting the respondent that the
response must be revised. Such range limits help to improve data quality by alerting
respondents to what are typically either keying errors or errors caused by the
respondent misunderstanding what information is being requested.
•
Yes/No Grids. Most check-all-that-apply questions were converted to grids of Yes/No
questions. The Yes/No format ensures that respondents consider each individual item
rather than skimming the list and, perhaps, only attending to one or two items. This
approach should be more effective in the ACASI environment where an interviewer is
not able to prompt a respondent to consider all items in the list.
•
Don’t Know and Refuse Responses.
Version 4 – February 2017 (Post IRB Approval)
239
•
– For each question, there is an explicit indication that a “don’t know” (DK) or refuse
(REF) is an option. Respondents will access these answer choices by using function
keys that have been labeled specifically for this purpose.
– Inclusion logic is provided where needed to clarify what should happen after a
respondent enters a “don’t know” answer or refuses a question.
Fills. Separate variables have been defined to create the text fills needed to tailor
questions based on a respondent’s answers to previous questions.
•
Renumbering. All items have been renumbered, in some cases several times, for logical
flow throughout the specifications. Renumbering will not be listed specifically in the
module-by-module summaries.
•
Module order. Modules were reordered several times during drafting. These changes
are not marked because the source documents were not specifically ordered when
received by RTI.
Because the changes noted above were made throughout the Adult Instrument, these categories of
changes are not repeated in the module-specific overviews that follow.
Key to Header Information Used in the Remaining Sections of this Document
The header for each section of this document contains the following information about the module.
•
Module Name
•
– There has been some renaming of CIDI modules as Dr. Kessler has worked to
create the CIDI 4.0 versions. The names included in this document are our best
understanding of how modules are now being referenced.
Mode
•
– CAPI = computer-assisted personal interviewing.
▪ Interviewers administer CAPI modules.
– ACASI = audio computer-assisted self-interviewing.
▪ Respondents read questions on their own or listen to the computer read the
questions to them through headphones.
▪ Interviewers remain nearby in order to provide showcards as requested by the
respondent and to answer any questions the respondent raises.
Coverage
– Part 1:
▪ All respondents will be administered at least one question from each module
assigned to Part 1.
– Part ½:
▪ All respondents will be randomly assigned to receive one or the other of the
paired modules assigned to Part ½.
– Screened +:
▪ Only respondents who screen positive for the disorder that is the subject of the
module will receive a “Screened +” module.
– Part 2:
Version 4 – February 2017 (Post IRB Approval)
240
▪ All respondents who screen positive to one or more of the disorder modules in
▪
the CIDI Screener will receive “Part 2” modules.
In addition, 25% of respondents who screen negative to all disorder modules
will also receive “Part 2” modules.
Version 4 – February 2017 (Post IRB Approval)
241
1.
Core Demographics | CAPI—Part 1
•
Overview
– Collects basic demographic information including age, race, ethnicity, marital
status, and educational attainment.
– Includes routing to ensure respondents who are younger than 13 are not interviewed
at all and that respondents younger than 18 are not interviewed using the adult
instrument.
– Also asks for height, weight, country/state of origin, other languages spoken, and
how well the respondent speaks English.
•
Changes from Original
– Changed age-related inclusion logic from 12 to 13.
– Removed ADQ04, ADQ04OTHR, AQD05ASIA, AQD05OTHA, and
AQD05OTHR, which asked about more specific ethnic and racial groups.
– Simplified responses in QD05 to include only five categories instead of nine.
– Removed QD08, which asked how many times a respondent had been married.
– Removed ADQ12, which asked about overall health; this was moved to “Your
Health” (B1).
– Made decision to exclude reporting in metric because so few NSDUH respondents
interviewed in English opt to respond in these units (In the 2015 NSDUH, 1.75% of
respondents interviewed in English provided height in meters and 1.42% provided
weight in kilograms). The following items were removed: ADQ13, ADQ16,
ADQ17, ADQ18, and ADQ22.
– Added required HHS language item, QD55, which asks respondents how well they
speak English.
– Added questions from the Childhood Demographics modules that relate to age of
entry to the United States and other languages spoken in the home as they seemed
to fit more naturally with other items already included in the Core Demographics
module. The specific items added are QDDE4_a, and QDDE7. Similar items that
were included in this module in earlier drafts have been removed. These items are
DE5_1, DE5_2, and DE8.
Version 4 – February 2017 (Post IRB Approval)
242
2.
Military Service | CAPI—Part 1
•
Overview
– If the respondent says that he or she has ever been in the United States Armed
Forces, the respondent is asked more questions about military service.
▪ Duration, timing, and kind of service
▪ Rank
– Active duty military personnel are excluded from participation in NMHS.
•
Changes from Original
– Removed AMS7, which asked for the military branch or branches for which the
respondent served.
– AMS10:
▪ Clarified question text FROM: “Highest rank at separation or current rank
(Select One)” TO: “What was your rank at the time you separated from the
service? Was it enlisted, non-commissioned officer, warrant officer, or
officer?” (if “NOW SEPARATED OR RETIRED FROM THE MILITARY”)
or the following “What is your current rank? Is it enlisted, non-commissioned
officer, warrant officer, or officer?” (if “IN A RESERVE COMPONENT”).
▪ Added response category “warrant officer”.
– Removed AMS11/AMS11_OTHER, which asked where the respondent was
stationed.
– Removed AMS17, which asked about active duty in a military combat zone or an
area where you drew imminent danger pay or hostile fire pay.
Version 4 – February 2017 (Post IRB Approval)
243
3.
Beginning ACASI | CAPI—Part 1
•
Overview
– The interviewer introduces the respondent to audio computer-assisted selfinterviewing (ACASI).
•
Changes from Original
– No high-level changes made.
Version 4 – February 2017 (Post IRB Approval)
244
4.
ACASI Tutorial | ACASI—Part 1
•
Overview
– The respondent follows instructions and completes practice questions, using
ACASI.
•
Changes from Original
– Removed PLAYINFO, which showed respondents how to answer a question type
not included in the NMHS.
Version 4 – February 2017 (Post IRB Approval)
245
5.
Your Health | ACASI—Part 1
•
Overview
– Asks a variety of physical and mental health questions.
▪ general health
▪ impairment
▪ cancer history
▪ health condition history
▪ symptoms in past 30 days
▪ sleep problems
▪ organization and concentration problems
▪ difficulties with daily activities during worst month in past 12 months
▪ basic categories of treatment in the past 12 months
– HHS impairment questions are included in this module, labeled as B8a–f.
•
Changes from Original
– Removed B6 and B7, which asked about height and weight.
– Removed B8, which asked if respondent has a severe vision or hearing problem,
severe paralysis or spinal cord injury, or any other serious long-term physical
impairment or disability.
– Added B8a: Are you deaf or do you have serious difficulty hearing?
– Added B8b: Are you blind or do you have serious difficulty seeing, even when
wearing glasses?
– Added B8c: Because of a physical, mental, or emotional condition, do you have
serious difficulty concentrating, remembering, or making decisions?
– Added B8d: Do you have serious difficulty walking or climbing stairs?
– Added B8e: Do you have difficulty dressing or bathing?
– Added B8f: Because of a physical, mental, or emotional condition, do you have
difficulty doing errands alone such as visiting a doctors’ office or shopping?
– Removed B11a, B11b, B11c, B11d, B11e, B11f, B11g, B11h, B11i, B11j, and
B11k, which asked about age of first diagnosis
– B13—Changed from “check all that apply” format to a series of “Yes/No”
questions.
– Removed B13k: Did you ever in your life have any of the following problems? Any
other type of psychotic disorder?
– Removed B16b, which asked about how often in the past 30 days respondents felt
so angry that they thought they might explode.
– Removed B19a–i, B20, and B21, which asked about problems with organization
and concentration.
– B22Bd—Revised question text by adding “nerves”: “In the past 12 months, how
many times have you been hospitalized overnight for problems with emotions,
nerves, or mental health?”
Version 4 – February 2017 (Post IRB Approval)
246
– Removed B23: What kinds of health coverage or insurance do you have?
– B17, B18, and B19 were already deleted in the source document as we received it
from NIMH.
Version 4 – February 2017 (Post IRB Approval)
247
6.
CIDI Screener | ACASI—Part 1
•
Overview
– Includes questions designed to screen respondents into later modules for several
disorders.
▪ Mania
▪ Panic
▪ Social Anxiety
▪ Agoraphobia
▪ Eating Disorders
▪ Intermittent Explosive Disorder (IED)
▪ Specific Phobia
▪ Obsessive Compulsive Disorder (OCD)
•
Changes from Original
– Lisa Colpe’s deletion in source document: SC2a Have you ever had a period lasting
several days or longer when most of the time you were so irritable that you either
started arguments, shouted at people, or hit people?
– Lisa Colpe’s deletion in source document: Removed screens for depression and
Generalized Anxiety Disorder (GAD).
*SC2. Have you ever in your life had a period lasting several days or longer when most
of the day you felt sad, empty, or depressed?
*SC2a. Have you ever had a period lasting several days or longer when most of the day
you were very discouraged about how things were going in your life?
*SC3. Have you ever had a period lasting several days or longer when you lost interest
in most things you usually enjoy like work, hobbies, and personal relationships?
*SC6. Did you ever have a time in your life when you were a “worrier” – that is,
when you worried a lot more about things than other people with the same
problems as you?
*SC6a. Did you ever have a time in your life when you were much more
nervous or anxious than most other people with the same problems
as you?
*SC6b. Did you ever have a period lasting one month or longer when you were
anxious and worried most days? (GAD)
– Per Lisa Colpe, added inclusion logic so only those who respond “yes” to SC6
receive SC6a.
– Per Lisa Colpe, skip logic changed at SC4 FROM: if “yes” skip to SC8 TO: if “yes”
skip to SC5.
– Per Lisa Colpe, skip logic removed at SC2 that indicated respondents who answer
“no” should skip to SC6.
Version 4 – February 2017 (Post IRB Approval)
248
– Per Lisa Colpe, respondents who endorse one IED screener item skip over the next
ones. Specifically, those who answer “yes” to SC8 should be skipped past SC8a and
SC8b. If a respondent endorses SC8a, the program will skip past SC8b.
Version 4 – February 2017 (Post IRB Approval)
249
7.
Depression | ACASI—Part 1
•
Overview
– Asks about depression symptoms in the past 30 days.
– Asks about depression symptoms in the worst period in life that lasted 2 weeks or
longer.
– If the respondent has experienced one or more of the initial set of worst-2-weeks
symptoms at least “most of the time,” asks follow-up questions about that 2-week
period.
▪ frequency experienced other symptoms
▪ degree of impairment
– If enough of the worst-2-weeks symptoms were experienced “some of the time” or
more frequently, follow-up questions are asked:
▪ age first time had depression episode
▪ whether first episode started in past 12 months
▪ years in life had an episode
▪ duration of longest episode
▪ how much episodes interfered with life
▪ number of months in past 12 months that had an episode
▪ age at time of most recent episode
•
Changes from Original
– Added the following questions.
▪ DE4d: Have sleep problems, such as getting to sleep, staying asleep, waking
too early, or sleeping too much?
▪ DE4e: Feel tired out, low in energy, or easily fatigued?
▪ DE4f: Talk or move more slowly than usual?
▪ DE4f_1: Did other people notice or comment that you were talking or moving
more slowly?
▪ DE4g: Have a poor appetite or overeat?
▪ DE4i: Feel restless, tense, wound up, or on edge?
▪ DE4h: Did other people notice or comment that you were restless or wound
up?
– Edited logic throughout the module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
250
8.
Mania | ACASI—Screened +
•
Overview
– Only administers the first question to respondents who have not already screened
positive for mania elsewhere in the instrument.
– If screened positive on the first question or already screened positive for mania
elsewhere in the instrument, follow-up questions are asked:
▪ whether other people ever noticed or commented on high mood
▪ for each of several symptoms, frequency during a typical intense episode
If key symptoms from a typical intense episode were frequent enough, asks
follow-up questions:
o for each of several additional symptoms, frequency during a typical
intense episode
o how often the episode interfered with life
– If screened positive when considering the full set of key symptoms from a typical
intense episode, asks more follow-up questions:
▪ age first time had episode
▪ whether first episode started in past 12 months
▪ years in life had an episode
▪ duration of longest episode
▪ how much episodes interfered with life
▪ whether ever hospitalized as a result of an episode
▪ number of months in past 12 months that had an episode
▪ whether had episode in the past 30 days
▪ age at time of most recent episode
•
Changes from Original
– Edited logic throughout the module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
251
9.
Anxiety and Worry (GAD) | ACASI—Part 1
•
Overview
– Asks all respondents frequency of experiencing a first set of symptoms in the past
30 days.
▪ If experienced a sufficient number of the first set of symptoms frequently,
then asks frequency of experiencing a second set of symptoms in the past 30
days.
– If 30-day symptoms were not frequent, asks for frequency of symptoms in the most
intense 6-month period in life.
– If had several symptoms frequently either in the past 30 days or in the most intense
6-month period in life, asks follow-up questions:
▪ age first time had an anxiety or worry episode
▪ whether started in past 12 months
▪ number of years in life had episode
▪ duration of longest episode
▪ number of days in a typical week during the episodes when anxious or
worried at least a little of the time
▪ how much episodes ever interfered with life
▪ number of months in past 12 months had an episode
▪ age had most recent episode
•
Changes from Original
– AW1a and AW3a—Added “about a number of activities” to “feel anxious or
nervous about a number of activities?”
– Revised text in AW1b and AW3b from “things” to “events or activities”: “worry
about a number of different events or activities?”
– Revised text in AW1e and AW3e from “have trouble controlling your anxiety or
worry” to “have trouble stopping yourself from being anxious or worried?”
– Made the following changes to the AW2 series:
▪ Removed “have trouble relaxing?”
▪ Revised “have difficulty concentrating because of your nerves or worry” TO:
“have difficulty concentrating or your mind going blank because of your
nerves or worry?”
▪ Added “feel tired out, low in energy, or easily fatigued?”
▪ Added “feel irritated, annoyed, or grouchy?”
▪ Added “have difficulty falling or staying asleep or have restless, unsatisfying
sleep because of your anxiety or worry?”
▪ Added “have psychological distress because of your anxiety or worry?”
Version 4 – February 2017 (Post IRB Approval)
252
▪ Revised time period from 30 days to 6 months. FROM: “How often in the past
–
–
–
–
–
–
30 days did anxiety or worry interfere with your work or personal life?” TO:
How often during those 6 months did your anxiety and worry interfere with
your work or personal life?
AW3, AW4, AW5—Changed reference period from 1 month to 6 months.
Made the following changes to the AW4 series.
▪ Removed “have trouble relaxing or feeling restless, fidgety, keyed up, or on
edge?”
▪ Removed “get easily irritated?”
▪ Revised “have difficulty concentrating or your mind going blank” TO: “have
difficulty concentrating or your mind going blank because of your nerves or
worry?”
▪ Revised “have sleep problems (getting to sleep, staying asleep, waking too
early, sleeping too much)?” TO: “have difficulty falling or staying asleep or
have restless, unsatisfying sleep because of your anxiety or worry?”
▪ Revised “experience serious psychological distress because of your anxiety or
worry?” TO: “have psychological distress because of your anxiety or worry?”
▪ Added “feel restless, keyed up, or on edge?”
▪ Added “feel irritated, annoyed, or grouchy?”
Revised text in AW5 from “About how old were you the very first time you had an
episode lasting one month or longer when you felt anxious, or worried and also
had other problems like trouble relaxing, trouble concentrating, low energy, or
irritability?” to “About how old were you the very first time you had an episode
lasting 6 months or longer when you felt anxious, nervous, or worried and also had
some of the other problems you just reviewed?”
Edited AW8_UNIT to remove “weeks” as a possible response option and deleted
AW8_WKS, which allowed respondents to report how many weeks their longest
episode was.
Added AW9: During those episodes, about how many days in a typical week did
you feel [AW9_FILL] at least a little of the time?
Edited logic throughout the module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
253
10.
Social Anxiety | ACASI—Screened +
•
Overview
– Module administered to respondents who endorse either SC4 or SC4a in the CIDI
Screener module.
– For each of five social situations, asks if there was ever a time in the respondent’s
life when he or she was very afraid, anxious, or extremely shy in that situation.
– For each of five performance situations, asks if there was ever a time in the
respondent’s life when he or she was very afraid, anxious, or extremely
uncomfortable in that situation.
– If the respondent reports problems in three or more situations, asks about the
intensity of reactions when at their worst.
– If intensity was high, asks whether respondent had each of five fears.
– If had at least one of the five listed fears, asks how often got very upset.
– If had at least one of the five listed fears and got very upset in problematic
situations, asks follow-up questions about the period in life with the most intense
reactions:
▪ how often tried to avoid the situations
▪ how much fears or avoidance interfered with life
▪ age when first had reactions
▪ whether reactions started in past 12 months
▪ years in life had reactions
▪ number of months in past 12 months that would have had reactions
▪ whether would have had reactions in the past 30 days
▪ age most recent time would have had reactions
•
Changes from Original
– Removed SP4a: Which of the following things were you afraid might happen in
these situations? That you might have a panic attack?
– Edited SP4c to ask about doing or saying something to offend others rather than
asking about being trapped and unable to escape.
– Added SP10B to ask respondents who reported only one year of social anxiety
problems the number of months they would have gotten very upset if they were in a
situation where they might be unable to escape or get help.
– Edited logic throughout the module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
254
11.
Agoraphobia | ACASI—Screened +
•
Overview
– Module administered to respondents who endorse SC5 in the CIDI Screener
module.
– For each of five situations, asks if there was ever a time in the respondent’s life
when he or she feared escape might be difficult or help might not be available when
in the situation.
– If reported fear in at least two situations, asks follow-up questions:
▪ what was feared most in the situations
▪ how upset the respondent got during time in life when symptoms were most
severe
– If would get very or extremely upset, asks how often would get very upset when in
situations where might be unable to escape or get help.
– If almost always got very upset when in situations where might be unable to escape
or get help, asks follow-up questions.
▪ Regarding the time when fear was most severe…
how soon after entered situation the respondent would usually get very upset
how often would try to avoid situations
how much interfered with life
age when fear started
whether started in past 12 months
years in life had the fear
number of months in past 12 months that would have gotten very upset if
were in one of the situations
whether would have had the reaction in the past 30 days
age most recent time would have become upset
•
Changes from Original
– Introduction statement added to AG1.
– AG1 and AG2 revised from “check all that apply” to “Yes/No” format.
– Added AG10b to ask respondents who reported only one year of getting very upset
in situations where they might not be able to escape or get help, the number of
months they would have gotten very upset if they were in a situation where they
might be unable to escape or get help.
– Edited logic throughout module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
255
12.
Panic Disorder | ACASI—Screened +
•
Overview
– Only administers the first question to respondents who have not already screened
positive for panic disorder elsewhere in the instrument.
– If screened positive on the first question or already screened positive for panic
disorder elsewhere in the instrument, asks whether attacks occurred “out of the
blue” versus when the respondent had a strong fear or was in real danger.
– If at least some of the attacks occurred “out of the blue”, follow-up questions are
asked:
▪ proportion of “out of the blue” attacks that occurred when under the influence
of alcohol or drugs
▪ proportion of “out of the blue” attacks that occurred when asleep
▪ total number of “out of the blue” attacks in lifetime
▪ whether had each of 14 symptoms
▪ If at least some of the 14 listed symptoms reported, asks more follow-up
questions.
whether had a month or longer when worried due to symptoms
whether respondent had a month or longer when he or she changed everyday
activities due to symptoms
age at first “out of the blue” attack
If previous answers left uncertainty, asks one or more of the following as
well:
o whether respondent’s first attack was in past 12 months
o whether had first attack in the past 30 days
o years in life had at least one attack
o number of months in past 12 months that had an attack
o age at time of most recent attack
o number of days out of the past 30 days that had an attack
•
Changes from Original
– Edited logic throughout the module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
256
13.
Eating Disorders | ACASI—Screened +
•
Overview
– If reported in CIDI Screener that there was ever a time in life when had a great deal
of concern about or strongly feared being too fat or overweight but weighed less
than other people (SC6 and SC6a both answered “yes”), asks several follow-up
questions:
▪ lowest body weight had on purpose after age of 12
▪ height when at lowest weight
▪ whether respondent feared he or she would gain weight, when at lowest
weight
if feared would gain weight, asks whether did things to keep weight low
if did things to keep weight low, asks whether:
o felt too heavy
o thought some parts of body were too fat
o felt self-esteem or confidence dependent on staying thin or losing more
weight
o anyone told respondent that their low weight was bad for own health
– If reported in CIDI Screener that ever have had a time in life when went on eating
binges at least once a week for 3 three months or longer (SC7), asks several followup questions:
▪ whether felt loss of control during time when binged
▪ If felt loss of control during time when binged, asks follow-up questions.
whether respondent experienced each of five symptoms.
o If experienced three of the five symptoms, asks about four other
symptoms.
whether did each of six actions in order to control weight
o If took one or more of the weight control actions, asks if ever did it/them
at least once a week for 3 three months or longer.
o If did weight control action(s) for 3 three months or longer, asks followup questions about the long episode(s).
age first time had an episode
whether episode started in the past 12 months
number of years in life had such episodes
duration of the longest episode ever had
how much the episodes interfered with life
number of episodes in the past 12 months
age at time of most recent episode
•
Changes from Original
– Removed EA1 and EA1a. These questions are included in the CIDI Screener
module.
– Removed EA16a question but kept introductory text. This question is included in
the CIDI Screener module.
Version 4 – February 2017 (Post IRB Approval)
257
– Revised text in EA17e from “Around the time you were binge eating, were you very
afraid that you would gain weight? To “During episodes of binge eating, were you
very afraid that you would gain weight?”
– Edited EA25 to EA25_BUL to ask only about binge and purging behaviors.
– Added EA25_BIN to ask about episodes of binge eating without purging behaviors.
– Revised text in ED7 from “About how many months out of 12 in the past year did
you have one of these episodes for 3 months or longer?” to “In the past 12 months,
how many of these episodes, lasting 3 months or longer, did you have?”
– Edited logic throughout the module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
258
14.
Intermittent Explosive Disorder | ACASI—Screened +
•
Overview
– If reported in CIDI Screener that there was ever a time when had attacks of anger
(SC8 or SC8a or SC8b = yes), asks a series of follow-up items.
– Asks number of anger attacks had in lifetime.
– If had one or more anger attacks in lifetime, asks follow-up questions:
▪ age when had first attack
▪ whether first attack was in the past 12 months
▪ whether first attack was in the past 30 days
▪ If had 20 or more anger attacks, asks if had anger attack clusters lasting 3
months long or longer.
▪ If had 3-month-long anger attack cluster(s), asks follow-up questions about
those clusters:
age when first 3-month-long cluster began
whether first 3-month-long clusters occurred in past 12 months
years in life had 3-month-long clusters
number of months in the past 12 months had two or more attacks each week
age when had most recent anger attack cluster that was 1-month-long or
longer
▪ If previous answers indicate could have had one or more attacks in the past 30
days and, if when asked how many 1-month-long attack clusters in the past 12
months, said 1–12, then asks number of days in the past 30 days had an anger
attack of any kind.
– Asks number of violent anger attacks in lifetime.
– If had one or more violent anger attack(s) in lifetime, asks follow-up questions:
▪ age when had first violent attack
▪ whether first violent attack was in the past 12 months
▪ If had only one violent attack and answer not already clear, asks whether the
one violent attack happened in the past 30 days.
▪ If had three or more violent attacks in lifetime, asks whether had a cluster of
three or more violent attacks in one year.
▪ If had violent anger attack cluster(s), asks follow-up questions.
age when first cluster began
whether clusters occurred in past 12 months
years in life had clustered attacks
▪ number of months in the past 12 months had a violent attack
▪ age at time of most recent violent anger attack
▪ number of days in past 30 days had a violent anger attack
Version 4 – February 2017 (Post IRB Approval)
259
•
Changes from Original
– Added “anger” to question text for the following questions: K6, K8, K9, K11, K16,
K17, and K19.
– Added logic from CIDI screener to K12.
– Removed K23c: Do the attacks either get you into trouble or interfere with your work
or personal life?
– Revised text in K25 from “How many of your anger attacks occurred when you had
been drinking, using drugs, taking medications that caused you to be impulsive, or
when you were in the midst of a depressive or manic episode?” to “How many of
your anger attacks occurred when you had been drinking, using drugs, taking
medications that caused you to be impulsive, or when you were having other mental
health problems?”
– Revised text in K26 from “Did you ever in your life have a full year or longer
when you had 3 or more anger attacks just about every week?” to “Did you ever in
your life have a full year or longer when your anger attacks were more persistent,
that is you had three or more anger attacks just about every week?”
– Edited logic throughout the module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
260
15.
Suicidality | ACASI—Part 1
•
Overview
– Asks if the respondent ever seriously thought about killing himself or herself. If the
respondent answers yes, asks several questions about suicidality:
▪ age first time seriously thought about killing self
▪ occurrence in the past 12 months
▪ age last time
▪ whether made plan
age first time
occurrence in the past 12 months
age last time
if ever tried to kill self, asks:
number of attempts
age first time (if more than once)
description of intent first time (if more than once)
occurrence in the past 12 months
age at (last) time
injuries or poisoning
medical attention required
overnight hospitalization required
description of intent (last) time
method
– Asks whether ever hurt self on purpose without wanting to die. If so, asks follow-up
questions:
▪ age first time
▪ occurrence in the past 12 months
▪ age last time
•
Changes from Original
– Added text to SD15 to explain to respondents that they will receive a hotline
number at the end of the interview if they feel they need to talk to someone about
mental health issues.
– Removed the following questions: SD2, SD2a, SD3, SD3a, SD4, SD4a, SD5,
SD5a, SD6, SD6a, SD8, SD9, SD10, SD10a, SD11, SD12, SD13, SD14, and
SD14.2
– Changed terminology in remaining questions FROM: “committing suicide” TO:
“killing yourself”
– Statements in SD22 and SD27 changed from “I”, “myself”, and “my” to “you”,
“yourself”, and “your”.
– Added SD30: “Have you ever done something to hurt yourself on purpose, but
without wanting to die, such as cutting yourself, hitting yourself, or burning
yourself?”
Version 4 – February 2017 (Post IRB Approval)
261
– Added SD30a: “How old were you the first time this happened?”
– Added SD31: “Have you done something to hurt yourself on purpose, but without
wanting to die at any time in the past 12 months?”
– Added SD31a: “How old were you the last time this experience happened to you?”
Version 4 – February 2017 (Post IRB Approval)
262
16.
Unusual Experiences | ACASI—Part 1
•
Overview
– For each of seven psychotic experiences, asks whether the respondent ever had that
experience.
– Asks follow-up questions about each psychotic experience reported:
▪ age of first experience
▪ lifetime count of experiences
▪ years in life had experiences at least one time
▪ duration of the experience(s)—where applicable
▪ whether had the experience in the past 12 months
▪ age most recent time had the experience
▪ level of belief about reality of experience(s)
▪ how distressing experiences were/experience was
– If one or more types of psychotic experience reported, asks about help in dealing
with the experiences:
▪ ever talked to doctor or mental health professional
▪ cause, per doctor or mental health professional
▪ whether medication was taken for experiences and, if so, which medication
▪ interference with life
•
Changes from Original
– Name of module was changed from Psychotic Experiences to Unusual Experiences.
– Revised text in PE23 from “a victim of this mind control” to “experiencing this
mind control”. “About how many different times in your life did you think you
were experiencing this mind control? Your best estimate is fine if you cannot
remember the exact number.”
– Added a Yes/No question asking if any medications were prescribed for these
problems.
– PE40: Mark Edlund reviewed and revised the drug list as follows: listed brand
names first in each category and added several medications (Saphris or Asenapine;
Fanapt or Iloperidone; Latuda or Lurasidone; Invega or Paliperidone; Prolixin
decanoate, Fluphenazine decanoate).
Version 4 – February 2017 (Post IRB Approval)
263
17.
Psychosis | ACASI—Part ½
•
Overview
– Module removed.
Version 4 – February 2017 (Post IRB Approval)
264
18.
Treatment of Emotional Problems | ACASI—Part 1
•
Overview
– Asks whether respondent stayed overnight or longer in a hospital due to emotion,
nerves, or mental health. If yes, follow-up questions are asked:
▪ number of times hospitalized
▪ age (first) time
▪ started in past 12 months or not
▪ number of nights in the past 12 months
▪ age most recent time
– For each of six sources, asks if ever received counseling or medication:
▪ mental health professional
▪ general medical care provider
▪ spiritual advisor
▪ certified peer counselor
▪ self-help or support group
▪ computerized or internet-based mental health treatment program
– For each source reported, asks follow-up questions:
▪ type of help received, if unclear given source
▪ age (first) time
▪ whether started in past 12 months
▪ years in life received help from that source
▪ help in past 12 months
▪ kind of sessions in past 12 months, if from mental health professional
▪ age most recent time
▪ whether help is still being received (categories collapsed)
if not, why stopped
– If did not receive professional help in the past 12 months, asks whether there was
ever a time in past 12 months when respondent felt such help was needed.
if yes, then asks why professional help was not obtained
•
Changes from Original
– Revised TR8 and TR15 so that respondents can report receiving only counseling,
only medication, or both.
– Revised wording from “outpatient treatment” to “treatment”. “About how many
treatment sessions with a mental health professional did you have in the past 12
months, counting face-to-face visits, phone calls, and texting sessions, but…?”
– Added TR13d.
Version 4 – February 2017 (Post IRB Approval)
265
– Revised text in TR50 from “Are you still either in counseling or the self-help
group? Or have you stopped both treatment and the self-help group?” to “Are you
still either in counseling or the self-help group? Or have you stopped both
counseling and the self-help group?
Version 4 – February 2017 (Post IRB Approval)
266
19.
Pharmacoepidemiology | ACASI—Part 1
•
Overview
– Asks total number of different kinds of prescription and nonprescription
medications taken in past 7 days.
– Asks if over the past 12 months any of the following prescription medications taken
for emotions, substance use, energy, concentration, sleep, or ability to cope with
stress: sleeping pills/sedatives, anti-depressants, tranquilizers,
amphetamines/stimulants, antipsychotics.
▪ If none of the above, asks if any type of prescription medication was taken for
emotions, substance use, energy, concentration, sleep, or ability to cope with
stress over the past 12 months.
▪ If any of the above reported, asks which medications were taken in the past 12
months.
– For up to 20 medications reported, asks the following:
▪ Number of days taken in past 30 days and past 12 months and best estimate of
first date taken in past 12 months
– For up to three medications reported, asks the following.
▪ Problem medication was taken for and effectiveness of medication
▪ If medication was taken with health professional’s supervision or without, and
who prescribed the medication
▪ Number of days in the past 30 forgot to take or took less than instructed
▪ If still taking the medication
If no longer taking, asks if health professional instructed respondent to stop
taking
If health professional did not instruct to stop taking the medication, asks if
the health professional agreed with decision to stop
If medication was stopped because felt better
Other reason for stopping the medication
If side effects were the reason for stopping, asks about the nature of the side
effects
•
Changes from Original
– Removed APH1, APH1DK, APH2, and APHDK, which asked about any
prescription or nonprescription medication use in the past seven days.
– Added introduction statement to APH3.
– APH5INTRO—Revised question text to allow a respondent to more easily report
multiple medications using a grid format.
– Removed APHINTRO2 because this question was included in the revised
APH5INTRO.
– Added APH5_OT4, APH5_OT4a, APH5_OT5, and APH5_OT5A to measure use
of any other prescription medication.
Version 4 – February 2017 (Post IRB Approval)
267
– Removed APH8ayr, APH8mo, APH8aday, APH9ayr, APH9amo, and APH9aday,
which measured first use and recency of use of a prescription medication.
– Removed APH10a, APH11a, and APH12a, which measured how and in what
quantity a respondent took a prescription medication.
– Removed APH13 and APH14, which measured reasons for taking a prescription
medication.
– Revised APH16 to better specify prescription drug misuse.
– Revised AH21 from “Did the professional agree with your decision to stop?” to
“Did the health professional agree with your decision to stop?”
– Removed APH24, APH25, and APH26, which measured reason for discontinuing
use of a prescription drug and any side effects that could have led to discontinuing
use.
– Revised ID numbers for drugs.
– Mark Edlund reviewed and revised the drug list to reflect recent additions to these
classes of medication and to remove drugs that are no longer prescribed.
– Removed PENTER1 and ENDAUDIO because this module is no longer the end of
the adult ACASI portion.
Version 4 – February 2017 (Post IRB Approval)
268
20.
Trait Fear | ACASI—Part ½
•
Overview
– Asks 20 questions related to trait fear.
– Respondents will be randomly assigned to receive either the Trait Fear and
Disinhibition modules or the Personality module.
•
Changes from Original
– Removed instruction for respondent to work quickly and not spend too much time
on any one statement from TF_INTRO.
Version 4 – February 2017 (Post IRB Approval)
269
21.
Disinhibition | ACASI—Part ½
•
Overview
– Asks 20 questions related to disinhibition.
– Respondents will be randomly assigned to receive either the Trait Fear and
Disinhibition modules or the Personality module.
•
Changes from Original
– Removed instruction for respondent to choose the answer that best describes them
from DIS1.
Version 4 – February 2017 (Post IRB Approval)
270
22.
Personality | ACASI—Part ½
•
Overview
– Asks 26 personality questions.
– Respondents will be randomly assigned to receive either the Personality module or
the Trait Fear and Disinhibition modules.
•
Changes from Original
– Revised text in PERINTRO from “This is a list of things different people might say
about themselves. We are interested in how you would describe yourself. There are
no right or wrong answers. So you can describe yourself as honestly as possible, we
will keep your responses confidential. We’d like you to take your time and read
each statement carefully, selecting the response that best describes you.” to “This is
a list of things different people might say about themselves. We are interested in
how you would describe yourself. Please select the response that best describes
you.”
– Statements changed from “me” to “you”; “I” to “you”; “I’m” to “You’re”; “My” to
“Your”.
Version 4 – February 2017 (Post IRB Approval)
271
23.
BPD Screen | ACASI—Part 1
•
Overview
– Asks a single grid of 12 Yes/No questions of all respondents.
•
Changes from Original
– BPD—Added introduction statement.
– ABPD2—Removed “How about made a suicide attempt?” and added the following
separate question: “Have you ever attempted suicide?”
– ABPD5—Removed “How about often acted in an angry or sarcastic manner?” and
added the following separate question: “Have you often acted in an angry or
sarcastic manner?”
Version 4 – February 2017 (Post IRB Approval)
272
24.
Firearms Access | ACASI—Part 1
•
Overview
– Module removed.
Version 4 – February 2017 (Post IRB Approval)
273
25.
Prison | ACASI—Part1
•
Overview
– Begins by asking respondents if they have ever been arrested. Those who have
continue; those who have not skip to the next module.
– Asks respondents if they were ever in a jail, prison, or correctional facility since the
age of 18. Those who indicate yes are then asked for the total time they have spent
in a jail, prison, or correctional facility since the age of 18, as well as the amount of
time during the past 12 months.
– Asks about being on probation, parole, supervised release, or other conditional
release during the past 12 months.
•
Changes from Original
– Revised text in APR4 from “How long altogether were you in one of these facilities
since the age of 18?” to “Now think about all the time you have spent in a jail,
prison, or correctional facility since you turned 18. What would be the easiest way
for you to give your answer?”
– Added APR4a: What is the [total number of weeks/months/years] you were in a
jail, prison, or correctional facility since you turned 18?
– APR6—Revised response categories to make them mutually exclusive.
Version 4 – February 2017 (Post IRB Approval)
274
26.
Homelessness | ACASI—Part 1
•
Overview
– Begins by asking respondents if they have ever been homeless. Those who have
continue; those who have not skip to the next module.
– Asks respondents when they were homeless, where they slept while homeless, and
how much of their life they have been homeless.
•
Changes from Original
– Added AHOM2a: Were you homeless in the past 12 months?
– Added AHOM7: Altogether, how much of the past 12 months have you been
homeless?
Version 4 – February 2017 (Post IRB Approval)
275
27.
Head Injuries | ACASI—Part 1
•
Overview
– Asks number of lifetime head or neck injuries that:
▪ perforated eardrum
▪ resulted in lost consciousness
▪ caused “seeing stars” or other confusion
▪ caused memory lapse
– If memory lapse reported, asks number of times a head or neck injury caused
memory loss lasting less than 30 minutes, between 30 minutes and 24 hours, and
more than 24 hours.
•
Changes from Original
– Revised text in AHINJ1 from “The next questions are about head, neck, or blast
injuries that you had at any time in your life. How many times in your life, (including
childhood and adulthood), did you have a head, neck, or blast injury that…” to “The
next questions are about head or neck injuries that you had at any time in your life.
How many times in your life, including childhood and adulthood, did you have a head
or neck injury that…”
– Removed HINJ1a, which asked about head injuries that perforated or burst the
respondent’s eardrum.
– Revised text in AHINJ2 from “How many times in your life did you have a head, or
blast injury that caused memory loss lasting…” to “How many times in your life did
you have a head or neck injury that caused memory loss lasting…”
Version 4 – February 2017 (Post IRB Approval)
276
28.
Stressful Experiences (Post-Traumatic Stress Disorder) | ACASI—Screen +
•
Overview
– Asks whether respondent ever had each of 18 stressful experiences.
– For each stressful experience ever experienced, asks follow-up questions.
▪ number of times or months/years had the experience
▪ age (first) time
– Asks how much bothered by each of eight symptoms in the past 30 days.
– Asks how much bothered by each of eight symptoms in the worst month in life.
▪ If at least moderately bothered by two or more symptoms, asks how much
bothered by each of an additional set of 15 symptoms.
▪ If bothered enough by key sets of symptoms, asks follow-up questions.
age first time had symptoms
years in life had at least a month with symptoms
number of months had symptoms
age most recent time had symptoms
how much episodes interfered with life
– Asks whether respondent had each of 16 stressful life events in the past 12 months.
– Asks about level of current stress in each of nine areas of life.
– Respondent asked to rate ability to handle stress in each of five ways.
•
Changes from Original
– P12—Revised FILL to match P1i and P1j wording: FROM: “natural or manmade
disaster” TO: “life-threatening natural or manmade disaster”
– P22e—Added “because of a highly stressful experience” to “Difficulty
concentrating because of a highly stressful experience?”
– P22f—Added “because of a highly stressful experience” to “Feeling jumpy or
easily startled because of a highly stressful experience?”
– Per Lisa Colpe, removed: “P24p Interference with your work or personal life
because of your reactions?” because P29 is essentially the same (How much did
these reactions ever interfere with your work or personal life?).
– P30—Changed from “check all that apply” format to a series of “Yes/No”
questions.
– Edited logic throughout the module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
277
29.
Family Medical History (ACE) | ACASI—Part 2
•
Overview
– Asks questions about biological mother and father, including:
▪ if still living
▪ current age or age at time of death
▪ education
▪ has or had Autism spectrum disorder, bipolar disorder, an anxiety disorder,
depression, or schizophrenia
– Asks about siblings, alive and living, followed by total number of siblings, total
number of full siblings, number of older full siblings, total number of half siblings,
and number of older half siblings.
▪ If any siblings are reported, asks if any of them has or had Autism spectrum
disorder, bipolar disorder, an anxiety disorder, depression, or schizophrenia.
▪ If any of the above disorders are reported, asks if full siblings, half siblings, or
both had each disorder (Autism, bipolar, anxiety, depression, schizophrenia).
▪ Asks about likelihood on scale of 0–100 percent chance of events happening
to respondent: living to age 75 or older and becoming seriously depressed in
lifetime.
•
Changes from Original
– A list of approximately 27 disorders/conditions was trimmed down to 5, in an effort
to minimize the length of the module.
– Depression was added to the list of conditions.
– Three items from the Childhood Demographics module—Q900, Q901, and Q902—
were moved to the end of the module because they seemed out of place in the
Childhood Demographics module.
– Removed AFM9a, which asked how many siblings a respondent has.
– Added a new FM9a, which asks how many of a respondent’s siblings are full
siblings and includes a definition of full sibling.
– Added FM9b, which asks how many of a respondent’s siblings are half siblings and
includes a definition of half sibling.
– Revised FM10 to include introductory fills for all possible combinations of full and
half siblings.
– Revised FM10a from “Autistic disorder, (including Asperger’s and autistic
spectrum disorder)? to “Autism spectrum disorder, including Asperger’s?”
– Added FM11–FM15 to ask if it is a full sibling, a half sibling, or both full and half
siblings that have each condition reported in FM10.
– Removed AFM9b, AFM9bb, AFM9bCC, AFM9b1, AFM9b2, AFM9c, AFM9cCC,
AFM9cCC2, AFM9c1, AFM9c2, and earlier versions of AFM10-15 as they were
no longer needed because of the restructuring of the full and half sibling questions.
– Questions added about whether biological mother, biological father, as well as
siblings are alive as well as their age at death.
Version 4 – February 2017 (Post IRB Approval)
278
30.
Tobacco, Alcohol, and Drugs | ACASI—Part 2
•
Overview
– Asks about age of first use (if ever) of alcohol, tobacco, marijuana, and various
prescription and nonprescription drugs.
▪ If ever used, asks for frequency of use in the past 12 months.
▪ Also asks for number of uses per day for tobacco products and number of
drinks per day for alcohol.
– Respondents reporting a higher quantity/frequency of alcohol use are asked for
more information about their alcohol use, including any resulting problems.
– Respondents reporting drug use are asked for more information about their use,
including any resulting problems.
– Asks about hospitalizations resulting from drug or alcohol use.
– Asks about treatment for problematic drug or alcohol use.
•
Changes from Original
– Revised TAD1 to ask if a respondent has ever used the substances listed in the
TAD1 grid, rather than asking age of first use. This changes the response options
from an open-ended age measurement to yes/no.
– Removed TAD1b, TAD1d, and TAD1e, which asked about frequency of use of
tobacco or alcohol and binge drinking.
– Removed “Quaaludes” from TAD1i text, per Mark Edlund’s recommendation.
– Added TAD2 and TAD3, which asks about age of first and frequency of use of
tobacco.
– Removed previous TAD2 and TAD3 grids, which asked about frequency of use of
several substances.
– Added TAD5 and TAD6, which ask about frequency of use of tobacco in the past
12 months and age of first use of tobacco at least once a week for a full 12 months.
– Added TAD7 and TAD8, which ask about age of first use and frequency of use of
alcohol.
– Added TAD10, TAD11, TAD12, and TAD13, which ask about frequency of use of
alcohol in the past 12 months, age of first use of alcohol at least once a month for a
full year, and binge drinking.
– Added TAD14 and TAD15, which ask about age of first use and frequency of use
of marijuana or hashish.
– Added TAD16 and TAD17, which ask about age of first use and frequency of use
of other illegal drugs.
– Added TAD18, TAD19, TAD20, TAD21, TAD22, and TAD23, which ask about
age of first use and frequency of use of prescription stimulants, tranquilizers, and
pain relievers.
Version 4 – February 2017 (Post IRB Approval)
279
31.
Relationships and Social Networks | ACASI—Part 2
•
Overview
– Asks about sexual orientation, sex on the respondent’s birth certificate, and gender
identity.
– Asks about relationship status/marital status.
▪ If ever married, asks about marital history including number of marriages, age
at time of first marriage, and if applicable, duration of marriage and how the
marriage ended.
▪ If married or in a steady relationship, asks questions about the quality of the
relationship (e.g., how much your partner cares about you, how much your
partner understands you, etc.).
– Asks for number and ages of biological children, as well as adoptive or stepchildren.
– Asks if respondent or his or her partner is currently pregnant.
– Asks about respondent’s social life including time spent with friends, attending
meetings or recreational groups, and role of religion or spiritual beliefs in the
respondent’s life.
– Asks about number of people the respondent can rely on for comfort or support as
well as whether the respondent believes he or she is a burden to others.
– Asks about use of internet for social networking and playing games and whether
these activities are relaxing or frustrating.
•
Changes from Original
– Added introduction statement to U1A.
– Removed U1: Do you consider yourself to be: Heterosexual or straight;
Gay/lesbian/homosexual; Bisexual; Transgender: Transgender, Male-to-Female
(MTF); Transgender, Female-to-Male (FTM); Transgender, do not identify as male
or female.
– Removed U4, U4a, U5, U6, U7, and U8, which asked detailed questions about
marriage.
– Added U4x and U4y, which ask about age at first marriage and length of current
marriage.
– Added an introduction statement to U9.
– Removed U13.1 and U14.
– U22—Added skip logic so women over 55 are not asked about being pregnant.
– Removed SN2_2a, SN2_2b, SN2_3, and SN2_4, which asked about religion.
Added a single religion item, SN2r, instead.
– Removed SN5, which asked the number of people the respondent would feel
comfortable confiding a serious personal problem in.
– Removed SN9a, SN9b, and SN9c, which asked how a respondent felt getting close
to other people.
Version 4 – February 2017 (Post IRB Approval)
280
– Added questions on use of social media: SN10a, SN10b, SN11, SN12, SN14,
SN15a, and SN15b. Removed SN13, which also asked about social media.
Version 4 – February 2017 (Post IRB Approval)
281
32.
Childhood Demographics | ACASI—Part 2
•
Overview
– Asks primarily about the respondent’s experience in school, including learning
disorders, mental or emotional problems, school engagement, participation in sports
and other extracurricular activities, and exercise.
•
Changes from Original
– Removed question about birthdate (DE2), country born in (DE4), how old when
came to US (DE4a), number of parents born in US (DE5_1), number of
grandparents born in the US (DE5_2), speak language other than English growing
up (DE7), speak English growing up (DE8), number of full brothers and sisters
(DE9.1), is sibling/how many siblings older than you (DE9.7, DE9.4), number of
step/half/adopted siblings (DE9.5), is step/half/adopted sibling/ how many older
than you (DE9.7, DE9.8), did you attend all girls/boys school (DE20.2), how many
years attend all girls/boys school (DE20.2a), in what grades attend all girls/boys
school (DE20.4), did school system have middle school or junior high (DE20.7),
which grads in middle school or junior high (DE20.8), one of younger, older, or
average in terms of age in school (DE20.8a), religion growing up (DE20.9),
weather (CFA2T), chance of living to age of 75 or more (Q900), chance of
becoming seriously depressed (Q901), important events (Q902), highest grade of
school completed (DE20). As noted earlier, DE4a, DE5_1, DE5_2, DE7, and DE8
were relocated to the Core Demographics module.
– Removed Q15a, which asked about books in the home.
– Revised text in Q18b from “Dyslexia (a problem stating words correctly or in order
when reading” to “Dyslexia”.
– Added following text to Q19: “The next questions are about things you may have
done in high school. By high school, we mean public or private high school and
homeschooling for grades 9 through 12.”
– Removed Q22, Q23, Q23a, Q23b, and Q24, which asked about community service,
foreign language study, and extracurricular activities.
– Removed Q26, Q26b1, Q26b2, Q26b3, Q26b4, and Q26c, which asked about
injuries sustained in school sports.
– Removed Q27, Q27a, Q27b, Q27c, Q28, Q28a, Q28b, and Q28c, which asked
about the frequency of moderate and vigorous physical activities. Added Q29 as a
single measure of frequency of moderate and vigorous physical activity.
Version 4 – February 2017 (Post IRB Approval)
282
33.
Childhood Experiences | ACASI—Part 2
•
Overview
– All respondents are asked about their experiences before the age of 18, including
▪ major life events involving the respondent’s parents, such as death, divorce,
suicide, incarceration, and problems with drugs/alcohol or mental illness.
▪ frequency of troublesome behaviors, such as bullying, fighting, lying,
skipping school, arguing with adults, and disobeying rules.
▪ frequency of homelessness, sexual abuse, physical abuse, emotional abuse,
etc.
– Respondents between the ages of 18 and 30 are asked if they have ever been bullied
and if they themselves have bullied someone. If yes, they are asked if it happened
during the past 12 months. The same questions are asked about electronic bullying.
•
Changes from Original
– Added X7–X14, which ask about bullying.
Version 4 – February 2017 (Post IRB Approval)
283
34.
Employment | ACASI—Part 1
•
Overview
– Asks if respondent worked at a job or business last week.
▪ If respondent did not work last week, asks if respondent had a job.
▪ Hours worked at job or business last week and whether usually works 35
hours or more per week.
▪ If did not work last week, asks reason.
▪ If did not have a job, asks main reason for this and if respondent was making
specific efforts to find work.
– Asks if respondent worked at a job or business in past 12 months.
– Asks if respondent was self-employed in past 12 months.
▪ If worked at a job or business, asks number of employers in past 12 months
(including self if self-employed).
▪ Was there ever a time in the past 12 months without a job or business.
If so, how many weeks without job or business.
▪ If did not have a job, year and month last worked at a job or business.
▪ Number of days in the past 30 missed due to personal illness or injury and
number of days in the past 30 missed because “just didn’t want to be there”.
– ACASI closeout/end of audio (will be moved once final ACASI module is
determined).
•
Changes from Original
– Removed QD26–QD36 and replaced with simplified employment questions in E1–
E5.
– Added PENTER1 and ENDAUDIO because this is the last ACASI module in the
adult instrument.
Version 4 – February 2017 (Post IRB Approval)
284
35.
Household Roster | CAPI—Part 1
•
Overview
– Asks about total number of people living in household.
– For each person reported, asks age on last birthday, gender, and relationship to
respondent.
•
Changes from Original
– No high-level changes.
Version 4 – February 2017 (Post IRB Approval)
285
36.
Proxy Information | CAPI—Part 1
•
Overview
– Determines whether proxy (adult household member or person present) would be
better able to answer questions about income and insurance.
•
Changes from Original
– No high-level changes.
Version 4 – February 2017 (Post IRB Approval)
286
37.
Income | CAPI—Part 1
•
Overview
– Asks if any of the following were received last year.
▪ Social Security or Railroad Retirement
▪ Supplemental Security Income
▪ Supplemental Nutrition Assistance Program
▪ Cash assistance
▪ Other non-monetary assistance
– If any received, asks number of months received last year.
– Asks if income from other sources including a job or business.
– Total personal income and total family income last year.
•
Changes from Original
– No high-level changes.
Version 4 – February 2017 (Post IRB Approval)
287
38.
Health Insurance | CAPI—Part 1
•
Overview
– Asks if received Medicare, Medicaid, state CHIP, military health insurance (e.g.,
TRICARE or CHAMPUS/CHAMPVA), or private health insurance.
– If covered by private health insurance, was this obtained through work.
– Covered by any health insurance.
– Any time in past 12 months without health insurance, and how many months if so.
– Length of time since last covered.
•
Changes from Original
– Removed QHI01–QHI13 and replaced with simplified health insurance questions in
HI_1–HI_3.
– Removed QHI15, which asked how long the respondent had gone without health
care.
– Removed QH117, which asked for the main reason why the respondent stopped
being covered by health insurance.
– Removed QH118, which asked the reasons why the respondent has never had
health insurance.
– Added two questions, GPS1 and GPS2, to ask for permission to collect GPS data on
the household.
Version 4 – February 2017 (Post IRB Approval)
288
39.
Verification | CAPI—Part 1
•
Overview
– Covers the closeout of the interview. Information is collected to assist RTI
International in verifying a portion of each interviewer’s work.
– The interviewer is instructed to provide the incentive payment, sign the incentive
receipt form, provide a copy of the receipt form to the respondent, and thank him or
her for participating in the study.
•
Changes from Original
– The incentive amount was revised to $40.
– The Quality Control Form is now an electronic form on the tablet. Added
instructions to the interviewer on how to access and complete this form.
Version 4 – February 2017 (Post IRB Approval)
289
NATIONAL MENTAL HEALTH
STUDY (NMHS): ADOLESCENT
INSTRUMENT DRAFT
SPECIFICATIONS
Please see Appendix A for a summary of the content of each National Mental Health
Study (NMHS) Questionnaire module and a high-level overview of changes made to
the module when compared to the source documents originally provided to RTI.
Substance Abuse and Mental Health Services Administration
Center for Behavioral Health Statistics and Quality
Rockville, Maryland
National Institute of Mental Health
Rockville, Maryland
NATIONAL MENTAL HEALTH
STUDY (NMHS): ADOLESCENT
INSTRUMENT DRAFT
SPECIFICATIONS
Contract No. HHSS283201300001C
RTI Project No. 0213985.301.002.001
RTI Authors:
RTI Project Director:
Suzanne Triplett
Christine Carr
Rachel A. Caspar
Elizabeth Dean
Mark Edlund
Gretchen McHenry
Brenna Muldavin
Ashley Richards
Leyla Stambaugh
SAMHSA Project Officer:
Peter Tice
NIMH Project Officer:
Lisa Colpe
For questions about this report, please e-mail Peter.Tice@samhsa.hhs.gov.
Prepared for Substance Abuse and Mental Health Services Administration,
Rockville, Maryland, and National Institute of Mental Health, Rockville,
Maryland
Prepared by RTI International, Research Triangle Park, North Carolina
February 27, 2017
Recommended Citation: Center for Behavioral Health Statistics and Quality. (2016).
National Mental Health Study (NMHS): Adolescent Instrument Draft Specifications
(unpublished internal documentation). Substance Abuse and Mental Health Services
Administration; National Institute of Mental Health, Rockville, MD.
Acknowledgments
This report was prepared for the Substance Abuse and Mental Health Services Administration,
Center for Behavioral Health Statistics and Quality, and the National Institute of Mental Health
by RTI International (a registered trademark and a trade name of Research Triangle Institute).
Contributors to this report at RTI include Kathy Batts, Debbie Bond, Claudia Clark, and Heather
Ringeisen.
ii
Table of Contents
Section ...................................................................................................................................... Page
1.
Core Demographics ............................................................................................................ 1
2.
Beginning ACASI ............................................................................................................... 9
3.
Tutorial .............................................................................................................................. 11
4.
Your Health ....................................................................................................................... 14
5.
Columbia Impairment Scale ............................................................................................. 21
6.
CIDI Screener ................................................................................................................... 23
7.
Depression......................................................................................................................... 26
8.
Mania ................................................................................................................................ 33
9.
Anxiety and Worry (GAD) ............................................................................................... 37
10.
Social Anxiety ................................................................................................................... 44
11.
Agoraphobia ...................................................................................................................... 48
12.
Panic Disorder ................................................................................................................... 51
13.
Eating Disorders................................................................................................................ 57
14.
Suicidality ......................................................................................................................... 62
15a.
Unusual Experiences ......................................................................................................... 66
16.
Treatment of Emotional Problems .................................................................................... 79
17a.
Trait Fear ........................................................................................................................... 96
17b.
Disinhibition ..................................................................................................................... 98
17c.
Personality....................................................................................................................... 100
17d.
Affective Reactivivity Index ........................................................................................... 102
18.
BPD Screen ..................................................................................................................... 103
19.
Attention and Concentration (ADHD) ............................................................................ 105
20.
Oppositional-Defiant Disorder........................................................................................ 110
21.
Conduct Disorder ............................................................................................................ 113
22.
Separation Anxiety Disorder........................................................................................... 117
23.
Juvenile Justice and Detention ........................................................................................ 121
24.
Homelessness .................................................................................................................. 124
25.
Head Injuries ................................................................................................................... 126
26.
Stressful Experiences (Post-Traumatic Stress Disorder) ................................................ 130
27.
Family Medical History (ACE) ...................................................................................... 139
Version 4 – February 2017 (Post IRB Approval)
iii
28.
Tobacco, Alcohol, Drugs, and Treatment ....................................................................... 145
29.
Relationships and Social Networks ................................................................................ 160
30.
Childhood Demographics ............................................................................................... 166
31.
Childhood Experiences ................................................................................................... 169
32.
Employment .................................................................................................................... 173
33.
Household Roster ............................................................................................................ 176
34.
Proxy Information ........................................................................................................... 186
35.
Pharmacoepidemiology................................................................................................... 203
36.
Income............................................................................................................................. 218
37.
Health Insurance ............................................................................................................. 230
38.
Verification ..................................................................................................................... 233
39.
Showcards ....................................................................................................................... 235
Appendix A ................................................................................Error! Bookmark not defined.45
Version 4 – February 2017 (Post IRB Approval)
iv
1.
Core Demographics
BEGIN TIME STAMP
NOTE: QUESTIONS DESIGNED TO DETERMINE AGE OF THE RESPONDENT WILL BE
INTERVIEWER ADMINISTERED.
QD_REMINDFI
HAVE YOU READ THE “INTRO TO CAI” IN YOUR SHOWCARD
BOOKLET ALOUD TO THE RESPONDENT?
1
2
YES
NO
QD_INTROCAI
[IF QD_REMINDFI = 2] YOU MUST READ THE “INTRO TO CAI” IN
YOUR SHOWCARD BOOKLET ALOUD TO THE RESPONDENT BEFORE
YOU CONTINUE WITH THE INTERVIEW! DO SO NOW. WHEN YOU ARE
FINISHED, PRESS “1" TO CONTINUE.
QD_AGE1
What is your date of birth?
ENTER MM-DD-YYYY
DOB: ___ [RANGE: 01–12] ___ [RANGE: 01–31] ____ [RANGE: 1900–2015]
DK/REF
DEFINE CALCAGE: CALCAGE = AGE CALCULATED BY "SUBTRACTING" DATE OF
BIRTH FROM DATE OF INTERVIEW.
QD_CONFDOB
[IF QD_AGE1 NE DK OR REF] I have entered your date of birth as
[QD_AGE1]. Is this correct?
1
YES
2
NO
DK/REF
HARD ERROR: [IF QD_CONFDOB = 2] PRESS [ENTER] TO GO BACK AND CORRECT
THE RESPONDENT’S DATE OF BIRTH. [NOTE: DO NOT DEFINE CALCAGE UNTIL
QD_CONFDOB = YES]
QD_CONFIRM
[IF QD_AGE1 NE DK/REF AND QD_CONFDOB NE DK/REF] That would
make you [CALCAGE] years old. Is this correct?
1
YES
2
NO
DK/REF
HARD ERROR: [IF QD_CONFIRM = 2] PRESS [ENTER] TO GO BACK AND CORRECT
THE RESPONDENT’S DATE OF BIRTH.
Version 4 – February 2017 (Post IRB Approval)
1
QD_UNDER13 [IF QD_CONFIRM = 1 OR DK/REF AND CALCAGE < 13] Since you are
[CALCAGE] years old, we cannot interview you for this study. Thank you for your
cooperation.
PRESS [ENTER] TO CONTINUE. [NOTE: PROGRAM SHOULD ROUTE TO
FIEXIT.]
QD_DKREFAGE [IF (CALCAGE IS 13 OR OLDER AND CONFIRM = DK/REF) OR
QD_AGE1 = DK/REF OR QD_CONFDOB = DK/REF] I need your correct age so I
can ask you the right questions. What is your correct age?
______________ AGE [RANGE: 1–110]
DK/REF
IF QD_DKREFAGE NOT (BLANK OR DK/REF), THEN CALCAGE =
QD_DKREFAGE
QD_UNDER13B
[IF QD_DKREFAGE < 13] Since you are [CALCAGE] years old, we cannot
interview you for this study. Thank you for your cooperation.
PRESS [ENTER] TO CONTINUE. [NOTE: PROGRAM SHOULD ROUTE TO
FIEXIT.]
QD_LASTCHANCE [IF QD_DKREFAGE = DK/REF] Since I am not certain what your age is, I
cannot interview you for this study. Thank you for your cooperation.
PRESS [ENTER] TO CONTINUE. [NOTE: PROGRAM SHOULD ROUTE TO
FIEXIT.]
DEFINE CURNTAGE: IF CALCAGE > 12 AND QD_CONFIRM = 1, CURNTAGE =
CALCAGE
IF CALCAGE > 12 AND QD_CONFIRM = DK/REF AND QD_DKREFAGE > 12,
CURNTAGE = QD_DKREFAGE
IF QD_AGE1 = DK/REF AND QD_DKREFAGE > 12, CURNTAGE = QD_DKREFAGE ELSE
RESPONDENT IS INELIGIBLE; ROUTE TO FIEXIT
QD_FIPE4
INTERVIEWER: IN WHAT STATE IS THIS SAMPLE DWELLING UNIT (SDU)
LOCATED?
1
2
3
4
5
6
7
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
Version 4 – February 2017 (Post IRB Approval)
27
28
29
30
31
32
33
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
2
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
QD_FIPE5
DELAWARE
THE DISTRICT OF
COLUMBIA (WASHINGTON, DC)
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
34
NORTH CAROLINA
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
INTERVIEWER: THE STATE YOU ENTERED IS [QD_FIPE4 STATE NAME
FILL]. IS THIS CORRECT?
1
2
YES
NO
HARD ERROR: [IF QD_FIPE5 = 2] PRESS [ENTER] TO GO BACK AND CORRECT THE
STATE WHERE YOU ARE CONDUCTING THIS INTERVIEW.
QD01 INTERVIEWER: RECORD RESPONDENT’S SEX:
5
9
QD01a
MALE
FEMALE
INTERVIEWER: YOU HAVE ENTERED THAT THE RESPONDENT IS
[FILL QD01]. IS THIS CORRECT?
1
2
YES
NO
HARD ERROR: [IF QD01a = 2] PRESS [ENTER] TO GO BACK AND CORRECT THE
RESPONDENT’S SEX.
QD03
The first few questions are for statistical purposes only, to help us analyze the results of
the study.
Are you of Hispanic, Latino, or Spanish origin or descent?
Version 4 – February 2017 (Post IRB Approval)
3
1
YES
2
NO
DK/REF
QD05 HAND R SHOWCARD 1.
Which of these groups describes you? Just give me the number or numbers from the
card.
TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR
BETWEEN EACH CATEGORY YOU SELECT.
RESPONDENTS WHO REPORT THEIR RACE AS NATIVE AMERICAN
SHOULD BE INCLUDED IN RESPONSE CATEGORY 1.
1
AMERICAN INDIAN OR ALASKA NATIVE
2
ASIAN
3
BLACK OR AFRICAN AMERICAN
4
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
5
WHITE
DK/REF
QD07
[IF CURNTAGE = 15 OR OLDER] Are you now married, widowed, divorced,
separated, or have you never married?
1
MARRIED
2
WIDOWED
3
DIVORCED
4
SEPARATED
5
HAVE NEVER MARRIED
DK/REF
INTERVIEWER NOTE:
If the respondent is divorced but currently remarried, code as married.
By “divorce” we mean a legal cancellation or annulment of a marriage.
By “separated” we mean legally or informally separating due to marital discord.
QD11 HAND R SHOWCARD 2.
What is the highest grade or year of school you have completed? Just give me the
number from the card.
Version 4 – February 2017 (Post IRB Approval)
4
INCLUDE ANY JUNIOR OR COMMUNITY COLLEGE ATTENDANCE; DO NOT
INCLUDE ATTENDANCE AT TECHNICAL SCHOOLS SUCH AS TRAINING TO
BECOME A MECHANIC OR BEAUTICIAN.
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
NO SCHOOLING COMPLETED
1ST GRADE COMPLETED
2ND GRADE COMPLETED
3RD GRADE COMPLETED
4TH GRADE COMPLETED
5TH GRADE COMPLETED
6TH GRADE COMPLETED
7TH GRADE COMPLETED
8TH GRADE COMPLETED
9TH GRADE COMPLETED
10TH GRADE COMPLETED
11TH GRADE COMPLETED
REGULAR HIGH SCHOOL DIPLOMA
12TH GRADE, NO DIPLOMA
GED CERTIFICATE OF HIGH SCHOOL COMPLETION
SOME COLLEGE CREDIT, BUT NO DEGREE
ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS)
BACHELOR’S DEGREE (FOR EXAMPLE, BA, BS)
MASTER’S DEGREE (FOR EXAMPLE, MA, MS, MENG, M. ED, MSW,
MBA)
19
DOCTORATE DEGREE (FOR EXAMPLE, PHD, EDD)
20
PROFESSIONAL DEGREE BEYOND A BACHELOR’S DEGREE (FOR
EXAMPLE, MD, DDS, DVM, LLB, JD)
DK/REF
QD14
About how tall are you, without shoes?
INTERVIEWER: RECORD FEET ON THIS SCREEN. THEN PRESS ENTER TO
RECORD INCHES ON THE NEXT SCREEN.
______ FEET [RANGE: 2–8]
DK/REF
QD15
[IF QD14 NE DK/RF]
INTERVIEWER: RECORD INCHES ON THIS SCREEN.
______ INCHES [RANGE: 0–11]
DK/REF
QD21
About how much do you weigh?
________ POUNDS [RANGE: 40–850]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
5
QD23
Were you born in the United States?
1
YES
2
NO
DK/REF
QD_DE4_a
[IF QD23 = 2] How old were you when you first came to live in the United States?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
QD24
[IF QD23 = 2] In what country were you born?
1
ARMENIA
2
AUSTRIA
3
AZERBAIJAN
4
CAMBODIA
5
CANADA
6
CHINA
7
CUBA
8
DOMINICAN REPUBLIC
9
ESTONIA
10
EL SALVADOR
11
GEORGIA
12
GERMANY
13
GUATAMALA
14
HUNGARY
15
INDIA
16
IRELAND
17
ITALY
18
KOREA
19
KYRGYZSTAN
20
LATVIA
21
MEXICO
22
PHILIPPINES
23
POLAND
24
RUSSIA
25
SOVIET UNION
26
TAJIKISTAN
TURKMENISTAN
27
28
UKRAINE
29
UZBEKISTAN
30
UNITED KINGDOM
31
VIETNAM
32
OTHER COUNTRY
DK/REF
Version 4 – February 2017 (Post IRB Approval)
6
QD24a
[IF QD24 = 29] INTERVIEWER: RECORD RESPONDENT’S COUNTRY OF
BIRTH
COUNTRY OF BIRTH: _________________ [ALLOW 80 CHARACTERS]
DK/REF
QD25
[IF QD24 NE BLANK OR DK/REF] And what city were you born in?
NON-U.S. CITY OF BIRTH: _______________ [ALLOW 80 CHARACTERS]
DK/REF
QD26
[IF QD23 = 1] In what state were you born?
1
2
3
4
5
6
7
8
9
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
THE DISTRICT OF
COLUMBIA (WASHINGTON, DC)
10
FLORIDA
11
GEORGIA
12
HAWAII
13
IDAHO
14
ILLINOIS
15
INDIANA
16
IOWA
17
KANSAS
18
KENTUCKY
19
LOUISIANA
20
MAINE
21
MARYLAND
22
MASSACHUSETTS
23
MICHIGAN
24
MINNESOTA
25
MISSISSIPPI
26
MISSOURI
DK/REF
QD27
27
28
29
30
31
32
33
34
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
[IF QD26 NE BLANK OR DK/REF] In what city in [QD26] were you born?
CITY OF BIRTH: _____________________ [ALLOW 80 CHARACTERS]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
7
QD_DE7
Did you speak a language other than English at home when you were growing up?
1
YES
2
NO
DK/REF
QD55
How well do you speak English: very well, well, not well, or not at all?
1
VERY WELL
2
WELL
3
NOT WELL
4
NOT AT ALL
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
8
2.
Beginning ACASI
BEGIN TIME STAMP
IntroAcasi1 You will do an important part of this interview on your own, using the computer and
headphones.
Before you start, we’ll go through a short practice session so you can learn how to use
this computer and our interview program. Let me quickly point out the keys you will
use. The computerized practice session that follows will go through what each key does
in greater detail.
MOVE COMPUTER SO RESPONDENT CAN SEE THE KEYBOARD AND POINT
OUT THE FOLLOWING:
[POINT TO THE ROW OF FUNCTION KEYS] First, these are the function keys. The
function keys and what they do are labeled for you.
[POINT TO F3] If you don’t know the answer to a question, press F3.
[POINT TO F4] If you don’t want to answer a question, press F4.
PRESS [ENTER] TO CONTINUE.
IntroAcasi3 These next items will help you enter your answers into the computer.
[POINT TO THE ROW OF NUMBER KEYS] These are the number keys.
[POINT TO THE ENTER KEY] The Enter key is here,
[POINT TO THE SPACE BAR] the space bar is here,
[POINT TO THE BACKSPACE KEY] and the Backspace key is here.
[POINT TO THE BOTTOM OF THE SCREEN] The answers that you enter will show
up here at the bottom of the screen.
PRESS [ENTER] TO CONTINUE.
IntroAcasi4 There are a couple of computer features that you will not use.
[POINT TO ON/OFF SWITCH] This button up here turns the machine on and off.
Please do not press it! It will turn the machine off, and we’ll lose the interview.
[POINT TO TOUCHPAD] Also, please do not touch this pad. This might disrupt the
interview.
PRESS [ENTER] TO CONTINUE.
Version 4 – February 2017 (Post IRB Approval)
9
IntroAcasi2 These headphones will allow you to listen while the computer voice reads the interview
questions.
HAND HEADPHONES TO RESPONDENT.
You can adjust the volume here [DEMONSTRATE VOLUME ADJUSTMENT ON
THE HEADPHONE CORD].
Please put on your headphones. When you are ready, let me know.
MOVE COMPUTER SO RESPONDENT CAN USE IT.
ONCE RESPONDENT HAS HEADPHONES ON, PRESS “1" AND [ENTER] SO R
CAN BEGIN PRACTICE SESSION.
HeadPhone
This screen will play while you adjust the volume in your headphones. When you have
adjusted the volume to a level that is comfortable to you, press the large [ENTER] key
on the right side of the keyboard to continue with the practice session. The [ENTER]
key is the one with the symbol on it.
Version 4 – February 2017 (Post IRB Approval)
10
3.
Tutorial
BEGIN TIME STAMP
INTRO1
Welcome to RTI’s self-interviewing system, which lets you control the interview and
answer in complete privacy.
First, you will learn how to use the system and complete some practice questions. You
will learn how to enter answers and how to back up if you make a mistake and want to
change an answer.
Press the large [ENTER] key to move to the next screen.
INTRO2
In this system you can read the questions on the computer screen and hear them read
through the headphones. If you would like to just see the questions on the screen, you
can turn down the volume.
Press [ENTER] to continue.
GOTDOG
You answer questions by putting in the number that is shown next to your answer.
To answer a question, you first press the correct number and then press [ENTER].
Practice Question #1: Do you have a dog?
1
Yes
2
No
DK/REF
EYECOLOR Other questions will have more answers to choose from, and you will pick your
answer from a list.
Practice Question #2: What color are your eyes? Put in the number that best fits you
and press [ENTER].
1
Blue
2
Brown
3
Gray
4
Green
DK/REF
ALLAPPLY
Some questions will let you choose more than one answer. For these questions, you
will use the space bar to separate the answers you type in. Practice this now.
Practice Question #3: What kinds of music do you listen to?
To select more than one kind of music from the list, press the space bar between each
Version 4 – February 2017 (Post IRB Approval)
11
number you type. When you have finished, press [ENTER] to go to the next question.
1
2
3
4
Classical
Country
Hip Hop
Jazz
DK/REF
NUMBER
Other questions will ask you to type in a number instead of choosing a number from a
list.
Practice Question #4: In the past 30 days, on how many days did you eat breakfast?
Type in the number of days you ate breakfast and press [ENTER].
[RANGE: 0–30]
DK/REF
GRID
In some cases there will be more than one question to answer on a screen. For these
questions you will enter your answers one at a time in the order the questions are shown
on the screen.
Practice Question #5: Which kinds of fruit have you eaten in the past 30 days…
GRID1 apples?
GRID2 bananas?
Yes
1
1
No
2
2
DK/REF
BACKUP
If you want to change or see your answer to a previous question, you can back up using
the [F9] key. Each time you press the [F9] key, the computer will go back one
question.
You can tell the computer to repeat a question by pressing [F10]. Try this now.
When you are finished, press [ENTER] to continue.
rangeerr
For some questions, the computer can only accept certain answers. For example, in the
question below, the only numbers the computer will accept are 1 for YES or 2 for NO.
If you try to enter some other number, an instruction box will appear. To correct your
answer, you must press [ENTER] to make the box disappear. You can then answer the
question again.
Try this with the question below. Type a 3 as your answer. Press [ENTER] to remove
Version 4 – February 2017 (Post IRB Approval)
12
the instruction box, then type in a valid answer.
Practice Question #6: Do you have a cat?
1
Yes
2
No
DK/REF
ANYQUES
If you have any questions, please ask your interviewer now. If not, press [ENTER] to
begin. Please answer all of the questions to the best of your abilities.
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
13
4.
Your Health
BEGIN TIME STAMP
B1
In general, would you say your health is:
1
Excellent
2
Very good
3
Good
4
Fair
5
Poor
DK/REF
B2
The following questions are about activities you might do during a typical day. How much, if
at all, does your health now limit you in these activities?
Vigorous activities, such as running, lifting heavy
objects, or participating in strenuous sports
B2b Moderate activities, such as moving a table, pushing a
vacuum cleaner, bowling, or playing golf
B2c Climbing several flights of stairs
B2d Walking several blocks
DK/REF
B2a
B3
Yes,
Limited
a Little
2
No, Not
Limited
at All
3
1
2
3
1
1
2
2
3
3
During the past 30 days, how often have you had any of the following problems with your
work or other regular activities as a result of your physical health?
Accomplished less than you would like
Were limited in the kind of work or other
activities you could do
B3c Had difficulty performing work or other
activities -- for example, it took extra
effort
DK/REF
B3a
B3b
B5
Yes,
Limited a
Lot
1
All of
the
Time
1
1
Most
of the
Time
2
2
Some
of the
Time
3
3
A
Little
of the
Time
4
4
None
of the
Time
5
5
1
2
3
4
5
During the past 30 days, how much of the time have problems with your physical health or
emotional and behavioral problems interfered with your social activities -- like visiting with
friends or relatives?
1
All of the time
Version 4 – February 2017 (Post IRB Approval)
14
2
Most of the time
3
Some of the time
4
A little of the time
5
None of the time
DK/REF
B8a
Are you deaf or do you have serious difficulty hearing?
1
Yes
2
No
DK/REF
B8b
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
1
Yes
2
No
DK/REF
B8c
Because of a physical, mental, or emotional condition, do you have serious difficulty
concentrating, remembering, or making decisions?
1
Yes
2
No
DK/REF
B8d
Do you have serious difficulty walking or climbing stairs?
1
Yes
2
No
DK/REF
B8e
Do you have difficulty dressing or bathing?
1
Yes
2
No
DK/REF
B8f
Because of a physical, mental, or emotional condition, do you have difficulty doing errands
alone such as visiting a doctors’ office or shopping?
1
Yes
2
No
DK/REF
B10
Did a health professional ever say you had any of the following conditions?
Version 4 – February 2017 (Post IRB Approval)
15
Allergies, including food, drug, insect, or other types, such as eczema
Arthritis
Asthma
Blood disorders, such as Sickle Cell Disease, Thalassemia, Anemia,
or Hemophilia
Cerebral Palsy
Cystic Fibrosis
Diabetes
Epilepsy or seizure disorder
Heart condition
Tourette Syndrome
Ear infections
Speech or language difficulties
Any other seriously impairing or life-threatening physical health
condition
B10ay
B10by
B10cy
B10dy
B10ey
B10fy
B10gy
B10hy
B10iy
B10jy
B10ky
B10ly
B10my
Yes
1
1
1
1
No
2
2
2
2
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
DK/REF
B12
Do you currently have any of the following health problems?
B12a
B12b
B12c
Frequent or very painful back or
neck pain
Frequent or very painful headaches
Some other frequent or very painful
condition that has been going on for
at least 6 months
Yes
1
No
2
1
1
2
2
DK/REF
B13
B13a
B13b
B13c
B13d
B13e
B13f
B13g
B13h
B13i
B13j
Have you ever in your life been told by a professional, or have you personally believed, that
you had any of the following problems?
Attention-deficit hyperactivity disorder, also known as ADHD
Depression
Panic attacks, also known as anxiety attacks
Phobias, that is, extreme fears of particular situations
Post-traumatic stress disorder, also known as PTSD
Obsessive-compulsive disorder
Generalized anxiety disorder, that is, being very nervous, worried, or anxious
Manic depression, also known as bipolar disorder
Problems with anger control
Schizophrenia or other psychotic disorder
Version 4 – February 2017 (Post IRB Approval)
Yes
1
1
1
1
1
1
1
1
1
1
No
2
2
2
2
2
2
2
2
2
2
16
Yes
1
1
1
Any other serious emotional problem
B13l
Problems with alcohol use
B13m
Problems with drug use
B13n
DK/REF
B14
How often in the past 30 days did you have each of the following?
B14a Memory problems
B14c Difficulty concentrating or your
mind going blank
B14d Sleep problems, such as getting to
sleep, staying asleep, waking too
early, or sleeping too much
B14e Feeling tired out, low in energy, or
easily fatigued
B14f Feeling emotionally much happier
or excitable than usual
B14g Being much more hyper or wound
up than usual
B14h Having thoughts race through your
mind so fast you could hardly keep
track of them
DK/REF
B15
No
2
2
2
All or
Almost
All of
the
Time
1
1
Most of
the
Time
2
2
Some of
the
Time
3
3
A Little
of the
Time
4
4
None of
the
Time
5
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
How often in the past 30 days did you have each of the following?
B15a Pain in your back, neck, arms, legs,
or joints -- such as your knees or
hips
B15b Headaches
B15c Pain in any other part of the body
B15d Muscle tension
B15e Dizziness
DK/REF
Version 4 – February 2017 (Post IRB Approval)
All or
Almost
All of
the
Time
1
Most of
the
Time
2
Some of
the
Time
3
A Little
of the
Time
4
None of
the
Time
5
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
17
B16
How often in the past 30 days did you experience each of the following?
B16a Feeling irritated, annoyed, or grouchy
B16c Feeling that your anger was out of
control
B16d Talking or moving more slowly than
usual
B16e Feeling calm or peaceful
B16f Feeling restless, tense, wound up, or on
edge
B16g Poor appetite or overeating
DK/REF
B17a
All or
Almost
All of
the
Time
1
1
Most of
the
Time
2
2
Some
of the
Time
3
3
A
Little
of the
Time
4
4
None
of the
Time
5
5
1
2
3
4
5
1
1
2
2
3
3
4
4
5
5
1
2
3
4
5
About how many days out of the past 30 were you totally unable to go to school, work, or
carry out your other usual activities because of problems with your physical or behavioral
health?
__________ NUMBER OF DAYS [RANGE: 0–30]
DK/REF
DEFINE B17B_FILL
IF B17A > 0 AND (B17a NE DK OR REF), THEN B17a_FILL = “Other than the [B17a] days when
you were totally unable to go to school, work, or carry out your other usual activities because of
problems with your physical or behavioral health, about”
ELSE B17A_FILL = “About”
B17b
[B17b_FILL] how many days out of the past 30 were you able to go to school or work, but
had to cut down on either the quantity or quality of your work because of problems with
your physical or behavioral health?
__________ NUMBER OF DAYS [RANGE: 0–30]
DK/REF
B17c
[IF B14d ≤ 4] You mentioned sleep problems. About how many nights a week do you…
B17Ca take more than 30 minutes to
fall asleep at night?
Version 4 – February 2017 (Post IRB Approval)
Every or
Nearly
Every
Night
3–4
Nights a
Week
1–2
Nights a
Week
Less than
1 Night a
Week
Never
1
2
3
4
5
18
B17Cb wake up three or more times
during a single night -- either
with or without provocation?
B17Cc wake up at night and take
more than 30 minutes to get
back to sleep?
B17Cd wake up more than 30
minutes too early in the
morning?
B17Ce feel tired or unrested in the
morning, even after a full
night’s sleep?
B17Cf sleep longer than you need to
or have trouble getting up
after sleeping all night?
DK/REF
Every or
Nearly
Every
Night
3–4
Nights a
Week
1–2
Nights a
Week
Less than
1 Night a
Week
Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE B17C_COUNT (PERFORM EACH TIME MOVE AWAY FROM B17C)
SET B17C_COUNT = 0
IF B17CA = 1 OR 2, ADD 1 TO B17C_COUNT
IF B17CB = 1 OR 2, ADD 1 TO B17C_COUNT
IF B17CC = 1 OR 2, ADD 1 TO B17C_COUNT
IF B17CD = 1 OR 2, ADD 1 TO B17C_COUNT
IF B17CE = 1 OR 2, ADD 1 TO B17C_COUNT
IF B17CF = 1 OR 2, ADD 1 TO B17C_COUNT
B18
[IF B17C_COUNT ≥ 1] How much do your sleep problems interfere with your daytime
functioning?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
B22B In the past 12 months, how many times have you…
B22Ba been hospitalized overnight for a
physical health problem?
Version 4 – February 2017 (Post IRB Approval)
Number of Times
If None, Enter “0”
_____
[RANGE: 0–365]
19
B22Bb been treated in an emergency
department or ER?
B22Bc seen a health care professional as an
outpatient for a physical health
problem?
B22Be been hospitalized or in a rehab center
overnight for alcohol or drug
problems?
DK/REF
Number of Times
If None, Enter “0”
_____
[RANGE: 0–365]
_____
[RANGE: 0–365]
____
[RANGE: 0–365]
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
20
5.
Columbia Impairment Scale
BEGIN TIME STAMP
CISa
The following questions ask about areas of behavior for you to rate on a scale from 0 –
No Problem for you to 4 – Very Bad Problem for you. Rate each item by choosing the
number that best describes your behavior at the present time. Since your behavior will
change over time, only take into consideration how you feel your recent behavior,
within the past week or two, has been.
In general, how much of a problem do you think you have with…
CIS1
CIS2
CIS3
CIS4
CIS5
CIS6
CIS7
getting into trouble?
getting along with your
mother or mother figure?
getting along with your
father or father figure?
feeling unhappy or sad?
your behavior at school or
at your job?
having fun?
getting along with adults
other than your mother or
father?
No
Problem
0
Minor
Problem
1
Some
Problem
2
Bad
Problem
3
Very Bad
Problem
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
DK/REF
CISc
CIS8
CIS10
CIS11
CIS12
CIS13
DK/REF
CIS9
How much of a problem do you have with…
feeling nervous or afraid?
getting along with other
kids your age?
getting involved in
activities like sports or
hobbies?
your school work or doing
your job?
your behavior at home?
No
Problem
0
Minor
Problem
1
Some
Problem
2
Bad
Problem
3
Very Bad
Problem
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
How much of a problem do you have with getting along with your brothers or sisters?
0
1
No problem
Minor problem
Version 4 – February 2017 (Post IRB Approval)
21
2
Some problem
3
Bad problem
4
Very bad problem
5
I do not have any brothers or sisters
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
22
6.
CIDI Screener
BEGIN TIME STAMP
The next question is about episodes you when you were full of energy,
more active or talkative than usual or your mood was better than usual.
HM1
Yes
1
No
2
1
2
During these episodes, people are more active than usual, talk a lot
faster, and often feel more outgoing or self-confident than usual.
Their thoughts often go very quickly and they may have trouble
sitting still.
They are often much happier, hyper, or excitable than usual.
They are sometimes more irritable or quick to take offense than usual.
They sometimes do things during these episodes that are unusual for
them such as spending too much money or engaging in risky behavior
or other behavior that could cause problems in their lives.
With this definition in mind, did you ever in your life have an episode of
this sort lasting more than a few days or longer?
Do not count episodes caused by drinking or using drugs.
[IF HM1 = 1] During one of these episodes, did other people notice or
comment that you were much more active or energetic than usual?
HM2
DK/REF
SP1
Was there ever a time in your life when you felt very afraid, anxious, or really, really shy in
any of the following social situations?
SP1a Meeting new people, including adults and people who are about your age
SP1b Going to a party or social gathering
SP1c Going on a date
SP1d Using a bathroom when away from home
SP1e Any other social situation where something embarrassing might happen
DK/REF
Yes
1
1
1
1
1
No
2
2
2
2
2
DEFINE SP1_YCOUNT (PERFORM EACH TIME MOVES FROM SP1E TO SP2)
SET SP1_YCOUNT = 0
IF SP1A = 1, ADD 1 TO SP1_YCOUNT
IF SP1B = 1, ADD 1 TO SP1_YCOUNT
IF SP1C = 1, ADD 1 TO SP1_YCOUNT
IF SP1D = 1, ADD 1 TO SP1_YCOUNT
IF SP1E = 1, ADD 1 TO SP1_YCOUNT
Version 4 – February 2017 (Post IRB Approval)
23
SP2
Was there ever a time in your life when you felt very afraid, anxious, or uncomfortable in any
of the following performance situations?
SP2a Talking to people in authority or in leadership roles
SP2b Talking to people you did not know
SP2c Speaking up in a meeting or class
SP2d Giving a speech, acting, or performing in front of an audience
SP2e Any other performance situation where you might be the center of attention
DK/REF
Yes
1
1
1
1
1
No
2
2
2
2
2
DEFINE SP2_YCOUNT (PERFORM EACH TIME MOVES FROM SP2E TO SP3)
SET SP2_YCOUNT = 0
IF SP2A = 1, ADD 1 TO SP2_YCOUNT
IF SP2B = 1, ADD 1 TO SP2_YCOUNT
IF SP2C = 1, ADD 1 TO SP2_YCOUNT
IF SP2D = 1, ADD 1 TO SP2_YCOUNT
IF SP2E = 1, ADD 1 TO SP2_YCOUNT
SC5
SC3
Have you ever in your life felt so frightened of going out of the house
alone, being in a crowd, standing in lines, going over bridges, or travelling
by bus, train, or car that it got in the way of you having a normal life?
The next question is about panic attacks, sometimes called anxiety
attacks. These are sudden, strong feelings of fear or anxiety that are
usually accompanied by physical reactions like a racing heart, shortness of
breath, feeling faint, or feeling sick to your stomach. With this definition
in mind, have you ever in your life had panic attacks?
Yes
1
No
2
1
2
Yes
1
No
2
1
2
1
2
DK/REF
SC6
SC6a
SC7
Have you ever had a time in your life when you had a great deal of
concern about or strongly feared being too fat or overweight?
[IF SC6 = 1] Have you ever had this strong worry or fear at a time when
you actually weighed less than most other people?
The next question is about “eating binges,” where a person eats a large
amount of food during a short period, like 2 hours. By “a large amount,”
we mean eating so much food that it would be like eating two or more
entire meals in one sitting, or eating so much of one particular food -- like
candy or ice cream -- that it would make most people feel sick. With that
definition in mind, have you ever had a time in your life when you went
on eating binges at least once a week for 3 months or longer?
DK/REF
Version 4 – February 2017 (Post IRB Approval)
24
SC9
SC12
Have you ever in your life felt so afraid of some other specific thing like
heights, bugs, animals, thunder, or blood that you either refused to go near
a situation that would expose you to this feared thing or you became
extremely anxious whenever you were exposed to that thing?
Some people get very upset when they are separated from someone
important in their life or someone who takes care of them. Examples
include worrying a lot that their loved ones might leave them, worrying
that some other terrible things might happen to separate them from their
loved ones, and being very anxious when they are away from their loved
one.
Yes
1
No
2
1
2
Yes
1
No
2
1
2
1
2
1
2
1
2
1
2
Did you ever have a time in your life when you had a lot of anxiety about
separation from someone important in your life or someone who takes
care of you?
DK/REF
SC13
SC13a
SC14
SC15
SC15a
SC15b
The next question is about concentration problems that usually start
before the age of twelve. These problems include not being able to keep
your mind on what you were doing, losing interest very quickly in games
or work, trouble finishing what you started without being distracted, and
not listening when people spoke to you. Was there ever a period lasting
six months or longer when you had a lot more trouble with problems
of this sort than most people your age?
Some people are very restless and fidgety and so impatient that they often
interrupt people and have trouble waiting their turn. Did you ever have a
time before the age of twelve lasting six months or longer when you
were like that?
Did you ever have a period lasting six months or longer when you often
did things that got you in trouble with adults such as losing your temper,
arguing or talking back to adults, or refusing to do what your teachers or
parents asked you?
Many people go through periods when they do things adults don’t want
them to do, like lying, stealing, or breaking rules. Did you ever go
through a period during your childhood or teenage years when you did
any of these things?
Did you ever go through a period where you either broke into cars, set
fires, or destroyed property on purpose?
Did you ever run away from home, repeatedly play hooky from school, or
often stay out much later at night than you were supposed to?
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
25
7.
Depression
BEGIN TIME STAMP
DEFINE DE1FILL
IF R REPORTED “DEPRESSON” IN B13b (B13b = 1), THEN DE1FILL = “Earlier you reported
having a history of depression. The next questions are about recent feelings of that sort.”
ELSE DE1FILL = “The next questions are about recent feelings of depression and low mood.”
DE1
[DE1FILL] How often in the past 30 days did you…
feel sad or depressed?
feel empty or hopeless?
feel discouraged about how things were
going in your life?
DE1d take little or no interest or become bored
with almost everything like school, work,
hobbies, and things you like to do for
fun?
DE1d2 feel irritable, grouchy, or in a bad mood?
DE1e feel down on yourself, no good, or
worthless?
DE1a
DE1b
DE1c
All or
Almost
All the
Time
1
1
Most
of the
Time
2
2
Some
of the
Time
3
3
A Little
of the
Time
4
4
None
of the
Time
5
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DK/REF
DEFINE DE1_COUNT
SET DE1_COUNT = 0
IF (DE1a = (1 OR 2)) OR (DE1b = (1 OR 2)) OR (DE1c = (1 OR 2) OR (DE1d2 = 1 OR 2)), ADD 1
TO DE1_COUNT
IF DE1d = (1 OR 2), ADD 1 TO DE1_COUNT
DEFINE PHOLDER1
IF DE_COUNT ≥ 1 THEN PHOLDER1 = 1
ELSE PHOLDER1 = 3
Version 4 – February 2017 (Post IRB Approval)
26
DE2
[IF DE1_COUNT ≥ 1] How often in the past 30 days did you…
DE2a1 have trouble concentrating?
DE2a2 have trouble making day-to-day
decisions?
DE2b think a lot about death, either your own,
someone else’s, or death in general?
DE2e have psychological distress because of
your depression or low mood?
DE2f have depression or low mood that
interfered with your school, work or
personal life?
DK/REF
All or
Almost
All the
Time
1
Most
of the
Time
2
Some
of the
Time
3
A Little
of the
Time
4
None
of the
Time
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE DE3_COUNT
SET DE3_COUNT = 0
IF DE1a = (1 OR 2), ADD 1 TO DE3_COUNT
IF DE1b = (1 OR 2), ADD 1 TO DE3_COUNT
IF DE1c = (1 OR 2), ADD 1 TO DE3_COUNT
IF DE1d = (1 OR 2), ADD 1 TO DE3_COUNT
IF DE1d2 = (1 OR 2), ADD 1 to DE3_COUNT
IF DE1e= (1 OR 2), ADD 1 TO DE3_COUNT
IF DE2a1 = (1 OR 2), ADD 1 TO DE3_COUNT
IF DE2a2 = (1 OR 2), ADD 1 TO DE3_COUNT
IF DE2b = (1 OR 2), ADD 1 TO DE3_COUNT
IF B14d = (1 or 2), ADD 1 TO DE3_COUNT
IF B14e = (1 or 2), ADD 1 TO DE3_COUNT
IF (B16d = (1 or 2)) OR (B16g = (1 or 2)), ADD 1 TO DE3_COUNT
IF B16f = (1 or 2), ADD 1 TO DE3_COUNT
DEFINE DE3_COUNTA
SET DE3_COUNTA = 0
IF DE2e = (1 OR 2 OR 3), ADD 1 TO DE3_COUNTA
IF DE2f = (1 OR 2 OR 3), ADD 1 TO DE3_COUNTA
DEFINE PHOLDER2
IF DE3_COUNT ≥ 5 OR DE3_COUNTA ≥ 1 THEN PHOLDER2 = 1
ELSE PHOLDER2 = 3
DE3
[IF DE3_COUNT < 5 OR DE3_COUNTA < 1] Think of a time lasting 2 weeks or longer in
your life when you had the largest number of problems with depression, low mood, and
related problems, such as feeling empty, helpless, down on yourself, like life is not worth
Version 4 – February 2017 (Post IRB Approval)
27
living, or losing interest in things you used to enjoy. How often during those 2 weeks did
you…
DE3a
DE3b
DE3c
DE3d
DE3e
DK/REF
feel sad or depressed?
feel empty or hopeless?
feel discouraged about how things were
going in your life?
take little or no interest or become bored
with things you usually like to do for fun?
feel irritable, grouchy, or in a bad mood?
All or
Almost
All the
Time
1
1
Most
of the
Time
2
2
Some
of the
Time
3
3
A Little
of the
Time
4
4
None
of the
Time
5
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
DEFINE DE3_COUNTB
SET DE3_COUNTB = 0
IF (DE3a = (1 OR 2)) OR (DE3b = (1 OR 2)) OR (DE3c = (1 OR 2) OR (DE3e = (1 OR 2)), ADD 1
TO DE3_COUNTB
IF DE3d = (1 OR 2), ADD 1 TO DE3_COUNTB
DE4_1 [IF DE3_COUNTB ≥ 1] How often during those 2 weeks did you…
DE4a
DE4b1
DE4b2
DE4c
DE4d1
DE4d2
DE4e
DE4f
DK/REF
feel down on yourself, no good, or
worthless?
have trouble concentrating?
have trouble making day-to-day
decisions?
think a lot about death, either your own,
someone else’s, or death in general?
have trouble getting to sleep, staying
asleep, or waking too early?
[IF DE4d1 = 4 or 5] sleep a lot longer
than you needed or intended?
feel tired out, low in energy, or easily
fatigued?
talk or move more slowly than usual?
All or
Almost
All the
Time
Most
of the
Time
Some
of the
Time
A Little
of the
Time
None
of the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DE4f_1 [IF DE4f = 1 OR 2] Did other people notice or comment that you were talking or moving
more slowly?
Version 4 – February 2017 (Post IRB Approval)
28
1
Yes
2
No
DK/REF
DE4_2 [IF DE3_COUNTB ≥ 1] How often during those 2 weeks did you…
DE4g1 have a poor appetite?
DE4g2 [IF DE4g1 = 4 or 5] eat more than usual
or have an increased appetite?
DE4h have psychological distress because of
your depression or low mood?
DE4i feel restless, tense, wound up, or on
edge?
DK/REF
All or
Almost
All the
Time
1
Most
of the
Time
2
Some
of the
Time
3
A Little
of the
Time
4
None
of the
Time
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DE4i_1 [IF DE4i = 1 OR 2] Did other people notice or comment that you were restless or wound up?
1
Yes
2
No
DK/REF
DE4j
[IF DE3_COUNTB ≥ 1] How often during that 2 weeks did depression or low mood interfere
with your school, work or personal life?
1
All or almost all the time
2
Most of the time
3
Some of the time
4
A little of the time
5
None of the time
DK/REF
DE4k [IF DE4H=(1 OR 2 OR 3 OR 4)] How severe was your psychological distress during those 2
weeks?
1
Mild
2
Moderate
3
Severe
4
Very severe
DK/REF
DE4l [IF DE4j =(1 OR 2 OR 3 OR 4)] How much did your low mood and related problems interfere
with your school, work or personal life during those two weeks?
Version 4 – February 2017 (Post IRB Approval)
29
1
A little
2
Some
3
A lot
4
Extremely
DK/REF
DEFINE DE4_COUNT
SET DE4_COUNT = 0
IF DE3a = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE3b = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE3c = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE3d = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE3e = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4a = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4b1 = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4b2 = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4c = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4d1 = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4d2 = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4e = (1 OR 2), ADD 1 TO DE4_COUNT
IF (DE4f_1 = 1) OR (DE4i_1 = 1), ADD 1 TO DE4_COUNT
IF DE4g1 = (1 OR 2), ADD 1 TO DE4_COUNT
IF DE4g2 = (1 OR 2), ADD 1 TO DE4_COUNT
DEFINE DE4_COUNTA
SET DE4_COUNTA = 0
IF DE4h = (1 OR 2 OR 3), ADD 1 TO DE4_COUNTA
IF DE4j = (1 OR 2 OR 3), ADD 1 TO DE4_COUNTA
DEFINE DE5_ASK
IF (DE3_COUNT ≥ 5 AND DE3_COUNTA ≥ 1) OR (DE4_COUNT ≥ 5 AND DE4_COUNTA ≥ 1)],
THEN SET DE5_ASK=1.
ELSE, SET DE5_ASK=0.
DE5
[IF DE5_ASK=1] About how old were you the very first time you had an episode lasting 2
weeks or longer when most of the time you had depression or low mood plus some of the
other problems you were just asked about? Your best estimate is fine if you cannot remember
your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DE6
[IF DE5 = (CURNTAGE – 1)] Did that episode start in the past 12 months or more than 12
months ago?
Version 4 – February 2017 (Post IRB Approval)
30
1
IN THE PAST 12 MONTHS
2
MORE THAN 12 MONTHS AGO
DK/REF
DE7
[IF DE5_ASK=1 AND DE5 NE CURNTAGE AND NE (CURNTAGE-1)] During about
how many years in your life did you have at least one episode like this lasting 2 weeks or
longer? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
DE8
[IF DE5 = (CURNTAGE – 1) OR DE7 NE 0] The next question asks about the longest
episode you ever had. What would be the easiest way for you to tell us how long that episode
lasted?
1
Total number of weeks the episode lasted
2
Total number of months the episode lasted
3
Total number of years the episode lasted
DK/REF
DE8W [IF DE8 = (1 OR DK OR REF)] How many weeks was the longest episode you ever had?
_____ NUMBER OF WEEKS [RANGE: 1-104]
DK/REF
DE8M [IF DE8 = 2] How many months was the longest episode you ever had?
_____ NUMBER OF MONTHS [RANGE: 1-48]
DK/REF
DE8Y [IF DE8 = 3] How many years was the longest episode you ever had?
_____ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
DE9
[IF DE5_ASK=1] How much did these episodes ever interfere with your work or personal
life?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
Version 4 – February 2017 (Post IRB Approval)
31
DE10
[IF (DE5_ASK=1] During about how many months in the past 12 months did you have an
episode like this lasting 2 weeks or longer? Your best estimate is fine if you cannot remember
the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
DE11
[IF (DE10 NE OR LESS THAN 1) OR (DE5 NE CURNTAGE) OR (DE5 NE (CURNTAGE
– 1))] About how old were you the most recent time you had an episode like this lasting 2
weeks or longer? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
32
8.
Mania
BEGIN TIME STAMP
DEFINE HM3_FILL
IF B13h = 1 THEN HM3_FILL = “Earlier, you reported that you’ve had a problem with manic
depression, also known as bipolar disorder. Manic depression, or bipolar disorder, involves
episodes lasting several days or longer when a person is full of energy, more active than usual,
and the person’s mood is better than usual”
IF HM1 = 1 THEN HM3_FILL = “Earlier, you reported having had an episode lasting several days or
longer when you were full of energy, more active than usual, and your mood was better than
usual.”
HM3 [IF HM1 = 1] [HM3_FILL] Think of a typical intense episode of this sort. How often during
that episode did you have each of the following experiences?
HM3a You were happier or more excitable
than usual
HM3b You were much more irritable or
quick to take offense than usual
HM3c You were much more full of
energy, hyper, or wound up than
usual
HM3d You became much more active than
usual at school, work, or home
DK/REF
All or
Almost
All the
Time
Most of
the
Time
Some of
the
Time
A Little
of the
Time
None of
the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE HM3_COUNT (PERFORM EACH TIME MOVES AWAY FROM HM3)
SET HM3_COUNT = 0
IF [HM3A = (1 OR 2 OR 3) OR HM3B = (1 OR 2 OR 3)], ADD 1 TO HM3_COUNT
IF [HM3C = (1 OR 2 OR 3) OR HM3D = (1 OR 2 OR 3)], ADD 1 TO HM3_COUNT
HM4 [IF HM3_COUNT = 2] During that episode how often did you…
Version 4 – February 2017 (Post IRB Approval)
33
HM4a find that your thoughts raced
through your mind so fast you
could hardly keep track of them?
HM4b sleep much less than usual and still
not get tired or sleepy?
HM4c talk so much that other people
couldn’t get their say?
HM4d feel extremely self-confident or
optimistic or believe you could do
things you really couldn’t do?
HM4e make bad decisions related to your
feeling happy or overly optimistic
that could have caused problems for
you?
HM4f find it hard to keep your mind on
what you were doing?
HM4g do reckless things like spend too
much money, drive or bike too fast,
or do things that are unsafe?
DK/REF
All or
Almost
All the
Time
Most of
the
Time
Some of
the
Time
A Little
of the
Time
None of
the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
HM4h [IF HM3_COUNT ≥ 1] How often did this episode interfere with your school, work, or
personal life?
1
All or almost all the time
2
Most of the time
3
Some of the time
4
A little of the time
5
None of the time
DK/REF
DEFINE HM4_COUNT (PERFORM EACH TIME MOVES AWAY FROM HM4)
SET HM4_COUNT = 0
IF HM3D = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
IF HM4A = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
IF HM4B = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
IF HM4C = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
IF HM4D = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
IF HM4E = (1 OR 2 OR 3) OR HM4G = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
IF HM4F = (1 OR 2 OR 3), ADD 1 TO HM4_COUNT
Version 4 – February 2017 (Post IRB Approval)
34
DEFINE HM5_ASK
IF (HM4_COUNT ≥ 3) AND (HM4H = 1 OR 2 OR 3), SET HM5_ASK=1,
ELSE SET HM5_ASK=0.
HM5 [IF HM5_ASK = 1] About how old were you the very first time you had an episode like that
lasting several days or longer? Your best estimate is fine if you cannot remember your exact
age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
HM5a [IF ((CURNTAGE – HM5) = 1) AND (HM5 NE DK OR REF) AND (CURNTAGE NE DK
OR REF)] Did it start in the past 12 months or more than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
HM6 [IF ((CURNTAGE – HM5) NE 1) OR (HM5=DK OR REF) OR (CURNTAGE=DK OR REF)]
During about how many years in your life did you have an episode like that lasting several
days or longer? Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
HM7 [IF (HM4_COUNT ≥ 3) AND (H4MH = 1 OR 2 OR 3)] How long was the longest episode
you ever had?
1
3 days or less
2
4–6 days
3
1–2 weeks
4
3–4 weeks
5
More than 4 weeks
DK/REF
HM8 [IF (HM4_COUNT ≥ 3) AND (HM4H = 1 OR 2 OR 3)] How much did these episodes ever
interfere with your school, work, or personal life?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
HM8a [IF (HM4_COUNT ≥ 3) AND (HM4H = 1 OR 2 OR 3)] Were you ever hospitalized as a
result of having an episode?
1
Yes
Version 4 – February 2017 (Post IRB Approval)
35
2
No
DK/REF
HM9 [IF (HM4_COUNT ≥ 3) AND (HM4H = 1 OR 2 OR 3)] During about how many months in
the past 12 months did you have one of these episodes? Your best estimate is fine if you
cannot remember the exact number.
______ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
HM10 [IF HM9 ≥ 1] Did you have one of these episodes at any time in the past 30 days?
1
Yes
2
No
DK/REF
HM11 [IF HM9 = 0 OR DK OR REF] About how old were you the most recent time you had one
of these episodes for several days or longer? Your best estimate is fine if you cannot
remember your exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
36
9.
Anxiety and Worry (GAD)
BEGIN TIME STAMP
DEFINE AW1_FILL
IF B13g = 1 (R REPORTED “ANXIETY DISORDER” IN B13), THEN AW1_FILL = “Earlier, you
reported having a history of anxiety. The next questions are about recent feelings of that sort.”
ELSE AW1_FILL = “The next questions are about recent feelings of anxiety and worry.”
AW1
[AW1_FILL] How often in the past 30 days did you…
AW1a feel anxious or nervous about a
number of activities?
AW1b worry about a number of different
events or activities?
AW1c feel more anxious or worried than
other people in your same situation?
AW1d worry about things that most other
people wouldn’t worry about?
AW1e have trouble stopping yourself from
being anxious or worried?
DK/REF
All or
Almost
All the
Time
Most
of the
Time
Some
of the
Time
A Little
of the
Time
None
of the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE AW1AB_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW1)
SET AW1AB_COUNT = 0
IF AW1A = (1 OR 2 OR 3), ADD 1 TO AW1AB_COUNT
IF AW1B = (1 OR 2 OR 3), ADD 1 TO AW1AB_COUNT
DEFINE AW1CD_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW1)
SET AW1CD_COUNT = 0
IF AW1C = (1 OR 2 OR 3), ADD 1 TO AW1CD_COUNT
IF AW1D = (1 OR 2 OR 3), ADD 1 TO AW1CD_COUNT
DEFINE AW1E_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW1)
SET AW1E_COUNT = 0
IF AW1E = (1 OR 2 OR 3), ADD 1 TO AW1E_COUNT
DEFINE AW2_ASK (PERFORM EACH TIME MOVES AWAY FROM AW1)
IF [(AW1AB_COUNT ≥ 1) AND (AW1CD_COUNT ≥ 1) AND (AW1E_COUNT ≥ 1), AW2_ASK =
1
ELSE, SET AW2_ASK = 0
Version 4 – February 2017 (Post IRB Approval)
37
AW2
[IF AW2_ASK = 1] How often in the past 30 days did you…
AW2a feel restless, keyed up, or on edge?
AW2b feel tired out, low in energy, or easily
fatigued?
AW2c have trouble concentrating or keeping
your mind on what you were doing?
AW2d feel irritated, annoyed, or grouchy?
AW2e have muscle aches or tension caused by
anxiety or worry?
AW2f have difficulty falling or staying asleep or
have restless, unsatisfying sleep because
of your anxiety or worry?
AW2g have psychological distress because of
your anxiety or worry?
AW2h have anxiety and worry that interfered
with your school, work, or personal life?
DK/REF
All or
Almost
All the
Time
1
Most
of the
Time
2
Some
of the
Time
3
A Little
of the
Time
4
None
of the
Time
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE AW2ABCDEF_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW2)
SET AW2ABCDEF_COUNT = 0
IF AW2A = (1 OR 2 OR 3), ADD 1 TO AW2ABCDEF_COUNT
IF AW2B = (1 OR 2 OR 3), ADD 1 TO AW2ABCDEF_COUNT
IF AW2C = (1 OR 2 OR 3), ADD 1 TO AW2ABCDEF_COUNT
IF AW2D = (1 OR 2 OR 3), ADD 1 TO AW2ABCDEF_COUNT
IF AW2E = (1 OR 2 OR 3), ADD 1 TO AW2ABCDEF_COUNT
IF AW2F = (1 OR 2 OR 3), ADD 1 TO AW2ABCDEF_COUNT
DEFINE AW2GH_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW2)
SET AW2GH_COUNT = 0
IF AW2G = (1 OR 2 OR 3), ADD 1 TO AW2GH_COUNT
IF AW2H = (1 OR 2 OR 3), ADD 1 TO AW2GH_COUNT
DEFINE AW3AW4_SKIP (PERFORM EACH TIME MOVE FROM AW2)
SET AW3AW4_SKIP = 0
IF AW2ABCDEF_COUNT ≥ 1 AND AW2GH_COUNT ≥ 1], SET AW3AW4_SKIP = 1
[PROGRAMMER: PLEASE PROGRAM THIS SKIP VARIABLE AND WRITE IT TO THE
DATASET EVEN THOUGH IT’S NOT CURRENTLY USED DOWNSTREAM.]
Version 4 – February 2017 (Post IRB Approval)
38
AW3
Think of a 6-month period in your life when you had the largest number of problems
with anxiety, nerves, or worry. How often during those 6 months did you...
All or
Almost
All the
Time
Most
of the
Time
Some
of the
Time
A Little
of the
Time
None
of the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
AW3a feel anxious or nervous about a number
of activities?
AW3b worry about a number of different events
or activities?
AW3c feel more anxious or worried than other
people in your same situation?
AW3d worry about things that most other people
wouldn’t worry about?
AW3e have trouble stopping yourself from being
anxious or worried?
DK/REF
DEFINE AW3AB_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW3)
SET AW3AB_COUNT = 0
IF AW3A = (1 OR 2 OR 3), ADD 1 TO AW3AB_COUNT
IF AW3B = (1 OR 2 OR 3), ADD 1 TO AW3AB_COUNT
DEFINE AW3CD_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW3)
SET AW3CD_COUNT = 0
IF AW3C = (1 OR 2 OR 3), ADD 1 TO AW3CD_COUNT
IF AW3D = (1 OR 2 OR 3), ADD 1 TO AW3CD_COUNT
DEFINE AW3E_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW3)
SET AW3E_COUNT = 0
IF AW3E = (1 OR 2 OR 3), ADD 1 TO AW3E_COUNT
AW4
[IF (AW3AB_COUNT ≥ 1) AND (AW3CD_COUNT ≥ 1) AND AW3E_COUNT ≥ 1]
How often during those 6 months did you…
AW4a feel restless, keyed up, or on edge?
AW4b feel tired out, low in energy, or easily
fatigued?
Version 4 – February 2017 (Post IRB Approval)
All or
Almost
All the
Time
1
Most
of the
Time
2
Some
of the
Time
3
A Little
of the
Time
4
None
of the
Time
5
1
2
3
4
5
39
AW4c have trouble with concentrating or
keeping your mind on what you were
doing?
AW4d feel irritated, annoyed, or grouchy?
AW4e have muscle aches or tension caused by
anxiety or worry?
AW4f have difficulty falling or staying asleep or
have restless, unsatisfying sleep because
of your anxiety or worry?
AW4g have psychological distress because of
your anxiety or worry?
AW4h have anxiety and worry that interfered
with your school, work, or personal life?
DK/REF
AW4i
All or
Almost
All the
Time
Most
of the
Time
Some
of the
Time
A Little
of the
Time
None
of the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
[IF AW4g = (1 OR 2 OR 3 OR 4)] How severe was your psychological distress during
those 6 months?
1
Mild
2
Moderate
3
Severe
4
Very severe
DK/REF
AW4j
[IF AW4h = (1 OR 2 OR 3 OR 4)] How much did your anxiety and worry interfere
with your work or personal life during those 6 months?
1
Extremely
2
A lot
3
Some
4
A little
DK/REF
DEFINE AW4ABCDEF_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW4)
SET AW4ABCDEF_COUNT = 0
IF AW4A = (1 OR 2 OR 3), ADD 1 TO AW4ABCDEF_COUNT
IF AW4B = (1 OR 2 OR 3), ADD 1 TO AW4ABCDEF_COUNT
IF AW4C = (1 OR 2 OR 3), ADD 1 TO AW4ABCDEF_COUNT
IF AW4D = (1 OR 2 OR 3), ADD 1 TO AW4ABCDEF_COUNT
IF AW4E = (1 OR 2 OR 3), ADD 1 TO AW4ABCDEF_COUNT
IF AW4F = (1 OR 2 OR 3), ADD 1 TO AW4ABCDEF_COUNT
DEFINE AW4GH_COUNT (PERFORM EACH TIME MOVES AWAY FROM AW4)
Version 4 – February 2017 (Post IRB Approval)
40
SET AW4GH_COUNT = 0
IF AW4G = (1 OR 2 OR 3), ADD 1 TO AW4GH_COUNT
IF AW4H = (1 OR 2 OR 3), ADD 1 TO AW4GH_COUNT
DEFINE AW5_ASK (PERFORM EACH TIME MOVES AWAY FROM AW3AW4_SKIP OR
AW4)
IF (AW4ABCDEF_COUNT ≥ 1) AND (AW4GH_COUNT ≥ 1), SET AW5_ASK = 1
ELSE SET AW5_ASK = 0
AW5
[IF AW5_ASK = 1] About how old were you the very first time you had an episode
lasting 6 months or longer when you felt anxious, nervous, or worried and also had
some of the other problems you just reviewed? Your best estimate is fine if you cannot
remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE AW6_ASK (PERFORM EACH TIME MOVES AWAY FROM AW5)
SET AW6_ASK = 0
IF (AW5 NE DK/REF) AND (AW5 = CURNTAGE-1), SET AW6_ASK = 1
AW6
[IF AW6_ASK = 1] Did that episode start in the past 12 months or more than 12
months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
AW7
[IF AW5_ASK = 1 AND ((AW6_ASK = 0 AND (AW5 NE CURNTAGE)) OR AW6
NE 1)] During about how many years in your life did you have an episode like this
lasting one month or longer? Your best estimate is fine if you cannot remember the
exact number.
______ NUMBER OF YEARS [RANGE: 1– CURNTAGE]
DK/REF
AW8_UNIT [IF AW5_ASK = 1] How long was the longest episode you ever had? Please indicate
whether you’d like to report in months or years.
1
Months
2
Years
DK/REF
AW8_MTHS [IF AW8_UNIT = (1 OR DK OR REF) AND (AW4ABCDEF_COUNT ≥ 3) AND
(AW4GH_COUNT ≥ 1)] How many months long was the longest episode you ever had?
Version 4 – February 2017 (Post IRB Approval)
41
______ MONTHS [RANGE: 1–12]
DK/REF
AW8_YRS
[IF AW8_UNIT = 2 AND (AW4ABCDEF_COUNT ≥ 3) AND (AW4GH_COUNT ≥ 1)]
How many years long was the longest episode you ever had?
______ YEARS [RANGE: 1–CURNTAGE]
DK/REF
DEFINE AW9_FILL
IF (AW1A = (1 OR 2 OR 3) OR AW3A = (1 OR 2 OR 3)) AND (AW1B = (1 OR 2 OR 3) OR AW3B
= (1 OR 2 OR 3)), THEN AW9_FILL = “anxious or worried”
IF (AW1A = (1 OR 2 OR 3) OR AW3A = (1 OR 2 OR 3)) AND (AW1B NE (1 OR 2 OR 3) AND
(AW3B NE (1 OR 2 OR 3)), THEN AW9_FILL = “anxious”
IF (AW1A NE (1 OR 2 OR 3) AND (AW3A NE (1 OR 2 OR 3)) AND (AW1B = (1 OR 2 OR 3) OR
AW3B = (1 OR 2 OR 3)), THEN AW9_FILL = “worried”
AW9
[IF AW5_ASK = 1] During those episodes, about how many days in a typical week
did you feel [AW9_FILL] at least a little of the time?
1
Nearly every day
2
4–5 days a week
3
2–3 days a week
4
1 day a week
5
Less than 1 day a week
DK/REF
AW10
[IF AW5_ASK = 1] How much did these episodes ever interfere with your school,
work, or personal life?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
AW11
[IF AW5_ASK = 1] During about how many months in the past 12 months did you
have an episode like this? Your best estimate is fine if you cannot remember the exact
number.
______ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
AW12
[IF AW11 = 0 OR AW11 = DK/REF OR ((AW5 ≤ (CURNTAGE-1) AND (AW5 NE
DK OR REF))] About how old were you the most recent time you had an episode like
this? Your best estimate is fine if you cannot remember your exact age.
Version 4 – February 2017 (Post IRB Approval)
42
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
43
10.
Social Anxiety
BEGIN TIME STAMP
DEFINE SP3_FILL
IF SP1_YCOUNT > 0 AND SP2_YCOUNT = 0, THEN SP3_FILL = social
IF SP1_YCOUNT = 0 AND SP2_YCOUNT > 0, THEN SP3_FILL = performance
IF SP1_YCOUNT > 0 AND SP2_YCOUNT > 0, THEN SP3_FILL = social and performance
DEFINE SP3_FILL2
IF SP1_YCOUNT > 0 AND SP2_YCOUNT = 0, THEN SP3_FILL2 = or really, really shy
IF SP1_YCOUNT = 0 AND SP2_YCOUNT > 0, THEN SP3_FILL2 = or uncomfortable
IF SP1_YCOUNT > 0 AND SP2_YCOUNT > 0, THEN SP3_FILL2 = uncomfortable, or really,
really shy
DEFINE SP3_FILL3
IF SP1a = 1 OR SP1b = 1 OR SP1c = 1 OR SP1d = 1, THEN SP3_FILL4 = Another
ELSE, SP3_FILL4 = A
DEFINE SP3_FILL4
IF SP2a = 1 OR SP2b = 1 OR SP2c = 1 OR SP2d = 1, THEN SP3_FILL4 = Another
ELSE, SP3_FILL4 = A
SP3
[IF (SP1_YCOUNT≥ 1 OR SP2_YCOUNT) ≥ 1] Earlier, you mentioned that you have had a
time in your life when you felt very afraid, anxious, [SP3_FILL2] in the following [SP3_FILL]
situations:
[IF SP1a = 1] Meeting new people, including adults and people who are about your age
[IF SP1b = 1] Going to a party or social gathering
[IF SP1c = 1] Going on a date
[IF SP1d = 1] Using a bathroom when away from home
[IF SP1e = 1] [SP3_FILL3] social situation where something embarrassing might
happen
[IF SP2a = 1] Talking to people in authority or in leadership roles
[IF SP2b = 1] Talking to people you did not know
[IF SP2c = 1] Speaking up in a meeting or class
[IF SP2d = 1] Giving a speech, acting, or performing in front of an audience
[IF SP2e = 1] [SP3_FILL4] performance situation where you might be the center of
attention
Think of the time in your life when you had the most intense reactions to [SP3_FILL]
situations. How fearful, upset, or anxious would you get when you were in these situations?
1
Extremely
2
Very
3
Somewhat
4
Only a little
DK/REF
Version 4 – February 2017 (Post IRB Approval)
44
SP4
[IF SP3 = 1 OR 2 OR DK OR REF] Which of the following things were you afraid might
happen in these situations?
SP4a That you might have a panic attack
SP4b That you might do something else embarrassing
SP4c That you might do or say something to offend others
SP4d That people might talk about you or think negative things of you
SP4e That you might be in real physical danger of getting attacked
DK/REF
Yes
1
1
1
1
1
No
2
2
2
2
2
DEFINE SP4_YCOUNT (PERFORM EACH TIME MOVES FROM SP4D TO SP5)
SET SP4_YCOUNT = 0
IF SP4A = 1, ADD 1 TO SP4_YCOUNT
IF SP4B = 1, ADD 1 TO SP4_YCOUNT
IF SP4C = 1, ADD 1 TO SP4_YCOUNT
IF SP4D = 1, ADD 1 TO SP4_YCOUNT
IF SP4E = 1, ADD 1 TO SP4_YCOUNT
SP5
[IF SP4_YCOUNT > 0] Again thinking of the time in your life when you had the most intense
reactions to [SP3_FILL] situations, how often would you get very upset when you were in
these situations?
1
Almost always
2
Most of the time
3
Only some of the time
DK/REF
SP5a [IF SP4_YCOUNT > 0] How often were you much more afraid than most other people would
have been in the same situation?
1
Almost always
2
Most of the time
3
Some of the time
4
A little of the time
5
None of the time
DK/REF
SP6
[IF SP5 = 1 OR 2 OR DK OR REF] During that time in your life, how often did you try to
avoid [SP3_FILL] situations?
1
Whenever you could
2
Most of the time
3
Only some of the time
4
Never
DK/REF
Version 4 – February 2017 (Post IRB Approval)
45
SP7
[IF SP5 = 1 OR 2 OR DK OR REF] How much did your fears or avoidance of these situations
ever interfere with your work, school, or personal life?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
DEFINE SP8_FILL
IF SP1_YCOUNT > 0 AND SP2_YCOUNT = 0, THEN SP8_FILL = really, really shy in social
IF SP1_YCOUNT = 0 AND SP2_YCOUNT > 0, THEN SP8_FILL = very uncomfortable in
performance
IF SP1_YCOUNT > 0 AND SP2_YCOUNT > 0, THEN SP8_FILL = really, really shy or very
uncomfortable in social or performance
SP8
[IF SP5 = 1 OR 2 OR DK OR REF] About how old were you when you first started being
[SP8_FILL] situations? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE SP8_YRAGEDIFF
IF SP8 NE DK/REF, THEN SP8_YRAGEDIFF = (CURNTAGE) – SP8
IF SP8 = DK/REF, THEN SP8_YRAGEDIFF = DK/REF
SP9
[IF SP8_YRAGEDIFF = 1] Did it start in the past 12 months or more than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
SP10 [IF SP8_YRAGEDIFF >1 OR SP8 = DK/REF] During about how many years in your life did
you have these reactions? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
SP10B [IF SP10 = 1]During about how many months in that year would you have gotten very upset if
you were in a situation where you might be unable to escape or get help? Your best estimate is fine if
you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 1–12]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
46
DEFINE SP11_FILL
IF SP1_YCOUNT > 0 AND SP2_YCOUNT = 0 THEN SP11_FILL = social
IF SP1_YCOUNT = 0 AND SP2_YCOUNT > 0 THEN SP11_FILL = performance
IF SP1_YCOUNT > 0 AND SP2_YCOUNT > 0 THEN SP11_FILL = social or performance
SP11 [IF SP5 = 1 OR 2 OR DK OR REF] About how many months in the past 12 months would
you have had these reactions if you were put in a [SP11_FILL] situation? Your best estimate is
fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
SP12 [IF SP11 > 0 AND SP11 < 12] How recently would you have had these reactions -- in the past
30 days or more than 30 days ago?
1
In the past 30 days
2
More than 30 days ago
DK/REF
SP13 [(IF SP11 = 0 OR DK/REF) AND ((SP8_YRAGEDIFF > 1 YEAR) OR (SP8 = DK/REF))]
About how old were you the most recent time you would have had these reactions? Your best
estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
47
11.
Agoraphobia
BEGIN TIME STAMP
AG1
[IF SC5 = 1] Earlier, you reported that you felt so frightened of going out of the house alone,
being in a crowd, standing in lines, going over bridges, or travelling by bus, train, or car that it
got in the way of you having a normal life.
People sometimes fear situations in which escape might be difficult or help might not be
available if they need it. Have you ever had a fear of this sort related to any of the following
situations?
AG1a
AG1b
AG1c
AG1d
AG1e
DK/REF
Standing in line or being in a crowd
Being outside of your home alone
Being in enclosed public spaces like a mall or movie theater
Being in open spaces like a park, on a bridge, or in a parking lot
Riding in a car, bus, airplane, or train
Yes
1
1
1
1
1
No
2
2
2
2
2
DEFINE AGPHOBIA
IF AT LEAST 2 ITEMS IN AG1a – AG1e = 1 THEN AGPHOBIA = 1
ELSE AGPHOBIA = 2
AG2
[IF AGPHOBIA = 1] What did you fear most about these situations?
AG2a
AG2b
AG2c
AG2d
AG2e
DK/REF
AG3
That you might be trapped and unable to escape
That you might have a panic attack and not be able to get help or escape
That you might need to go to the bathroom and end up wetting your pants
That you might have a health problem and be unable to get help
Something else
Yes
1
1
1
1
1
No
2
2
2
2
2
[IF AGPHOBIA = 1] Think of the time in your life when this fear of being unable to escape or
get help was most severe. How fearful, upset, or anxious would you get when you were in that
phobia situation?
1
Extremely
2
Very
3
Somewhat
4
Only a little
DK/REF
Version 4 – February 2017 (Post IRB Approval)
48
AG4
[IF AG3 = 1 OR 2] How often would you get very upset when you were in a situation where
you might be unable to escape or get help?
1
Almost always
2
Most of the time
3
Only some of the time
DK/REF
AG5
[IF AG4 = 1] How often were you much more afraid than most other people would have been
in the same situation?
1
Almost always
2
Most of the time
3
Some of the time
4
A little of the time
5
None of the time
DK/REF
AG6
[IF AG4 = 1] During the time in your life when this fear was most severe, how often did you
try to avoid these kinds of situations?
1
Whenever you could
2
Most of the time
3
Only some of the time
DK/REF
AG7
[IF AG4 = 1] How much did this fear of being unable to escape or get help ever interfere with
your school, work, daily activities, or social or personal life?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
AG8
[IF AG4 = 1] About how old were you when this fear started? Your best estimate is fine if you
cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
AG9
[IF AG8 = CURNTAGE – 1] Did it start in the past 12 months or more than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
Version 4 – February 2017 (Post IRB Approval)
49
AG10
[IF AG4 = 1 AND AG8 NE CURNTAGE AND AG8 NE CURNTAGE – 1] During
about how many years in your life did you have this fear? Your best estimate is fine if
you cannot remember the exact number.
_____ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
AG10b
[IF AG10 = 1] About how many months in that year would you have gotten very upset
if you were in a situation where you might be unable to escape or get help? Your best
estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 1–12]
DK/REF
AG11
[IF AG4 = 1] About how many months in the past 12 months would you have gotten
very upset if you were in a situation where you might be unable to escape or get help?
Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
AG12
[IF AG11 = 1–11 OR AG11 = DK OR REF] How recently would you have had that
reaction?
1
In the past 30 days
2
More than 30 days ago
DK/REF
AG13
[IF (CURNTAGE – AG8 > 1) AND (AG11 = 0 OR (AG11 = DK OR REF AND AG12
= 2))] About how old were you the most recent time that you would have become very
upset if you were in that kind of situation? Your best estimate is fine if you cannot
remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
50
12.
Panic Disorder
BEGIN TIME STAMP
L2
[IF SC3 = 1] The next question is about panic attacks, also sometimes called anxiety attacks.
Panic attacks sometimes happen “out of the blue” or for no apparent reason and other times
they occur in situations where a person has a strong fear, such as a fear of snakes or of heights,
or is in real danger, such as in a car accident.
Earlier, you reported having at least one panic or anxiety attack. When have your attacks
occurred?
1
2
All of your attacks occurred “out of the blue”
Some of your attacks occurred “out of the blue” and others in situations where you had
a strong fear or were in real danger
3
All of your attacks occurred in situations where you had a strong fear or were in real
danger
DK/REF
L2_DK
[IF L2 = DK] What is your best guess of when your attacks occurred?
1
2
All of your attacks occurred “out of the blue”
Some of your attacks occurred “out of the blue” and others in situations where
you had a strong fear or were in real danger
3
All of your attacks occurred in situations where you had a strong fear or were in
real danger
DK/REF
L2_REF
[IF L2 = REF] The answers that people give us about their panic or anxiety attacks are
important to this study’s success. We know that this information is personal, but
remember your answers will be kept confidential.
Please think again about answering this question: When have your attacks occurred?
1
2
All of your attacks occurred “out of the blue”
Some of your attacks occurred “out of the blue” and others in situations where
you had a strong fear or were in real danger
3
All of your attacks occurred in situations where you had a strong fear or were in
real danger
DK/REF
DEFINE L3_FILL
IF L2 = 2 OR L2_DK = 2 OR L2_REF = 2 THEN L3_FILL = that happened “out of the blue”
ELSE L2_FILL IS BLANK.
Version 4 – February 2017 (Post IRB Approval)
51
L3
[IF (L2 = 1 OR L2 = 2) OR (L2_DK = 1 OR L2_DK = 2) OR (L2_REF = 1 OR L2_REF = 2)]
How many of your attacks [L3_FILL] occurred when you were under the influence of alcohol
or drugs?
1
All
2
Most
3
Some
4
None
DK/REF
L3_DK
[IF L3 = DK] What is your best guess of how many of your attacks [L3_FILL]
occurred when you were under the influence of alcohol or drugs?
1
All
2
Most
3
Some
4
None
DK/REF
L3_REF
[IF L3 = REF] The answers that people give us about their panic or anxiety attacks are
important to this study’s success. We know that this information is personal, but
remember your answers will be kept confidential.
Please think again about answering this question: How many of your attacks [L3_FILL]
occurred when you were under the influence of alcohol or drugs?
1
All
2
Most
3
Some
4
None
DK/REF
L4
[IF ((L2 = 1 OR L2 = 2) OR (L2_DK = 1 OR L2_DK = 2) OR (L2_REF = 1 OR L2_REF =
2))AND ((L3 = 2 OR 3 OR 4) OR (L3_DK = 2 OR 3 OR 4) OR (L3_REF = 2 OR 3 OR 4))]
How many of your attacks [L3_FILL] started when you were asleep and woke you up from
your sleep?
1
All
2
Most
3
Some
4
None
DK/REF
L4_DK
[IF L4 = DK] What is your best guess of how many of your attacks [L3_FILL] started
when you were asleep and woke you up from your sleep?
1
All
2
Most
3
Some
4
None
Version 4 – February 2017 (Post IRB Approval)
52
DK/REF
L4_REF
[IF L4 = REF] The answers that people give us about their panic or anxiety attacks are
important to this study’s success. We know that this information is personal, but
remember your answers will be kept confidential.
Please think again about answering this question: How many of your attacks [L3_FILL]
started when you were asleep and woke you up from your sleep?
1
All
2
Most
3
Some
4
None
DK/REF
DEFINE L5_ASK
IF ((L2 = 1 OR L2 = 2) OR (L2_DK = 1 OR L2_DK = 2) OR (L2_REF = 1 OR L2_REF = 2)) AND
((L3 = 2 OR 3 OR 4) OR (L3_DK = 2 OR 3 OR 4) OR (L3_REF = 2 OR 3 OR 4)) AND (L4 = 1 OR 2
OR 3 OR 4) OR (L4_DK = 1 OR 2 OR 3 OR 4) OR (L4_REF = 1 OR 2 OR 3 OR 4)), SET
L5_ASK=1
ELSE, SET L5_ASK=0.
L5
[IF L5_ASK = 1] What is your best estimate of the total number of panic attacks [L3_FILL]
you have ever had in your life? Your best estimate is fine if you cannot remember the exact
number.
_______ NUMBER OF ATTACKS [RANGE: 0–9,999]
DK/REF
DEFINE L6_FILL
IF L5 = 1 THEN L6_FILL = that attack, did you
IF L5 NE 1 THEN L6_FILL = those attacks, did you usually
L6
L6a
L6b
L6c
L6d
L6e
L6f
L6g
L6h
L6i
[IF L5 > 0] When you had [L6_FILL] have reactions like...
a pounding or racing heart?
sweating?
trembling or shaking?
shortness of breath?
feelings of choking?
chest pain or discomfort?
feeling like you might throw up?
feeling dizzy or faint?
chills or heat sensations?
Version 4 – February 2017 (Post IRB Approval)
Yes
1
1
1
1
1
1
1
1
1
No
2
2
2
2
2
2
2
2
2
53
numbness or tingling?
fear of losing control or going crazy?
fear of dying?
feeling like things around you were unreal or like a dream?
feeling like you were “not really there,” like you were watching a movie of
yourself?
DK/REF
L6j
L6k
L6l
L6m
L6n
Yes
1
1
1
1
No
2
2
2
2
1
2
DEFINE L6_COUNT
SET L6_COUNT = 0
IF L6a = 1, ADD 1 TO L6_COUNT
IF L6b = 1, ADD 1 TO L6_COUNT
IF L6c = 1, ADD 1 TO L6_COUNT
IF L6d = 1, ADD 1 TO L6_COUNT
IF L6e = 1, ADD 1 TO L6_COUNT
IF L6f = 1, ADD 1 TO L6_COUNT
IF L6g = 1, ADD 1 TO L6_COUNT
IF L6h = 1, ADD 1 TO L6_COUNT
IF L6i = 1, ADD 1 TO L6_COUNT
IF L6j = 1, ADD 1 TO L6_COUNT
IF L6k = 1, ADD 1 TO L6_COUNT
IF L6l = 1, ADD 1 TO L6_COUNT
IF L6m = 1, ADD 1 TO L6_COUNT
IF L6n = 1, ADD 1 TO L6_COUNT
DEFINE L7_FILL
IF L5 = 1 THEN L7_FILL = this attack
IF L5 NE 1 THEN L7_FILL = one of these attacks
L7
[IF L6_COUNT ≥ 4] After having [L7_FILL], have you ever had a time lasting one month or
longer when…
L7a you often worried that you might have another attack or that something
terrible might happen because of the attacks, like an accident, heart attack, or
losing control?
L7b you changed your everyday activities because of fear about having another
attack?
DK/REF
Yes
No
1
2
1
2
DEFINE L8_FILL
IF L5 = 1 THEN L8_FILL = when you had that panic or anxiety attack
IF L5 NE 1 THEN L8_FILL = the very first time you had a panic or anxiety attack
DEFINE BLUE_FILL
IF L2 = 2 OR L2_DK = 2 OR L2_REF = 2 THEN BLUE_FILL = that happened “out of the blue”
Version 4 – February 2017 (Post IRB Approval)
54
ELSE BLUE_FILL IS BLANK
L8
[IF L6_COUNT ≥ 4 AND (IF L5 > 0 OR L5 = DK/REF)] About how old were you [L8_FILL]
[BLUE_FILL]? Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE L9_CKPT:
IF CURNTAGE – L8 = 1, L9_CKPT = 1
IF CURNTAGE = L8, L9_CKPT = 2
IF CURNTAGE – L8 > 1, L9_CKPT = 3
L9
[IF L9_CKPT = 1] Was that in the past 12 months or more than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
L10
[IF L9_CKPT = 2 OR (L5 = 1 & L9 = 1)] Was it in the past 30 days or more than 30 days ago?
1
In the past 30 days
2
More than 30 days ago
DK/REF
L11
[IF IF L6_COUNT ≥ 4 AND ((L9_CKPT = 3 AND L5 NE 1) OR (L9_CKPT = 3 AND L5 >
2))] About how many years in your life did you have at least one panic attack [BLUE_FILL]?
Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
L12
[IF L6_COUNT ≥ 4 AND L5 > 1 AND L9_CKPT < 3] About how many months in the past
12 months did you have at least one panic attack [BLUE_FILL]?
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
L13
[IF L12 = 0] About how old were you the most recent time you had an attack of that sort?
Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
L14
[IF L12 NE 0 OR L12 = DK/REF] About how many days out of the past 30 days did you
have a panic attack?
_____ NUMBER OF DAYS [RANGE: 0–30]
Version 4 – February 2017 (Post IRB Approval)
55
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
56
13.
Eating Disorders
BEGIN TIME STAMP
EA2
[IF SC6 = 1 AND SC6a = 1] The next questions are about your body, including your height
and weight.
What was the lowest body weight you ever purposefully had after the age of 12?
______ WEIGHT (POUNDS)
DK/REF
EA3FT
[IFSC6 = 1 AND SC6a = 1] How tall were you at that time? First, please type in the number
of feet, then press [ENTER].
______ FEET [RANGE: 2–8]
DK/REF
EA3IN
[IFSC6 = 1 AND SC6a = 1] Please type in the number of inches and then press [ENTER].
______ INCH(ES) [RANGE: 0–11]
DK/REF
DEFINE MINWGTFE
IF QD01 = 9 AND EA3FT < 4 AND EA2 < 111, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 4 AND EA3IN ≤ 10 AND EA2 < 111, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 4 AND EA3IN = 11 AND EA2 < 114, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 0 AND EA2 < 116, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 1 AND EA2 < 119, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 2 AND EA2 < 122, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 3 AND EA2 < 125, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 4 AND EA2 < 128, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 5 AND EA2 < 132, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 6 AND EA2 < 135, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 7 AND EA2 < 139, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 8 AND EA2 < 142, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 9 AND EA2 < 145, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 10 AND EA2 < 147, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT = 5 AND EA3IN = 11 AND EA2 < 150, THEN MINWGTFE = 1
IF QD01 = 9 AND EA3FT ≥ 6 AND EA2 < 152, THEN MINWGTFE = 1
ALL ELSE, MINWGTFE = 2
DEFINE MINWGTMA
IF QD01 = 5 AND EA3FT < 5 AND EA2 < 128, THEN MINWGTFE = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN ≤ 2 AND EA2 < 128, THEN MINWGTFE = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 3 AND EA2 < 130, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 4 AND EA2 < 133, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 5 AND EA2 < 136, THEN MINWGTMA = 1
Version 4 – February 2017 (Post IRB Approval)
57
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 6 AND EA2 < 139, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 7 AND EA2 < 143, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 8 AND EA2 < 146, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 9 AND EA2 < 150, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 10 AND EA2 < 153, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 5 AND EA3IN = 11 AND EA2 < 156, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 6 AND EA3IN = 0 AND EA2 < 160, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 6 AND EA3IN = 1 AND EA2 < 163, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 6 AND EA3IN = 2 AND EA2 < 167, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 6 AND EA3IN = 3 AND EA2 < 172, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT = 6 AND EA3IN ≥ 4 AND EA2 < 176, THEN MINWGTMA = 1
IF QD01 = 5 AND EA3FT > 6 AND EA2 < 176, THEN MINWGTMA = 1
ALL ELSE, MINWGTMA = 2
EA6
[IF MINWGTFE OR MINWGTMA = 1] At the time you weighed [EA2] pounds were you
very afraid that you might gain weight?
1 Yes
2 No
DK/REF
EA7
[IF EA6 = 1] Did you do things to keep your weight low, such as dieting or exercising?
1 Yes
2 No
DK/REF
[IF EA7 = 1] Did you feel like you were heavier than you should have been
or heavier than you wanted to be?
EA10b [IF EA7 = 1] Did you think that some parts of your body were too fat?
EA10c [IF EA7 = 1] Did you feel like your self-esteem or confidence depended on
your ability to stay thin or to lose even more weight?
EA10d [IF EA7 = 1] Did anyone tell you that your low weight was bad for your
health?
DK/REF
EA10
EA16b
Yes
No
1
2
1
2
1
2
1
2
[IF SC7 = 1] Earlier you reported that you have had a time in your life when you went on
eating binges, where you ate a large amount of food during a short period of time. During
times when you ate an unusually large amount of food, did you experience a loss of control
or feel like you couldn’t stop eating or control how much you were eating?
1 Yes
2 No
DK/REF
Version 4 – February 2017 (Post IRB Approval)
58
EA17a [IF SC7 = 1 AND EA16b = 1] During the binges, did you usually eat much
more quickly than usual?
EA17b [IF SC7 = 1 AND EA16b = 1] Did you usually eat until you felt
uncomfortably full?
EA17c [IF SC7 = 1 AND EA16b = 1] Did you usually continue to eat even when
you didn’t feel hungry?
EA17d [IF E SC7 = 1 AND EA16b = 1] Did you usually eat alone because you
were embarrassed by how much you ate?
EA17e [IF SC7 = 1 AND EA16b = 1] Did you feel guilty, very upset with
yourself, or depressed after you binged?
DK/REF
Yes
No
1
2
1
2
1
2
1
2
1
2
DEFINE BINGE
IF SUM (EA17a = 1, EA17b = 1, EA17c = 1, EA17d = 1, EA17e = 1) ≥ 3, THEN BINGE = 1
ALL ELSE, THEN BINGE = 2
[IF BINGE = 1] During episodes of binge eating, were you very afraid that
you would gain weight?
EA17g [IF BINGE = 1] Did you feel like your self-esteem and confidence
depended on your weight or body shape?
EA17h [IF BINGE = 1] Did you worry about the long-term effects of binging on
your health, on your weight, or on your body shape?
EA17i [IF BINGE = 1] Did you often get upset both during and after the binges
that your eating was out of your control?
DK/REF
EA17f
Yes
No
1
2
1
2
1
2
1
2
EA23
[IF SC7 = 1 AND EA16b = 1] Have you ever done any of the following things regularly or
after binges in order to control your weight?
EA23a
EA23b
Did you fast by not eating at all or only taking liquids for 8 hours or longer?
[IF SC7 = 1 AND EA16b = 1] Did you take water pills, diuretics, or weight
control medicines?
[IF SC7 = 1 AND EA16b = 1] Did you make yourself vomit?
[IF SC7 = 1 AND EA16b = 1] Did you take laxatives or enemas?
[IF SC7 = 1 AND EA16b = 1] Did you exercise excessively?
[IF SC7 = 1 AND EA16b = 1] Did you chew and then spit out your food?
EA23c
EA23d
EA23e
EA23f
DK/REF
Yes
1
No
2
1
2
1
1
1
1
2
2
2
2
BULIMIA KEY PHRASES
IF EA23a = 1: “fasted”
IF EA23b = 1: “took water pills, diuretics or weight control medicines”
IF EA23c = 1: “made yourself vomit”
IF EA23d = 1: “took laxatives or enemas”
IF EA23e = 1: “exercised excessively”
Version 4 – February 2017 (Post IRB Approval)
59
IF EA23f = 1: “chewed and then spit out your food”
DEFINE EA25FIL1
IF ONE YES IN EA23 SERIES, THEN EA25FIL1 = BULIMIA KEY PHRASE
IF TWO YESES IN EA23 SERIES, THEN EA25FIL1 = FIRST BULIMA KEY PHRASE, “and”,
THEN SECOND BULIMA KEY PHRASE
IF THREE OR MORE YESES IN EA23 SERIES, THEN EA25FIL1 = BULLETED LIST OF
BULIMA KEY PHRASES
DEFINE EA25FIL2
IF ONE YES IN EA23 SERIES, THEN EA25FIL2 = “this”
IF TWO YESES IN EA23 SERIES, THEN EA25FIL2 = “either of these things”
IF THREE OR MORE YESES IN EA23 SERIES, THEN EA25FIL2 = “any of these things”
EA25_BUL [IF (EA23 OR EA23a OR EA23b OR EA23c OR EA23d OR EA23e OR EA23f) = 1]
You [EA25FILL]. Have you ever done [EA25FIL2] at least once a week for 3 months or
longer?
1 Yes
2 No
DK/REF
EA25_BIN [IF BINGE=1 AND EA25_BUL= (2 OR DK OR REF OR MISSING)] Have you ever
had episodes of binge eating at least once a week for 3 months or longer?
1
Yes
2
No
DK/REF
ED3
[IF (EA25_BUL = 1) OR (EA25_BIN = 1)] How old were you the very first time you had
you had an episode of eating like this for 3 months or longer? Your best estimate is fine if
you cannot remember your exact number.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
ED3a
[IF ED3 = (CURNTAGE – 1)] Did it start in the past 12 months or more than 12 months
ago?
1 In the past 12 months
2 More than 12 months ago
DK/REF
ED4
[IF ED3 < (CURNTAGE-1) OR ED3 = DK/REF] During about how many years in your
life did you have episodes of eating like that lasting 3 months or longer? Your best estimate
is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1-CURNTAGE]
Version 4 – February 2017 (Post IRB Approval)
60
DK/REF
ED5
[IF (EA25_BUL = 1) OR (EA25_BIN = 1)] How long was the longest episode you ever
had? Your best estimate is fine if you cannot remember the exact number.
1 3–4 months
2 5–6 months
3 7–8 months
4 9–10 months
5 11–12 months
6 13–24 months
7 25 or more months
DK/REF
ED6
[IF (EA25_BUL = 1) OR (EA25_BIN = 1)] How much did these episodes ever interfere
with your school, work, or personal life?
1 Extremely
2 A lot
3 Some
4 A little
5 Not at all
DK/REF
ED7
[IF ((EA25_BUL = 1) OR (EA25_BIN = 1)) AND ED4 NE 1] In the past 12 months, how
many of these episodes, lasting 3 months or longer, did you have? Your best estimate is fine
if you cannot remember the exact number.
______ NUMBER OF EPISODES [RANGE: 0–4]
DK/REF
ED8
[IF ED7 NE0 OR DK OR REF AND ED3 NE CURNTAGE] About how old were you the
most recent time you had one of these episodes for 3 months or longer? Your best estimate
is fine if you cannot remember your exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
61
14.
Suicidality
BEGIN TIME STAMP
SD15
The next few questions are about thoughts of hurting yourself. At the end of this interview,
you will receive a hotline number you can call if you ever feel you need to talk to someone
about mental health issues.
Have you ever seriously thought about killing yourself?
1
Yes
2
No
DK/REF
SD15a
[IF SD15 = 1] How old were you the first time this happened?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SD16
[IF SD15 = 1] Have you seriously thought about killing yourself at any time in the past 12
months?
1
Yes
2
No
DK/REF
SD16a
[IF SD16 = 2 OR DK OR REF] How old were you the last time this experience happened to
you?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SD17
[IF SD15 = 1] Have you ever made a plan for killing yourself?
1
Yes
2
No
DK/REF
SD17a
[IF SD17 = 1] How old were you the first time this happened?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SD18
[IF SD17 = 1] Did you make a plan for killing yourself at any time in the past 12 months?
1
2
Yes
No
Version 4 – February 2017 (Post IRB Approval)
62
DK/REF
SD18a
[IF SD18 = 2 OR DK OR REF] How old were you the last time this experience happened to
you?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SD19
[IF SD15 = 1] Have you ever tried to kill yourself?
1
Yes
2
No
DK/REF
SD19a
[IF SD19 = 1] How many times have you tried to kill yourself in your lifetime?
__________ NUMBER OF TIMES [RANGE: 1-500]
DK/REF
SD21
[IF SD19a NE 1] How old were you the first time?
__________ YEARS OLD [RANGE: 0- CURNTAGE]
DK/REF
SD22
[IF SD19a NE 1] Which of the three statements below best describes your situation when
you tried to kill yourself the first time?
1
You made a serious attempt to kill yourself and it was only luck that you did not
succeed.
2
You tried to kill yourself but knew that the method was not foolproof.
3
Your attempt was a cry for help, that is, you did not intend to die.
DK/REF
SD23
[IF SD19 = 1] Have you attempted suicide in the past 12 months?
1
Yes
2
No
DK/REF
DEFINE ATTEMPT_FILL
IF SD19a = 1 THEN ATTEMPT_FILL = when
IF SD19a NE 1 THEN ATTEMPT_FILL = the last time
SD23a
[IF SD23 = 2 OR DK OR REF] How old were you [ATTEMPT_FILL] you tried to kill
yourself?
Version 4 – February 2017 (Post IRB Approval)
63
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SD24
[IF SD23 = 1] Did it result in an injury or poisoning?
1
Yes
2
No
DK/REF
SD25
[IF SD24 = 1] Did it require medical attention?
1
Yes
2
No
DK/REF
SD26
[IF SD25 = 1] Did it require overnight hospitalization?
1
Yes
2
No
DK/REF
SD27
[IF SD19 = 1] Which of the three statements below best describes your situation when you
tried to kill yourself the last time?
1
You made a serious attempt to kill yourself and it was only luck that you did not
succeed.
2
You tried to kill yourself but knew that the method was not foolproof.
3
Your attempt was a cry for help, that is, you did not intend to die.
DK/REF
DEFINE ATTEMPT_FILL2
IF SD19a = 1 THEN ATTEMPT_FILL = when
IF SD19a NE 1 THEN ATTEMPT_FILL = the last time
SD29
[IF SD23 = 1] Which method did you use [ATTEMPT_FILL2] you tried to kill yourself?
1
Gun
2
Razor, knife, or other sharp instrument
3
Overdose of prescription medications
4
Overdose of over-the-counter medications
5
Overdose of other drugs, for example, heroin, crack, or alcohol
6
Poison, for example, carbon monoxide or rat poison
7
Hanging, strangulation, or suffocation
8
Drowning
9
Jumping from high places
10
Motor vehicle crash
11
Other
DK/REF
Version 4 – February 2017 (Post IRB Approval)
64
SD29OTH
[IF SD29 = 11] Please provide the method you used [ATTEMPT_FILL2] you tried to
kill yourself.
_______________ [ALLOW 60 CHARACTERS]
DK/REF
SD30
Have you ever done something to hurt yourself on purpose, but without wanting to die,
such as cutting yourself, hitting yourself, or burning yourself?
1
Yes
2
No
DK/REF
SD30a
[IF SD30 = 1] How old were you the first time this happened?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SD31
[IF SD30 = 1 AND SD30a NE CURNTAGE] Have you done something to hurt yourself on
purpose, but without wanting to die, at any time in the past 12 months?
1
Yes
2
No
DK/REF
SD31a
[IF SD31 = 2 OR DK OR REF] How old were you the last time you hurt yourself on purpose,
but without wanting to die?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
65
15a.
Unusual Experiences
BEGIN TIME STAMP
PE1
The next questions are about unusual experiences, like seeing visions or hearing voices. As you
answer these questions, please do not include times you had these experiences when you were
feverish, dreaming, half asleep, or under the influence of alcohol or drugs. With these
exclusions in mind, have you ever in your life had any of the following experiences?
Have you ever seen a vision, that is, something other people who were there
could not see? We don’t mean having good eyesight, but rather seeing things
that other people said were not there, like seeing a face, or people, or strange
objects.
Have you ever heard voices that other people could not hear? We don't mean
having good hearing, but rather hearing things that other people said did not
exist, like strange voices coming from inside your head talking to you or
about you, or voices coming out of the air when there was no one around.
Have you ever believed that some mysterious force was inserting strange
thoughts--that were definitely not your own thoughts -- directly into your
head by means of x-rays or laser beams or other methods?
Have you ever believed that your thoughts were being stolen out of your
mind by some strange force?
Have you ever thought your mind was being taken over by strange forces
with laser beams or other methods that were making you do things you did
not choose to do?
Have you ever thought some strange force was trying to communicate
directly with you by sending special signs or signals that you could
understand but that no one else could understand, such as through the radio or
television?
Have you ever believed there was a plot going on to harm you or have people
follow you that your family and friends did not believe was true?
PE1a
PE1b
PE1c
PE1d
PE1e
PE1f
PE1g
Yes
No
1
2
1
2
1
2
1
2
1
2
1
2
1
2
DK/REF
PE2
[IF PE1a = 1] How old were you the very first time you saw a vision? Remember to report
only times you were not having a fever, not dreaming, not half asleep, and not under the
influence of alcohol or drugs. Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE2a
[IF (CURNTAGE – PE2 = 1)] When was the very first time you saw a vision?
1
2
In the past 12 months
More than 12 months ago
Version 4 – February 2017 (Post IRB Approval)
66
DK/REF
PE3
[IF PE1a = 1] About how many different times in your life did you see a vision? Your best
estimate is fine if you cannot remember the exact number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE4
[IF PE1a = 1 AND (PE2 NE CURNTAGE) AND (PE2a NE 1) AND PE3 NE 1] About how
many different years in your life did you see a vision at least one time? Your best estimate is
fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
DEFINE PE4a_FILL
IF PE3 = 1 THEN PE4a_FILL = “this vision last?”
ELSE PE4a_FILL = “these visions usually last?”
PE4a [IF PE1a = 1] How long did [PE4a_FILL] If it varied, answer for the average duration.
1
Less than 1 minute
2
At least 1 minute but less than 5 minutes
3
At least 5 minutes but less than 30 minutes
4
At least 30 minutes but less than 60 minutes
5
60 minutes or longer
DK/REF
PE5
[IF PE1a = 1 AND PE2a NE 1] Did you see a vision at any time in the past 12 months?
1
Yes
2
No
DK/REF
PE6
[IF PE1a = 1 AND PE5 NE 1] About how old were you the most recent time you saw a
vision? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE PE6a_FILL
IF PE3=1 THEN PE6a_FILL = “this experience”
ELSE PE6a_FILL = “these experiences”
DEFINE PE6b_FILL
IF PE3=1 THEN PE6b_FILL = “it was”
ELSE PE6b_FILL = “they were”
Version 4 – February 2017 (Post IRB Approval)
67
PE6a [IF PE1a = 1 AND PE5 NE 1] When you were having [PE6a_FILL], how convinced were you
that [PE6b_FILL] real rather than your mind playing tricks on you?
1
You strongly believed [PE6b_FILL] real
2
You were unsure if [PE6b_FILL] real
3
You did not believe [PE6b_FILL] real
DK/REF
DEFINE PE6b2_FILL
IF PE3=1 THEN PE6b2_FILL = “was this experience”
ELSE PE6b2_FILL = “were these experiences”
PE6b [IF PE1a = 1 AND PE5 NE 1] How distressing [PE6b2_FILL] to you?
1
Not at all distressing
2
A little
3
Some
4
A lot
5
Extremely distressing
DK/REF
PE7
[IF PE1b = 1] How old were you the very first time you heard voices that other people could
not hear? Remember to report only times you were not having a fever, not dreaming, not half
asleep, and not under the influence of alcohol or drugs. Your best estimate is fine if you cannot
remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE7a
[IF (CURNTAGE – PE7 = 1)] When was the very first time you heard voices that other
people could not hear?
1
In the past 12 months
2
More than 12 months ago
DK/REF
PE8
[IF PE1b = 1] About how many different times in your life did you hear voices? Your best
estimate is fine if you cannot remember the exact number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE9
[IF PE1b = 1 AND (PE7 NE CURNTAGE) AND (PE7a NE 1) AND PE8 NE 1] About how
many different years in your life did you hear voices at least one time? Your best estimate is
fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
68
DEFINE PE9a_FILL
IF PE8 = 1 THEN PE9a_FILL = “this vision last”
ELSE PE9a_FILL = “these visions usually last”
PE9a [IF PE1b = 1] How long did [PE9a_FILL]? If it varied, answer for the most common duration.
1
Less than 1 minute
2
At least 1 minute but less than 5 minutes
3
At least 5 minutes but less than 30 minutes
4
At least 30 minutes but less than 60 minutes
5
60 minutes or longer
DK/REF
PE10 [IF PE1b = 1 AND PE7a NE 1] Did you hear voices at any time in the past 12 months?
1
Yes
2
No
DK/REF
PE11 [IF PE1b = 1 AND PE10 NE 1] About how old were you the most recent time you heard
voices? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE PE11a_FILL
IF PE8 = 1 THEN PE11a_FILL = “this experience”
ELSE PE11a_FILL = “these experiences”
DEFINE PE11a2_FILL
IF PE8 = 1 THEN PE11a2_FILL = “it was”
ELSE PE11a2_FILL = “they were”
PE11a [IF PE1b = 1 AND PE10 NE 1] When you were having [PE11a_FILL], how convinced were
you that [PE11a2_FILL] real rather than your mind playing tricks on you?
1
You strongly believed [PE11a2_FILL] real
2
You were unsure if [PE11a2_FILL] real
3
You did not believe [PE11a2_FILL] real
DK/REF
DEFINE PE11b_FILL
IF PE8 = 1 THEN PE11b_FILL = “was this experience”
ELSE PE11b_FILL = “were these experiences”
PE11b [IF PE1b = 1 AND PE10 NE 1] How distressing [PE11b_FILL] to you?
Version 4 – February 2017 (Post IRB Approval)
69
1
Not at all distressing
2
A little
3
Some
4
A lot
5
Extremely distressing
DK/REF
PE12 [IF PE1c = 1] How old were you the very first time you thought some mysterious force was
inserting strange thoughts into your head? Remember to report only times when you were not
having a fever, not dreaming, not half asleep, and not under the influence of alcohol or drugs.
Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE12a [IF (CURNTAGE – PE12 = 1)] When was the very first time you thought some mysterious
force was inserting strange thoughts into your head?
1
In the past 12 months
2
More than 12 months ago
DK/REF
PE13 [IF PE1c = 1] About how many different times in your life did you think this kind of thought
insertion was happening to you? Your best estimate is fine if you cannot remember the exact
number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE14 [IF PE1c = 1 AND (PE12 NE CURNTAGE) AND (PE12a NE 1) AND PE13 NE 1] About
how many different years in your life did you at least some of the time think you were
experiencing thought insertion? Your best estimate is fine if you cannot remember the exact
number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
PE15 [IF PE1c = 1 AND PE12a NE 1] Did you think you were experiencing thought insertion at any
time in the past 12 months?
1
Yes
2
No
DK/REF
PE16 [IF PE1c = 1 AND PE15 NE 1] About how old were you the most recent time you thought it
was happening? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
Version 4 – February 2017 (Post IRB Approval)
70
DK/REF
PE16a [IF PE1c = 1] When you were experiencing thought insertion, how convinced were you that it
was real rather than your mind playing tricks on you?
1
You strongly believed it was real
2
You were unsure if it was real
3
You did not believe it was real
DK/REF
DEFINE PE16b_FILL
IF PE13 = 1 THEN PE16b_FILL = “was this experience”
ELSE PE16b_FILL = “were these experiences”
PE16b [IF PE1c = 1] How distressing [PE16b_FILL] to you?
1
Not at all distressing
2
A little
3
Some
4
A lot
5
Extremely distressing
DK/REF
PE17 [IF PE1d = 1] How old were you the very first time you believed that thoughts were being
stolen out of your mind? Remember to report only times you were not having a fever, not
dreaming, not half asleep, and not under the influence of alcohol or drugs. Your best estimate
is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE17a [IF (CURNTAGE – PE17 = 1)] When was the very first time you believed that thoughts were
being stolen out of your mind?
1
In the past 12 months
2
More than 12 months ago
DK/REF
PE18 [IF PE1d = 1] About how many different times in your life did you think thoughts were being
stolen out of your mind? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE19 [IF PE1d = 1 AND (PE17 NE CURNTAGE) AND (PE17a NE 1) AND PE18 NE 1] About
how many different years in your life did you at least one time think this was happening? Your
best estimate is fine if you cannot remember the exact number.
Version 4 – February 2017 (Post IRB Approval)
71
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
PE20 [IF PE1d = 1 AND PE17a NE 1] Did you think thoughts were being stolen out of your mind at
any time in the past 12 months?
1
Yes
2
No
DK/REF
PE21 [IF PE1d = 1 AND PE20 NE 1] About how old were you the most recent time you thought
this was happening? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE21a [IF PE1d = 1] When you were experiencing thoughts being stolen out of your mind, how
convinced were you that it was real rather than your mind playing tricks on you?
1
You strongly believed it was real
2
You were unsure if it was real
3
You did not believe it was real
DK/REF
DEFINE PE21b_FILL
IF PE18 = 1 THEN PE21b_FILL = “was this experience”
ELSE PE21b_FILL = “were these experiences”
PE21b [IF PE1d = 1] How distressing [PE21b_FILL] to you?
1
Not at all distressing
2
A little
3
Some
4
A lot
5
Extremely distressing
DK/REF
PE22 [IF PE1e = 1] How old were you the very first time you thought your mind was being taken over
by strange forces making you do things you did not choose to do? Remember to report only times
you were not having a fever, not dreaming, not half asleep, and not under the influence of
alcohol or drugs. Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE22a [IF (CURNTAGE – PE22 = 1)] When was the very first time you thought your mind was
being taken over by strange forces making you do things you did not choose to do?
Version 4 – February 2017 (Post IRB Approval)
72
1
In the past 12 months
2
More than 12 months ago
DK/REF
PE23 [IF PE1e = 1] About how many different times in your life did you think you were
experiencing this mind control? Your best estimate is fine if you cannot remember the exact
number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE24 [IF PE1e = 1 AND (PE22 NE CURNTAGE) AND (PE22a NE 1) AND PE23 NE 1] About
how many different years in your life did you at least one time think you were experiencing
mind control? Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
PE25 [IF PE1e = 1 AND PE22a NE 1] Did you think you were experiencing mind control at any
time in the past 12 months?
1
Yes
2
No
DK/REF
PE26 [IF PE1e = 1 AND PE25 NE 1] About how old were you the most recent time you
experienced mind control? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE26a [IF PE1e = 1] When you were experiencing mind control, how convinced were you that it
was real rather than your mind playing tricks on you?
1
You strongly believed it was real
2
You were unsure if it was real
3
You did not believe it was real
DK/REF
DEFINE PE26b_FILL
IF PE23 = 1 THEN PE26b_FILL = “was this experience”
ELSE PE26b_FILL = “were these experiences”
PE26b [IF PE1e = 1] How distressing [PE26b_FILL] to you?
1
2
3
Not at all distressing
A little
Some
Version 4 – February 2017 (Post IRB Approval)
73
4
A lot
5
Extremely distressing
DK/REF
PE27 [IF PE1f = 1] How old were you the very first time you thought a strange force was trying to
send you special signs or signals that no one else could understand? Remember to report only
times you were not having a fever, not dreaming, not half asleep, and not under the influence
of alcohol or drugs. Your best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE27a [IF (CURNTAGE – PE27 = 1)] When was the very first time you thought a strange force was
trying to send you special signs or signals that no one else could understand?
1
In the past 12 months
2
More than 12 months ago
DK/REF
PE28 [IF PE1f = 1] About how many different times in your life did you think you were getting
these kinds of special communications? Your best estimate is fine if you cannot remember the
exact number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE29 [IF PE1f = 1 AND (PE27 NE CURNTAGE) AND (PE27a NE 1) AND PE28 NE 1] About
how many different years in your life did you at least one time think you were getting these
kinds of special communications? Your best estimate is fine if you cannot remember the exact
number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
PE30 [IF PE1f = 1 AND PE27a NE 1] Did you think you were getting these kinds of special
communications at any time in the past 12 months?
1
Yes
2
No
DK/REF
PE31 [IF PE1f = 1 AND PE30 NE 1] About how old were you the most recent time you thought
this was happening? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
74
PE31a [IF PE1f=1] When you thought you were getting these kinds of special communications, how
convinced were you that it was real rather than your mind playing tricks on you?
1
You strongly believed it was real
2
You were unsure if it was real
3
You did not believe it was real
DK/REF
DEFINE PE31b_FILL
IF PE28 = 1 THEN PE31b_FILL = “was this experience”
ELSE PE31b_FILL = “were these experiences”
PE31b [IF PE1f=1] How distressing [PE31b_FILL] to you?
1
Not at all distressing
2
A little
3
Some
4
A lot
5
Extremely distressing
DK/REF
PE32 [IF PE1g = 1] How old were you the very first time you thought there was a plot going on to
harm you or have people follow you? Remember to report only times you were not having a
fever, not dreaming, not half asleep, and not under the influence of alcohol or drugs. Your best
estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE32a [IF (CURNTAGE – PE32 = 1)] When was the very first time you thought there was a plot
going on to harm you or have people follow you?
1
In the past 12 months
2
More than 12 months ago
DK/REF
PE33 [IF PE1g = 1] About how many different times in your life did you think you were the victim
of a plot? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF TIMES [RANGE: 1–500]
DK/REF
PE34 [IF PE1g = 1 AND (PE32 NE CURNTAGE) AND (PE32a NE 1) AND PE33 NE 1] About
how many different years in your life did you think you were the victim of a plot? Your best
estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
75
PE35 [IF PE1g = 1 AND PE32a NE 1] Did you think you were the victim of a plot at any time in the
past 12 months?
1
Yes
2
No
DK/REF
PE36 [IF PE1g = 1 AND PE35 NE 1] About how old were you the most recent time you thought
you were the victim of a plot? Your best estimate is fine if you cannot remember your exact
age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
PE36a [IF PE1g = 1] When you were experiencing being a victim of a plot, how convinced were you
that it was real rather than your mind playing tricks on you?
1
You strongly believed it was real
2
You were unsure if it was real
3
You did not believe it was real
DK/REF
DEFINE PE36b_FILL
IF PE33 = 1 THEN PE36b_FILL = “was this experience”
ELSE PE26b_FILL = “were these experiences”
PE36b [IF PE1g = 1] How distressing [PE36b_FILL] to you?
1
Not at all distressing
2
A little
3
Some
4
A lot
5
Extremely distressing
DK/REF
DEFINE PE37_FILL
IF PE1a = 1 PE37_FILL = visions
IF PE1b = 1 PE37_FILL = voices
IF PE1c = 1 PE37_FILL = thought insertion
IF PE1d = 1 PE37_FILL = stolen thoughts
IF PE1e = 1 PE37_FILL = mind control
IF PE1f = 1 PE37_FILL = special communications
IF PE1g = 1 PE37_FILL = plots
PE37 [IF AT LEAST 1 YES RESPONSE IN PE1a-g] Have you ever talked to a doctor or mental
health professional for help in dealing with these experiences with [PE37_FILL]?
Version 4 – February 2017 (Post IRB Approval)
76
1
Yes
2
No
DK/REF
DEFINE PE38_FILL
IF ONLY 1 YES IN PE1a-g SERIES PE38_FILL = this experience
ELSE PE38_FILL = these experiences
PE38 [IF AT LEAST 1 YES RESPONSE IN PE1a-g AND PE37=1] What did the doctor say was
causing [PE38_FILL]?
To select more than one answer, press the space bar between each number you type.
1
Schizophrenia or psychosis
2
Manic depression or bipolar disorder
3
Some other mental health problem
4
A physical illness or injury
5
Medication
6
Alcohol or drugs
7
Something else
DK/REF
PE38OT
[IF PE38 = 7] What did the doctor say was causing [PE38_FILL]?
______________ [ALLOW 300 CHARACTERS]
DK/REF
PE39 [IF PE38 NE 1] Were you ever prescribed any medications for these problems?
1
Yes
2
No
DK/REF
PE40 [IF PE39=1] Were you ever prescribed any of the following medications for these problems?
PE40a
PE40b
PE40c
PE40d
PE40e
PE40f
PE40g
PE40h
PE40i
PE40j
PE40k
Abilify or Aripiprazole
Saphris or Asenapine
Thorazine or Chlorpromazine
Clozaril or Clozapine
Fluanxol or Flupenthixol
Haldol or Haloperidol
Fanapt or Iloperidone
Loxitane, Loxapac, or Loxapine
Latuda or Lurasidone
Zyprexa or Olanzapine
Invega or Paliperidone
Version 4 – February 2017 (Post IRB Approval)
Yes
1
1
1
1
1
1
1
1
1
1
1
No
2
2
2
2
2
2
2
2
2
2
2
77
PE40l
PE40m
PE40n
PE40o
PE40p
PE40q
DK/REF
Trilafon, Etrafon, or Perphenazine
Prolixin, Prolixin decanoate, Permitil, Modecate, Fluphenazine, or
Fluphenazine decanoate
Seroquel or Quetiapine
Risperdal or Risperidone
Stelazine or Trifluoperazine
Geodon or Ziprasidone
Yes
1
No
2
1
2
1
1
1
1
2
2
2
2
DEFINE PE40_FILL
IF ONLY ONE ITEM IN PE1a - g = 1 THEN PE40_FILL = “this experience”
ELSE PE40_FILL = “these experiences ever”
PE41 [IF AT LEAST 1 YES RESPONSE IN PE1a-g] How much did [PE40_FILL] interfere with
your work, school, or personal life?
1
Not at all
2
A little bit
3
Moderately
4
Quite a bit
5
Extremely
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
78
16.
Treatment of Emotional Problems
BEGIN TIME STAMP
TR1
The next questions are about treatments you might have received for problems with your
emotions, behavior, or mental health.
Have you ever in your life stayed overnight or longer in a hospital or other facility to receive
treatment for problems with your emotions, behavior, or mental health?
By “other facilities” we mean places like treatment centers, group homes or foster homes,
juvenile justice facilities, and emergency shelters.
1
Yes
2
No
DK/REF
TR1A [If TR1=1] In which of these places did you ever stay overnight to receive treatment for
problems with your emotions, behavior, or mental health?
TR1Aa
TR1Ab
TR1Ac
TR1Ad
TR1Ae
TR1Af
TR1Ag
DK/REF
Emergency room
Psychiatric hospital
General medical hospital
Residential treatment center or group home
Foster home or therapeutic foster care
Detention center, prison, or jail
Some other type of facility
Yes
1
1
1
1
1
1
No
2
2
2
2
2
2
1
2
TR1A_OTH [If TR1Ah = 1] Please describe the other type of facility where you stayed overnight to
receive treatment for problems with your emotions, behavior, or mental health.
_____________________ DESCRIPTION [RANGE: 1–50 CHARACTERS]
DK/REF
DEFINE TR1A_COUNT (PERFORM EACH TIME LEAVE TR1A)
SET TR1A_COUNT = 0
IF TR1Aa = 1, ADD 1 TO TR1A_COUNT
IF TR1Ab = 1, ADD 1 TO TR1A_COUNT
IF TR1Ac = 1, ADD 1 TO TR1A_COUNT
IF TR1Ad = 1, ADD 1 TO TR1A_COUNT
IF TR1Ae = 1, ADD 1 TO TR1A_COUNT
IF TR1Af = 1, ADD 1 TO TR1A_COUNT
IF TR1Ag = 1, ADD 1 TO TR1A_COUNT
Version 4 – February 2017 (Post IRB Approval)
79
DEFINE TR1AA_FILL
IF TR1AA = 1, THEN TR1Aa_FILL = “an emergency room”
DEFINE TR1AB_FILL
IF TR1AB = 1, THEN TR1Ab_FILL = “a psychiatric hospital”
DEFINE TR1AC_FILL
IF TR1AC = 1, THEN TR1Ac_FILL = “a general medical hospital”
DEFINE TR1AD_FILL
IF TR1AD = 1 =1, THEN TR1Ad_FILL = “a residential treatment center or group home”
DEFINE TR1AE_FILL
IF TR1AE = 1, THEN TR1Ae_FILL = “a foster home or therapeutic foster care”
DEFINE TR1AF_FILL
IF TR1AF = 1, THEN TR1Af_FILL = “a detention center, prison, or jail”
DEFINE TR1AG_FILL
IF TR1AG = 1, THEN TR1Ag_FILL = “the facility you described earlier -- {TR1a_OTH} --”
PROGRAMMER NOTE:
FOR EACH FACILITY REPORTED IN TR1A, ASK ALL PERTINENT QUESTIONS IN THE
TR2-TR6 SERIES BEFORE ASKING THAT SAME SERIES ABOUT ANY OTHER FACILITY
REPORTED.
THE “X” USED IN VARIABLE NAMES IN TR2-TR6 IS ONLY A PLACEHOLDER FOR THE
LETTERS A-H, WHICH SHOULD BE USED WHEN PERTINENT.
ANSWERS FOR EACH FACILITY SHOULD BE STORED IN SEPARATE VARIABLES
LABELLED WITH THE LETTER OF THE FACILITY ABOUT WHICH WE ASKED.
FOR EXAMPLE, WHEN TR1AA = 1, ASK ABOUT THE FACILITY FROM TR1AA
(HOSPITAL) AND SAVE ANSWERS INTO TR2A, TR3A, TR3A_2, TR3A_3, TR3A_4, TR6A,
ETC.
TR2X [IF TR1AX = 1] How many times were you admitted to stay overnight in [TR1AX_FILL] to
receive treatment for problems with your emotions, behavior, or mental health?
Your best estimate is fine if you cannot remember the exact number.
_______ NUMBER OF TIMES [RANGE: 1–90]
DK/REF
DEFINE TR2_GT1 (PERFORM EACH TIME MOVES AWAY FROM ANY IN THE TR2X SERIES)
SET TR2_GT1 = 0
IF (TR2A + TR2B + TR2C + TR2D + TR2E + TR2F + TR2G) ≥ 1, THEN TR2_GT1 = 1
Version 4 – February 2017 (Post IRB Approval)
80
DEFINE TR3X_FILL
IF TR2X = 1, THEN TR3X_FILL = “when that happened”
ELSE, TR3X_FILL = “the first time you stayed overnight in a [TR1AX_FILL] to receive treatment for
problems with your emotions, behavior, or mental health”
TR3X [IF TR1AX = 1] How old were you [TR3X_FILL]?
________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TR3X_2
[IF TR1AX = 1 AND (TR2X > 1 OR (TR3X ≥ CURNTAGE-1)] During the past 12
months, did you stay overnight in [TR1AX_FILL] to receive treatment for problems with
your emotions, behavior, or mental health?
1
Yes
2
No
DK/REF
TR3X_3
[IF TR3X_2 = 1] Next, we are going to ask how long you stayed in [TR1AX_FILL] to
receive treatment for these kinds of problems during the past 12 months. Would you prefer
to answer in days, weeks, or months?
1
Days
2
Weeks
3
Months
DK/REF
TR3X_3_DY [IF TR3X_3 = 1] During the past 12 months, how many days did you stay in
[TR1AX_FILL] to receive treatment for these kinds of problems?
________ NUMBER OF DAYS [RANGE: 1–365]
DK/REF
TR3X_3_WK [IF TR3X_3 = 2] During the past 12 months, how many weeks did you stay in
[TR1AX_FILL] to receive treatment for these kinds of problems?
________ NUMBER OF WEEKS [RANGE: 1–52]
DK/REF
TR3X_3_MN [IF TR3X_3 = 3] During the past 12 months, how many months did you stay in
[TR1AX_FILL] to receive treatment for these kinds of problems?
________ NUMBER OF MONTHS [RANGE: 1–12]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
81
TR3X_4
[TR1AX = 1] Next, we’re going to ask how much time you stayed in [TR1AX_FILL] to
receive treatment for these kinds of problems, in your entire life. Would you prefer to
answer in days, weeks, or months?
1
Days
2
Weeks
3
Months
DK/REF
TR3X_4_DY [IF TR3X_4 = 1] In your entire life, how many days did you stay in [TR1AX_FILL] to
receive treatment for these kinds of problems?
________ NUMBER OF DAYS [RANGE: 1–365]
DK/REF
TR3X_4_WK [IF TR3X_4 = 2] In your entire life, how many weeks did you stay in [TR1AX_FILL] to
receive treatment for these kinds of problems?
________ NUMBER OF WEEKS [RANGE: 1–52]
DK/REF
TR3X_4_MN [IF TR3X_4 = 3] In your entire life, how many months did you stay in [TR1AX_FILL] to
receive treatment for these kinds of problems?
________ NUMBER OF MONTHS [RANGE: 1–12]
DK/REF
DEFINE TR4X_FILL
IF TR2X = 1, THEN TR4X_FILL = “that”
ELSE, TR4X_FILL = “your first overnight stay in [TR1AX_FILL]”
TR4X [IF TR3X = (CURNTAGE – 1)] Did [TR4X_FILL] start in the past 12 months or more than
12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
TR6X [IF TR1AX = 1 AND (TR2X>1) AND (TR2X NE (DK OR REF)) AND (TR3X _2 = DK,
REF, OR MISSING)] About how old were you the most recent time you were in
[TR1AX_FILL] overnight to receive treatment for problems with your emotions, behavior, or
mental health? Your best estimate is fine if you cannot remember the exact age.
________ YEARS OLD [0–CURNTAGE]
DK/REF
TRTST1
Have you ever in your life received special testing or an evaluation for problems with your
emotions, behavior, or mental health?
Version 4 – February 2017 (Post IRB Approval)
82
1
Yes
2
No
DK/REF
TRTST2
[IF TRTST1 = 1] About how old were you the very first time you received special testing
or an evaluation for problems with your emotions, behavior, or mental health? Your best
estimate is fine if you cannot remember your exact age.
________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TRTST3
[IF TRTST2 = CURNTAGE – 1] Did you start this testing in the past 12 months or more
than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
DEFINE TR7_FILL2
IF TR1Aa = 1 AND TR1A_COUNT = 1, THEN TR7_FILL2 = “an emergency room”
IF TR1Ab = 1 AND TR1A_COUNT = 1, THEN TR7_FILL2 = “a psychiatric hospital”
IF TR1Ac = 1 AND TR1A_COUNT = 1, THEN TR7_FILL2 = “a general medical hospital”
IF TR1Ad = 1 AND TR1A_COUNT = 1, THEN TR7_FILL2 = “a residential treatment center or group
home”
IF TR1Ae = 1 AND TR1A_COUNT = 1, THEN TR7_FILL2 = “a foster home or therapeutic foster
home”
IF TR1Af = 1 AND TR1A_COUNT = 1, THEN TR7_FILL2 = “a detention center, prison, or jail”
IF TR1Ag = 1 AND TR1A_COUNT = 1, THEN TR7_FILL2 = “the facility you described earlier -{TR1a_OTH} --”
ELSE, TR7_FILL2 = “any of the facilities you mentioned earlier,”
DEFINE TR7_FILL
IF TR1 = 1 AND TR1A_COUNT = 1 AND TR2_GT1 = 0, THEN TR7_FILL = “Not counting the time
when you stayed overnight at [TR7_FILL2], did”
IF TR1 = 1 AND (TR1A_COUNT > 1 OR TR2_GT1 = 1) THEN TR7_FILL = “Not counting times when
you stayed overnight at [TR7_FILL2], did”
ELSE, TR7_FILL = “Did”
TR7
[TR7_FILL] you ever in your life receive counseling or medication from any of the following
sources for problems with your emotions, behavior, or mental health?
Version 4 – February 2017 (Post IRB Approval)
83
A mental health professional? A “mental health professional” includes a
psychiatrist, psychologist, mental health counselor or social worker, and
marriage and family counselor. These professionals can be seen in oneon-one sessions, group sessions, telephone sessions, or computerized
texting sessions.
A general medical doctor, pediatrician, nurse, or other general medical
care provider?
A minister, priest, rabbi, or other spiritual advisor?
A Certified Peer Counselor? A “Certified Peer Counselor” is a person
who has experienced mental health issues firsthand and has been trained
to help facilitate mental health recovery in others.
A self-help or support group? A “self-help or support group” is a group
for people with emotional, family, or substance problems that is run by
the people themselves without a mental health professional running the
group.
A computerized or internet-based mental health treatment program? A
“computerized or internet-based mental health treatment program” is a
special type of self-help program where you work through exercises that
give you practice in strategies that can help you improve your mental
health. Sometimes these programs are accompanied by telephone calls or
texting sessions with mental health professionals. When this is the case,
we want you to report both receiving counseling from a mental health
professional and participating in a computerized or internet-based
program.
TR7a
TR7b
TR7c
TR7d
TR7e
TR7f
Yes
No
1
2
1
2
1
2
1
2
1
2
1
2
DK/REF
TR8
[IF TR7a = 1] You reported receiving counseling or medication from a mental health
professional. Which did you receive: counseling, medication, or both?
1
Only Counseling
2
Only Medication
3
Counseling and Medication
DK/REF
DEFINE TR8HLPTYP
IF TR8= 1, THEN, TR8HLPTYP = “counseling”
IF TR8 = 2, THEN TR8HLPTYP = “medication”
IF TR8=3, THEN TR8HLPTYP = “counseling and medication”
IF TR8 = DK/REF, THEN TR8HLPTYP = “counseling or medication”
TR9
[IF TR7a = 1] About how old were you the very first time you received [TR8HLPTYP] from
a mental health professional? Your best estimate is fine if you cannot remember your exact
age.
________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
84
TR10
[IF TR9 = CURNTAGE – 1] Did you start this [TR8HLPTYP] in the past 12 months or more
than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
TR11
[IF TR7A = 1 AND ((TR9 < (CURNTAGE – 1) OR (TR9 = DK OR REF))] During about
how many years of your life did you receive any treatment from a mental health professional?
Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
DEFINE HOSPFILL
IF TR1 = 1, THEN HOSPFILL = “Not counting any hospitalizations, about”
IF TR1 NE 1, THEN HOSPFILL = “About”
TR12
[IF TR7A = 1 AND (TR11 NE 1)] [HOSPFILL] how many treatment sessions with a mental
health professional did you have in the past 12 months, counting face-to-face visits, phone
calls, and texting sessions? Your best estimate is fine if you cannot remember the exact
number.
______ NUMBER OF TREATMENT SESSIONS [RANGE: 0–365]
DK/REF
TR13
TR13a
TR13b
TR13c
TR13d
DK/REF
TR14
[IF (TR12 ≥ 1) AND (TR12 NE DK OR REF)] What kind of treatment did you get?
Face-to-face
Phone call
Texting
Video calling or messaging
Yes
1
1
1
1
No
2
2
2
2
[IF TR7A = 1 AND (TR11 NE 1) AND (TR9 NE CURNTAGE) AND (TR12 = DK, REF,
OR MISSING)] [HOSPFILL] how old were you the most recent time you received
treatment from a mental health professional? Your best estimate is fine if you cannot
remember the exact age.
______ YEARS OLD [RANGE: 0– CURNTAGE]
DK/REF
DEFINE TR15_FILL
IF TR7A = 1, THEN TR15_FILL = “also”
ELSE, TR15_FILL = “”
Version 4 – February 2017 (Post IRB Approval)
85
TR15
[IF TR7B = 1] You [TR15_FILL] reported receiving counseling or medication for problems
with your emotions, behavior, or mental health from a general medical doctor, nurse, or
other general medical care provider. Which did you receive: counseling, medication, or
both?
1
Only Counseling
2
Only Medication
3
Counseling and Medication
DK/REF
DEFINE TR15HLPTYP
IF TR15 = 1, THEN, TR15HLPTYP = “counseling”
IF TR15 = 2, THEN TR15HLPTYP = “medication”
IF TR15 = 3, THEN TR15HLPTYP = “counseling and medication”
IF TR15 = DK/REF, THEN TR15HLPTYP = “counseling or medication”
TR16
[IF TR7B = 1] About how old were you the very first time you received [TR15HLPTYP] for
mental health problems from a general medical care provider? Your best estimate is fine if
you cannot remember your exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TR17
[IF TR16 = CURNTAGE – 1] Did you start this treatment in the past 12 months or more than
12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
TR18
[IF TR7B = 1 AND ((TR16 < (CURNTAGE – 1) OR (TR16 = DK OR REF))] During about
how many years of your life did you receive this kind of treatment from a general medical
care provider? Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
TR19
[IF TR7B = 1 AND (TR18 NE 1) AND TR18 NE MISSING] About how many treatment
sessions of this sort did you have with a general medical professional in the past 12 months?
Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF TREATMENT SESSIONS [RANGE: 0–365]
DK/REF
TR20
[IF TR7B = 1 AND (TR18 NE 1) AND (TR16 NE CURNTAGE) AND (TR19 = DK OR
REF, OR MISSING)] About how old were you the most recent time you received this kind
of treatment from a general medical professional? Your best estimate is fine if you cannot
remember the exact age.
Version 4 – February 2017 (Post IRB Approval)
86
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TR21_FILL
IF TR7A = 1 or TR7B = 1, THEN TR21_FILL = “also”
ELSE, TR21_FILL = “”
TR21
[IF TR7C = 1] You [TR21_FILL] reported receiving counseling for problems with your
emotions, behavior, or mental health from a minister, priest, rabbi, or other spiritual advisor.
About how old were you the very first time you received this kind of counseling? Your best
estimate is fine if you cannot remember your exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TR22
[IF TR21 = CURNTAGE – 1] Did you start this counseling in the past 12 months or more
than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
TR23
[IF TR7C = 1 AND ((TR21 < (CURNTAGE – 1) OR (TR21 = DK OR REF))] During about
how many years of your life did you receive this kind of counseling from a spiritual advisor?
Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
TR24
[IF TR7C = 1 and (TR23 NE 1)] About how many of these counseling sessions with a
spiritual advisor did you have in the past 12 months? Your best estimate is fine if you cannot
remember the exact number.
______ NUMBER OF SESSIONS [RANGE: 0–365]
DK/REF
TR25
[IF TR7C = 1 AND (TR23 NE 1) AND (TR21 NE CURNTAGE) AND (TR24 = DK, REF,
OR MISSING)] About how old were you the most recent time you had one of these sessions
with a spiritual advisor? Your best estimate is fine if you cannot remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TR26_FILL
IF TR7A = 1 OR TR7B = 1 OR TR7C = 1, THEN TR26_FILL = “also”
ELSE, TR26_FILL = “”
Version 4 – February 2017 (Post IRB Approval)
87
TR26
[IF TR7D = 1] You [TR26_FILL] reported receiving counseling for problems with your
emotions, behavior, or mental health from a Certified Peer Counselor. About how old were
you the very first time you received this kind of counseling? Your best estimate is fine if you
cannot remember your exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TR27
[IF TR26 = CURNTAGE – 1] Did you start this counseling in the past 12 months or more
than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
TR28
[IF TR7D = 1 AND ((TR26 < (CURNTAGE – 1) OR (TR26 = DK OR REF))] During about
how many years of your life did you receive this kind of counseling from a Certified Peer
Counselor? Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
TR29
[IF TR7D = 1 AND (TR28 NE (1 OR MISSING))] About how many of these counseling
sessions with a Certified Peer Counselor did you have in the past 12 months? Your best
estimate is fine if you cannot remember the exact number.
______ NUMBER OF SESSIONS [RANGE: 0–365]
DK/REF
TR30
[IF TR7D = 1 AND (TR28 NE (1 OR MISSING)) AND (TR26 NE CURNTAGE) AND
(TR29 = DK OR REF OR MISSING)] About how old were you the most recent time you
had one of these sessions with a Certified Peer Counselor? Your best estimate is fine if you
cannot remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TR31_FILL
IF TR7A = 1 OR TR7B = 1 OR TR7C = 1 OR TR7D = 1, THEN TR31_FILL = “also”
ELSE, TR31_FILL = “”
TR31
[IF TR7E = 1] You [TR31_FILL] reported going to a self-help or support group for problems
with your emotions, behavior, or mental health. About how old were you the very first time
you went to this kind of group? Your best estimate is fine if you cannot remember your exact
age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
88
TR32
[IF TR31 = CUNRTAGE – 1] Did you start going in the past 12 months or more than 12
months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
TR33
[IF TR7E = 1 AND ((TR31 < (CURNTAGE – 1) OR (TR31 = DK OR REF))] During about
how many years of your life did you go to a group of this sort? Your best estimate is fine if
you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
TR34
[IF TR7E = 1 AND (TR33 NE (1 OR MISSING))] About how many meetings did you go to
in the past 12 months? Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF MEETINGS [RANGE: 0–365]
DK/REF
TR35
[IF TR7E = 1 AND (TR33 NE (1 OR MISSING)) AND (TR31 NE CURNTAGE) AND
(TR34 = DK OR REF OR MISSING)] About how old were you the most recent time you
went to a self-help group meeting of this sort? Your best estimate is fine if you cannot
remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TR36_FILL
IF TR7A = 1 OR TR7B = 1 OR TR7C = 1 OR TR7D = 1 OR TR7E = 1, THEN TR36_FILL = “also”
ELSE, TR36_FILL = “”
TR36
[IF TR7F = 1] You [TR36_FILL] reported trying a computerized or internet-based mental
health treatment program. About how old were you the very first time you tried such a
program? Your best estimate is fine if you cannot remember your exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TR37
[IF TR36 = CURNTAGE – 1] Did you start it in the past 12 months or more than 12 months
ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
Version 4 – February 2017 (Post IRB Approval)
89
TR38
[IF TR7F = 1 AND ((TR36 < (CURNTAGE – 1) OR (TR36 = DK OR REF))] During about
how many years of your life did you use a computerized or internet-based mental health
treatment program? Your best estimate is fine if you cannot remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
TR39
[IF TR7F = 1 AND (TR38 NE (1 OR MISSING))] During about how many days did you
spend time online with this program in the past 12 months? Your best estimate is fine if you
cannot remember the exact number.
______ NUMBER OF DAYS [RANGE: 0–365]
DK/REF
TR40
[IF TR39 ≥ 1] Do you still spend any time working on the computerized treatment program?
Or have you stopped?
1
Still working on the program
2
Stopped
DK/REF
TR41
[IF TR39=0 OR TR40 = 2] How important was each of the following reasons for why you
stopped?
TR41a You got better and no longer
need the program
TR41b The program was not helping
TR41c The program took too much
time
DK/REF
TR42
Very
Important
Somewhat
Important
Not Very
Important
Not at All
Important
1
2
3
4
1
2
3
4
1
2
3
4
[TR7F = 1 AND (TR38 NE (1 OR MISSING)) AND (TR36 NE CURNTAGE) AND (TR39
= DK OR REF OR MISSING)] About how old were you the most recent time you spent
time online with a computerized or internet-based mental health treatment program? Your
best estimate is fine if you cannot remember the exact age.
______ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TR43_ASK (PERFORM EACH TIME MOVE TO TR43)
IF TR12 ≥ 1 AND (TR12 NE DK OR REF) AND (TR19 = DK, REF, OR MISSING) AND (TR24 =
DK, REF, OR MISSING) AND (TR29 = DK, REF, OR MISSING) AND (TR34 = DK, REF, OR
MISSING); SET TR43_ASK = 1
ELSE, SET TR43_ASK = 0
DEFINE TR44_ASK (PERFORM EACH TIME MOVE TO TR44)
Version 4 – February 2017 (Post IRB Approval)
90
IF TR19 ≥ 1 AND (TR19 NE DK OR REF) AND (TR12 = DK, REF, OR MISSING) AND (TR24 =
DK, REF, OR MISSING) AND (TR29 = DK, REF, OR MISSING) AND (TR34 = DK, REF, OR
MISSING); SET TR44_ASK = 1
ELSE, SET TR44_ASK = 0
DEFINE TR45_ASK (PERFORM EACH TIME MOVE TO TR45)
IF TR24 ≥ 1 AND (TR24 NE DK OR REF) AND (TR12 = DK, REF, OR MISSING) AND (TR19 =
DK, REF, OR MISSING) AND (TR29 = DK, REF, OR MISSING) AND (TR34 = DK, REF, OR
MISSING); SET TR45_ASK = 1
ELSE, SET TR45_ASK = 0
DEFINE TR46_ASK (PERFORM EACH TIME MOVE TO TR46)
IF TR29 ≥ 1 AND (TR29 NE DK OR REF) AND (TR12 = DK, REF, OR MISSING) AND (TR19 =
DK, REF, OR MISSING) AND (TR24 = DK, REF, OR MISSING) AND (TR34 = DK, REF, OR
MISSING); SET TR46_ASK = 1
ELSE, SET TR46_ASK = 0
DEFINE TR47_ASK (PERFORM EACH TIME MOVE TO TR47)
IF TR34 ≥ 1 AND (TR34 NE DK OR REF) AND (TR12 = DK, REF, OR MISSING) AND (TR19 =
DK, REF, OR MISSING) AND (TR24 = DK, REF, OR MISSING) AND (TR29 = DK, REF, OR
MISSING); SET TR47_ASK = 1
ELSE, SET TR47_ASK = 0
DEFINE TR48_ASK (PERFORM EACH TIME MOVE TO TR48)
IF ((TR12 ≥ 1 AND (TR12 NE DK OR REF)) OR (TR19 ≥ 1 AND (TR19 NE DK OR REF)) AND
((TR24 ≥ 1 AND (TR24 NE DK OR REF)) OR (TR29 ≥ 1 AND (TR29 NE DK OR REF)) AND
(TR34 = DK 0R REF OR MISSING); THEN SET TR48_ASK = 1
ELSE, SET TR48_ASK = 0
DEFINE TR49_ASK (PERFORM EACH TIME MOVE TO TR49)
IF ((TR12 ≥ 1 AND (TR12 NE DK OR REF)) OR (TR19 ≥ 1 AND (TR19 NE DK OR REF)) AND
((TR24 = DK OR REF OR MISSING) AND (TR29 = DK OR REF OR MISSING)) AND (TR34 ≥ 1
AND (TR34 NE DK OR REF)); THEN SET TR49_ASK = 1
ELSE, SET TR49_ASK = 0
DEFINE TR50_ASK (PERFORM EACH TIME MOVE TO TR50)
IF ((TR12 = DK OR REF OR MISSING) AND (TR19 = DK OR REF OR MISSING)) AND ((TR24
≥ 1 AND (TR24 NE DK OR REF)) OR (TR29 ≥ 1 AND (TR = 29 NE DK OR REF)) AND (TR34 ≥ 1
AND (TR34 NE DK OR REF)); THEN SET TR50_ASK = 1
ELSE, SET TR50_ASK = 0
DEFINE TR51_ASK (PERFORM EACH TIME MOVE TO TR51)
IF ((TR12 ≥ 1 AND (TR12 NE DK OR REF)) OR (TR19 ≥ 1 AND (TR19 NE DK OR REF)) AND
((TR24 ≥ 1 AND (TR24 NE DK OR REF)) OR (TR29 ≥ 1 AND (TR29 NE DK OR REF)) AND
(TR34 ≥ 1 AND (TR34 NE DK OR REF)); THEN SET TR51_ASK = 1
ELSE, SET TR51_ASK = 0
Version 4 – February 2017 (Post IRB Approval)
91
TR43
[IF TR43_ASK = 1] Are you still receiving [TR8HLPTYP] from a mental health
professional? Or have you stopped receiving [TR8HLPTYP]?
1
Still receiving [TR8HLPTY]
2
Stopped receiving [TR8HLPTYP]
DK/REF
TR44
[IF TR44_ASK = 1] Are you still in treatment for these problems with a general medical
profession? Or have you stopped receiving treatment?
1
Still in treatment
2
Stopped
DK/REF
TR45
[IF TR45_ASK = 1] Are you still receiving counseling for these problems from a spiritual
advisor? Or have you stopped receiving counseling?
1
Still in counseling
2
Stopped counseling
DK/REF
TR46
[IF TR46_ASK = 1] Are you still receiving counseling from a Certified Peer Counselor? Or
have you stopped receiving counseling?
1
Still in counseling
2
Stopped counseling
DK/REF
TR47
[IF TR47_ASK = 1] Are you still attending self-help group meetings? Or have you stopped?
1
Still attending
2
Stopped attending
DK/REF
TR48
[IF TR48_ASK = 1] Are you still either in treatment or receiving counseling for your mental
health problems? Or have you stopped both treatment and counseling?
1
Still either in treatment or counseling
2
Stopped both treatment and counseling
DK/REF
TR49
[IF TR49_ASK = 1] Are you still either in treatment or in the self-help group? Or have you
stopped both treatment and the self-help group?
1
Still either in treatment or the self-help group
2
Stopped both treatment and the self-help group
DK/REF
Version 4 – February 2017 (Post IRB Approval)
92
TR50
[IF TR50_ASK = 1] Are you still either in counseling or the self-help group? Or have you
stopped both counseling and the self-help group?
1
Still either in counseling or the self-help group
2
Stopped both counseling and the self-help group
DK/REF
TR51
[IF TR51_ASK = 1] Are you still either in treatment, counseling, or the self-help group? Or
have you stopped all of them?
1
Still either in treatment, counseling, or the self-help group
2
Stopped all of them
DK/REF
DEFINE TR52_ASK (PERFORM EACH TIME MOVE TO TR52)
IF TR43 = 2 OR TR44 = 2 OR TR45 = 2 OR TR46 = 2 OR TR47 = 2 OR TR48 = 2 OR TR49 = 2 OR
TR50 = 2 or TR51 = 2, THEN SET TR52_ASK = 1
ELSE, SET TR52_ASK = 0
DEFINE TR52_FILL1 (PERFORM EACH TIME MOVE TO TR52)
IF ((TR12 ≥ 1 AND (TR12 NE DK OR REF)) OR (TR19 ≥ 1 AND (TR19 NE DK OR REF))) OR
((TR24 ≥ 1 AND (TR24 NE DK OR REF)) OR (TR29 ≥ 1 AND (TR29 NE DK OR REF))), THEN
TR52_FILL1 = “treatment”,
ELSE, TR52_FILL1 = “”
DEFINE TR52_FILL3 (PERFORM EACH TIME MOVE TO TR52)
IF (TR34 ≥ 1 AND (TR34 NE DK OR REF)), THEN TR52_FILL3 = “the self-help group”,
ELSE, TR52_FILL3 = “”
DEFINE TR52_FILL2 (PERFORM EACH TIME MOVE TO TR52)
IF TR52_FILL1 = “treatment” AND TR52_FILL3 = “the self-help group”, THEN TR52_FILL2 = “
and ”,
ELSE, TR52_FILL2 = “”
TR52
[IF TR52_ASK = 1] How important was each of the following reasons for why you stopped
[TR52_FILL1][TR52_FILL2][TR52_FILL3]?
TR52a You got better and no longer
needed help
TR52b It was not helping; you were
not getting better
TR52c Financial reasons
TR52d Inconvenience — for example,
problems with time,
transportation, or scheduling
Version 4 – February 2017 (Post IRB Approval)
Very
Important
Somewhat
Important
Not Very
Important
Not at All
Important
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
93
TR52e Embarrassment or concern
about what people would think
if they knew you were in
treatment
TR52f You preferred to handle the
problem on your own or with
the help of family and friends
DK/REF
1
2
3
4
1
2
3
4
TR52g [IF TR52_ASK = 1] Was there some other important reason why you stopped
[TR52_FILL1][TR52_FILL2][TR52_FILL3]?
1
Yes
2
No
DK/REF
TR52G_OTH
[IF TR52G = 1] Please briefly describe the other reason why you stopped.
OTHER IMPORTANT REASON:
__________________________________________ [RANGE: 1–100
CHARACTERS]
DK/REF
TR52H Did you ever in your life receive any of the following special school services?
Yes No
TR52Ha Placement in a special school for students with emotional or behavioral
problems?
TR52H b Placement in a special classroom in a regular school for students with
emotional or behavioral problems?
TR52Hc Special testing in school for emotional or behavioral problems?
TR52Hd Other counseling or therapy in school for emotional or behavioral problems?
DK/REF
1
2
1
2
1
1
2
2
DEFINE TR53_ASK (PERFORM EACH TIME MOVE TO TR53)
IF (TR12 = DK, REF, OR MISSING) AND (TR19 = DK, REF, OR MISSING) AND (TR24 = DK,
REF, OR MISSING) AND (TR29 = DK, REF, OR MISSING) AND (TR34 = DK, REF, OR
MISSING); SET TR53_ASK = 1
ELSE, SET TR53_ASK = 0
TR53
[TR53_ASK = 1] Was there ever a time in the past 12 months when you felt that you might
need professional help with your emotions, behavior, or mental health?
1
Yes
2
No
DK/REF
Version 4 – February 2017 (Post IRB Approval)
94
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
95
17a.
Trait Fear
BEGIN TIME STAMP
PROGRAMMER: RANDOMIZE RESPONDENT TO RECEIVE EITHER MODULE 16a (TRAIT
FEAR) OR MODULE 16b (DISINHIBITION) OR MODULE 16c (PERSONALITY) OR MODULE
16d (Affective Reactive Index).
TF_INTRO
TF1
TF2
TF3
TF4
TF5
TF6
TF7
TF8
TF9
TF10
TF11
TF12
TF13
TF14
TF15
TF16
TF17
The next section contains statements that different people might use to describe
themselves. Each statement is followed by four choices: True, Somewhat True,
Somewhat False, and False. For each statement, select the choice that describes you
best. There are no right or wrong answers.
You tend to be unsure of yourself in
tough situations.
You like doing physically dangerous
things.
You’re always willing to rush in where
others fear to tread.
You are afraid of a lot of things.
You find it frightening to be in a strange
new place on your own.
You have a great deal of courage.
You stay calm, cool, and collected in
scary situations.
You don’t like walking into new
situations, even when there’s nothing to
fear.
You are very easily frightened.
You gladly do things you’ve never done
before, even if they might be dangerous.
You sometimes shy away from crowds of
people.
You are fearless.
Major tasks or challenges can seem
overwhelming to you.
You’re afraid of far fewer things than
most people.
It does not disturb you when you have to
do something novel and unfamiliar.
You stay away from physical danger as
much as you can.
You are never as afraid as most other
people.
Version 4 – February 2017 (Post IRB Approval)
True
Somewhat
True
Somewhat
False
False
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
96
TF18
TF19
TF20
It bothers you to be in new situations
where things are uncertain.
In challenging situations, you love to be
in the “driver’s seat.”
You enjoy doing new things that other
people are afraid to do.
True
Somewhat
True
Somewhat
False
False
1
2
3
4
1
2
3
4
1
2
3
4
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
97
17b.
Disinhibition
BEGIN TIME STAMP
PROGRAMMER: RANDOMIZE RESPONDENT TO RECEIVE EITHER MODULE 16a (TRAIT
FEAR) OR MODULE 16b (DISINHIBITION) OR MODULE 16c (PERSONALITY) OR MODULE
16d (Affective Reactive Index).
DIS1
DIS1a
DIS1b
DIS1c
DIS1d
DIS1e
DIS1f
DIS1g
DIS1h
DIS1i
DIS1j
DIS1k
DIS1l
DIS1m
DIS1n
The following section contains statements that different people might use to describe
themselves. Each statement is followed by four choices: True, Somewhat True,
Somewhat False, and False. For each statement, select the choice that describes you
best. There are no right or wrong answers.
You often act on immediate
needs.
You’ve often missed things
you promised to attend.
Your impulsive decisions
have caused problems with
loved ones.
You have missed work
without bothering to call in.
You jump into things without
thinking.
You’ve gotten in trouble
because you missed too much
school.
You have good control over
yourself.
You have taken money from
someone’s purse or wallet
without asking.
People often abuse your trust.
You keep appointments you
make.
You often get bored quickly
and lose interest.
You have conned people to
get money from them.
You get in trouble for not
considering the consequences
of your actions.
You have taken items from a
store without paying for them.
Version 4 – February 2017 (Post IRB Approval)
True
Somewhat
True
Somewhat
False
False
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
98
DIS1o
DIS1p
DIS1q
DIS1r
DIS1s
DIS1t
You have a hard time waiting
patiently for things you want.
You have lost a friend
because of irresponsible
things you’ve done.
Others have told you they are
concerned about your lack of
self-control.
You have robbed someone.
You have had problems at
work because you were
irresponsible.
You have stolen something
out of a vehicle.
True
Somewhat
True
Somewhat
False
False
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
99
17c.
Personality
BEGIN TIME STAMP
PROGRAMMER: RANDOMIZE RESPONDENT TO RECEIVE EITHER MODULE 16a (TRAIT
FEAR) OR MODULE 16b (DISINHIBITION) OR MODULE 16c (PERSONALITY) OR MODULE
16d (Affective Reactive Index).
PERINTRO This is a list of things different people might say about themselves. We are interested in
how you would describe yourself. Please select the response that best describes you.
PER1
PER2
PER3
PER4
PER5
PER6
PER7
PER8
PER9
PER10
PER11
PER12
PER13
PER14
People would describe you
as reckless.
You feel like you act
totally on impulse.
Even though you know
better, you can’t stop
making rash decisions.
You often feel like nothing
you do really matters.
Others see you as
irresponsible.
You’re not good at
planning ahead.
Your thoughts often don’t
make sense to others.
You worry about almost
everything.
You get emotional easily,
often for very little reason.
You fear being alone in
life more than anything
else.
You get stuck on one way
of doing things, even when
it’s clear it won’t work.
You have seen things that
weren’t really there.
You steer clear of romantic
relationships.
You’re not interested in
making friends.
Version 4 – February 2017 (Post IRB Approval)
Very False
or Often
False
Sometimes
or
Somewhat
False
Sometimes
or
Somewhat
True
Very True
or Often
True
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
100
PER15 You get irritated easily by
all sorts of things.
PER16 You don’t like to get too
close to people.
PER17 It’s no big deal if you hurt
other people’s feelings.
PER18 You rarely get enthusiastic
about anything.
PER19 You crave attention.
PER20 You often have to deal
with people who are less
important than you are.
PER21 You often have thoughts
that make sense to you but
that other people say are
strange.
PER22 You use people to get what
you want.
PER23 You often “zone out” and
then suddenly come to and
realize that a lot of time
has passed.
PER24 Things around you often
feel unreal or more real
than usual.
PER25 It is easy for you to take
advantage of others.
DK/REF
Very False
or Often
False
Sometimes
or
Somewhat
False
Sometimes
or
Somewhat
True
Very True
or Often
True
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
101
17d.
Affective Reactivivity Index
BEGIN TIME STAMP
PROGRAMMER: RANDOMIZE RESPONDENT TO RECEIVE EITHER MODULE 16a (TRAIT
FEAR) OR MODULE 16b (DISINHIBITION) OR MODULE 16c (PERSONALITY) OR MODULE
16d (Affective Reactive Index).
INTRO
The questions below ask about feeling irritated or easily annoyed or feeling angry or
losing your temper. These questions are about how often you have been bothered by the
feelings listed below during the past 7 days.
In the last seven days and compared to others of the same age, how well does each of
the following statements describe your behavior or feelings?
AR1
AR2
AR3
AR4
AR5
AR6
AR7
DK/REF
Am easily annoyed by others.
Often lose my temper.
Stay angry for a long time.
Am angry most of the time.
Get angry frequently.
Lose temper easily.
Overall irritability causes me problems.
Not True
0
0
0
0
0
0
0
Somewhat
True
1
1
1
1
1
1
1
Certainly
True
2
2
2
2
2
2
2
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
102
18.
BPD Screen
BEGIN TIME STAMP
BPD
The next items are about your emotions and behaviors.
Yes
No
BPD1
Have any of your closest relationships been troubled by a lot
of arguments or repeated breakups?
1
2
BPD2a
Have you deliberately hurt yourself physically? For example,
have you ever punched yourself, cut yourself, or burned
yourself?
1
2
BPD2b
[IF SD19 NE 1] Have you ever attempted suicide?
1
2
BPD3
Have you had at least two problems with doing things
suddenly or unexpectedly without giving thought to what
might happen? For example, have you had problems with
eating binges, spending sprees, drinking too much, or verbal
outbursts?
1
2
BPD4
Have you been extremely moody?
1
2
BPD5a
Have you felt very angry a lot of the time?
1
2
BPD5b
Have you often acted in an angry or sarcastic manner?
1
2
BPD6
Have you often been distrustful of other people?
1
2
BPD7
Have you frequently felt unreal or as if things around you
were unreal?
1
2
BPD8
Have you often felt empty inside?
1
2
BPD9
Have you often felt that you had no idea of who you are or
that you have no identity?
1
2
BPD10
Have you made desperate efforts to avoid feeling abandoned
or being abandoned? For example, have you repeatedly called
someone to reassure yourself that he or she still cared, begged
them not to leave you, or clung to them physically?
1
2
DK/REF
BPD_COUNT
SET BPD_COUNT=0
IF BPD1=1, THEN ADD 1 TO BPD_COUNT.
IF BPD2A=1 OR BPD2B =1, THEN ADD 1 TO BPD_COUNT.
IF BPD3=1, THEN ADD 1 TO BPD_COUNT.
IF BPD4=1, THEN ADD 1 TO BPD_COUNT.
IF BPD5A=1 OR BPD5B =1, THEN ADD 1 TO BPD_COUNT.
IF BPD6=1, THEN ADD 1 TO BPD_COUNT.
IF BPD7=1, THEN ADD 1 TO BPD_COUNT.
IF BPD8=1, THEN ADD 1 TO BPD_COUNT.
IF BPD9=1, THEN ADD 1 TO BPD_COUNT.
IF BPD10=1, THEN ADD 1 TO BPD_COUNT.
Version 4 – February 2017 (Post IRB Approval)
103
DEFINE BPD_P
IF BPD_COUNT>=7, THEN SET BPD_P=1.
ELSE SET BPD_P=0.
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
104
19.
Attention and Concentration (ADHD)
BEGIN TIME STAMP
[IF SC13 = 1] Earlier in the interview you mentioned having a time lasting 6 months or
longer when you had a lot more trouble than most people with concentration or attention.
The next questions are about that time.
C1
How often did you have the following problems during that 6 month period?
Very
Often
Problems keeping your mind on what
you were doing if things were going on
nearby
People saying that you did not seem to
be listening or that you were
“daydreaming” when they spoke to you
Problems finishing chores, work, or
homework even when you meant to get
them done
Quickly losing interest in games you
were playing or in work you were doing
at home or at school
Making careless mistakes on your
homework or assignments
C1a
C1b
C1c
C1d
C1e
Often Sometimes Rarely Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DK/REF
DEFINE C1_FIRSTCOUNT
SET C1_FIRSTCOUNT = 0
IF C1A = (1 OR 2 OR 3), ADD 1 TO C1_FIRSTCOUNT
IF C1B = (1 OR 2 OR 3), ADD 1 TO C1_FIRSTCOUNT
IF C1C = (1 OR 2 OR 3), ADD 1 TO C1_FIRSTCOUNT
IF C1D = (1 OR 2 OR 3), ADD 1 TO C1_FIRSTCOUNT
IF C1E = (1 OR 2 OR 3), ADD 1 TO C1_FIRSTCOUNT
C1.1
How often did you have the following problems during that 6 month period?
Very
Often
C1f
C1g
Avoiding or delaying getting started on
things that required a lot of thought
Problems remembering what you were
supposed to be doing or had planned to
do
Version 4 – February 2017 (Post IRB Approval)
Often Sometimes Rarely Never
1
2
3
4
5
1
2
3
4
5
105
Very
Often
C1h
C1i
Problems getting things in order when
you had to do a project that required
organization
Problems losing things like homework
or personal belongings
Often Sometimes Rarely Never
1
2
3
4
5
1
2
3
4
5
DK/REF
DEFINE C1_SECONDCOUNT
SET C1_SECONDCOUNT = 0
IF C1F = (1 OR 2 OR 3), ADD 1 TO C1_SECONDCOUNT
IF C1G = (1 OR 2 OR 3), ADD 1 TO C1_SECONDCOUNT
IF C1H = (1 OR 2 OR 3), ADD 1 TO C1_SECONDCOUNT
IF C1I = (1 OR 2 OR 3), ADD 1 TO C1_SECONDCOUNT
DEFINE C1_ALLCOUNT
C1_ALLCOUNT = 0
C1_ALLCOUNT = C1_FIRSTCOUNT + C1_SECONDCOUNT
C2
C2a
C2b
C2c
C2d
[C1_ALLCOUNT ≥ 6] How often did these concentration and attention problems ever cause
you problems…
at school?
at home?
at work?
in your personal relationships or
social life?
Very
Often
1
1
1
1
Often Sometimes Rarely Never
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
DK/REF
C2_5
[IF C1_ALLCOUNT ≥ 6] About how old were you the very first time you had problems with
attention or concentration? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
C2_6
[IF C1_ALLCOUNT ≥ 6] About how many years in your life have you had problems with
attention or concentration? Your best estimate is fine if you cannot remember the exact
number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
106
C2_7 [IF C1_ALLCOUNT ≥ 6 AND C2_5 < 12] About how many months in the past 12 months did
you have problems with attention or concentration? Your best estimate is fine if you cannot
remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
C2_8
[C2_6 ≥ 1] Did you have these problems at any time in the past 30 days?
1
Yes
2
No
DK/REF
C2_9
[C2_7 = 0 or C2_7 = DK/REF] About how old were you the most recent time you had
problems with attention or concentration? Your best estimate is fine if you cannot remember
your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
C3
C3a
C3b
C3c
C3d
C3e
DK/REF
[IF SC13A = 1] Earlier in the interview you mentioned having a time lasting 6 months or
longer when you had a lot more trouble than most people with being very restless, fidgety, or
impatient. How often did you have the following problems during that 6 month period?
Feeling overly active and compelled to
move or do things, like you were driven
by a motor
Fidgeting or squirming with your hands
or feet when you had to sit down for a
long time
Trouble stopping yourself from doing
things like getting out of your seat at
school or at dinnertime
Blurting out answers to other people’s
questions before they finish
Difficulty doing quiet activities
Very
Often
Often Sometimes Rarely Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE C3_FIRSTCOUNT
SET C3_FIRSTCOUNT = 0
IF C3A = (1 OR 2 OR 3), ADD 1 TO C3_FIRSTCOUNT
IF C3B = (1 OR 2 OR 3), ADD 1 TO C3_FIRSTCOUNT
IF C3C = (1 OR 2 OR 3), ADD 1 TO C3_FIRSTCOUNT
IF C3D = (1 OR 2 OR 3), ADD 1 TO C3_FIRSTCOUNT
IF C3E = (1 OR 2 OR 3), ADD 1 TO C3_FIRSTCOUNT
Version 4 – February 2017 (Post IRB Approval)
107
How often did you have the following problems during that 6 month period?
C3.1
Difficulty waiting to take your turn
Being very active even when you were
not supposed to be — for example,
climbing on things or running around —
even after being asked to keep still
Interrupting people or joining other
people’s conversations without being
asked to do so
Talking a lot more than other people your
age
C3f
C3g
C3h
C3i
Very
Often
1
Often Sometimes Rarely Never
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DK/REF
DEFINE C3_SECONDCOUNT
SET C3_SECONDCOUNT = 0
IF C3f = (1 OR 2 OR 3), ADD 1 TO C3_SECONDCOUNT
IF C3g = (1 OR 2 OR 3), ADD 1 TO C3_SECONDCOUNT
IF C3h = (1 OR 2 OR 3), ADD 1 TO C3_SECONDCOUNT
IF C3i = (1 OR 2 OR 3), ADD 1 TO C3_SECONDCOUNT
DEFINE C3_ALLCOUNT
C3_ALLCOUNT = 0
C3_ALLCOUNT = C3_FIRSTCOUNT + C3_SECONDCOUNT
[IF C3_ALLCOUNT ≥ 6] How often did your feelings of restlessness or impatience ever
cause you problems…
C4
at school or work?
at home?
in your personal relationships or
social life?
C4a
C4b
C4d
Very
Often
1
1
1
Often Sometimes Rarely Never
2
3
4
5
2
3
4
5
2
3
4
5
DK/REF
C5
[IF C3_ALLCOUNT ≥ 6] About how old were you the very first time you had problems with
restlessness or impatience? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
108
C6
[IF C3_ALLCOUNT ≥ 6] About how many years in your life have you had problems with
restlessness or impatience? Your best estimate is fine if you cannot remember the exact
number.
______ NUMBER OF YEARS [RANGE: 1– CURNTAGE]
DK/REF
C7
[IF C3_ALLCOUNT ≥ 6 AND C5 < 12] About how many months in the past 12 months did
you have problems with restlessness or impatience? Your best estimate is fine if you cannot
remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
C8
[C6 ≥ 1] Did you have these problems at any time in the past 30 days?
1
Yes
2
No
DK/REF
C9
[C = 7 or C7 = DK/REF] About how old were you the most recent time you had problems
with restlessness or impatience? Your best estimate is fine if you cannot remember your exact
age.
_____ YEARS OLD [RANGE: 0– CURNTAGE]
DK/REF
END TIMESTAMP
Version 4 – February 2017 (Post IRB Approval)
109
20.
Oppositional-Defiant Disorder
BEGIN TIME STAMP
D1
[SC14 = 1] Earlier in the interview you mentioned having a time lasting six months or
longer when you often did things that got you in trouble with adults. The next questions are
about that time.
How often during that time did you…
D1a
D1b
D1c
D1d
D1e
D1f
D1g
D1h
D1i
D1j
lose your temper?
argue with or “talk back” to adults?
disobey rules at home, school, or work?
get angry?
refuse to follow directions from adults
like your parents, teachers, or boss?
annoy people on purpose by doing or
saying things just to bother them?
feel you were being taken advantage of
or treated unfairly?
easily get mad at the way people treated
you?
blame others for your mistakes or bad
behavior?
do mean things to “pay people back” for
things they did that you didn’t like?
DK/REF
Very
Often
1
1
1
1
Often Sometimes Rarely Never
2
3
4
5
2
3
4
5
2
3
4
5
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE D1 FILL
IF D1a = 1 OR 2 OR 3, THEN FILL “lost your temper”
IF D1b = 1 OR 2 OR 3, THEN FILL “argued or “talked back” to adults”
IF D1c OR D1e = 1 OR 2 OR 3, THEN FILL “disobeyed rules at home, school, or work”
IF D1d or D1g = 1 OR 2 OR 3, THEN FILL “were often angry or resentful”
IF D1f = 1 OR 2 OR 3, THEN FILL “annoyed people on purpose by doing or saying things just to
bother them”
IF D1h = 1 OR 2 OR 3, THEN FILL “easily got mad at the way people treated you”
IF D1i = 1 OR 2 OR 3, THEN FILL “blamed others for your mistakes or bad behavior”
IF D1j = 1 OR 2 OR 3, THEN FILL “did mean things to “pay people back” for things they did that
you didn’t like”
DEFINE D1_COUNT
SET D1_COUNT = 0
IF D1a = (1 OR 2 OR 3), ADD 1 TO D1_COUNT
IF D1b = (1 OR 2 OR 3), ADD 1 TO D1_COUNT
Version 4 – February 2017 (Post IRB Approval)
110
IF D1c = (1 OR 2 OR 3), ADD 1 TO D1_COUNT
IF D1d = (1 OR 2 OR 3), ADD 1 TO D1_COUNT
IF D1e = (1 OR 2 OR 3), ADD 1 TO D1_COUNT
IF D1f = (1 OR 2 OR 3), ADD 1 TO D1_COUNT
IF D1g = (1 OR 2 OR 3), ADD 1 TO D1_COUNT
IF D1h = (1 OR 2 OR 3), ADD 1 TO D1_COUNT
IF D1i = (1 OR 2 OR 3), ADD 1 TO D1_COUNT
IF D1j = (1 OR 2 OR 3), ADD 1 TO D1_COUNT
D2
[[IF D1_COUNT ≥ 4] You reported that you had a six month period of time or longer when
you…
[D1 FILL AS BULLETED LIST]
About how old were you the very first time when you had six months or longer of feeling or
acting like this? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
D3
[IF D2 NE BLANK] How much did these behaviors cause problems with your school, work,
or relationships with family or friends?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
D4
[IF D2 NE BLANK] About how many months in the past 12 months did you feel or act like
this? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
D5
[IF D4 NE 0] Did you feel or act like this in the past 30 days?
1
Yes
2
No
DK/REF
D6
[IF D4 = 0 OR DK OR REF] About how old were you the most recent time you felt or acted
like this? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
111
END TIMESTAMP
Version 4 – February 2017 (Post IRB Approval)
112
21.
Conduct Disorder
BEGIN TIMESTAMP
CD1
CD1a
CD1b
CD1c
CD1d
CD1e
CD1f
CD1g
[IF SC15, 15a, or 15b = 1] You mentioned earlier that you had a time in your life when you
did things adults don’t want young people to do. The next questions are about that time in
your life. How often did you do the following things?
Bully or threaten other kids.
Get into fights.
Hurt or threaten someone with a weapon
like a bat, brick, broken bottle, knife, or
gun.
Deliberately cause someone physical
pain and suffering.
Hurt animals on purpose.
Rob, mug, or forcibly take something
from someone by threatening him or
her.
Force someone to have sex with you, to
get undressed, or to touch you sexually.
Very
Often
1
1
Often Sometimes Rarely Never
2
3
4
5
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DK/REF
DEFINE CD1_COUNT
SET CD1_COUNT = 0
IF CD1A = (1 OR 2 OR 3), ADD 1 TO CD1_COUNT
IF CD1B = (1 OR 2 OR 3), ADD 1 TO CD1_COUNT
IF CD1C = (1 OR 2 OR 3), ADD 1 TO CD1_COUNT
IF CD1D = (1 OR 2 OR 3), ADD 1 TO CD1_COUNT
IF CD1E = (1 OR 2 OR 3 OR 4), ADD 1 TO CD1_COUNT
IF CD1F = (1 OR 2 OR 3 OR 4), ADD 1 TO CD1_COUNT
\
IF CD1G = (1 OR 2 OR 3 OR 4), ADD 1 TO CD1_COUNT
CD1_1 [IF CD1_COUNT < 3] During that time in your life, how often did you do each of the
following things?
CD1_1a Set fires.
CD1_1b Deliberately destroy things that weren’t
yours.
CD1_1c Break into houses, other buildings, or
cars.
Version 4 – February 2017 (Post IRB Approval)
Very
Often
1
Often Sometimes Rarely Never
2
3
4
5
1
2
3
4
5
1
2
3
4
5
113
Very
Often
CD1_1d Lie to get what you wanted from
someone or to avoid doing something.
CD1_1e Steal or shoplift things or forge a
signature.
CD1_1f Run away from home and stay away
overnight.
CD1_1g Stay out very late, long after you were
supposed to be home.
CD1_1h Skip school.
DK/REF
CD1_1ga
Often Sometimes Rarely Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
[IF CD1_1g = 1 OR 2 OR 3] How old were you the first time you stayed out very late,
long after you were supposed to be home?
__________ YEARS OLD [RANGE: 0 – CURNTAGE]
DK/REF
CD1_1ha
[IF CD1_1h = 1 OR 2 OR 3] How old were you the first time you skipped school?
___________ YEARS OLD [RANGE: 0 – CURNTAGE]
DK/REF
DEFINE CD1_1COUNT
SET CD1_1COUNT = 0
IF CD1_1A = (1 OR 2 OR 3), ADD 1 TO CD1_1COUNT
IF CD1_1B = (1 OR 2 OR 3), ADD 1 TO CD1_1COUNT
IF CD1_1C = (1 OR 2 OR 3), ADD 1 TO CD1_1COUNT
IF CD1_1D = (1 OR 2 OR 3), ADD 1 TO CD1_1COUNT
IF CD1_1E = (1 OR 2 OR 3 OR 4), ADD 1 TO CD1_1COUNT
IF CD1_1F = (1 OR 2 OR 3), ADD 1 TO CD1_1COUNT
IF CD1_1Ga < 13ADD 1 TO CD1_1COUNT
IF CD1_1Ha < 13, ADD 1 TO CD1_1COUNT
DEFINE CD2_FILL_LIST
PROGRAMMER: SHOW APPLICABLE FILLS IN A BULLETED LIST
IF CD1a = (1 OR 2 OR 3), THEN INCLUDE: “bullied or threatened other kids”
IF CD1b = (1 OR 2 OR 3), THEN INCLUDE: “got into fights”
IF CD1c = (1 OR 2 OR 3), THEN INCLUDE: “hurt or threatened someone with a weapon like a
bat, brick, broken bottle, knife, or gun”
Version 4 – February 2017 (Post IRB Approval)
114
IF CD1d = (1 OR 2 OR 3), THEN INCLUDE: “deliberately caused someone physical pain and
suffering”
IF CD1e = (1 OR 2 OR 3 OR 4), THEN INCLUDE: “hurt animals on purpose”
IF CD1f = (1 OR 2 OR 3 OR 4), THEN INCLUDE: “robbed, mugged, or forcibly took something
from someone by threatening him or her”
IF CD1g = (1 OR 2 OR 3 OR 4), THEN INCLUDE: “forced someone to have sex with you, to get
undressed, or to touch you sexually”
IF CD1_1a = (1 OR 2 OR 3), THEN INCLUDE: “set fires”
IF CD1_1b = (1 OR 2 OR 3), THEN INCLUDE: “deliberately destroyed things that weren’t
yours”
IF CD1_1c = (1 OR 2 OR 3), THEN INCLUDE: “broke into houses, other buildings, or cars”
IF CD1_1d = (1 OR 2 OR 3), THEN INCLUDE: “lied to get what you wanted from someone or to
avoid doing something”
IF CD1_1e = (1 OR 2 OR 3 OR 4), THEN INCLUDE”: “stole or shoplifted things or forged a
signature”
IF CD1_1f = (1 OR 2 OR 3 OR 4), THEN INCLUDE: “ran away from home and stayed away
overnight”
IF CD1_1g = (1 OR 2 OR 3), THEN INCLUDE: “stayed out very late, long after you were
supposed to be home”
IF CD1_1h = (1 OR 2 OR 3 OR 4), THEN INCLUDE: “skipped school”
CD2
[IF (CD1_COUNT ≥ 3) OR (CD1_1COUNT ≥ 3)] You reported that you…
[CD2_FILL_LIST]
About how old were you the very first time you did any of these things? Your best estimate is
fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
CD3
[IF (CD1_COUNT ≥ 3) OR (CD1_1COUNT ≥ 3)] How much did these behaviors cause
problems with your school, work, or your relationships with family or friends?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
CD4
[IF (CD1_COUNT ≥ 3) OR (CD1_1COUNT ≥ 3)] About how many months in the past 12
months did you do these behaviors? Your best estimate is fine if you cannot remember the
exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
115
CD4_1 [IF CD4 ≥ 1] Did you do any of these behaviors in the past 6 months?
1
Yes
2
No
DK/REF
CD5
[IF CD4 = 0] About how old were you the most recent time you did behaviors like these that
got you in trouble with adults? Your best estimate is fine if you cannot remember your exact
age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIMESTAMP
Version 4 – February 2017 (Post IRB Approval)
116
22.
Separation Anxiety Disorder
BEGIN TIME STAMP
SA1
[If SC12 = 1] Earlier you reported you had a time in your life when you had a lot of anxiety
about separation from someone important in your life or someone who takes care of you.
Press [ENTER] to continue.
SA2
SA2a
SA2b
SA2c
SA2d
SA2e
SA2f
[If SC12 = 1] Think of a month in your life when you had the most intense anxiety about
separation. How often during that month did you…
stay home or not go out in order
to stay close to this person?
refuse to go places without this
person because doing so upset
you so much?
plead with this person to stay
home or to take you with them if
they had to go out even for a
short time?
have trouble sleeping unless this
person was nearby?
have nightmares about this
person being harmed or about
being separated from you?
feel sick to your stomach or get
headaches when this person
went away?
All or
Almost
All the
Time
Most of
the
Time
Some of
the
Time
A Little
of the
Time
None of
the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DK/REF
DEFINE SA2_COUNT
SET SA2_COUNT = 0
IF SA2A = (1 OR 2 OR 3), ADD 1 TO SA2_COUNT
IF SA2B = (1 OR 2 OR 3), ADD 1 TO SA2_COUNT
IF SA2C = (1 OR 2 OR 3), ADD 1 TO SA2_COUNT
IF SA2D = (1 OR 2 OR 3), ADD 1 TO SA2_COUNT
IF SA2E = (1 OR 2 OR 3), ADD 1 TO SA2_COUNT
Version 4 – February 2017 (Post IRB Approval)
117
[IF SA2_COUNT < 3] get very
sad, worried, or upset when you
had to be apart from this person?
[IF SA2_COUNT < 3] fear that
this person might be seriously
injured in an accident or that
some other terrible thing might
have happened to them?
[IF SA2_COUNT < 3] worry
that this person might leave
you?
[IF SA2_COUNT < 3] worry
that something bad might
happen to you like getting lost
or kidnapped that might separate
you from this person?
[IF SA2_COUNT < 3] worry
that something might happen to
prevent you from seeing them
ever again, like having an
accident or becoming ill?
SA2g
SA2h
SA2i
SA2j
SA2k
All or
Almost
All the
Time
Most of
the
Time
Some of
the
Time
A Little
of the
Time
None of
the
Time
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DK/REF
SA2l. [If SC12 = 1] How severe was your distress about separation during that month?
1
2
3
4
Mild
Moderate
Severe
Very severe
DK/REF
DEFINE SA_ALL
SET SA_ALL = 0
IF SA2a = (1 OR 2 OR 3), ADD 1 TO SA_ALL
IF SA2b OR SA2g = (1 OR 2 OR 3), ADD 1 TO SA_ALL
IF SA2c = (1 OR 2 OR 3), ADD 1 TO SA_ALL
IF SA2d = (1 OR 2 OR 3), ADD 1 TO SA_ALL
IF SA2e = (1 OR 2 OR 3), ADD 1 TO SA_ALL
IF SA2f = (1 OR 2 OR 3), ADD 1 TO SA_ALL
IF SA2h OR SA2i = (1 OR 2 OR 3), ADD 1 TO SA_ALL
Version 4 – February 2017 (Post IRB Approval)
118
IF SA2j or SA2k = (1 OR 2 OR 3), ADD 1 TO SA_ALL
SA3
[IF SA_ALL ≥ 3] How much did this anxiety about separation ever interfere with your
school, work, or personal life?
1
Extremely
2
A lot
3
Some
4
A little
5
Not at all
DK/REF
SA4
[IF SA_ALL ≥ 3] About how old were you the very first time you started having this kind of
anxiety? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
SA5
[IF SA4 = (CURNTAGE – 1)] Did your anxiety about separation start in the past 12 months
or more than 12 months ago?
1
In the past 12 months
2
More than 12 months ago
DK/REF
SA6
[IF SA4 NE CURNTAGE OR (CURNTAGE – 1)] About how many years in your life did
you have problems with anxiety about separation? Your best estimate is fine if you cannot
remember the exact number.
______ NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
SA7
[IF SA_ALL ≥ 3] How many months in the past 12 months did you have problems with
separation anxiety? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
SA8
[IF SA7 = 1–11] How recently did you have that anxiety — in the past 30 days or more than
30-days ago?
1
In the past 30 days
2
More than 30 days ago
DK/REF
Version 4 – February 2017 (Post IRB Approval)
119
SA9
[IF SA7 = 0 OR DK OR REF AND SA4 ≥ CURNTAGE – 2)] About how old were you the
most recent time you had problems with anxiety about separation? Your best estimate is fine
if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
END TIMESTAMP
Version 4 – February 2017 (Post IRB Approval)
120
23.
Juvenile Justice and Detention
BEGIN TIME STAMP
JJ01
Next, we’ll ask about encounters with the police or the court system.
Not counting minor traffic violations, have you ever been arrested and booked for breaking
a law?
1 Yes
2 No
DK/REF
JJ02
[IF JJ01 = 1] Not counting minor traffic violations, how many times have you been arrested
and booked for breaking a law?
__________ TIMES [RANGE: 1–100]
DK/REF
JJ03
[IF JJ01 = 1] Not counting minor traffic violations, how many times during the past 12
months have you been arrested and booked for breaking a law?
__________ TIMES [RANGE: 1–100]
DK/REF
JJ04
[IF JJ01 = 1] Have you ever been arrested for a property crime, such as theft or burglary?
1 Yes
2 No
DK/REF
JJ05
[IF JJ01 = 1] Have you ever been arrested for a violent crime, such as assault or armed
robbery?
1 Yes
2 No
DK/REF
JJ06
[IF JJ01 = 1] Have you ever been arrested for an age-based crime, such as skipping school,
using tobacco or alcohol, breaking curfew, or running away?
1 Yes
2 No
DK/REF
JJ07
[IF JJ01 = 1] How old were you the first time you were arrested?
__________ YEARS OLD [RANGE: 0–CURNTAGE]
Version 4 – February 2017 (Post IRB Approval)
121
DK/REF
JJ08
[IF JJ01 = 1] Have you ever been in jail, a detention center, or any other juvenile justice or
adult criminal justice facility?
1 Yes
2 No
DK/REF
JJ09a
[IF JJ08 = 1] This question asks about the amount of time you spent in jail, a detention
center, or any other juvenile justice or adult criminal justice facility. What would be the
easiest way for you to give your answer?
1 Total number of days
2 Total number of weeks
3 Total number of months
4 Total number of years
DK/REF
DEFINE JJ09a_FILL
IF JJ09a = 1 OR DK OR REF THEN JJ09a_FILL = total number of days
IF JJ09a = 2 THEN JJ09a_FILL = total number of weeks
IF JJ09a = 3 THEN JJ09a_FILL = total number of months
IF JJ09a = 4 THEN JJ09a_FILL = total number of years
JJ09
[IF JJ08 = 1] What is the [JJ09a_FILL] you were you in jail, a detention center, or any other
juvenile justice or adult criminal justice facility?
____________ DURATION NUMBER [RANGE: 0–1000]
DK/REF
JJ10
[IF JJ08 = 1] How old were you the first time you were sent to jail, a detention center, or
any other juvenile justice or adult criminal justice facility?
_____________ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
JJ11
[IF JJ08 = 1] Have you been in jail, a detention center, or any other juvenile justice or adult
criminal justice facility during the past 12 months?
1 Yes
2 No
DK/REF
JJ12
[IF JJ11 = 1] How long altogether were you in jail, a detention center, or any other juvenile
justice or adult criminal justice facility during the past 12 months?
Version 4 – February 2017 (Post IRB Approval)
122
1
2
3
4
5
6
JJ13
A week or less
More than a week but less than 1 month
At least 1 month but less than 3 months
At least 3 months but less than 6 months
At least 6 months but less than 9 months
More than 9 months
DK/REF
[IF JJ01 = 1] Were you on probation at any time during the past 12 months?
1 Yes
2 No
DK/REF
JJ14
[IF JJ01 = 1] Sometimes when people commit a crime that could cause them to go to jail or
prison, they are instead sentenced to a program that keeps them out of jail or prison. These
programs include:
Group homes
Mental health treatment programs
Substance abuse treatment programs
Home confinement or house arrest
Career training programs
Mentoring programs
During the past 12 months, were you required to participate in a program like the
examples listed above as an alternative to going to jail or prison?
1 Yes
2 No
DK/REF
JJ15
[IF JJ01 = 1] Were you on parole, supervised release, or other conditional release from
prison at any time during the past 12 months?
1 Yes
2 No
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
123
24.
Homelessness
BEGIN TIME STAMP
HOM1
Now we would like to know about whether you have ever been homeless. Have you
ever had a time in your life when you considered yourself homeless?
1
Yes
2
No
DK/REF
HOM2[IF HOM1 = 1] Were you homeless in the last 5 years?
1
Yes
2
No
DK/REF
HOM2a
[IF HOM2 = 1] Were you homeless in the past 12 months?
1
Yes
2
No
DK/REF
HOM345
HOM3
HOM4
HOM5
HOM6
[IF HOM2a= 1] While you were homeless, did you ever sleep in…
a shelter for homeless people or in another temporary residence because
you did not have a place to stay?
a park, in an abandoned building, in the street, or in a train or bus
station?
a friend’s or relative’s home because you were homeless?
DK/REF
Yes
No
1
2
1
2
1
2
[IF HOM1 = 1] Altogether, how much of your life have you been homeless—would
you say less than a week, more than a week but less than a month, more than a month
but less than a year, or more than a year?
1
Less than a week
2
More than a week but less than a month
3
More than a month but less than a year
4
More than a year
DK/REF
HOM7
[IF HOM2a = 1] Altogether, how much of the past 12 months have you been homeless?
1
2
Less than a week
At least a week but less than 1 month
Version 4 – February 2017 (Post IRB Approval)
124
3
At least 1 month but less than 3 months
4
At least 3 months but less than 6 months
5
At least 6 months but less than 9 months
6
9 months or more
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
125
25.
Head Injuries
BEGIN TIME STAMP
HINJ1
The next questions are about head or neck injuries that you had at any time in your life.
How many times in your life did you have a head or neck injury that…
Number of Times
[RANGE: 0 – 100]
HINJ1b
HINJ1c
HINJ1d
knocked you out, that is, you lost consciousness even if
only for a short time?
didn’t knock you out, but caused you to be dazed or
confused or to “see stars”?
caused you to have a lapse in memory of events, before,
during, or after the injury?
DK/REF
HINJ2
[IF HINJ1d ≥ 1] How many times in your life did you have a head or neck injury that
caused memory loss lasting…
Number of Times
[RANGE: 0 – 100]
HINJ2a
HINJ2b
HINJ2c
DK/REF
less than 30 minutes?
between 30 minutes and 24 hours?
more than 24 hours?
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
126
Eligibility for Part 2 Modules
Part 2 modules will be asked of all respondents who met CRS disorder threshold criteria for any
disorder plus a randomly chosen 25% of those who do not meet CRS threshold criteria for any
disorder. The random selection will take place once for each non-threshold respondent, not
separately for each Part 2 module. That is, a respondent is either administered all Part 2 modules or
receive none of the Part 2 modules.
DEFINE THRSHLD_PART2
IF ANY OF THE FOLLOWING ARE TRUE, THEN SET THRSHLD_PART2=1
Variable Values
DE5_ASK=1
HM5_ASK=1
AW5_ASK = 1
IF (SP5 = 1 OR
2 OR DK OR
REF)
AG4=1
L5_ASK=1
Disorder
Depression
Plain Language Description
Within the Depression module, the
respondent’s answers to the worst2-weeks symptoms qualified the
respondent to be asked age of onset
and other follow-up questions (DE5
onward).
Mania
Within Mania, answers qualified the
respondent to be asked age of onset
and other follow-up questions
(HM5 onward).
Generalized Within the Anxiety and Worry
Anxiety
module, the respondent’s answers
qualified him/her to be asked age of
onset and other follow-up questions
about anxiety episodes (AW5
onward).
Social
Within Social Anxiety, the
Anxiety
respondent’s answers qualified
him/her to be asked age of onset
and other follow-up questions (SP6
onward).
Agoraphobia Within the Agoraphobia module the
respondent’s answers qualified
him/her to be asked age of onset
and other follow-up questions in the
Agoraphobia module (AG5
onward).
Panic
Within the Panic Disorder module,
Disorder
the respondent’s answers qualified
him or her to be asked age of onset
and other follow-up questions about
the respondent’s attacks (L5
onward).
Version 4 – February 2017 (Post IRB Approval)
127
Variable Values
EA25=1
Disorder
Eating
Disorders
Plain Language Description
Within Eating Disorders, answers
qualified the respondent to be asked
age of onset for eating binges and
other follow-up questions (ED3
onward).
SD15=1
Suicidality
BPD_P=1
BPD Screen
Within Suicidality, answer qualified
the respondent to be asked age of
first occurance regarding suicidality
and other follow-up questions
(SD15a-SD29, as applicable)
Within the BPD Screen module, the
respondent gave 7 or more “yes”
answers to current equivalents of
the items that were in the original
10-point McLean Instrument for
BPD.
(C1_ALLCOUNT Attention
≥ 6)
Deficit
Disorder
OR
(ADHD)
Within Attention and
Concentration, answer qualified the
respondent to be asked age of first
occurance regarding either attention
or concentration (C2a) or
(C3_ALLCOUNT
restlessness or impatience (C5) and
≥ 6)
subsequent follow-up questions, as
applicable)
FOUR OR
Oppositional Within the Oppositional Defiant
MORE D1
Defiant
Disorder module, the respondent’s
SERIES = 1 OR Disorder
answers qualified him or her to be
2 OR 3
asked age of onset and other followup questions about the respondent’s
attacks (D2 onward).
(CD1_COUNT ≥ Conduct
Within the Conduct Disorder
3)
Disorder
module, the respondent’s answers
qualified him or her to be asked age
OR
of onset and other follow-up
questions about the respondent’s
(CD1_1COUNT
attacks (CD2 onward).
≥ 3)
Separation
Within the Sepration Anxiety
SA_ALL ≥ 3
Anxiety
module, the respondent’s answers
qualified him or her to be asked age
of onset and other follow-up
questions about the respondent’s
attacks (SA4 onward).
Version 4 – February 2017 (Post IRB Approval)
128
ELSE, SET THRSHLD_PART2=0.
DEFINE RAND25
RANDOMLY SET RAND25=1 WITH 25% PROBABILITY,
ELSE SET RAND25=0.
DEFINE PART2_SHOW
SET PART2_SHOW=0,
IF THRSHLD_PART2=1, RESET PART2_SHOW=1.
IF THRSHLD_PART2=0 AND RAND25=1, THEN PART2_SHOW=1.
Version 4 – February 2017 (Post IRB Approval)
129
26.
Stressful Experiences (Post-Traumatic Stress Disorder)
BEGIN TIME STAMP
ONLY SHOW THIS MODULE IF PART2_SHOW=1.
P1
The next questions are about highly stressful experiences that might have happened to you at
any time in your life. Have you ever had any of the following experiences?
You were threatened or attacked with a knife, gun, baseball bat, bomb, or other
weapon
P1b You were beaten up or physically assaulted
P1c You were sexually assaulted or raped
P1e You were kidnapped or held hostage
P1f You had a life-threatening illness or injury
P1g You were in a serious motor vehicle accident
P1h You had some other serious accident at home, school, work, or during
recreational activity
P1i You were in a life-threatening natural disaster, like a hurricane or earthquake
P1j You were in a life-threatening manmade disaster, like a fire, explosion, or toxic
chemical exposure
P1k You had some other experience that put you at serious risk of injury or death
P1l You witnessed a serious assault, murder, or suicide
P1m You witnessed a serious accidental injury or death
P1n You witnessed any other highly stressful situation where people were in pain,
suffering, dying, or dead
P1o You caused someone else to have serious suffering, injury, or death
P1p A close friend or relative experienced sudden violent death
P1q A close friend or relative experienced accidental death
P1r A close friend or relative had any other experience that put them at serious risk
of injury or death
DK/REF
P1a
Yes
No
1
2
1
1
1
1
1
2
2
2
2
2
1
2
1
2
1
2
1
1
1
2
2
2
1
2
1
1
1
2
2
2
1
2
DEFINE P2_FILL
IF P1a = 1 AND P1b NE 1 THEN P2_FILL = threatened or attacked with a weapon
IF P1a NE 1 and P1b = 1 THEN P2_FILL = beaten up
IF P1a = 1 AND P1b = 1 THEN P2_FILL = threatened or attacked with a weapon or beaten up
P2
[IF P1a = 1 OR P1b = 1] How many times in your life were you [P2_FILL]?
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
130
DEFINE P3_FILL
IF P2 = 1 THEN P3_FILL = when
ELSE P3_FILL = the first time
P3
[IF P2 NE 0 OR BLANK] How old were you [P3_FILL] you were [P2_FILL]?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P4
[IF P1c = 1] How many times in your life were you sexually assaulted or raped?
_____ NUMBER OF TIMES [RANGE: 0–100]
DK/REF
DEFINE P5_FILL
IF P4 = 1 THEN P5_FILL = when
ELSE P5_FILL = the first time
P5
[IF P4 NE 0 OR BLANK] How old were you [P5_FILL] you were sexually assaulted or raped?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P8
[IF P1e = 1] How old were you when you were first kidnapped?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P9a
[IF P1e = 1] Now think about the amount of time you were in captivity. Would it be easiest for
you to provide this time in the number of days, months, or years?
1
Number of days
2
Number of months
3
Number of years
DK/REF
DEFINE P9_FILL
IF P9a = 1 OR DK/REF THEN P9_FILL = days
IF P9a = 2 THEN P9_FILL = months
IF P9a = 3 THEN P9_FILL = years
P9b
[IF P1e = 1] How many [P9_FILL] were you in captivity?
_____ [P9_FILL] [RANGE: 0–999]
DK/REF
P10
[IF P1f = 1] How many times in your life have you had a life-threatening illness or injury?
Version 4 – February 2017 (Post IRB Approval)
131
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
DEFINE P11_FILL
IF P10 = 1 THEN P11_FILL = when
ELSE P11_FILL = the first time
P11
[IF P10 NE 0 OR BLANK] How old were you [P11_FILL] you had a life-threatening illness or
injury?
____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE P12_FILL
IF P1g = 1 OR P1h = 1 THEN P12_FILL = serious accident
IF P1i = 1 OR P1j = 1 THEN P12_FILL = life-threatening natural or manmade disaster
IF (P1g = 1 OR P1h = 1) AND (P1i = 1 OR P1j = 1) THEN P12_FILL = serious accident or lifethreatening natural or manmade disaster
P12
[IF P1g = 1 OR P1h = 1 OR P1i = 1 OR P1j = 1] How many times in your life have you been
in a [P12_FILL]?
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
DEFINE P13_FILL
IF P12 = 1 THEN P13_FILL = when
ELSE P13_FILL = the first time
P13
[IF P12 NE 0 OR BLANK] How old were you [P13_FILL] you were in a [P12_FILL]?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE P14_FILL
IF P1a = 1 OR P1b = 1 OR P1c = 1 OR P1d = 1 OR P1e = 1 OR P1f = 1 OR P1g = 1 OR P1h = 1 OR
P1i = 1 OR P1j = 1 THEN P14_FILL = any other
ELSE P14_FILL = an
P14
[IF P1k = 1] How many times in your life have you had [P14_FILL] experience that put you at
serious risk of injury or death?
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
DEFINE P15_FILL
IF P14 = 1 THEN P15_FILL = when
ELSE P15_FILL = the first time
Version 4 – February 2017 (Post IRB Approval)
132
P15
[IF P14 NE 0 OR BLANK] How old were you [P15_FILL] you had [P14_FILL] experience
that put you at serious risk of injury or death?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P16
[IF P1l = 1 OR P1m = 1 OR P1n = 1] How many times in your life have you witnessed a
serious assault, injury, death, or other highly stressful experience?
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
DEFINE P17_FILL
IF P16 = 1 THEN P17_FILL = when
ELSE P17_FILL = the first time
P17
[IF P16 NE 0 OR BLANK] How old were you [P17_FILL] you witnessed a serious assault,
injury, death, or other highly stressful experience?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P18
[IF P1o = 1] How many times in your life have you done something that caused serious injury,
death, or suffering to someone else?
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
DEFINE P19_FILL
IF P18 = 1 THEN P19_FILL = when
ELSE P19_FILL = the first time
P19
[IF P18 NE 0 OR BLANK] How old were you [P19_FILL] you did something that caused
serious injury, death, or suffering to someone else?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE P20_FILL
IF P1p = 1 AND P1q NE 1 AND P1r NE 1 THEN P20_FILL = a sudden violent death
IF P1p NE1 AND P1q = 1 AND P1r NE 1 THEN P20_FILL = an accidental death
IF P1p NE 1 AND P1q NE 1 AND P1r = 1 THEN P20_FILL = an experience that put them at serious
risk of injury or death
IF P1p = 1 AND P1q = 1 AND P1r NE 1 THEN P20_FILL = a sudden violent death or an accidental
death
IF P1p = 1 AND P1q NE 1 AND P1r = 1 THEN P20_FILL = a sudden violent death or any other
experience that put them at serious risk of injury or death
Version 4 – February 2017 (Post IRB Approval)
133
IF P1p NE 1 AND Pq1 = 1 AND P1r = 1 THEN P20_FILL = an accidental death or any other
experience that put them at serious risk of injury or death
IF P1p = 1 AND P1q = 1 AND P1r = 1 THEN P20_FILL = a sudden violent death, an accidental
death, or any other experience that put them at serious risk of injury or death
P20
[IF P1p = 1 OR P1q = 1 OR P1r = 1] How many times in your life has one of your close
friends or relatives experienced [P20_FILL]?
_____ NUMBER OF TIMES [RANGE: 0–9,999]
DK/REF
DEFINE P21_FILL
IF P20 = 1 THEN P21_FILL = when
ELSE P21_FILL = the first time
P21
[IF P20 NE 0 OR BLANK] How old were you [P21_FILL] one of your close friends or
relatives experienced [P20_FILL]?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P22
[IF P1a=1 OR P1b=1 OR P1c=1 OR P1d=1 OR P1e=1 OR P1f=1 OR P1g=1 OR P1h=1 OR
P1i=1 OR P1j=1 OR P1k=1 OR P1l=1 OR P1m=1 OR P1n=1 OR P1o=1 OR P1p=1 OR
P1q=1 OR P1r=1] Highly stressful experiences can cause upsetting reactions that often last for
months or even years after the experiences occur. In the past 30 days, how much were you
bothered by…
P22a repeated, disturbing, and
unwanted memories of a
highly stressful experience?
P22b strong physical reactions when
something reminded you of a
highly stressful experience, for
example, heart pounding,
trouble breathing, or sweating?
P22c avoiding memories, thoughts,
or feelings related to a highly
stressful experience?
P22d avoiding external reminders of
a highly stressful experience,
for example, people, places,
conversations, activities,
objects, or situations?
P22e difficulty concentrating?
P22f feeling jumpy or easily
startled?
Version 4 – February 2017 (Post IRB Approval)
Extremely
Quite
a Bit
Moderately
A Little
Bit
Not at
All
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
134
P22g serious psychological distress
because of your reactions to a
highly stressful experience?
P22h interference with your work or
personal life because of your
reactions to a highly stressful
experience?
DK/REF
P23
Extremely
Quite
a Bit
Moderately
A Little
Bit
Not at
All
1
2
3
4
5
1
2
3
4
5
[IF P1a=1 OR P1b=1 OR P1c=1 OR P1d=1 OR P1e=1 OR P1f=1 OR P1g=1 OR P1h=1 OR
P1i=1 OR P1j=1 OR P1k=1 OR P1l=1 OR P1m=1 OR P1n=1 OR P1o=1 OR P1p=1 OR
P1q=1 OR P1r=1] Think of a month in your life when you had the largest number of
reactions like these to a highly stressful experience. During that month, how much were you
bothered by…
P23a repeated, disturbing, and
unwanted memories of a
stressful experience?
P23b having strong physical
reactions when something
reminded you of a stressful
experience, like heart
pounding, trouble breathing, or
sweating?
P23c avoiding memories, thoughts,
or feelings related to a highly
stressful experience?
P23d avoiding external reminders of
a stressful experience, like
people, places, or activities
that reminded you of an
experience?
P23e having difficulty
concentrating?
P23f feeling jumpy or easily
startled?
DK/REF
Extremely
Quite
a Bit
Moderately
A Little
Bit
Not at
All
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE P24LOGIC
IF 2 OR MORE IN THE P23 SERIES = 1, 2, OR 3 THEN P24LOGIC = 1
ELSE P24LOGIC = 0
Version 4 – February 2017 (Post IRB Approval)
135
P24
[IF P24LOGIC = 1] Still thinking about that same month in your life when you had the largest
number of reactions to a highly stressful experience, how much were you bothered by…
P24a repeated, disturbing dreams of
a stressful experience?
P24b suddenly feeling or acting as if
a stressful experience were
happening again, like you
were actually back there
reliving it?
P24c feeling very upset when
something reminded you of a
stressful experience?
P24d trouble falling or staying
asleep?
P24e feeling irritable, having angry
outbursts, or acting
aggressively?
P24f taking too many risks or doing
things that could cause you
harm?
P24g being “super-alert” or
watchful or on guard?
P24h having amnesia or trouble
remembering important parts
of a stressful experience?
P24i blaming yourself or someone
else for a stressful experience
or what happened after it?
P24j having strong negative beliefs
about yourself, other people,
or the world, like thoughts that
you are bad, that no one can
be trusted, or that the world is
completely dangerous?
P24k having strong negative
feelings such as fear, horror,
anger, guilt, or shame?
P24l losing interest in activities that
you used to enjoy?
P24m feeling distant or cut off from
other people?
Version 4 – February 2017 (Post IRB Approval)
Extremely
Quite
a Bit
Moderately
A Little
Bit
Not at
All
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
136
P24n having trouble experiencing
positive feelings, like being
unable to have loving feelings
for people close to you, or
feeling emotionally numb?
DK/REF
Extremely
Quite
a Bit
1
2
Moderately
A Little
Bit
Not at
All
3
4
5
DEFINE P25LOGIC
IF ALL OF THE FOLLOWING CONDITIONS ARE MET:
P23a < 4 OR P23b < 4 OR P24a < 4 OR P24b < 4 OR P24c < 4
P23c < 4 OR P23d < 4
2 OR MORE OF P24h-P24n < 4
2 OR MORE OF P23e, P23f, P24d, P24e, P24f, P24g < 4
THEN P25LOGIC = 1
ELSE P25LOGIC = 0
P24o [IF P25LOGIC = 1] You mentioned being bothered by a number of reactions. How much
psychological distress did these reactions cause?
1
None
2
Mild
3
Moderate
4
Severe
5
Very severe
DK/REF
P25
[IF P25LOGIC = 1] About how old were you the very first time you had a month or longer
when you had reactions like these to a highly stressful experience? Your best estimate is fine if
you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE P26 LOGIC
IF CURNTAGE – P25 = 1 THEN P26LOGIC = 0
IF CURNTAGE = P25 THEN P26LOGIC = 0
ELSE P26LOGIC = 1
P26
[IF (P25LOGIC = 1) AND (P26LOGIC = 1)] About how many years in your life have you had
at least one month when you had reactions like these? Your best estimate is fine if you cannot
remember the exact number.
_______NUMBER OF YEARS [RANGE: 1–CURNTAGE]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
137
P27
[IF P25LOGIC = 1] During about how many months in the past 12 months have you had
reactions like these? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
P28
[IF P27 < 1 OR P27 = DK/REF] About how old were you the most recent time you had a
month of that sort? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
P29
[IF P25LOGIC = 1] How much did these reactions ever interfere with your school, work, or
personal life?
6
Extremely
7
A lot
8
Some
9
A little
10
Not at all
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
138
27.
Family Medical History (ACE)
BEGIN TIME STAMP
ONLY SHOW THIS MODULE IF PART2_SHOW=1.
FMIN
These next questions are about your biological mother. Are you able to answer
questions about your biological mother?
1
Yes
2
No
DK/REF
FM2a
[IF FMIN = 1] Is your biological mother still living?
1
Yes
2
No
DK/REF
FM2b
[IF FM2a = 2] How old was your mother at the time of her death?
__________ YEARS OLD [RANGE: 0–100]
DK/REF
FM2
[IF FM2a = 1 OR DK OR REF] What is your biological mother’s current age?
__________ YEARS OLD [RANGE: 0–100]
DK/REF
FM3
[IF FMIN = 1] What was the last grade or year of school your biological mother
completed?
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
No schooling completed
1st grade completed
2nd grade completed
3rd grade completed
4th grade completed
5th grade completed
6th grade completed
7th grade completed
8th grade completed
9th grade completed
10th grade completed
11th grade completed
Regular high school diploma
12th grade, no diploma
GED certificate of high school completion
Some college credit, but no degree
Version 4 – February 2017 (Post IRB Approval)
139
16
17
18
19
20
Associate’s degree, for example, AA or AS
Bachelor’s degree, for example, BA or BS
Master’s degree, for example, MA, MS, MENG, M. ED, MSW, or MBA
Doctorate degree, for example, PHD or EDD
Professional degree beyond a bachelor’s degree, for example, MD, DDS, DVM,
LLB, or JD
DK/REF
DEFINE FM4_FILL
IF FM2a = 1 OR DK OR REF, THEN FM4_FILL = “currently has or has ever had”
IF FM2a = 2, THEN FM4_FILL = “ever had”
FM4
FM4a
FM4b
FM4c
FM4d
FM4e
DK/REF
FMIN2
[IF FMIN = 1] Please indicate whether your biological mother [FM4_FILL] any of the
following conditions.
Autism spectrum disorder, including Asperger’s
Bipolar disorder, also known as manic depression
An anxiety disorder such as phobia, panic disorder, generalized anxiety
disorder, post-traumatic stress disorder, or any other anxiety disorder
Depression
Schizophrenia
Yes
1
1
No
2
2
1
2
1
1
2
2
These next questions are about your biological father. Are you able to answer questions
about your biological father?
1
Yes
2
No
DK/REF
FM5a
[IF FMIN2 = 1] Is your biological father still living?
1
Yes
2
No
DK/REF
FM5b
[IF FM5a = 2] How old was your father at the time of his death?
__________ YEARS OLD [RANGE: 0–100]
DK/REF
FM6
[IF FM5a = 1 OR DK OR REF] What is your biological father’s current age?
__________ YEARS OLD [RANGE 1–100]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
140
FM7
[IF FMIN2 = 1] What was the last grade or year of school your biological father
completed?
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
No schooling completed
1st grade completed
2nd grade completed
3rd grade completed
4th grade completed
5th grade completed
6th grade completed
7th grade completed
8th grade completed
9th grade completed
10th grade completed
11th grade completed
Regular high school diploma
12th grade, no diploma
GED certificate of high school completion
Some college credit, but no degree
Associate’s degree, for example, AA or AS
Bachelor’s degree, for example, BA or BS
Master’s degree, for example, MA, MS, MENG, M. ED, MSW or MBA
Doctorate degree, for example, PHD or EDD
Professional degree beyond a bachelor’s degree, for example, MD, DDS, DVM,
LLB or JD
DK/REF
DEFINE FM8_FILL
IF FM5a = 1 OR DK OR REF, THEN FM8_FILL = “currently has or has ever had”
IF FM5a = 2, THEN FM8_FILL = “ever had”
FM8
FM8a
FM8b
FM8c
FM8d
FM8e
DK/REF
FM9
[IF FMIN2 = 1] Please indicate whether your biological father [FM8_FILL] any of the
following conditions.
Autism spectrum disorder, including Asperger’s
Bipolar disorder, also known as manic depression
An anxiety disorder such as phobia, panic disorder, generalized anxiety
disorder, post-traumatic stress disorder, or any other anxiety disorder
Depression
Schizophrenia
Yes
1
1
No
2
2
1
2
1
1
2
2
The next questions are about any siblings you may have. For these questions, please
think about siblings who are alive as well as those who are no longer living.
Do you have, or have you ever had, any siblings?
Version 4 – February 2017 (Post IRB Approval)
141
1
Yes
2
No
DK/REF
FM9a
[IF FM9 = 1] How many of your siblings are full siblings?
A full sibling is a brother or sister who has the same biological mother and biological
father as you.
_________ [RANGE: 0 – 25]
DK/REF
FM9b
[IF FM9 = 1] How many of your siblings are half siblings?
A half sibling is a brother or sister with whom you share one biological parent.
________ [RANGE: 0 – 25]
DK/REF
DEFINE FULLSIB
IF FM9a NE DK OR REF THEN FULLSIB = FM9a
ELSE FULLSIB = BLANK
DEFINE HALFSIB
IF FM9b NE DK OR REF THEN HALFSIB = FM9b
ELSE HALFSIB = BLANK
FM10
[IF FULLSIB NE BLANK AND HALFSIB NE BLANK] Please indicate whether any of
your full or half siblings currently have or have ever had any of the following conditions.
[IF FULLSIB = 1 AND HALFSIB = BLANK] Please indicate whether your full sibling
currently has or has ever had any of the following conditions.
[IF FULLSIB > 1 AND HALFSIB = BLANK] Please indicate whether any of your full
siblings currently have or have ever had any of the following conditions.
[IF FULLSIB = BLANK and HALFSIB = 1] Please indicate whether your half sibling
currently has or has ever had any of the following conditions.
[IF FULLSIB = BLANK and HALFSIB > 1] Please indicate whether any of your half
siblings currently have or have ever had any of the following conditions.
FM10a
FM10b
Autism spectrum disorder, including Asperger’s
Bipolar disorder, also known as manic depression
Version 4 – February 2017 (Post IRB Approval)
Yes
1
1
No
2
2
142
FM10c
FM10d
FM10e
DK/REF
FM11
An anxiety disorder such as phobia, panic disorder, generalized
anxiety disorder, post-traumatic stress disorder, or any other
anxiety disorder
Depression
Schizophrenia
Yes
No
1
2
1
1
2
2
[IF (FULLSIB ≥ 1 AND HALFSIB ≥ 1) AND FM10a = 1] You reported having a sibling
with autism spectrum disorder.
Is it a full sibling, half sibling, or both that currently has or has ever had autism spectrum
disorder?
1 [IF FULLSIB = 1, FILL: “Full sibling”] [IF FULLSIB > 1, FILL: “Full sibling or
siblings”]
2 [IF HALFSIB = 1, FILL: “Half sibling” [IF HALFSIB > 1, FILL: “Half sibling or
siblings”]
3 Both full and half siblings
DK/REF
FM12
[IF (FULLSIB ≥ 1 AND HALFSIB ≥ 1) AND FM10b = 1] You reported having a sibling
with bipolar disorder, also known as manic depression.
Is it a full sibling, half sibling, or both that currently has or has ever had bipolar disorder?
1 [IF FULLSIB = 1, FILL: “Full sibling”] [IF FULLSIB > 1, FILL: “Full sibling or
siblings”]
2 [IF HALFSIB = 1, FILL: “Half sibling” [IF HALFSIB > 1, FILL: “Half sibling or
siblings”]
3 Both full and half siblings
DK/REF
FM13
[IF (FULLSIB≥ 1 AND HALFSIB ≥ 1) AND FM10c = 1] You reported having a sibling
with an anxiety disorder, such as phobia, panic disorder, generalized anxiety disorder, or
post-traumatic stress disorder.
Is it a full sibling, half sibling, or both that currently has or has ever had an anxiety
disorder?
1 [IF FULLSIB = 1, FILL: “Full sibling”] [IF FULLSIB > 1, FILL: “Full sibling or
siblings”]
2 [IF HALFSIB = 1, FILL: “Half sibling” [IF HALFSIB > 1, FILL: “Half sibling or
siblings”]
3 Both full and half siblings
DK/REF
Version 4 – February 2017 (Post IRB Approval)
143
FM14
[IF (FULLSIB ≥ 1 AND HALFSIB ≥ 1) AND FM10d = 1] You reported having a sibling
with depression.
Is it a full sibling, half sibling, or both that currently has or has ever had depression?
1 [IF FULLSIB = 1, FILL: “Full sibling”] [IF FULLSIB > 1, FILL: “Full sibling or
siblings”]
2 [IF HALFSIB = 1, FILL: “Half sibling” [IF HALFSIB > 1, FILL: “Half sibling or
siblings”]
3 Both full and half siblings
DK/REF
FM15
[IF (FULLSIB ≥ 1 AND HALFSIB ≥ 1) AND FM10e = 1] You reported having a sibling
with schizophrenia. Is it a full sibling, half sibling, or both that currently has or has ever had
schizophrenia?
1 [IF FULLSIB = 1, FILL: “Full sibling”] [IF FULLSIB > 1, FILL: “Full sibling or
siblings”]
2 [IF HALFSIB = 1, FILL: “Half sibling” [IF HALFSIB > 1, FILL: “Half sibling or
siblings”]
3 Both full and half siblings
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
144
28.
Tobacco, Alcohol, Drugs, and Treatment
BEGIN TIME STAMP
ONLY SHOW THIS MODULE IF PART2_SHOW=1.
TAD1 The next questions are about your use of tobacco, alcohol, and drugs.. Have you ever in your
life used any of the following substances, even if it was only one time?
Yes
TAD1a
TAD1c
TAD1f
TAD1g
TAD1h
TAD1i
TAD1j
No
A cigarette, cigar, pipe, snuff, or smokeless tobacco?
A drink of alcohol, such as beer, wine, wine cooler,
shot of liquor, or mixed drink?
Marijuana or hashish?
Any other kind of illegal drug, such as cocaine,
ecstasy, speed, LSD, or poppers?
A prescription stimulant, such as Adderall,
amphetamines, or diet pills, on your own, that is
without a doctor’s prescription or in any way a doctor
did not direct you to use it?
A prescription tranquilizer or muscle relaxer, such as
Ativan, Valium, or sedatives, such as Ambien, on your
own?
A prescription pain reliever, such as Codeine or
OxyContin, on your own?
DK/REF
TAD2
[IF TAD1a = 1] About how old were you the very first time you smoked a cigarette, cigar,
or pipe, or used snuff, or smokeless tobacco?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD3
[IF TAD1a = 1] In the past 12 months, how often did you use any tobacco product, such as
a cigarette, cigar, pipe, snuff, or smokeless tobacco?
1 4-7 days a week
2 2-3 days a week
3 2-4 days a month
4 Monthly or less
5 Haven’t Used in Past 12 Months
DK/REF
TAD4 [IF TAD3 NE 5] On the days you used tobacco products in the past 12 months, about how
many cigarettes, cigars, pipes, dips, or chews did you usually have per day?
Version 4 – February 2017 (Post IRB Approval)
145
_____ NUMBER PER DAY [RANGE: 1–70]
DK/REF
TAD5 [IF TAD1a = 1] Have you ever used tobacco products at least once a week for a full 12
months?
1 Yes
2 No
DK/REF
TAD6 [IF TAD5 = 1] About how old were you the very first time you used tobacco products at
least once a week for a full 12 months?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD7 [IF TAD1c = 1] About how old were you when you had your first drink of alcohol, such as
beer, wine, a wine cooler, a shot of liquor, or a mixed drink?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD8 [IF TAD1c = 1] In the past 12 months, how often did you have at least 1 drink of alcohol?
1
4-7 days a week
2
2-3 days a week
3
2-4 days a month
4
Monthly or less
5
Never
DK/RE
TAD9 [IF TAD8 NE 5] On the days you used alcohol in the past 12 months, about how many
drinks did you usually have per day?
_____ NUMBER OF DRINKS PER DAY [RANGE: 1–50]
DK/REF
TAD10 [IF TAD1c = 1] Have you ever drank alcohol at least once a month for a full year?
1 Yes
2 No
DK/REF
TAD11 [IF TAD10 = 1] About how old were you the very first time you drank alcohol at least once a
month for a full year?
_________[RANGE: 0–CURNTAGE]
Version 4 – February 2017 (Post IRB Approval)
146
DK/REF
TAD12 [IF TAD1c = 1] Have you ever had [IF QD01 = 5 FILL: five; IF QD01 = 9 FILL: four] or
more drinks of alcohol on the same day?
1 Yes
2 No
DK/REF
TAD13 [IF TAD12 = 1] About how old were you the very first time you had [IF QD01 = 5 FILL:
five; IF QD01 = 9 FILL: four] or more drinks of alcohol on the same day?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD14 [IF TAD1f = 1] About how old were you the very first time you used marijuana or hashish?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD15 [IF TAD1f = 1] In the past 12 months, how often did you use marijuana or hashish….
1
4-7 days a week
2
2-3 days a week
3
2-4 days a month
4
Monthly or less
5
Never
DK/REF
TAD16 [IF TAD1g = 1] About how old were you the very first time you used any other kind of
illegal drug, such as cocaine, ecstasy, speed, LSD, or poppers?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD17 [IF TAD1g = 1] In the past 12 months, how often did you use any other kind of illegal drug?
1
4-7 days a week
2
2-3 days a week
3
2-4 days a month
4
Monthly or less
5
Never
DK/REF
TAD18 [IF TAD1h = 1] About how old were you the very first time you used a prescription
stimulant, such as Adderall, amphetamines, or diet pills, on your own, that is without a
doctor’s prescription or in any way a doctor did not direct you to use it?
Version 4 – February 2017 (Post IRB Approval)
147
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD19 [IF TAD1h = 1] In the past 12 months, how often did you use a prescription stimulant on
your own?
1
4-7 days a week
2
2-3 days a week
3
2-4 days a month
4
Monthly or less
5
Never
DK/REF
TAD20 [IF TAD1i = 1] About how old were you the very first time you used a prescription
tranquilizer or muscle relaxer, such as Ativan, Valium, or sedatives, such as Ambien, on your
own?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD21 [IF TAD1i = 1] In the past 12 months, how often did you use a prescription tranquilizer,
muscle relaxer or sedative on your own?
1
4-7 days a week
2
2-3 days a week
3
2-4 days a month
4
Monthly or less
5
Never
DK/REF
TAD22 [IF TAD1j = 1] About how old were you the very first time you used a prescription pain
reliever, such as Codeine or OxyContin, on your own?
_________[RANGE: 0–CURNTAGE]
DK/REF
TAD23 [IF TAD1j = 1] In the past 12 months, how often did you use a prescription pain reliever on
your own?
1
4-7 days a week
2
2-3 days a week
3
2-4 days a month
4
Monthly or less
5
Never
DK/REF
Version 4 – February 2017 (Post IRB Approval)
148
TAD24 [IF TAD1c = 1] Think of the time in your life when you used the most alcohol. During that
time, how often did you drink?
1
4–7 days a week
2
2–3 days a week
3
2–4 days a month
4
Monthly or less
DK/REF
TAD25 [IF TAD1c = 1 ] On the days you used alcohol during that time in your life, about how many
drinks did you usually have per day?
_____ NUMBER OF DRINKS PER DAY [RANGE: 1–50]
DK/REF
TAD26 [IF (TAD8 = 1) OR (TAD8 = 2 AND TAD9 ≥ 2) OR (TAD8 = 3 AND TAD9 ≥ 3) OR
(TAD8 = 4 AND TAD9 ≥ 5) OR (TAD12 = 1) OR (TAD24 = 1) OR (TAD24 = 2 AND
TAD25 ≥ 2) OR (TAD24 = 3 AND TAD25 ≥ 3) OR (TAD24 = 4 AND TAD25 ≥ 5)] In
answering the next questions, think of the one year in your life when your use of alcohol
interfered most with your life. During that year, how often did you have each of the following
problems?
TAD26a Your drinking or being hung over
interfered with your
responsibilities at school, home,
or work?
TAD26b You continued drinking even
when it caused problems with
your family, friends, neighbors, or
co-workers?
TAD26c You were under the influence in
hazardous situations, like when
driving or operating a machine?
TAD26d You either drank more or spent
more time drinking than you
intended when you started?
TAD26e You greatly reduced important
activities with family, friends, or
at work because of your drinking?
DK/REF
4-7
Days a
Week
2-3
Days a
Week
2-4
Days a
Month
Monthly
or Less
Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE TAD26_COUNT
SET TAD26_COUNT = 0
IF TAD26a = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD26_COUNT
Version 4 – February 2017 (Post IRB Approval)
149
IF TAD26b = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD26_COUNT
IF TAD26c = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD26_COUNT
IF TAD26d = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD26_COUNT
IF TAD26e = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD26_COUNT
DEFINE TAD27RAND = random number between 0.00–1.00
TAD27 [IF TAD26_COUNT ≥ 1 OR (TAD26_COUNT = 0 AND TAD27RAND ≤ 0.10)] Still
thinking about the one year in your life when your use of alcohol interfered most with your
life, how often during that year did you have each of these other problems?
TAD27a You tried to cut down or control
your drinking but were unable to
do so?
TAD27b You spent a great deal of time
drinking or recovering from
drinking?
TAD27c You had such a strong desire or
craving to drink that you couldn’t
think of anything else?
TAD27d You continued to drink even when
it caused physical or emotional
health problems?
TAD27e You developed alcohol tolerance,
that is, either the same amount no
longer had the same effect or you
needed to drink a lot more to get
the same effect?
TAD27f You experienced withdrawal
symptoms like fatigue, headaches,
diarrhea, the shakes, or emotional
problems when you tried to cut
down your drinking?
TAD27g You continued to drink in order to
avoid having withdrawal
symptoms?
DK/REF
4-7
Days a
Week
2-3
Days a
Week
2-4
Days a
Month
Monthly
or Less
Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE TAD28_COUNT
SET TAD28_COUNT = 0
IF TAD26a = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD26b = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD26c = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
Version 4 – February 2017 (Post IRB Approval)
150
IF TAD26d = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD26e = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27a = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27b = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27c = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27d = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27e = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27f = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
IF TAD27g = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD28_COUNT
DEFINE TAD28_FILL
IF TAD28_COUNT = 2 THEN TAD28_FILL = “these problems”
ELSE TAD28_FILL = “at least two of these problems”
TAD28
[IF TAD28_COUNT ≥ 2] You reported [TAD28_COUNT] problems associated with your
alcohol use. About how old were you the very first time you had [TAD28_FILL] in the
same year? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TAD29
[IF TAD28 = (CURNTAGE – 1)] Did that start in the past 12 months or more than 12
months ago?
1 In the past 12 months
2 More than 12 months ago
DK/REF
TAD30
[IF (TAD28_COUNT ≥ 2) AND TAD28 NE CURNTAGE AND NE (CURNTAGE – 1)]
About how many years in your life did you have [TAD28_FILL] in the same year? Your
best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF YEARS [RANGE: 1–(CURNTAGE – 2)]
DK/REF
TAD31
[IF TAD28_COUNT ≥ 2] During about how many months in the past 12 months did you
have these problems? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
TAD32
[(TAD28_COUNT ≥ 2) AND TAD31 NE 1–12] About how old were you the most recent
time you had [TAD28_FILL] in the same year? Your best estimate is fine if you cannot
remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
151
DEFINE TAD33A_FILL
IF TAD1f OR TAD1g OR TAD1h OR TAD1i OR TAD1j = 1 THEN TAD33A_FILL = “also”
ELSE TAD33A_FILL = “”
DEFINE TAD33B_FILL
IF TAD1f = 1, TAD33B_FILL: “marijuana or hashish (and/,)”
IF TAD1g = 1, TAD33B_FILL: “other illegal drugs (and/,)”
IF TAD1h = 1, TAD33B_FILL: “prescription stimulants (and/,)”
IF TAD1i = 1, TAD33B_FILL: “prescription tranquilizers (and/,)”
IF TAD1j = 1, TAD33B_FILL: “prescription pain relievers”
DEFINE TAD33C_FILL
IF TAD1f = 1 AND TAD1g-TAD1j = 2 OR DK OR REF, TAD33C_FILL: “marijuana or hashish”
IF TAD1h = 1 AND TAD1f AND TAD1g AND TAD1i AND TAD1j = 2 OR DK OR REF,
TAD33C_FILL: “prescription stimulant”
IF TAD1i = 1 AND TAD1f AND TAD1g AND TAD1h AND TAD1j = 2 OR DK OR REF,
TAD33C_FILL: “prescription tranquilizer”
IF TAD1j = 1 AND TAD1f AND TAD1g AND TAD1h AND TAD1i = 2 OR DK OR REF,
TAD33C_FILL: “prescription pain reliever”
ELSE TAD33C_FILL: drug
TAD33
[IF TAD1f OR TAD1g OR TAD1h OR TAD1i OR TAD1j = 1] You [TAD33A_FILL]
reported using [TAD33B_FILL]. In answering the next questions, think of the one year in
your life when your [TAD33C_FILL] use interfered most with your life. During that year,
how often did you have each of the following problems?
TAD33a Your [TAD33C_FILL] use or
being under the influence
interfered with your
responsibilities at school, home,
or work?
TAD33b You continued to use even when
it caused problems with your
family, friends, neighbors, or coworkers?
TAD33c You were under the influence in
hazardous situations, like when
driving or operating a machine?
TAD33d You either used more or spent
more time using than you
intended when you started?
TAD33e You greatly reduced important
activities with family, friends, or
at work because of your use?
DK/REF
Version 4 – February 2017 (Post IRB Approval)
4-7
Days a
Week
2-3
Days a
Week
2-4
Days a
Month
Monthly
or Less
Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
152
DEFINE TAD33_COUNT
SET TAD33_COUNT = 0
IF TAD33a = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD33_COUNT
IF TAD33b = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD33_COUNT
IF TAD33c = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD33_COUNT
IF TAD33d = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD33_COUNT
IF TAD33e = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD33_COUNT
DEFINE TAD34RAND = random number between 0.00–1.00
TAD34
[IF TAD33_COUNT ≥ 1 OR (TAD33_COUNT = 0 AND TAD34RAND ≤ 0.10] Still
thinking about the one year in your life when your [TAD33C_FILL] use interfered most
with your life, how often during that year did you have each of these other problems?
TAD34a You tried to cut down or control
your use but were unable to do
so?
TAD34b You spent a great deal of time
using or recovering from use?
TAD34c You had such a strong desire or
craving to use that you couldn’t
think of anything else?
TAD34d You continued to use even when it
caused physical or emotional
health problems?
TAD34e You experienced
[TAD33C_FILL] tolerance, that
is, either the same amount no
longer had the same effect or you
needed to use a lot more to get the
same effect?
TAD34f You experienced withdrawal
symptoms like trouble sleeping,
emotional problems, restlessness,
sweating or nausea when you tried
to cut down your use?
TAD34g You continued to use in order to
avoid having withdrawal
symptoms?
DK/REF
4-7
Days a
Week
2-3
Days a
Week
2-4
Days a
Month
Monthly
or Less
Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
DEFINE TAD35_COUNT
Version 4 – February 2017 (Post IRB Approval)
153
SET TAD35_COUNT = 0
IF TAD33a = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD33b = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD33c = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD33d = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD33e = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34a = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34b = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34c = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34d = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34e = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34f = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
IF TAD34g = (1 OR 2 OR 3 OR 4), ADD 1 TO TAD35_COUNT
DEFINE TAD35_FILL
IF TAD35_COUNT = 2 THEN TAD35_FILL = “these problems”
IF TAD35_COUNT > 2 THEN TAD35_FILL = “at least two of these problems”
TAD35
[IF TAD35_COUNT ≥ 2] You reported [TAD35_COUNT] problems associated with your
drug use. About how old were you the very first time you had [TAD35_FILL] in the same
year? Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TAD36
[IF TAD35 = (CURNTAGE – 1)] Did that episode start in the past 12 months or more than
12 months ago?
1 In the past 12 months
2 More than 12 months ago
DK/REF
TAD37
[IF (TAD35_COUNT ≥ 2) AND TAD35 NE CURNTAGE AND (TAD35 NE
(CURNTAGE – 1))] About how many years in your life did you have
[TAD35_FILL] in the same year? Your best estimate is fine if you cannot remember
the exact number.
_____ NUMBER OF YEARS [RANGE: 1–(CURNTAGE – 2)]
DK/REF
TAD38
[IF TAD35_COUNT ≥ 2] During about how many months out of the past 12 did you have
these problems? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
154
TAD39
[IF (TAD35_COUNT ≥ 2) AND TAD38 NE (1–12)] About how old were you the most
recent time you had these problems because of your drug use? Your best estimate is fine if
you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TAD40_FILL
IF TAD28_COUNT ≥ 2 AND TAD35_COUNT ≥ 2 THEN TAD40_FILL = “alcohol or drug use”
IF TAD28_COUNT ≥ 2 AND TAD35_COUNT < 2 THEN TAD40_FILL = “alcohol use”
IF TAD28_COUNT < 2 AND TAD35_COUNT ≥ 2 THEN TAD40_FILL = “drug use”
TAD40
[IF ((TAD28_COUNT ≥ 2) OR (TAD35_COUNT ≥ 2) ] The next questions are about
treatment.
Have you ever in your life stayed overnight or longer in a substance abuse treatment center or
hospital to receive treatment for problems with [TAD40_FILL]?
1 Yes
2 No
DK/REF
TAD41
[IF TAD40 = 1] How many times were you hospitalized for problems with [TAD40_FILL]?
Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF TIMES [RANGE: 1–100]
DK/REF
DEFINE TAD42_FILL
IF TAD41 = 1 THEN TAD42_FILL = “when that happened?”
ELSE TAD42_FILL = “the first time you were hospitalized for those problems?”
TAD42
[IF TAD40=1] How old were you [TAD42_FILL]?
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TAD43_FILL
IF TAD41 = 1 THEN TAD43_FILL = “that”
ELSE TAD43_FILL = “your first hospitalization”
TAD43
[IF TAD42 = (CURNTAGE – 1)] Did [TAD43_FILL] start in the past 12 months or more
than 12 months ago?
1 In the past 12 months
2 More than 12 months ago
DK/REF
Version 4 – February 2017 (Post IRB Approval)
155
TAD44
[IF TAD40 =1] How many nights in the past 12 months were you in a hospital for problems
with [TAD40_FILL]? Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF NIGHTS IN A HOSPITAL [RANGE: 0–365]
DK/REF
TAD45
[IF TAD44 < 1 OR TAD42 NE CURNTAGE] About how old were you the most recent
time you were in a hospital overnight for problems with [TAD40_FILL]? Your best
estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 1–(CURNTAGE – 1)]
DK/REF
DEFINE TAD46_FILL
IF TAD40 = 1 AND TAD41 = 1 TAD46_FILL: “Not counting the time when you were hospitalized,
have”
IF TAD40 = 1 AND TAD41 NE 1 TAD46_FILL: “Not counting times when you were hospitalized,
have”
ELSE TAD46_FILL: “Have”
TAD46
[IF (TAD28_COUNT ≥ 2) OR (TAD35_COUNT ≥ 2)] People can receive treatment for
problems with [TAD40_FILL] by attending a self-help group, participating in a 12-step
program, receiving professional counseling, or taking medication.
[TAD46_FILL] you ever in your life received any of these kinds of treatment for problems
with [TAD40_FILL]?
1 Yes
2 No
DK/REF
TAD47
[IF TAD46 = 1] About how old were you the very first time you received this treatment?
Your best estimate is fine if you cannot remember your exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TAD48
[IF TAD47 = (CURNTAGE-1)] Did you start that treatment in the past 12 months or more
than 12 months ago?
1 In the past 12 months
2 More than 12 months ago
DK/REF
TAD49
[IF TAD46 = 1 AND (TAD47 NE CURNTAGE) AND (TAD48 NE1)] During about how
many years in your life did you receive treatment for problems with [TAD40_FILL] at least
once? Your best estimate is fine if you cannot remember the exact number.
Version 4 – February 2017 (Post IRB Approval)
156
_____ NUMBER OF YEARS [RANGE: 0–CURNTAGE]
DK/REF
DEFINE TAD50_FILL
IF TAD40 = 1 AND TAD41 = 1, TAD50_FILL: “Not counting time when you were hospitalized,
about”
IF TAD40 = 1 AND TAD41 NE 1, TAD50_FILL: “Not counting times when you were hospitalized,
about”
ELSE TAD50_FILL: “About”
TAD50
[IF TAD46 = 1 AND ((TAD47 NE CURNTAGE) OR IF ((TAD49 NE 1) AND (TAD47
NE (CURNTAGE – 2 OR MORE)) AND ((TAD31 NE (1–12)) OR (TAD38 NE (1–12)))]
A person can have a treatment session with a professional counselor by visiting face-toface, talking over the telephone, or by exchanging text messages. A person can also have a
treatment session by attending a self-help group or by participating in a 12-step program.
[TAD50_FILL] how many treatment sessions, for problems with [TAD40_FILL], did you
have in the past 12 months?
Your best estimate is fine if you cannot remember the exact number.
_____ NUMBER OF TREATMENT SESSIONS [RANGE: 1–1000]
DK/REF
TAD51
[TAD49 < 1] About how old were you the most recent time you received treatment? Your
best estimate is fine if you cannot remember the exact age.
_____ YEARS OLD [RANGE: 0–CURNTAGE]
DK/REF
TAD52
[IF TAD50 ≥ 1] Are you still in treatment? Or have you stopped treatment?
1 Still in treatment
2 Stopped treatment
DK/REF
TAD53
[IF TAD52 = 2] How important was each of the following reasons for why you stopped
treatment?
TAD53a You got better and no longer
needed help
TAD53b It was not helping; you were
not getting better
Version 4 – February 2017 (Post IRB Approval)
Very
Important
Somewhat
Important
Not Very
Important
Not at All
Important
1
2
3
4
1
2
3
4
157
TAD53c Financial reasons
TAD53d Inconvenience, such as
problems with time,
transportation, or scheduling
TAD53e Embarrassment or concern
about what people would
think if they knew you were in
treatment
TAD53f You preferred to handle the
problem on your own or with
the help of family and friends
TAD53g Some other important reason
DK/REF
TAD53OT
Very
Important
1
Somewhat
Important
2
Not Very
Important
3
Not at All
Important
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
[IF TAD53g = 1 OR 2] What was the other important reason you stopped treatment?
_________________ [ALLOW 200 CHARACTERS]
DK/REF
TAD54
[IF TAD40 = (2 OR DK OR REF) OR TAD46 = (2 OR DK OR REF) OR TAD48 = (2 OR
DK OR REF)] Was there ever a time in the past 12 months when you felt that you might
need treatment for your [TAD40_FILL]?
1 Yes
2 No
DK/REF
TAD55
[IF TAD54 = 1] How important was each of the following reasons for why you did not get
treatment?
TAD55a The problem got better and
you no longer needed help
TAD55b You didn’t know where to go
TAD55c You couldn’t find a place that
would see you when you
needed help
TAD55d Financial reasons
TAD55e Inconvenience, such as
problems with time,
transportation, or scheduling
Version 4 – February 2017 (Post IRB Approval)
Very
Important
Somewhat
Important
Not Very
Important
Not at All
Important
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
158
TAD55f Embarrassment or concern
about what people would
think if they knew you were in
treatment
TAD55g You preferred to handle the
problem on your own or with
the help of family and friends
TAD55h Some other important reason
DK/REF
TAD55OT
Very
Important
Somewhat
Important
Not Very
Important
Not at All
Important
1
2
3
4
1
2
3
4
1
2
3
4
[IF TAD55h = 1 OR 2] What was the other important reason you did not get treatment?
_________________ [ALLOW 200 CHARACTERS]
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
159
29.
Relationships and Social Networks
BEGIN TIME STAMP
ONLY SHOW THIS MODULE IF PART2_SHOW=1.
U4x
[IF QD07 = 1 OR 2 OR 3 OR 4] Earlier, you mentioned that you are now [FILL QD07]. How
old were you when you first got married?
__________ YEARS OLD [RANGE: 10–17]
DK/REF
U4y
[IF QD07 = 1] How long have you been married?
__________ YEARS [RANGE: 0–10]
DK/REF
U10
[IF QD07 NE 1] Next, we’ll ask about your relationships with other people. Which of the
following best describes your current dating situation?
1
Engaged to be married
2
Cohabitating or living together
3
Steadily dating one person, but not engaged
4
Dating one or more people, but not in one steady relationship
5
Not currently dating
DK/REF
DEFINE U11_FILL
IF QD07 = 1, THEN U11_FILL = spouse
IF U10 = 1, THEN U11_FILL = fiancé
ELSE U11_FILL= partner
U11
[IF QD07 =1 OR (U10 = 1 OR 2)] What is the sex of your [U11_FILL]?
1
Male
2
Female
3
Transgender
DK/REF
U12
[IF QD07 NE 1 AND U10 = 1 OR 2] How many years have you been in a steady relationship
with your [U11_FILL]? If less than one year, enter “0”.
Version 4 – February 2017 (Post IRB Approval)
160
__________ YEARS [RANGE: 0–CURNTAGE]
DK/REF
DEFINE U13_FILL
IF QD07 = 1, THEN U13_FILL = Counting your spouse, how
ELSE U13_FILL = How
U13
[U13_FILL] many people have you had sexual intercourse with in the past 12 months?
__________ NUMBER OF PEOPLE [RANGE: 0–300]
DK/REF
U14A [IF QD07 = 1 OR U9 = 1 OR U10 = 1 OR 2] Please think about your [U11_FILL] when
answering the next questions.
U14A1 How much does your [U11_FILL] really care
about you?
U14A2 How much does your [U11_FILL] understand the
way you feel about things?
U14A3 How much can you rely on your [U11_FILL] for
help if you have a serious problem?
U14A4 How much can you open up to your [U11_FILL]
if you need to talk about your worries?
DK/REF
A Lot
Some
A Little
Not at
All
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
U14B [IF QD07 = 1 OR U9 = 1 OR U10 = 1 OR 2] Please think about your [U11_FILL] when
answering the next questions.
U14B1 How often does your [U11_FILL] make too
many demands on you?
U14B2 How often does your [U11_FILL] criticize
you?
U14B3 How often does your [U11_FILL] let you
down when you are counting on them?
U14B4 How often does your [U11_FILL] get on
your nerves?
DK/REF
U15
Often
Sometimes
Rarely
Never
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
How many biological children have you had?
If you have no biological children, please enter 0.
__________ NUMBER OF CHILDREN [RANGE: 0–25]
DK/REF
DEFINE U16_FILL
Version 4 – February 2017 (Post IRB Approval)
161
IF U15 = 2, THEN U16_FILL = older
IF U15 > 2, THEN U16_FILL = oldest
ELSE, U16_FILL = BLANK
U16
[IF U15 > 0] How old is your [U16_FILL] biological child? If your child is less than 1 year
old, enter “0”.
__________ YEARS OLD [RANGE: 0–80]
DK/REF
DEFINE U17_FILL
IF U15 = 2, THEN U17_FILL = younger
IF U15 > 2, THEN U17_FILL = youngest
ELSE, U17_FILL = BLANK
U17
[IF U15 > 1] How old is your [U17_FILL] biological child? If your child is less than 1 year
old, enter “0”.
__________ YEARS OLD [RANGE: 0–80]
DK/REF
DEFINE U21_FILL
IF QD07 = 1, THEN U21_FILL = is your spouse
IF U10 = 1, THEN U21_FILL = is your fiancé
IF U10 = 2, THEN U21_FILL = is your partner
ELSE, THEN U21_FILL = are any of your sexual partners
U21
[IF QD01 = 5 AND U13 > 0] As far as you know, is your [U21_FILL] currently pregnant?
1
Yes
2
No
DK/REF
U22
[IF QD01 = 9 AND U13 > 0 AND CURNTAGE < 55] As far as you know, are you currently
pregnant?
1
Yes
2
No
DK/REF
SN1
The next few questions are about your social life.
How often do you talk on the phone, chat online, or get together with friends or relatives?
1
Most every day
Version 4 – February 2017 (Post IRB Approval)
162
2
A few times a week
3
A few times a month
4
Once a month
5
Less than once a month
6
Never
DK/REF
SN2
[IF SN1 = 1 OR 2 OR 3 OR 4 ] How many friends and relatives do you talk to on the phone,
chat with online, or get together with at least once a month?
__________ NUMBER OF FRIENDS AND RELATIVES [RANGE: 1–95]
DK/REF
SN2a
How often do you attend meetings of religious, fraternal, social, or recreation groups you
belong to?
1
Several times a week
2
1–2 times a week
3
Several times a month
4
1–2 times a month
5
Less than once a month
6
Never
DK/REF
SN2r
This next question is about the role that religious beliefs may play in your life. Please
indicate whether you strongly disagree, disagree, agree, or strongly agree.
Your religious beliefs are a very important part of your life.
1
Strongly Disagree
2
Disagree
3
Agree
4
Strongly Agree
DK/REF
SN3
How much could you rely on people in your personal life for support and comfort if you had
a serious personal problem?
1
A lot
2
Some
3
A little
4
Not at all
DK/REF
SN4
[IF SN3 = 1 OR 2] How many people could you rely on in this way?
Version 4 – February 2017 (Post IRB Approval)
163
__________ NUMBER OF PEOPLE [RANGE: 1–95]
DK/REF
SN6
How often do the people in your personal life make too many demands on you?
1
Often
2
Sometimes
3
Rarely
4
Never
DK/REF
SN7
How often do the people in your personal life argue with you or say things that make you feel
bad about yourself?
1
Often
2
Sometimes
3
Rarely
4
Never
DK/REF
SN8
SN8a
SN8b
SN8c
SN8d
How well do the following statements describe you?
Exactly
Like Me
A Lot
Like Me
Somewhat
Like Me
A Little
Like Me
Not at All
Like Me
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
The people in my
personal life would be
happier without me
I am a burden to the
people in my personal
life
I feel like I belong
The people in my
personal life need me
and would be much
worse off if I was not
around
DK/REF
SN10
The next questions are about using the internet for social networking and playing games with
other people.
SN10a Do you use the internet for playing games with other people?
Version 4 – February 2017 (Post IRB Approval)
Yes
1
No
2
164
SN10b Do you use the internet for social networking with other people?
DK/REF
SN11
Yes
1
No
2
[IF SN10a = 1] How often do you play online games with other people? Include any type of
online game you play with other people, such as website games, console games, and mobile
apps.
1
Less than once a day
2
Once a day
3
Several times a day
4
Many times a day
5
Constantly
DK/REF
SN12
[IF SN10b = 1] How often do you use social networking apps or sites like Facebook,
Snapchat, Instagram, and Twitter?
1
Less than once a day
2
Once a day
3
Several times a day
4
Many times a day
6
Constantly
DK/REF
SN14
[IF SN10a = 1 OR IF SN10b = 1] How many new friends, if any, have you made online?
1
None
2
One
3
2–5
4
More than 5
DK/REF
SN15
[IF SN10a = 1 OR IF SN10b = 1] When you use social networking apps or play games with
others online, do you ever…
SN15a feel more relaxed and happy?
SN15b feel more angry and frustrated?
DK/REF
Yes, a Lot
1
1
Yes, a Little
2
2
No
3
3
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
165
30.
Childhood Demographics
BEGIN TIME STAMP
ONLY SHOW THIS MODULE IF PART2_SHOW=1.
Now we have some questions about your childhood.
Q_DE2
Press [ENTER] to continue.
Q_DE20_12 How many times have you moved to a totally new neighborhood or town?
_____________ TIMES [RANGE: 0–50]
DK/REF
Q_DE20_5
The following questions are about specific educational experiences during different
periods of your life. How many different schools have you attended?
_____________ SCHOOLS [RANGE: 1–36]
DK/REF
Q_DE20
Are you currently enrolled in school?
If you are on a holiday or break from school, such as spring break or summer vacation,
but plan to return when the break is over, please answer yes.
1
Yes
2
No
DK/REF
Q_DE20B. [IF Q_DE20=1] As things stand now, how far in school do you think you will get?
1
Less than high school graduation
2
High school graduation or GED only
3
Attend or complete a 2-year school course in a community or vocational school
4
Attend college, but not complete a 4-year degree
5
Graduate from college
6
Obtain a Master's degree or equivalent
7
Obtain a Ph.D., M.D., or other advanced degree
DK/REF
Q15b
[IF Q_DE20 NE 2] How well do you do in math compared to other students in your class?
1
2
3
4
Much better
Better
About the same
Worse
Version 4 – February 2017 (Post IRB Approval)
166
5
Much worse
6
Do not have other students in your class
DK/REF
Q15c
[IF Q_DE20 NE 2] How well do you do in reading and writing, like spelling and grammar,
compared to other students in your class?
1
Much better
2
Better
3
About the same
4
Worse
5
Much worse
6
Did not have other children in your class
DK/REF
Q_DE208.a
When you were in grade school, were you usually one of the younger kids in your
classroom, one of the older kids, or about average in terms of age?
1
Younger
2
Older
3
Average
DK/REF
Q16
Have any of your teachers, principals, or school psychologists ever told you or your parents
that you had a problem with learning any of the following usual school subjects?
Q16a Reading
Q16b Writing
Q16c Mathematics or arithmetic
Q16d Speaking or language
DK/REF
Yes
1
1
1
1
No
2
2
2
2
DEFINE Q16_COUNT
SET Q16_COUNT=0
IF Q16a=1, ADD 1 TO Q16_COUNT
IF Q16b=1, ADD 1 TO Q16_COUNT
IF Q16c=1, ADD 1 TO Q16_COUNT
IF Q16d=1, ADD 1 TO Q16_COUNT
DEFINE Q16_FILL
IF Q16_COUNT=1, THEN SET Q16_FILL=“this learning problem”
IF Q16_COUNT>1, THEN SET Q16_FILL=“these learning problems”
Q17
[IF Q16a OR Q16b OR Q16c OR Q16d = 1] Because of [Q16_FILL], did you receive any of
the following at any time?
Version 4 – February 2017 (Post IRB Approval)
167
Q17a Special education testing to help understand the problem
Q17b Special or different classes provided by the school, because of the problem
Q17c Individual tutoring or counseling arranged by the school
Q17d Private tutoring arranged at home
Q17e A request to see a medical doctor or psychologist about this problem
Q17f A request to change to a different school
DK/REF
Q17g
Yes
1
1
1
1
1
1
No
2
2
2
2
2
2
[IF Q17f = 1] Did you actually change schools because of [Q16_FILL]?
1
Yes
2
No
DK/REF
Q25
[IF Q_DE20 NE 2] Approximately how many school clubs or organizations are you involved
with?
1
0
2
1–5
3
6–9
4
10–19
5
20 or more
DK/REF
Q26
Since you were in middle school, have you regularly participated in any kind of organized
sport, such as basketball, swimming, tennis, gymnastics, or snow sports?
1
Yes
2
No
DK/REF
Q29
In the past year, how often have you taken part in activities that are vigorous or
moderately energetic, such as running, working out, swimming, walking, dancing, or
tennis?
1
Every day
2
More than once a week
3
Once a week
4
One to three times a month
5
Hardly ever or never
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
168
31.
Childhood Experiences
BEGIN TIME STAMP
ONLY SHOW THIS MODULE IF PART2_SHOW=1.
X1
Next, we’ll ask about some experiences you may have had growing up. Which of the following
experiences have you had?
X1b Are your parents separated or divorced?
X1c Has either of your parents ever attempted or committed suicide?
X1d Has either parent ever been in prison or jail for 6 months or longer?
X1e Has either parent, or person who raised you, ever had a mental illness?
X1f Has either parent, or person who raised you, ever had an alcohol or drug problem?
X1g Have you ever been sent to a juvenile detention center?
DK/REF
X2
NUMBER OF YEARS
________ [RANGE: 0–17]
________ [RANGE: 0–17]
________ [RANGE: 0–17]
How often have you had each of the following experiences?
X5a Your family was on welfare
X5b You were homeless
X5c You had to do chores too hard or
dangerous for someone your age
DK/REF
X6
No
2
2
2
2
2
2
For how many years of your life have you lived…
X2a with your biological mother?
X2b with your biological father?
X2c in a foster home?
DK/REF
X5
Yes
1
1
1
1
1
1
Very
Often
1
1
1
Often Sometimes Rarely Never
2
2
3
3
4
4
5
5
2
3
4
5
How often have you had each of the following experiences?
Very
Often
X6f Someone in your family made you feel
important
X6g You felt loved and cared for
X6h Your family was a source of strength and
support
DK/REF
Version 4 – February 2017 (Post IRB Approval)
Often Sometimes Rarely Never
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
169
X7
The next questions ask about bullying. Bullying is when one or more people tease, threaten,
spread rumors about, hit, shove, or hurt another person over and over again. It is not bullying
when two people of about the same strength or power argue or fight or tease each other in a
friendly way.
With that definition in mind, have you ever in your life been bullied?
1
Yes
2
No
DK/REF
X8
[IF X7 = 1] During the past 12 months, have you been bullied?
1
Yes
2
No
DK/REF
X9
Have you ever in your life bullied someone?
1
Yes
2
No
DK/REF
X10
[IF X9 = 1] During the past 12 months, have you bullied someone?
1
Yes
2
No
DK/REF
X11
Electronic bullying is when someone bullies you through texting, instant messaging, e-mail,
chat rooms, or websites. Have you ever in your life been electronically bullied?
1
Yes
2
No
DK/REF
X12
[IF X11 = 1] During the past 12 months, have you been electronically bullied?
1
Yes
2
No
DK/REF
X13
Have you ever in your life bullied someone electronically?
1
Yes
2
No
DK/REF
Version 4 – February 2017 (Post IRB Approval)
170
X14
[IF X13 = 1] During the past 12 months, have you bullied someone electronically?
1
Yes
2
No
DK/REF
ACES1
Next, we are going to ask about grown-ups who take care of you. This means parents,
babysitters, adults who live with you, or others who watch you. Before we begin, we
want to remind you that your answers will be kept totally private. If there is a particular
question that you don’t want to answer, that’s O.K. But it is important that you be as
honest as you can, so that the researchers can get a better idea of the kinds of things that
kids your age sometimes face.
Not including spanking on your bottom, at any time in your life, did a grown-up in
your life hit, beat, kick, or physically hurt you in any way?
1
Yes
2
No
DK/REF
ACES2
At any time in your life, did a grown-up ever touch your private parts when they
shouldn’t have or make you touch their private parts?
1
Yes
2
No
DK/REF
ACES3
Did a grown-up ever force you to have sex, or try to force you to have sex?
1
Yes
2
No
DK/REF
ACES4
Now think about kids your age, like from school, a boyfriend or girlfriend, or even a
brother or sister. At any time in your life, did another child or teen make you do sexual
things?
1
Yes
2
No
DK/REF
ACES5
At any time in your life, did you get scared or feel really bad because grown-ups in
your life called you names, said mean things to you, or said they didn’t want you?
1
Yes
2
No
DK/REF
Version 4 – February 2017 (Post IRB Approval)
171
ACES6
When someone is neglected, it means that the grown-ups in their life don’t take care of
them the way they should. They might not get them enough food, take them to the
doctor when they are sick, or make sure they have a safe place to stay. At any time in
your life, did you get neglected?
1
Yes
2
No
DK/REF
ACES7
Has anyone in your household ever gone to prison?
1
Yes
2
No
DK/REF
ACES8
At any time in your life, did you see a parent get pushed, slapped, hit, punched, or beat
up by another parent or their boyfriend or girlfriend?
1
Yes
2
No
DK/REF
ACES9
[IF X6g NE 5] Thinking about your life up to now, was there someone in your family
who made you feel loved?
1
Yes
2
No
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
172
32.
Employment
BEGIN TIME STAMP
E1
[IF CURNTAGE > 14] The next few questions are about employment status. Which of the
following were you doing last week?
1
Working for pay at a job or business
2
With a job or business but not at work, such as on vacation or leave
3
Looking for work
4
Working, but not for pay, at a family-owned job or business
5
Not working at a job or business and not looking for work
DK/REF
DEFINE E2_FILL
IF E1 = 2, THEN E2_FILL = work last week
IF E1 = 5, THEN E2_FILL = have a job or business last week
E2
[IF E1 = 2 OR 5] What is the main reason you did not [E2_FILL]?
1
Taking care of house or family
2
Going to school
3
Retired
4
On a planned vacation from work
5
On family or maternity leave
6
Temporarily unable to work for health reasons
7
Have job/contract and off-season
8
On layoff
9
Disabled
10
Other
DK/REF
DEFINE E3_ASK
IF (E1 = 1 OR 4) OR (E2 = 4 OR 5 OR 6 OR 7), then E3_ASK=1,
ELSE E3_ASK=0.
DEFINE E3_FILL
IF E1 = 1 OR 4, THEN E3_FILL = did you work last week at all jobs or businesses
IF E2 = 4 OR 5 OR 6 OR 7, THEN E3_FILL = do you usually work at all jobs or businesses
E3
[IF E3_ASK=1] How many hours [E3_FILL]?
__________ NUMBER OF HOURS [RANGE: 1–168]
Version 4 – February 2017 (Post IRB Approval)
173
DK/REF
E3_SFTCK [IF E3 = 95 – 168] [FILL: E3] is an unusually high number. Is it correct that you
worked [E3] hours last week?
1
Yes
2
No
DK/REF
E3_2 [IF E3_SFTCK = 2 OR DK] How many hours [E3_FILL]?
_________ NUMBER OF HOURS [RANGE: 1 – 168]
DK/REF
E4
[IF E3 = 1 – 34 OR DK OR REF] Do you usually work 35 hours or more per week in total at
all jobs or businesses?
1
Yes
2
No
DK/REF
E5
[IF CURNTAGE > 14] Did you work for pay at any time in [4 DIGIT LAST FULL
CALENDAR YEAR]?
1
Yes
2
No
DK/REF
DEFINE E_EMPLY
IF (E1 = 1 OR 2 OR 4) AND (E2=4 OR 5 OR 6 OR 7), THEN E_EMPLY=1,
ELSE E_EMPLY=0.
QD37 [IF E1 = 1 OR 2 OR 4 OR DK OR REF] During the past 12 months, was there ever a time
when you did not have at least one job or business?
1
Yes
2
No
DK/REF
QD40 [IF E_EMPLY = 1] During the past 30 days, that is, from [DATEFILL] up to and including
today, how many whole days of work did you miss because you were sick or injured? Please
do not include days you missed because you stayed home with a sick child or other family
member.
__________ NUMBER OF DAYS [RANGE: 0–30]
DK/REF
Version 4 – February 2017 (Post IRB Approval)
174
QD41 [IF E_EMPLY = 1] During the past 30 days, that is, from [DATEFILL] up to and including
today, how many whole days of work did you miss because you just didn’t want to be there?
Please do not include days you missed because of a planned vacation or days that you stayed
home with a sick child or other family member.
__________ NUMBER OF DAYS [RANGE: 0–30]
DK/REF
PENTER1
Thank you for your help with this part of the interview. When you leave this screen, the
responses you entered into the computer will be locked and can no longer be seen by
you, the interviewer, or anyone else who uses this computer. When you are ready,
please press 1 and [ENTER] to complete this part of the interview and lock your
responses.
[ONCE 1 IS ENTERED FOR PENTER1, NO ONE CAN RE-ENTER THE ACASI PORTION
OF THE INTERVIEW.]
ENDAUDIO Your responses have been locked. Please tell your interviewer that you are finished.
INTERVIEWER: ENTER THE THREE-LETTER CODE TO MOVE TO THE NEXT SECTION.
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
175
33.
Household Roster
BEGIN TIME STAMP
HR_INTRODM2
For the next questions, I will read the question out loud, you can tell me your
answer, and I will enter it into the computer.
PRESS [ENTER] TO CONTINUE.
HR1
Altogether, how many people live here now, including yourself? Please include
anyone who (has lived/will live) here for most of (January, February, and
March/April, May, and June/July, August, and September/October,
November, and December).
NUMBER IN HOUSEHOLD:
DK/REF
[RANGE: 1–25]
INTERVIEWER: If you are interviewing in a transient shelter, enter “1”. If you
are interviewing in a group quarters unit that was listed by room, enter the
number of people living in the room.
IF HR1 = 1 OR DK/REF, SKIP TO FIRST QUESTION FOLLOWING HH
ROSTER, OTHERWISE CONTINUE.
DEFINE GRID WITH ROWS EQUAL TO HR1. EACH COLUMN OF THE
GRID IS A QUESTION AS SPEC’D BELOW.
PERAGEYR
[IF HR1 = 2–25] Now I need some additional information about each person
who lives here. Let’s start with the oldest. How old was he or she on his or her
last birthday? (WORDING FOR ADDITIONAL CYCLES: How old was the
next oldest person on his or her last birthday?)
INTERVIEWER: FOR CHILDREN LESS THAN 24 MONTHS (2 YEARS),
ENTER “1”. YOU WILL BE PROMPTED FOR THE AGE IN MONTHS ON
THE NEXT SCREEN.
AGE IN WHOLE YEARS:
DK/REF
CHAGEMON
[IF PERAGEYR = 1] ENTER THE AGE IN WHOLE MONTHS FOR THIS
HOUSEHOLD MEMBER. FOR BABIES UNDER 1 MONTH OLD, ENTER
1.
AGE IN MONTHS:
DK/REF
CHMONSEX
[RANGE: 1–110]
[RANGE: 1–23]
[IF CHAGEMON = 1–23] Is the [CHAGEMON FILL]-month-old child a
male or a female?
Version 4 – February 2017 (Post IRB Approval)
176
5
MALE
9
FEMALE
DK/REF
CHYRSEX
[IF CHAGEMON = DK/REF] Is this child a male or female?
5
MALE
9
FEMALE
DK/REF
PERYRSEX
[IF PERAGEYR = 2–110] Is the [PERAGEYR FILL]-year-old person male or
female?
5
MALE
9
FEMALE
DK/REF
PERSEX
[IF PERAGEYR = DK/REF] Is this person a male or a female?
5
MALE
9
FEMALE
DK/REF
MRELATON
[IF CHMONSEX OR CHYRSEX OR PERYRSEX OR PERSEX = 5]
[IF QD01 = 5] IF IT IS CLEAR THAT RESPONDENT IS TALKING ABOUT
HIMSELF: ASK “Is that you?” IF YES, ENTER “1” for “SELF”.
IF RESPONDENT IS NOT TALKING ABOUT SELF HAND R SHOWCARD
5. Please look at this card, and tell me which category best describes his
relationship to you.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
SELF
HUSBAND
SON (INCLUDES STEP, FOSTER, ADOPTIVE)
SON-IN-LAW
BROTHER (INCLUDES HALF, STEP, FOSTER, ADOPTIVE)
BROTHER-IN-LAW
FATHER (INCLUDES STEP, FOSTER, ADOPTIVE)
FATHER-IN-LAW
UNCLE
NEPHEW
GRANDFATHER
GRANDSON
COUSIN
EX-HUSBAND
UNMARRIED PARTNER
Version 4 – February 2017 (Post IRB Approval)
177
16
HOUSEMATE OR ROOMMATE
17
TENANT, BOARDER, OR EXCHANGE STUDENT
18
OTHER RELATIVE
19
OTHER NONRELATIVE
DK/REF
[R SEX] IF MRELATON = 1 AND QD01 = 9, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT IS MALE. EARLIER,
YOU RECORDED THE RESPONDENT’S SEX AS FEMALE. CONFIRM THE RESPONDENT’S
SEX, AND CORRECT THE ANSWER THAT WAS ENTERED INCORRECTLY.
CREATE ERROR BOX SO IT ALLOWS R TO GO TO EITHER ANSWER TO FIX IT.
[R AGE] IF MRELATON = 1 AND PERAGEYR DOES NOT EQUAL CURNTAGE, DISPLAY
ERROR BOX THAT SAYS: INTERVIEWER: YOU HAVE RECORDED THAT THE
RESPONDENT IS [FILL PERAGEYR]. EARLIER, THE RESPONDENT’S AGE WAS ENTERED
AS [FILL CURNTAGE]. PLEASE CONFIRM THE RESPONDENT’S AGE. IF YOU NEED TO
CORRECT THE AGE OR RELATIONSHIP GIVEN IN THE ROSTER, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWER YOU ENTERED IN THE
ROSTER IS CORRECT, HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
[NOTE: FI SHOULD ONLY BE ALLOWED TO CHANGE PERAGEYR AND MRELATON.]
SUPPMAGE
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
YOU HAVE CHOSEN TO SUPPRESS THIS ERROR.
ALLOW 200 CHARACTERS.
[GRANDPARENT YOUNGER THAN R] IF MRELATON = 11 AND PERAGEYR DOES NOT
EQUAL DK OR REF AND IS = OR < CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S GRANDFATHER IS
THE SAME AGE AS OR YOUNGER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH
THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPGDAD
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[GRANDCHILD OLDER THAN R] IF MRELATON = 12 AND PERAGEYR DOES NOT
EQUAL DK OR REF AND IS = OR > CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S GRANDSON IS THE
SAME AGE AS OR OLDER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH THE
RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION
Version 4 – February 2017 (Post IRB Approval)
178
NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT
“SUPPRESS” AND PRESS [ENTER].
SUPPGSON
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[SPOUSE/PARTNER < 16] IF MRELATON = 2 OR 15 OR 14 AND PERAGEYR = OR < 16,
DISPLAY ERROR BOX THAT SAYS: INTERVIEWER: YOU HAVE RECORDED THAT THE
RESPONDENT’S SPOUSE, EX-SPOUSE OR PARTNER IS 16 YEARS OLD OR YOUNGER.
PLEASE VERIFY THIS WITH THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY,
HIGHLIGHT THAT QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE
CORRECT AS IS, HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPHUS
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[IN-LAW < 16] IF MRELATON = 8 OR 4 AND PERAGEYR = OR < 16, DISPLAY ERROR BOX
THAT SAYS: INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S
[MRELATON] IS 16 YEARS OLD OR YOUNGER. PLEASE VERIFY THIS WITH THE
RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION
NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT
“SUPPRESS” AND PRESS [ENTER].
SUPPMIL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[SON IN-LAW OLDER THAN R] IF MRELATON = 4 AND PERAGEYR DOES NOT EQUAL
DK OR REF AND IS = OR > CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S SON-IN-LAW IS THE
SAME AGE AS OR OLDER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH THE
RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION
NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT
“SUPPRESS” AND PRESS [ENTER].
SUPPSIL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
Version 4 – February 2017 (Post IRB Approval)
179
[FATHER IN-LAW YOUNGER THAN R] IF MRELATON = 8 AND PERAGEYR DOES NOT
EQUAL DK OR REF AND IS = OR < CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S FATHER-IN-LAW IS
THE SAME AGE AS OR YOUNGER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH
THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPPIL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
BTWNTYPE
[IF QD_AGE1 = AGE OF THIS HOUSEHOLD MEMBER AND
MRELATON=5] Is he your identical twin, fraternal twin, or neither?
1
IDENTICAL TWIN
2
FRATERNAL TWIN
3
NEITHER
DK/REF
FRELATON
[IF CHMONSEX OR CHYRSEX OR PERYRSEX OR PERSEX = 9] IF QD01
= 9] IF IT IS CLEAR THAT RESPONDENT IS TALKING ABOUT
HERSELF: ASK “Is that you?” IF YES, ENTER “1” for “SELF”.
IF RESPONDENT IS NOT TALKING ABOUT SELF: HAND R
SHOWCARD 6. Please look at this card and tell me which category best
describes her relationship to you.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
SELF
WIFE
DAUGHTER (INCLUDES STEP, FOSTER, ADOPTIVE)
DAUGHTER-IN-LAW
SISTER (INCLUDES HALF, STEP, FOSTER, ADOPTIVE)
SISTER-IN-LAW
MOTHER (INCLUDES STEP, FOSTER, ADOPTIVE)
MOTHER-IN-LAW
AUNT
NIECE
GRANDMOTHER
GRANDDAUGHTER
COUSIN
EX-WIFE
UNMARRIED PARTNER
HOUSEMATE OR ROOMMATE
TENANT, BOARDER, OR EXCHANGE STUDENT
Version 4 – February 2017 (Post IRB Approval)
180
18
OTHER RELATIVE
19
OTHER NONRELATIVE
DK/REF
[R SEX] IF FRELATON = 1 AND QD01 = 5, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT IS FEMALE. EARLIER,
YOU RECORDED THE RESPONDENT’S SEX AS MALE. CONFIRM THE RESPONDENT’S
SEX, AND CORRECT THE ANSWER THAT WAS ENTERED INCORRECTLY.
CREATE ERROR BOX SO IT ALLOWS R TO GO TO EITHER ANSWER TO FIX IT.
[R AGE] IF FRELATON = 1 AND PERAGEYR DOES NOT EQUAL CURNTAGE, DISPLAY
ERROR BOX THAT SAYS: INTERVIEWER: YOU HAVE RECORDED THAT THE
RESPONDENT IS [FILL PERAGEYR]. EARLIER, THE RESPONDENT’S AGE WAS ENTERED
AS [FILL CURNTAGE]. PLEASE CONFIRM THE RESPONDENT’S AGE. IF YOU NEED TO
CORRECT THE AGE OR RELATIONSHIP GIVEN IN THE ROSTER, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWER YOU ENTERED IN THE
ROSTER IS CORRECT, HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
[NOTE: FI SHOULD ONLY BE ALLOWED TO CHANGE PERAGEYR AND FRELATON.]
SUPPFAGE
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
YOU HAVE CHOSEN TO SUPPRESS THIS ERROR.
ALLOW 200 CHARACTERS.
[GRANDPARENT YOUNGER THAN R] IF FRELATON = 11 AND PERAGEYR DOES NOT
EQUAL DK OR REF AND IS = OR < CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S GRANDMOTHER IS
THE SAME AGE AS OR YOUNGER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH
THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPGMOM
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[GRANDCHILD OLDER THAN R] IF FRELATON = 12 AND PERAGEYR DOES NOT EQUAL
DK OR REF AND IS = OR > CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S GRANDDAUGHTER
IS THE SAME AGE AS OR OLDER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH
THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
Version 4 – February 2017 (Post IRB Approval)
181
SUPPGDAU
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[SPOUSE/PARTNER < 16] IF FRELATON = 2 OR 15 OR 14 AND PERAGEYR = OR < 16,
DISPLAY ERROR BOX THAT SAYS: INTERVIEWER: YOU HAVE RECORDED THAT THE
RESPONDENT’S SPOUSE, EX-SPOUSE, OR PARTNER IS 16 YEARS OLD OR YOUNGER.
PLEASE VERIFY THIS WITH THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY,
HIGHLIGHT THAT QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE
CORRECT AS IS, HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPWIF
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[IN-LAW < 16] IF FRELATON = 8 OR 4 AND PERAGEYR = OR < 16, DISPLAY ERROR BOX
THAT SAYS: INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S
[FRELATON] IS 16 YEARS OLD OR YOUNGER. PLEASE VERIFY THIS WITH THE
RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION
NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT
“SUPPRESS” AND PRESS [ENTER].
SUPPFIL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[DAUGHTER IN-LAW OLDER THAN R] IF FRELATON = 4 AND PERAGEYR DOES NOT
EQUAL DK OR REF AND IS = OR > CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S DAUGHTER-IN-LAW
IS THE SAME AGE AS OR OLDER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH
THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPDIL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
Version 4 – February 2017 (Post IRB Approval)
182
[MOTHER IN-LAW YOUNGER THAN R] IF FRELATON = 8 AND PERAGEYR DOES NOT
EQUAL DK OR REF AND IS = OR < CURNTAGE, DISPLAY ERROR BOX THAT SAYS:
INTERVIEWER: YOU HAVE RECORDED THAT THE RESPONDENT’S MOTHER-IN-LAW IS
THE SAME AGE AS OR YOUNGER THAN THE RESPONDENT. PLEASE VERIFY THIS WITH
THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPGIL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
FTWNTYPE
[IF QD_AGE1 = AGE OF THIS HOUSEHOLD MEMBER AND
FRELATON=5] Is she your identical twin, fraternal twin, or neither?
1
IDENTICAL TWIN
2
FRATERNAL TWIN
3
NEITHER
DK/REF
MBRSELCT
[IF QD_FIPE1 = 1 AND MRELATON NE 1 AND FRELATON NE 1 AND
PERAGEYR = (12 OR OLDER OR DK/REF) AND MBRSELCT NE 1 FOR A
PREVIOUS ROSTER MEMBER] WAS THIS HOUSEHOLD MEMBER
ALSO SELECTED TO BE INTERVIEWED? (IF YOU ARE UNSURE,
ATTEMPT TO VERIFY WITH THIS RESPONDENT.)
1
YES
2
NO
DK/REF
RETURN TO PERAGEYR AND CYCLE THROUGH THE QUESTIONS FOR THE NEXT
HOUSEHOLD MEMBER. CONTINUE CYCLES UNTIL THE NUMBER OF CYCLES = THE
NUMBER REPORTED IN HR1.
[OTHER HH MEMBER SELECTED FOR INTERVIEW] IF QD_FIPE1 = 1 AND MBRSELCT
= 2 FOR ALL HOUSEHOLD MEMBERS, DISPLAY ERROR BOX: INTERVIEWER: EARLIER,
YOU RECORDED THAT TWO PEOPLE WERE SELECTED AT THIS HOUSEHOLD. THE
HOUSEHOLD ROSTER DOES NOT SHOW ANYONE LISTED AS THE SECOND
RESPONDENT. PLEASE VERIFY THE NUMBER OF PEOPLE SELECTED AT THIS
HOUSEHOLD, AND FIX THE APPROPRIATE ANSWER. IF YOU NEED TO CORRECT AN
ENTRY, HIGHLIGHT THAT QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS
ARE CORRECT AS IS, HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
PROGRAMMER: ONLY ALLOW EDITING OF MBRSELCT.
Version 4 – February 2017 (Post IRB Approval)
183
SUPPHHME
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
YOU HAVE CHOSEN TO SUPPRESS THIS ERROR.
ALLOW 200 CHARACTERS.
[MORE THAN 1 SELF] NOTE TO PROGRAMMERS: ONCE MRELATON OR FRELATON = 1,
PLEASE IMPLEMENT A HARD ERROR TO OCCUR IF THE FI ATTEMPTS TO ENTER A “1"
FOR EITHER OF THESE VARIABLES FOR SUBSEQUENT HOUSEHOLD MEMBERS. THE
MESSAGE BOX SHOULD READ: INTERVIEWER: YOU HAVE ALREADY RECORDED
“SELF” AS THE RELATIONSHIP FOR ANOTHER MEMBER OF THIS HOUSEHOLD. “SELF”
CAN ONLY BE CODED FOR ONE MEMBER OF THIS HOUSEHOLD. REVIEW YOUR
ENTRIES, AND CORRECT THE APPROPRIATE RELATIONSHIPS AS NECESSARY.
[MORE THAN 1 SPOUSE/PARTNER] NOTE TO PROGRAMMERS: ONCE MRELATON OR
FRELATON = 2 OR 15, PLEASE IMPLEMENT A HARD ERROR TO OCCUR IF THE FI
ATTEMPTS TO ENTER A “2” OR “15” FOR EITHER OF THESE VARIABLES FOR
SUBSEQUENT HOUSEHOLD MEMBERS. THE MESSAGE BOX SHOULD READ:
INTERVIEWER: YOU HAVE RECORDED THAT THIS IS THE RESPONDENT’S
[WIFE/HUSBAND/UNMARRIED PARTNER]. EARLIER, YOU ENTERED THAT THE
RESPONDENT ALREADY HAS [A/AN] [WIFE/HUSBAND/UNMARRIED PARTNER]. IF YOU
NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION NUMBER AND PRESS
[ENTER]. IF THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT “SUPPRESS” AND PRESS
[ENTER].
SUPPMULT
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[16-YEAR-OLD R MARRIED/COHABITATING] IF CURNTAGE = OR < 16, AND ANY
FRELATON OR MRELATON = 2 OR 14 OR 15, DISPLAY ERROR BOX: INTERVIEWER: YOU
HAVE ENTERED THAT THE [CURNTAGE]-YEAR-OLD RESPONDENT HAS BEEN MARRIED
OR COHABITATING. PLEASE VERIFY THIS WITH THE RESPONDENT. IF YOU NEED TO
CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION NUMBER AND PRESS [ENTER]. IF
THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPRMC
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[16-YEAR-OLD R HAS IN-LAW] IF CURNTAGE = OR < 16, AND ANY FRELATON OR
MRELATON = 8 OR 4, DISPLAY ERROR BOX: INTERVIEWER: YOU HAVE ENTERED THAT
THE [CURNTAGE]-YEAR-OLD RESPONDENT HAS AN IN-LAW. PLEASE VERIFY THIS
WITH THE RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT
Version 4 – February 2017 (Post IRB Approval)
184
QUESTION NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS,
HIGHLIGHT “SUPPRESS” AND PRESS [ENTER].
SUPPRINL
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
[GRANDPARENT/GRANDCHILD AND R LESS THAN 30 YEARS APART] IF FRELATON
OR MRELATON = (12 OR 11) AND PERAGEYR NE DK/REF AND IS 0–29 YEARS > OR <
CURNTAGE, DISPLAY ERROR BOX THAT SAYS: INTERVIEWER: YOU HAVE RECORDED
THAT THE RESPONDENT’S [GRANDPARENT/GRANDCHILD] IS LESS THAN 30 YEARS
[OLDER/YOUNGER] THAN THE RESPONDENT. PLEASE VERIFY THIS WITH THE
RESPONDENT. IF YOU NEED TO CORRECT AN ENTRY, HIGHLIGHT THAT QUESTION
NUMBER AND PRESS [ENTER]. IF THE ANSWERS ARE CORRECT AS IS, HIGHLIGHT
“SUPPRESS” AND PRESS [ENTER].
SUPPGR30
[IF FI CHOOSES TO SUPPRESS THE HARD ERROR ABOVE]
INTERVIEWER: PLEASE PROVIDE A BRIEF EXPLANATION FOR WHY
THE ANSWERS YOU HAVE ENTERED ARE CORRECT AS IS.
ALLOW 200 CHARACTERS.
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
185
34.
Proxy Information
BEGIN TIME STAMP
PROXYINT The next questions are about your medications, health insurance coverage, and the
kinds and amounts of income that you [IF FAMILY MEMBERS IN ROSTER THEN
FILL “and your family”] receive. This information will help in planning health care
services and finding ways to lower costs of care.
PRESS “1” AND [ENTER] TO CONTINUE.
FAMLY
IF HR1 = 1, SKIP TO HI_1
IF MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN
HOUSEHOLD, SKIP TO HI_1.
DEFINE FAMILY RELATIONSHIP FILLS
IF EXACTLY 1 IN ROSTER = (MRELATON = 2), FILL = “husband”
IF MORE THAN 1 IN ROSTER = (MRELATON = 2), FILL = “husbands”
IF EXACTLY 1 IN ROSTER = (MRELATON = 3), FILL = “son”
IF MORE THAN 1 IN ROSTER = (MRELATON = 3 AND), FILL = “sons”
IF EXACTLY 1 IN ROSTER = (MRELATON = 4), FILL = “son-in-law”
IF MORE THAN 1 IN ROSTER = (MRELATON = 4), FILL = “sons-in-law”
IF EXACTLY 1 IN ROSTER = (MRELATON = 5), FILL = “brother”
IF MORE THAN 1 IN ROSTER = (MRELATON = 5), FILL = “brothers”
IF EXACTLY 1 IN ROSTER = (MRELATON = 6), FILL = “brother-in-law”
IF MORE THAN 1 IN ROSTER = (MRELATON = 6), FILL = “brothers-in-law”
IF EXACTLY 1 IN ROSTER = (MRELATON = 7), FILL = “father”
IF MORE THAN 1 IN ROSTER = (MRELATON = 7), FILL = “fathers”
IF EXACTLY 1 IN ROSTER = (MRELATON = 8), FILL = “father-in-law”
IF MORE THAN 1 IN ROSTER = (MRELATON = 8), FILL = “fathers-in-law”
IF EXACTLY 1 IN ROSTER = (MRELATON = 9), FILL = “uncle”
IF MORE THAN 1 IN ROSTER = (MRELATON = 9), FILL = “uncles”
IF EXACTLY 1 IN ROSTER = (MRELATON = 10), FILL = “nephew”
IF MORE THAN 1 IN ROSTER = (MRELATON = 10), FILL = “nephews”
IF EXACTLY 1 IN ROSTER = (MRELATON = 11), FILL = “grandfather”
IF MORE THAN 1 IN ROSTER = (MRELATON = 11), FILL = “grandfathers”
Version 4 – February 2017 (Post IRB Approval)
186
IF EXACTLY 1 IN ROSTER = (MRELATON = 12), FILL = “grandson”
IF MORE THAN 1 IN ROSTER = (MRELATON = 12), FILL = “grandsons”
IF EXACTLY 1 IN ROSTER = (MRELATON = 13), FILL = “male cousin”
IF MORE THAN 1 IN ROSTER = (MRELATON = 13), FILL = “male cousins”
IF EXACTLY 1 IN ROSTER = (MRELATON = 14), FILL = “ex-husband”
IF MORE THAN 1 IN ROSTER = (MRELATON = 14), FILL = “ex-husbands”
IF EXACTLY 1 IN ROSTER = (MRELATON = 15 OR FRELATON = 15), FILL = “partner”
IF MORE THAN 1 IN ROSTER = (MRELATON = 15 OR FRELATON = 15), FILL = “partners”
IF EXACTLY 1 IN ROSTER = (MRELATON = 18), FILL = “other male relative”
IF MORE THAN 1 IN ROSTER = (MRELATON = 18), FILL = “other male relatives”
IF EXACTLY 1 IN ROSTER = (FRELATON = 2), FILL = “wife”
IF MORE THAN 1 IN ROSTER = (FRELATON = 2), FILL = “wives”
IF EXACTLY 1 IN ROSTER = (FRELATON = 3), FILL = “daughter”
IF MORE THAN 1 IN ROSTER = (FRELATON = 3), FILL = “daughters”
IF EXACTLY 1 IN ROSTER = (FRELATON = 4), FILL = “daughter-in-law”
IF MORE THAN 1 IN ROSTER = (FRELATON = 4), FILL = “daughters-in-law”
IF EXACTLY 1 IN ROSTER = (FRELATON = 5), FILL = “sister”
IF MORE THAN 1 IN ROSTER = (FRELATON = 5), FILL = “sisters”
IF EXACTLY 1 IN ROSTER = (FRELATON = 6), FILL = “sister-in-law”
IF MORE THAN 1 IN ROSTER = (FRELATON = 6), FILL = “sisters-in-law”
IF EXACTLY 1 IN ROSTER = (FRELATON = 7), FILL = “mother”
IF MORE THAN 1 IN ROSTER = (FRELATON = 7), FILL = “mothers”
IF EXACTLY 1 IN ROSTER = (FRELATON = 8), FILL = “mother-in-law”
IF MORE THAN 1 IN ROSTER = (FRELATON = 8), FILL = “mothers-in-law”
IF EXACTLY 1 IN ROSTER = (FRELATON = 9), FILL = “aunt”
IF MORE THAN 1 IN ROSTER = (FRELATON = 9), FILL = “aunts”
IF EXACTLY 1 IN ROSTER = (FRELATON = 10), FILL = “niece”
IF MORE THAN 1 IN ROSTER = (FRELATON = 10), FILL = “nieces”
IF EXACTLY 1 IN ROSTER = (FRELATON = 11), FILL = “grandmother”
IF MORE THAN 1 IN ROSTER = (FRELATON = 11), FILL = “grandmothers”
IF EXACTLY 1 IN ROSTER = (FRELATON = 12), FILL = “granddaughter”
IF MORE THAN 1 IN ROSTER = (FRELATON = 12), FILL = “granddaughters”
Version 4 – February 2017 (Post IRB Approval)
187
IF EXACTLY 1 IN ROSTER = (FRELATON = 13), FILL = “female cousin”
IF MORE THAN 1 IN ROSTER = (FRELATON = 13), FILL = “female cousins”
IF EXACTLY 1 IN ROSTER = (FRELATON = 14), FILL = “ex-wife”
IF MORE THAN 1 IN ROSTER = (FRELATON = 14), FILL = “ex-wives”
IF EXACTLY 1 IN ROSTER = (FRELATON = 18), FILL = “other female relative”
IF MORE THAN 1 IN ROSTER = (FRELATON = 18), FILL = “other female relatives”
[NOTE TO PROGRAMMERS: FAMILY RELATIONSHIP FILLS should be taken from the roster.
They should appear in lowercase and be separated by commas. In QP01, INTROINC, and INTROFI1,
the last FAMILY RELATIONSHIP FILL should be preceded by the word “and”. In all other
situations, the last FAMILY RELATIONSHIP FILL should be preceded by the word “or”. For
example, if a respondent has a father and a husband listed in the roster, INTROINC should read,
“These next questions are about the kinds and amounts of income received by your family living here,
including you, your father, and your husband.”]
HR2
[IF HR1 > 1 AND RESPONDENT IS ONLY FAMILY MEMBER 18 OR OLDER
AND ALL PERAGEYR NE DK/REF, SKIP TO HI_1]
[IF ROSTER HAS MORE THAN 1 ADULT FAMILY MEMBER LISTED AND ALL
PERAGEYR NE DK/REF] {FILL ONLY ADULT FAMILY MEMBERS
(PERAGEYR > 17) IN THIS QUESTION} I have listed as adult family members who
live here: your [FAMILY RELATIONSHIP FILLS]. Do you think one of these people
would be better able to give me the correct information about your medications, health
insurance coverage and the kinds of income you and your family receive?
[IF ROSTER HAS ONLY 1 ADULT FAMILY MEMBER LISTED] {FILL ONLY
ADULT FAMILY MEMBERS (PERAGEYR > 17) IN THIS QUESTION} Do you
think your [FAMILY RELATIONSHIP FILL] would be better able to give me the
correct information about your medications, health insurance coverage and the kinds of
income you and your family receive?
[IF ROSTER HAS NO FAMILY MEMBER OTHER THAN THE RESPONDENT
LISTED AS 18 OR OLDER, BUT THERE IS AT LEAST 1 DK OR REF ENTERED
FOR ANY PERAGEYR OR THERE IS MORE THAN 1 ADULT LISTED AND AT
LEAST 1 DK/REF ENTERED FOR ANY PERAGEYR] Is there anyone else who lives
here who is 18 or older who would be better able to give me the correct information
about your medications, health insurance coverage and the kinds of income you and
your family receive?
1
2
YES
NO [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
DK/REF [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
Version 4 – February 2017 (Post IRB Approval)
188
HR3
[IF HR2 = 1 AND MORE THAN 1 ADULT FAMILY MEMBER IN ROSTER] (Who
is the person you think can help us get the correct information for these questions?)
ENTER RELATIONSHIP OF PERSON WHO CAN BETTER ANSWER THESE
QUESTIONS.
[IF HR2 = 1 AND ONLY 1 ADULT FAMILY MEMBER IN ROSTER]
INTERVIEWER: ENTER “1”.
[FILL 1–9 WITH AGES AND RELATIONSHIPS FROM THE FIRST NINE ADULT
FAMILY MEMBERS OF THE HOUSEHOLD ROSTER, I.E., “father”. FILL
UNUSED LINES WITH “DO NOT USE”, AND MAKE THEM INVALID. IF
PERAGEYR = DK/REF AND MRELATON = 7, 8, OR 11 OR FRELATON = 7, 8,
OR 11, DISPLAY MRELATON/FRELATON IN HR3]
1
[ROSTER FILL]
2
[ROSTER FILL]
3
[ROSTER FILL]
4
[ROSTER FILL]
5
[ROSTER FILL]
6
[ROSTER FILL]
7
[ROSTER FILL]
8
[ROSTER FILL]
9
[ROSTER FILL]
10
OTHER ADULT RELATIVE
DK/REF
HR4
[IF HR2 = 1] (Is your [HR3 FILL] available right now?)
1
2
YES
NO [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
DK/REF [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
HR5
[IF HR4 = 1] (Would you ask your [HR3 FILL] to join us to help with these last
questions about medications, health insurance and income?)
1
2
YES
NO [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
DK/REF [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
HASJOIN
[IF HR5 = 1] HAS THE PERSON’S [HR3 FILL] JOINED R?
1
YES [ACTIVATE PROXYFILL AS “SAMPLE MEMBER/SAMPLE
MEMBER’S” FOR REMAINING QUESTIONS]
Version 4 – February 2017 (Post IRB Approval)
189
2
NO [ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING
QUESTIONS]
IF HASJOIN = 1, GO TOPROXY.
IF HASJOIN NE 1, GO TO DEFINE SAMPLE MEMBER.
HR6
[IF (HR4 = 2 OR DK/REF OR HR5 = 2 OR DK/REF OR HASJOIN = 2) AND
ADULTFAMRELCOUNT > 1] Is there any other adult family member available who
might be able to answer these questions?
1
YES
2
NO
DK/REF
IF HR6 = YES THEN RETURN TO HR3.
PROGRAMMER NOTE: IF HR2 = 2 OR DK/REF OR HR3 = 2 OR DR/REF OR HR4 = 2 OR
DK/REF OR HR5 = 2 OR DK/REF OR HASJOIN = 2 OR HRP4 = 2 OR DK/REF, THEN
ACTIVATE PROXYFILL AS “YOU/YOUR” FOR REMAINING QUESTIONS.
OVERVIEW OF SAMPLE MEMBER FILLS
Fill Name
Direct Fill
SAMPLE MEMBER
you
SAMPLE MEMBER POSS
your
SAMPLE MEMBER POSSPRO your
SAMPLE MEMBER A
Are you
SAMPLE MEMBER B
you are
SAMPLE MEMBER C
have you
SAMPLE MEMBER CC
Have you
SAMPLE MEMBER D
you have
SAMPLE MEMBER E
you were
SAMPLE MEMBER E PRO
you were
Proxy Fills
your ____
your ____’s
his/her
Is your ____
your ___ is
has your ____
Has your ____
your ____ has
your ____ was
he/she was
DEFINE SAMPLE MEMBER
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLEMEMBER = “you”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER = “your husband”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER = “your father”
Version 4 – February 2017 (Post IRB Approval)
190
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER = “your father-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER = “your brother”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER = “your brother-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER = “your son”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER = “your son-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER = “your nephew”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER = “your uncle”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER = “your grandson”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER = “your grandfather”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “cousin” (FRELATON = 13 or MRELATON = 13),
SAMPLE MEMBER = “your cousin”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER = “your ex-husband”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER = “your partner”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER = “your relative”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER = “your husband”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER = “your mother”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER = “your mother-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER = “your sister”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER = “your sister-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER = “your daughter”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER = “your daughter-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER = “your niece”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER = “your aunt”
Version 4 – February 2017 (Post IRB Approval)
191
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER = “your granddaughter”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER = “your grandmother”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “cousin” (MRELATON = 13 or FRELATON = 13),
SAMPLE MEMBER = “your cousin”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER = “your ex-wife”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER = “your partner”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER = “your relative”
DEFINE SAMPLE MEMBER POSS
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLE MEMBER POSS = “your”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER POSS = “your husband’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER POSS = “your father’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER POSS = “your father-in-law’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER POSS = “your brother’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER POSS = “your brother-in-law’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER POSS = “your son’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER POSS = “your son-in-law’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER POSS = “your nephew’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER POSS = “your uncle’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER POSS = “your grandson’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER POSS = “your grandfather’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “cousin” (FRELATON = 13 or MRELATON = 13),
SAMPLE MEMBER = “your cousin’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER POSS= “your ex-husband’s”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER POSS = “your partner’s”
Version 4 – February 2017 (Post IRB Approval)
192
IF QD01 = 5 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER POSS = “your relative’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER POSS = “your wife’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER POSS = “your mother’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER POSS = “your mother-in-law’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER POSS = “your sister’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER POSS = “your sister-in-law’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER POSS = “your daughter’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER POSS = “your daughter-in-law’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER POSS = “your niece’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER POSS = “your aunt”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER POSS = “your granddaughter’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER POSS = “your grandmother’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “cousin” (MRELATON = 13 or FRELATON = 13),
SAMPLE MEMBER POSS= “your cousin”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER POSS= “your ex-wife’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER POSS = “your partner’s”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER POSS = “your relative’s”
DEFINE SAMPLE MEMBER POSSPRO
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLE MEMBER POSSPRO = “your”
IF QD01 = 5, SAMPLE MEMBER POSSPRO = “his”
IF QD01 = 9, SAMPLE MEMBER POSSPRO = “her”
DEFINE SAMPLE MEMBER A
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLE MEMBER A = “Are you”
Version 4 – February 2017 (Post IRB Approval)
193
IF QD01 = 5 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER A = “Is your husband”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER A = “Is your father”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER A = “Is your father-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER A = “Is your brother”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER A = “Is your brother-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER A = “Is your son”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER A = “Is your son-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “niece”
(FRELATON = 9, SAMPLE MEMBER A = “Is your nephew”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER A = “Is your uncle”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER A = “Is your grandson”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER A = “Is your grandfather”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “cousin” (FRELATON = 13 or MRELATON = 13),
SAMPLE MEMBER = “Is your cousin”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER A = “Is your ex-husband”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER A = “Is your partner”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER A = “Is your relative”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER A = “Is your wife”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER A = “Is your mother”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER A = “Is your mother-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER A = “Is your sister”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER A = “Is your sister-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER A = “Is your daughter”
Version 4 – February 2017 (Post IRB Approval)
194
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER A = “Is your daughter-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER A = “Is your niece”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER A = “Is your aunt”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER A = “Is your granddaughter”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER A = “Is your grandmother”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “cousin” (MRELATON = 13 or FRELATON = 13),
SAMPLE MEMBER A = “Is your cousin”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER A = “Is your ex-wife”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER A = “Is your partner”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER A = “Is your relative”
DEFINE SAMPLE MEMBER B
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLE MEMBER B = “you are”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER B = “your husband is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER B = “your father is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER B = “your father-in-law is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER B = “your brother is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER B = “your brother-in-law is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER B = “your son is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER B = “your son-in-law is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER B = “your nephew is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER B = “your uncle is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER B = “your grandson is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER B = “your grandfather is”
Version 4 – February 2017 (Post IRB Approval)
195
IF QD01 = 5 AND SELECTED FILL IN HR3 = “cousin” (FRELATON = 13 or MRELATON = 13),
SAMPLE MEMBER = “your cousin is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER B = “your ex-husband is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER B = “your partner is”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER B = “your relative is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER B = “your wife is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER B = “your mother is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER B = “your mother-in-law is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER B = “your sister is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER B = “your sister-in-law is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER B = “your daughter is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER B = “your daughter-in-law is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER B = “your niece is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER B = “your aunt is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER B = “your granddaughter is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER B = “your grandmother is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “cousin” (MRELATON = 13 or FRELATON = 13),
SAMPLE MEMBER B= “your cousin is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER B= “your ex-wife is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER B = “your partner is”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER B = “your relative is”
DEFINE SAMPLE MEMBER C
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLE MEMBER C = “have you”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER C = “has your husband”
Version 4 – February 2017 (Post IRB Approval)
196
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER C = “has your father”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER C = “has your father-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER C = “has your brother”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER C = “has your brother-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER C = “has your son”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER C = “has your son-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “niece”
(FRELATON = 9, SAMPLE MEMBER C = “has your nephew”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER C = “has your uncle”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER C = “has your grandson”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER C = “has your grandfather”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “cousin” (FRELATON = 13 or MRELATON = 13),
SAMPLE MEMBER = “has your cousin”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER C = “has your ex-husband”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER C = “has your partner”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER C = “has your relative”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER C = “has your wife”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER C = “has your mother”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER C = “has your mother-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER C = “has your sister”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER C = “has your sister-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER C = “has your daughter”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER C = “has your daughter-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER C = “has your niece”
Version 4 – February 2017 (Post IRB Approval)
197
IF QD01 = 9 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER C = “has your aunt”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER C = “has your granddaughter”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER C = “has your grandmother”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “cousin” (MRELATON = 13 or FRELATON = 13),
SAMPLE MEMBER C= “has your cousin”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER C= “has your ex-wife”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER C = “has your partner”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER C = “has your relative”
DEFINE SAMPLE MEMBER CC
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLE MEMBER CC = “Have you”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER CC = “Has your husband”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER CC = “Has your father”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER CC = “Has your father-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER CC = “Has your brother”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER CC = “Has your brother-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER CC = “Has your son”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER CC = “Has your son-in-law”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “niece”
(FRELATON = 9, SAMPLE MEMBER CC = “Has your nephew”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER CC = “Has your uncle”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER CC = “Has your grandson”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER CC = “Has your grandfather”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “cousin” (FRELATON = 13 or MRELATON = 13),
SAMPLE MEMBER = “Has your cousin”
Version 4 – February 2017 (Post IRB Approval)
198
IF QD01 = 5 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER CC= “Has your ex-husband”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER CC = “Has your partner”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER CC = “Has your relative”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER CC = “Has your wife”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER CC = “Has your mother”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER CC = “Has your mother-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER CC = “Has your sister”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER CC = “Has your sister-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER CC = “Has your daughter”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER CC = “Has your daughter-in-law”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER CC = “Has your niece”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER CC = “Has your aunt”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER CC = “Has your granddaughter”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER CC = “Has your grandmother”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “cousin” (MRELATON = 13 or FRELATON = 13),
SAMPLE MEMBER CC= “Has your cousin”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER CC= “Has your ex-wife”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER CC = “Has your partner”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER CC = “Has your relative”
DEFINE SAMPLE MEMBER D
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLE MEMBER D = “you have”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER D = “your husband has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER D = “your father has”
Version 4 – February 2017 (Post IRB Approval)
199
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER D = “your father-in-law has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER D = “your brother has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER D = “your brother-in-law has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER D = “your son has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER D = “your son-in-law has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “niece”
(FRELATON = 9, SAMPLE MEMBER D = “your nephew has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER D = “your uncle has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER D = “your grandson has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER D = “your grandfather has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “cousin” (FRELATON = 13 or MRELATON = 13),
SAMPLE MEMBER = “your cousin has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER = “your ex-husband has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER D = “your partner has”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER D = “your relative has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER D = “your wife has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER D = “your mother has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER D = “your mother-in-law has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER D = “your sister has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER D = “your sister-in-law has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER D = “your daughter has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER D = “your daughter-in-law has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER D = “your niece has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER D = “your aunt has”
Version 4 – February 2017 (Post IRB Approval)
200
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER D = “your granddaughter has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER D = “your grandmother has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “cousin” (MRELATON = 13 or FRELATON = 13),
SAMPLE MEMBER = “your cousin has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER = “your ex-wife has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER D = “your partner has”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER D = “your relative has”
DEFINE SAMPLE MEMBER E
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLE MEMBER E = “you were”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER E = “your husband was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER E = “your father was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER E = “your father-in-law was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER E = “your brother was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER E = “your brother-in-law was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER E = “your son was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER E = “your son-in-law was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “niece”
(FRELATON = 9, SAMPLE MEMBER E = “your nephew was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER E = “your uncle was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER E = “your grandson was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER E = “your grandfather was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “cousin” (FRELATON = 13 or MRELATON = 13),
SAMPLE MEMBER = “your cousin was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER E = “your ex-husband was”
Version 4 – February 2017 (Post IRB Approval)
201
IF QD01 = 5 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER E = “your partner was”
IF QD01 = 5 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER E = “your relative was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “husband” (MRELATON = 2) OR “wife”
(FRELATON = 2), SAMPLE MEMBER E = “your wife was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son” (MRELATON = 3) OR “daughter”
(FRELATON = 3), SAMPLE MEMBER E = “your mother was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “son-in-law” (MRELATON = 4) OR “daughter-inlaw” (FRELATON = 4), SAMPLE MEMBER E = “your mother-in-law was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother” (MRELATON = 5) OR “sister”
(FRELATON = 5), SAMPLE MEMBER E = “your sister was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “brother-in-law” (MRELATON = 6) OR “sister-inlaw” (FRELATON = 6), SAMPLE MEMBER E = “your sister-in-law was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father” (MRELATON = 7) OR “mother”
(FRELATON = 7), SAMPLE MEMBER E = “your daughter was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “father-in-law” (MRELATON = 8) OR “mother-inlaw” (FRELATON = 8), SAMPLE MEMBER E = “your daughter-in-law was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “uncle” (MRELATON = 9) OR “aunt” (FRELATON
= 9, SAMPLE MEMBER E = “your niece was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “nephew” (MRELATON = 10) OR “niece”
(FRELATON = 10), SAMPLE MEMBER E = “your aunt was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandfather” (MRELATON = 11) OR
“grandmother” (FRELATON = 11), SAMPLE MEMBER E = “your granddaughter was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “grandson” (MRELATON = 12) OR
“granddaughter” (FRELATON = 12), SAMPLE MEMBER E = “your grandmother was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “cousin” (MRELATON = 13 or FRELATON = 13),
SAMPLE MEMBER E= “your cousin was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “ex-husband” (MRELATON = 14) OR “ex-wife”
(FRELATON = 14), SAMPLE MEMBER E= “your ex-wife was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “partner” (MRELATON = 15 OR FRELATON =
15), SAMPLE MEMBER E = “your partner was”
IF QD01 = 9 AND SELECTED FILL IN HR3 = “other male relative” (MRELATON = 18) OR “other
female relative” (FRELATON = 18), SAMPLE MEMBER E = “your relative was”
DEFINE SAMPLE MEMBER E PRO
IF HR1 = 1 OR (MRELATON = 16 OR MRELATON = 17 OR MRELATON = 19 OR FRELATON
= 16 OR FRELATON = 17 OR FRELATON = 19 FOR ALL PERSONS IN HOUSEHOLD) OR
HASJOIN = 2, SAMPLE MEMBER POSSPRO = “you were”
IF QD01 = 5, SAMPLE MEMBER POSSPRO = “he was”
IF QD01 = 9, SAMPLE MEMBER POSSPRO = “she was”
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
202
35.
Pharmacoepidemiology
BEGIN TIME STAMP
DEFINE PH_CAPI
IF CURNTAGE<18, THEN PH_CAPI=1.
ELSE, PH_CAPI=0.
PH0
PH0a
PH0b
PH0c
PH0d
PH0e
DK/REF
The next questions are about [SAMPLE MEMBER POSS] use of medicines.
[SAMPLE MEMBER CC] ever taken any of the following types of prescription
medications under the supervision of a doctor, for [SAMPLE MEMBER POSSPRO]
emotions or behavior or mental health?
Sleeping pills or other sedatives, such as Ambien or Sonata
Antidepressant medications, such as Prozac or Zoloft
Tranquilizers, such as Xanax or Ativan
Amphetamines or other stimulants, such as Ritalin or dextroamphetamine
Antipsychotic medications, such as Haldol or Risperdal
Yes
1
1
1
1
1
No
2
2
2
2
2
DEFINE PH_EVERMEDL
IF (PH0a OR PH0b OR PH0c OR PH0d OR PH0e) = 1, THEN PH_EVERMEDL=1
ELSE, PH_EVERMEDL=0
PH3
PH3a
PH3b
PH3c
PH3d
PH3e
DK/REF
[IF PH_EVERMEDL=1] In the past 12 months, did [SAMPLE MEMBER] take any
of the following types of prescription medications under the supervision of a doctor, for
[SAMPLE MEMBER POSSPRO] emotions or behavior or mental health?
Sleeping pills or other sedatives, such as Ambien or Sonata
Antidepressant medications, such as Prozac or Zoloft
Tranquilizers, such as Xanax or Ativan
Amphetamines or other stimulants, such as Ritalin or dextroamphetamine
Antipsychotic medications, such as Haldol or Risperdal
Yes
1
1
1
1
1
No
2
2
2
2
2
DEFINE PH_12MOMED
IF (PH3a OR PH3b OR PH3c OR PH3d OR PH3e) = 1 OR DK, THEN PH_12MOMED = 1
ALL ELSE, PH_12MOMED = 2
PH4
[IF PH_12MOMED = 2 AND (PH_EVERMEDL=1)] Did [SAMPLE MEMBER] take
any other type of prescription medicine in the past 12 months for problems with
Version 4 – February 2017 (Post IRB Approval)
203
[SAMPLE MEMBER POSSPRO] emotions, behavior, mental health, energy,
concentration, sleep, or ability to cope with stress? Include medicines even if
[SAMPLE MEMBER] took them only once.
1
Yes
2
No
DK/REF
DEFINE PH4a_FILL
IF PH_12MOMED = 2 AND PH4=2, THEN PH4a_FILL= “[SAMPLE MEMBER] last took a
prescription medication more than 12 months ago.”
IF PH12MOMED = 1, THEN PH4a_FILL= “”
PH4a
[IF (CURNTAGE<18) AND PH_EVERMEDL=1PH] HAND R SHOWCARD 4
On this card, each medicine has its own ID number.
[PH4a_FILL] What was the first prescription medication [SAMPLE MEMBER] ever
took for problems with [SAMPLE MEMBER POSSPRO] emotions, behavior, mental
health, energy, concentration, sleep, or ability to cope with stress?
Please tell me the number next to the medicine on the card for the medicine that
[SAMPLE MEMBER] took first and I will enter it into the computer.
If [SAMPLE MEMBER] first started taking more than one prescription medication at
the same time, tell me the numbers next to all the drugs [SAMPLE MEMBER] started
taking at that time.
IF RESPONDENT REPORTS PRESCRIPTION MEDICATIONS NOT INCLUDED
ON THE SHOWCARD, ENTER 990.
____________ MEDICINE ID NUMBERS FROM SHOWCARD 4 [RANGE 1–175]
PROGRAMMERS: ALLOW UP TO 20 ID NUMBERS
DK/REF
DEFINE PH5INTRO_FILL
IF PH_12MOMED = 2 AND PH4a IS NONMISSING, PH5INTRO_FILL= “Also include the
first medicine we just talked about, if [SAMPLE MEMBER] took it in the past 12 months.”
ELSE, PH5INTRO_FILL= “”
PH5INTRO
[IF PH_12MOMED = 1 OR PH4 = 1] HAND R SHOWCARD 4.
Version 4 – February 2017 (Post IRB Approval)
204
Please think about prescription medicines that [SAMPLE MEMBER] took in the
past 12 months for problems with [SAMPLE MEMBER POSSPRO] emotions,
nerves, mental health, energy, concentration, sleep, or ability to cope with stress.
Please tell me the number next to the medicine on the card for the medicine that
[SAMPLE MEMBER] took and I will enter it into the computer.
Include medicines even if [SAMPLE MEMBER] took them only once in the past 12
months. [PH5INTRO_FILL]
You can look at [SAMPLE MEMBER] prescription bottles if necessary.
If a prescription medicine is not included on Showcard 4, please tell me
Medicine ID
A prescription medicine you took in the past 12 months
for problems with your emotions, nerves, mental
health, energy, concentration, sleep, or ability to cope
with stress:
Another prescription medicine you took for any of
those problems in the past 12 months?
Another?
Another?
Another?
Another?
Another?
Another prescription medicine you took in the past 12
months for problems with your emotions, nerves,
mental health, energy, concentration, sleep, or ability
to cope with stress?
Another?
Another?
Another?
Another?
Another?
Another prescription medicine you took for any of
those problems in the past 12 months?
Another?
Another?
Another?
Another?
Another?
Another?
Version 4 – February 2017 (Post IRB Approval)
205
[RANGE 1 – 175, 990]
DK/REF
PROGRAMMERS: ALLOW UP TO 20 ID NUMBERS BUT HIDE LINES IN
THE GRID UNTIL THE IMMEDIATELY PREVIOUS LINE HAS BEEN FILLED
WITH A VALID ANSWER (IN RANGE).
IF THE RESPONDENT ANSWERS DK/REF, EXIT OUT OF THE QUESTION
GRID, BUT SAVE ANY ANSWERS ALREADY ENTERED INTO THE GRID.
DEFINE MEDFILL1 THROUGH MEDFILL20
FOR EACH CODE ENTERED, CREATE A FILL USING THE CORRESPONDING
MEDICINE NAME, AS SHOWN IN SHOWCARD 4.
FOR CODE 990, USE “a medicine that isn’t on Showcard 4”
IF FEWER THAN 20 CODES ENTERED, CONSIDER THE UNUSED FILLS AS
MISSING.
PH5_CKPT [IF SOME PH5INTRO1 FIELDS ARE IN RANGE (1-175 OR 990)] The computer
recorded that in the past 12 months [SAMPLE MEMBER] used the following prescription
medications, for problems with [SAMPLE MEMBER POSSPRO] emotions, nerves,
mental health, energy, concentration, sleep, or ability to cope with stress.
[PROGRAMMER: VERTICALLY LIST MEDFILL1 THROUGH MEDFILL20, WITH
ONE LINE FOR EACH NON-MISSING MEDFILL.]
Is this list correct?
[IF PH_CAPI=1, FILL: “ONLY READ OPTIONS ALOUD IF NECESSARY”]
1
Yes
2
No
DK/REF
HARD ERROR: [IF CKPT = 2] PRESS [ENTER] TO GO BACK TO PH5INTRO, SO THAT
THE RESPONDENT MAY CORRECT THE MEDICINE SELECTED.
Version 4 – February 2017 (Post IRB Approval)
206
SHOWCARD 4 (NOT TO BE INCLUDED IN PROGRAM)
1 -- ABILIFY
2 -- ABILIFY MAINTENA
3 -- ADDERAL
4 -- ADDERAL XR
5 -- ALPRAZOLAM
6 -- AMBIEN
7 -- AMITRIPTYLINE
30 -- CITALOPRAM
31 -- CLOMIPRAMINE
32 -- CLONAZEPAM
33 -- CLONIDINE
34 -- CLOZAPINE
35 -- CLOZARIL
36 -- COGENTIN
8 -- AMPHETAMINE
9 -- ANAFRANIL
10 -- ARIPIPRAZOLE
11 -- ARMODAFINIL
12 -- ARTANE
13 -- ASENAPINE
14 -- ATIVAN
15 -- ATOMOXETINE
16 -- BELSOMRA
17 -- BENZTROPINE
18 -- BRINTELLIX
37 -- CONCERTA
38-- CYMBALTA
39 -- CYTOMEL
40 -- DAYTRANA
41 -- DEPAKENE
42 -- DEPAKOTE
43 -- DEPAKOTE SPRINKLES
44 -- DESOXYN
45 -- DESVENLAFAXINE
46 -- DESYREL
47 -- DEXEDRINE
19 -- BUDEPRION SR
20 -- BUDEPRION XL
21 -- BUPROPION
48 -- DEXMETHYLPHENIDATE
49 -- DEXTROAMPHETAMINE
50 -- DEXTROAMPHETAMINE/
AMPHETAMINE
51 -- DIAZEPAM
52 -- DIVALPROEX
53 -- DOXEPIN
54 -- DULOXETINE
55 -- EFFEXOR
56 -- ELAVIL
57 -- ESCITALOPRAM
58 -- ESKALITH
117 -- PARNATE
118 -- PAROXETINE
119 -- PAXIL
120 -- PHENELZINE
121 -- PRAZOSIN
122 -- PREGABALIN
123 -- PRISTIQ
124 -- PROCENTRA
125 -- PROLIXIN
126 -- PROLIXIN DECANOATE
127 -- PROPRANOLOL
22 -- BUSPAR
23 -- BUSPIRONE
24 -- CARBAMAZEPINE
25 -- CARBATROL
26 -- CATAPRES
27 -- CELEXA
28 -- CHLORDIAZEPOZIDE
29 -- CHLORPROMAZINE
88 -- LEVOMILNACIPRAN
89 -- LEXAPRO
90 -- LIBRIUM
91 -- LISDEXAMFETAMINE
92 -- LITHIUM
93 -- LITHOBID
94 -- LORAZEPAM
95 -- LUNESTA
96 -- LURASIDONE
97 -- LUVOX
98 -- LYRICA
Version 4 – February 2017 (Post IRB Approval)
59 -- ESZOPICLONE
60 -- EVEKEO
61 -- FANAPT
62 -- FETZIMA
63 -- FLUOXETINE
64 -- FLUPHENAZINE
65 -- FLUPHENAZINE
DECANOATE
66 -- FLUVOXAMINE
67 -- FOCALIN
68 -- FORFIVO XL
69 -- GABAPENTIN
70 -- GABITRIL
71 -- GEODON
72 -- GUANFACINE
73 -- HALDOL
74 -- HALDOL DECANOATE
75 -- HALOPERIDOL
76 -- HALOPERIDOL
DECANOATE
77 -- HETLIOZ
78 -- ILOPERIDONE
79 -- INDERAL
80 -- INTUNIV
81 -- INVEGA
82 -- INVEGA SUSTENNA
83 -- ISOCARBOXAZID
84 -- KLONOPIN
85 -- LAMICTAL
86 -- LAMOTRIGINE
87 -- LATUDA
146 -- SUVOREXANT
147 -- TASIMELTEON
148 -- TEGRETOL
149 -- TEMAZEPAM.
150 -- TENEX
151 -- THORAZINE
152 -- TOPAMAX
153 -- TOPIRAMATE
154 -- TRANYLCYPROMINE
155 -- TRAZODONE
156 -- TRIHEXYPHENIDYL
207
99 -- MARPLAN
128 -- PROVIGIL
100 -- MELATONIN
101 -- METADATE
102 -- METHAMPHETAMINE
103 -- METHYLIN
104 -- METHYLPHENIDATE
105 -- MINIPRESS
106 -- MIRTRAZAPINE
107 -- MODAFINIL
108 -- NARDIL
109 -- NEURONTIN
110 -- NORTRIPTYLINE
111 -- NUVIGIL
112 -- OLANZAPINE
113 -- OXCARBAZEPINE
114 -- PALIPERIDONE
115 -- PALIPERIDONE
PALMITATE
(EXTENDED RELEASE
INJECTABLE)
116 -- PAMELOR
129 -- PROZAC
130 -- QUETIAPINE
131 -- QUILLIVANT XR
132 -- RAMELTEON
133 -- REMERON
134 -- RESTORIL
135 -- RISPERDAL
136 -- RISPERDAL CONSTA
137 -- RISPERIDONE
138 -- RITALIN
139 -- ROZEREM
140 -- SAPHRIS
141 -- SEROQUEL
142 -- SERTRALINE
143 -- SILENOR
144 -- SONATA
Version 4 – February 2017 (Post IRB Approval)
145 -- STRATTERA
157 -- TRIIODOTHYRONINE
(T3)
158 -- TRILEPTAL
159 -- VALIUM
160 -- VALPROIC ACID
161 -- VENLAFAXINE
162 -- VIIBRYD
163 -- VILAZODONE
164 -- VORTIOXETINE
165 -- VYVANSE
166 -- WELLBUTRIN
167 -- XANAX
168 -- ZALEPLON
169 -- ZENZEDI
170 -- ZIPRASIDONE
171 -- ZOLOFT
172 -- ZOLPIDEM
173 -- ZOLPIMIST
174 -- ZYPREXA
175 -- ZYPREXA RELPREVV
208
PH5_OT1 [IF PH5_CKPT=1 AND (LESS THAN 20 CODES ENTERED AT PH5INTRO) AND
(NONE OF THE CODES ENTERED AT PH5INTRO INCLUDE 990)] In the past 12
months [SAMPLE MEMBER C] used any other prescription medicine for problems
with [SAMPLE MEMBER POSSPRO] emotions, nerves, mental health, energy,
concentration, sleep, or ability to cope with stress?
[IF PH_CAPI=1, FILL: “ONLY READ OPTIONS ALOUD IF NECESSARY”]
1
Yes
2
No
DK/REF
DEFINE PH5_OT1A_FILL
IF PH5INTRO INCLUDES 990, THEN PH5_OT1A_FILL= “You indicated that [SAMPLE
MEMBER] used a prescription medicine in the past 12 months that doesn’t appear on Showcard 4.”
PH5_OT1A [IF PH5_OT1 = 1 OR (PH5INTRO INCLUDES 990)] [PH5_OT1A_FILL] Please tell
me the name of one prescription medicine [SAMPLE MEMBER D] used that doesn’t
appear on Showcard 4.
Please remember that we are only interested in prescription medicines that [SAMPLE
MEMBER D] taken for problems with [SAMPLE MEMBER POSSPRO] emotions,
nerves, mental health, energy, concentration, sleep, or ability to cope with stress.
If you’re not sure how to spell the name of the medicine, just make your best guess.
______________
PROGRAMMER: ALLOW 50 CHARACTERS
DK/REF
PROGRAMMER:
IF (PH5_OT1A NE MISSING OR DK OR REF) AND (PH5INTRO INCLUDES 990),
THEN USE PH5_OT1A TEXT TO REPLACE THE FILL TEXT FOR THE FIRST
990 ENTERED.
IF (PH5_OT1A NE MISSING OR DK OR REF) AND (PH5INTRO DID NOT
INCLUDE 990), THEN USE PH5_OT1A TEXT TO POPULATE A PREVIOUSLY
MISSING MEDFILL.
Version 4 – February 2017 (Post IRB Approval)
209
PH5_OT2
[IF PH5_OT1A NE (MISSING OR DK OR REF) AND (LESS THAN 19 CODES
ENTERED AT PH5INTRO)] In the past 12 months [SAMPLE MEMBER C] used any
other prescription medicine, other than those you’ve already reported, for problems
with [SAMPLE MEMBER POSSPRO] emotions, nerves, mental health, energy,
concentration, sleep, or ability to cope with stress?
1
Yes
2
No
DK/REF
PH5_OT2A [IF PH5_OT2=1] Please tell me the name of one more prescription medicine
[SAMPLE MEMBER D] used in the past 12 months for problems with [SAMPLE
MEMBER POSSPRO] emotions, nerves, mental health, energy, concentration, sleep,
or ability to cope with stress.
Only tell me the name of a medicine if you haven’t already reported it in an earlier
question.
______________
PROGRAMMER: ALLOW 50 CHARACTERS
DK/REF
PROGRAMMER:
IF (PH5_OT2A NE MISSING OR DK OR REF) AND (APH5INTRO INCLUDED AT
LEAST TWO 990 CODES), THEN USE PH5_OT2A TEXT TO REPLACE THE
FILL TEXT FOR THE SECOND 990 ENTERED.
IF (PH5_OT2A NE MISSING OR DK OR REF) AND (PH5INTRO DID NOT
INCLUDE AT LEAST TWO 990 CODES), THEN USE PH5_OT2A TEXT TO
POPULATE A PREVIOUSLY MISSING MEDFILL.
PH5_OT3
[PH5_OT2A NE (MISSING OR DK OR REF) AND (LESS THAN 18 CODES
ENTERED AT PH5INTRO)] In the past 12 months [SAMPLE MEMBER C] used any
other prescription medicine, other than those you’ve already reported, for problems
with [SAMPLE MEMBER POSSPRO] emotions, nerves, mental health, energy,
concentration, sleep, or ability to cope with stress?
1
Yes
2
No
DK/REF
Version 4 – February 2017 (Post IRB Approval)
210
PH5_OT3A [IF PH5_OT3=1] Please tell me the name of one more prescription medicine
[SAMPLE MEMBER D] used in the past 12 months for problems with [SAMPLE
MEMBER POSSPRO] emotions, nerves, mental health, energy, concentration, sleep,
or ability to cope with stress.
Only tell me the name of a medicine if you haven’t already reported it in an earlier
question.
______________
PROGRAMMER: ALLOW 50 CHARACTERS
DK/REF
PROGRAMMER:
IF (PH5_OT3A NE MISSING OR DK OR REF) AND (PH5INTRO INCLUDED AT
LEAST THREE 990 CODES), THEN USE PH5_OT3A TEXT TO REPLACE THE
FILL TEXT FOR THE THIRD 990 ENTERED.
IF (PH5_OT3A NE MISSING OR DK OR REF) AND (PH5INTRO DID NOT
INCLUDE AT LEAST THREE 990 CODES), THEN USE PH5_OT3A TEXT TO
POPULATE A PREVIOUSLY MISSING MEDFILL.
PH5_OT4
[PH5_OT3A NE (MISSING OR DK OR REF) AND (LESS THAN 17 CODES
ENTERED AT PH5INTRO)] In the past 12 months [SAMPLE MEMBER C] used
any other prescription medicine, other than those you’ve already reported, for
problems with [SAMPLE MEMBER POSSPRO] emotions, nerves, mental health,
energy, concentration, sleep, or ability to cope with stress?
1
Yes
2
No
DK/REF
PH5_OT4A [IF PH5_OT4=1] Please tell me the name of one more prescription medicine
[SAMPLE MEMBER D] used in the past 12 months for problems with [SAMPLE
MEMBER POSSPRO] emotions, nerves, mental health, energy, concentration, sleep,
or ability to cope with stress.
Only tell me the name of a medicine if you haven’t already reported it in an earlier
question.
______________
PROGRAMMER: ALLOW 50 CHARACTERS
DK/REF
PROGRAMMER:
Version 4 – February 2017 (Post IRB Approval)
211
PH5_OT5
IF (PH5_OT4A NE MISSING OR DK OR REF) AND (PH5INTRO INCLUDED AT
LEAST FOUR 990 CODES), THEN USE PH5_OT4A TEXT TO REPLACE THE
FILL TEXT FOR THE FOURTH 990 ENTERED.
IF (PH5_OT4A NE MISSING OR DK OR REF) AND (PH5INTRO DID NOT
INCLUDE AT LEAST FOUR 990 CODES), THEN USE PH5_OT4A TEXT TO
POPULATE ANOTHER MEDFILL.
[PH5_OT4A NE (MISSING OR DK OR REF) AND (LESS THAN 16 CODES
ENTERED AT PH5INTRO)] In the past 12 months [SAMPLE MEMBER C] used any
other prescription medicine, other than those you’ve already reported, for problems
with [SAMPLE MEMBER POSSPRO] emotions, nerves, mental health, energy,
concentration, sleep, or ability to cope with stress?
1
Yes
2
No
DK/REF
PH5_OT5A [IF PH5_OT5=1] Please give me the name of one more prescription medicine
[SAMPLE MEMBER D] used in the past 12 months for problems with [SAMPLE
MEMBER POSSPRO] emotions, nerves, mental health, energy, concentration, sleep,
or ability to cope with stress.
Only tell me the name of a medicine if you haven’t already reported it in an earlier
question.
______________
PROGRAMMER: ALLOW 50 CHARACTERS
DK/REF
PROGRAMMER:
IF (PH5_OT5A NE MISSING OR DK OR REF) AND (PH5INTRO INCLUDED AT
LEAST FIVE 990 CODES), THEN USE PH5_OT5A TEXT TO REPLACE THE FILL
TEXT FOR THE FIFTH 990 ENTERED.
IF (PH5_OT5A NE MISSING OR DK OR REF) AND (PH5INTRO DID NOT
INCLUDE AT LEAST FIVE 990 CODES), THEN USE PH5_OT5A TEXT TO
POPULATE ANOTHER MEDFILL.
DEFINE PH_COUNT
SET PH_COUNT= (THE TOTAL NUMBER OF NONMISSING MEDFILL VARIABLES)
DEFINE PH6INTRO_FILL
IF PH_COUNT=1, THEN PH6INTRO_FILL= “the prescription medicine”
Version 4 – February 2017 (Post IRB Approval)
212
IF PH_COUNT>1 AND PH_COUNT<5, THEN PH6INTRO_FILL= “each of the prescription
medicines”
IF PH_COUNT>1 AND PH_COUNT>5, THEN PH6INTRO_FILL= “some of the prescription
medicines”
PH6INTRO. [IF PH_COUNT >=1] Next, we’ll ask a couple of questions about [PH6INTRO_FILL]
that you reported.
NOTE TO PROGRAMMERS:
LOOP THROUGH PH6a THROUGH PH12a FOR EACH MEDICINE PROVIDED IN
PH5INTRO1, PH5INTRO2, PH5_OT1A, PH5_OT2A, OR PH5_OT3A, UP TO A TOTAL OF
5. IF MORE THAN 5 MEDICINES ARE PROVIDED, RANDOMLY SELECT 5 TO LOOP
THROUGH.
BELOW, ‘MEDFILLX’ IS USED TO REPRESENT THE MEDFILL RELEVANT TO THE
CURRENT ITERATION OF THE LOOP. FOR EXAMPLE, IF YOU ARE PASSING
THROUGH THE LOOP FOR THE FIRST TIME, THE ACTUAL MEDFILL REFERENCE
WOULD BE MEDFILL1.
PH6a
[IF MEDFILLX NE MISSING] About how many days out of the past 30 did
[SAMPLE MEMBER] take [MEDFILLX]?
DAYS [RANGE: 0–30]
DK/REF
PH7a
[IF MEDFILLX NE MISSING] About how many days out of the past 365 did
[SAMPLE MEMBER] take [MEDFILLX]?
DAYS [RANGE: 0–365]
DK/REF
NOTE TO PROGRAMMERS: AFTER COMPLETING THE PH6a THROUGH PH7a LOOP, LOOP
THROUGH PH15 THROUGH PH23 UP TO THREE TIMES. IF ONE TO THREE MEDICINES
INDICATED IN PH5INTRO1, PH5INTRO2, PH5_OT1A, PH5_OT2A, OR PH5_OT3A, ASK PH15
–PH23 SERIES FOR EACH. IF FOUR OR MORE MEDICINES INDICATED, RANDOMLY
SAMPLE THREE MEDICINES FROM AMONG THE MEDICINES PREVIOUSLY SELECTED
FOR THE PH6a THROUGH PH7a LOOP AND ASK PH15 –PH23 SERIES FOR EACH.
DEFINE PH15INTRO_FILL
IF PH_COUNT>3, FILL= “some of”
ELSE, FILL= “each of”
Version 4 – February 2017 (Post IRB Approval)
213
PH15INTRO. [PH_COUNT>1] Now, we’ll ask a few more questions about [PH15INTRO_FILL] the
medicines that you reported.
DEFINE PH15_FILL
IF PH_COUNT>1 AND THIS IS THE FIRST ITERATION OF THE LOOP, FILL: “First, let’s talk
about [MEDFILLX].”
IF PH_COUNT>1 AND THIS IS NOT THE FIRST ITERATION OF THE LOOP, FILL: “Now, let’s
talk about [MEDFILLX].”
IF PH_COUNT=1 FILL=“”
PH15
[IF MEDFILLX NE MISSING] [PH15_FILL]
Overall, how effective was [MEDFILLX] in doing the things [SAMPLE MEMBER]
expected it to? Was it very effective, somewhat effective, not very effective, or not at
all effective?
ONLY READ OPTIONS ALOUD IF NECESSARY
1
Very effective
2
Somewhat effective
3
Not very effective
4
Not at all effective
DK/REF
PH16
[IF MEDFILLX NE MISSING] Did [SAMPLE MEMBER] take [MEDFILLX] under
the supervision of a health professional? Or did [SAMPLE MEMBER] take it on
[SAMPLE MEMBER POSSPRO] own, that is without a doctor’s prescription or in
any way a doctor did not direct you to use it??
ONLY READ OPTIONS ALOUD IF NECESSARY
1
With supervision
2
On [SAMPLE MEMBER POSSPRO] own without supervision
DK/REF
PH17
[IF MEDFILLX NE MISSING] Who prescribed the [MEDFILLX]—a psychiatrist, a
general or family doctor, some other medical doctor, some other health professional, or
did no one prescribe the medication?
ONLY READ OPTIONS ALOUD IF NECESSARY
1
2
3
4
5
Psychiatrist
General or family doctor
Some other doctor
Some other health professional
No one prescribed the medication
Version 4 – February 2017 (Post IRB Approval)
214
DK/REF
PH18
[IF MEDFILLX NE MISSING] People do not always take their medicine as they are
supposed to. Think of a typical month when [SAMPLE MEMBER] took [MEDFILLX]
in the past 12 months. How many days out of 30 did [SAMPLE MEMBER] typically
either forget to take it or take less of it than [SAMPLE MEMBER E PRO] supposed to
take?
[IF PH_CAPI=1, FILL: “INTERVIEWER NOTE: If R was not supposed to take the
[MEDFILLX] regularly or did not take it for a full month, enter “996.””
___________________ NUMBER OF DAYS [RANGE: 0–30, 996]
DK/REF
PH19
[IF MEDFILLX NE MISSING AND HASJOIN = 2] Are you still taking
[MEDFILL2]?
[IF MEDFILLX NE MISSING AND HASJOIN = 1] Is [SAMPLE MEMBER] still
taking [MEDFILL2]?
1
Yes
2
No
DK/REF
PH20
[IF PH19 = 2 AND PH16 = 1] Did the health professional who supervised [SAMPLE
MEMBER POSS] use tell [SAMPLE MEMBER] to stop taking [MEDFILLX]?
ONLY READ OPTIONS ALOUD IF NECESSARY
1
Yes
2
No
DK/REF
PH21
[IF PH20 = 2] Did the health professional agree with [SAMPLE MEMBER POSS]
decision to stop?
ONLY READ OPTIONS ALOUD IF NECESSARY
1
Yes
2
No
DK/REF
PH22
[IF PH20 = 2] Did [SAMPLE MEMBER] stop taking [MEDFILLX] because
[SAMPLE MEMBER] felt so much better that [SAMPLE MEMBER] no longer
needed it? Or did [SAMPLE MEMBER] stop for some other reason?
ONLY READ OPTIONS ALOUD IF NECESSARY
Version 4 – February 2017 (Post IRB Approval)
215
1
Felt better
2
Other reason
DK/REF
PH23
[IF PH22 = 2]
[IF HASJOIN = 1 FILL: “HAND R SHOWCARD Y2
Which of the reasons on this card is why [SAMPLE MEMBER] stopped taking
[MEDFILL2]?
Tell me the number next to the reason or reasons on the card for why [SAMPLE
MEMBER] stopped taking [MEDFILLX] and I will enter it into the computer.]
1
2
3
4
5
6
7
8
9
The medicine was not helping
The child or one of his/her parents thought the problem would get better without
more medicine
The child’s family couldn’t afford to pay for the medicine
The child was too embarrassed to continue taking the medicine
The child or one of his/her parents wanted to solve the problems without
medications
The medicine caused side effects that made the child stop
The child was afraid that he/she would get dependent on the medication
Someone in the child’s personal life pressured him/her to stop
Any other reason for stopping
[IF HASJOIN = 2 FILL:
“HAND R SHOWCARD Y3
Which of the reasons on this card is why [SAMPLE MEMBER] stopped taking
[MEDFILL2]?
Tell me the number next to the reason or reasons on the card for why [SAMPLE
MEMBER] stopped taking [MEDFILLX] and I will enter it into the computer.]
1
2
more medicine
3
4
5
6
7
8
9
DK/REF
The medicine was not helping
You or one of your parents thought the problem would get better without
Your family couldn’t afford to pay for the medicine
You were too embarrassed to continue taking the medicine
You or one of your parents wanted to solve the problem without medications
The medicine caused side effects that made you stop
You were afraid that you would get dependent on the medication
Someone in your personal life pressured you to stop
Any other reason for stopping
Version 4 – February 2017 (Post IRB Approval)
216
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
217
36.
Income
BEGIN TIME STAMP
INC1
[IF NO FAMILY MEMBERS IN ROSTER] These next questions are about the kinds
and amounts of income that you receive.
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] These next
questions are about the kinds and amounts of income received by you and your
[FAMILY RELATIONSHIP FILL].
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] These next questions
are about the kinds and amounts of income received by [SAMPLE MEMBER] and you.
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN NE 1]
These next questions are about the kinds and amounts of income received by your
family living here, including you, your [FAMILY RELATIONSHIP FILLS].
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN = 1] These
next questions are about the kinds and amounts of income received by [SAMPLE
MEMBER] and [IF QD01 = 5 FILL his, QD01 = 9 FILL her] family living here,
including you, [IF QD01 = 5 FILL his, QD01 = 9 FILL her] [FAMILY
RELATIONSHIP FILLS]. [PROGRAMMER NOTE: THE PROXY SHOULD NOT
APPEAR IN [FAMILY RELATIONSHIP FILLS]. ALSO, USE “other” AS A
MODIFIER TO THE FAMILY RELATIONSHIP FILL WHEN THE
RELATIONSHIP TYPE IS EQUAL TO PROXY RELATIONSHIP TYPE AND ONE
OF THESE RELATIONSHIP TYPES IS STILL IN THE LIST. PLEASE PRECEDE
EACH RELATIONSHIP WITH “HIS/HER”. ]
[IF HASJOIN NE 1] These questions refer to the calendar year [CURRENT YEAR –
1] rather than to the past 12 months that were referred to in some earlier questions. The
calendar year [CURRENT YEAR – 1] would be from January 1st, [CURRENT YEAR
– 1], through December 31st, [CURRENT YEAR – 1].
INC2
Social Security or Railroad Retirement payments are paid by the U.S. Government to
persons who are retired, severely disabled, or are dependents or survivors of workers.
[IF NO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1], did you
receive Social Security or Railroad Retirement payments?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] In [CURRENT
YEAR – 1], did you or your [FAMILY RELATIONSHIP FILL] receive Social
Security or Railroad Retirement payments?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] In [CURRENT
YEAR – 1], did [SAMPLE MEMBER] or you receive Social Security or Railroad
Retirement payments?
Version 4 – February 2017 (Post IRB Approval)
218
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1],
did [SAMPLE MEMBER] or any of these same family members receive Social
Security or Railroad Retirement payments?
1
YES
2
NO
DK/REF
INC3
Supplemental Security Income or SSI is a program administered by a government
agency that makes assistance payments to people with low income who are aged, blind,
or disabled. This is not the same as Social Security.
[IF NO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1], did you
receive Supplemental Security Income or SSI?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] In [CURRENT
YEAR – 1], did you or your [FAMILY RELATIONSHIP FILL] receive Supplemental
Security Income or SSI?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] In [CURRENT
YEAR – 1], did [SAMPLE MEMBER] or you receive Supplemental Security Income
or SSI?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1],
did [SAMPLE MEMBER] or any of these same family members receive Supplemental
Security Income or SSI?
1
YES
2
NO
DK/REF
INC3a
The Supplemental Nutrition Assistance Program, or SNAP, formerly known as food
stamps, provides assistance for buying food. A special card is issued which can be used
to buy food in grocery stores. SNAP does not include WIC or free or reduced school
lunches.
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1 [IF NO FAMILY
MEMBERS IN ROSTER] In [CURRENT YEAR – 1], did you receive SNAP benefits?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] In [CURRENT
YEAR – 1], did you or your [FAMILY RELATIONSHIP FILL] receive SNAP
benefits?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] In [CURRENT
YEAR – 1], did [SAMPLE MEMBER] or you receive SNAP benefits?
Version 4 – February 2017 (Post IRB Approval)
219
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1],
did [SAMPLE MEMBER] or any of these same family members receive SNAP
benefits?
1
YES
2
NO
DK/REF
DEFINE CONDITION_FILL
IF QD_FIPE4 = 1 THEN CONDITION_FILL = the Family Assistance Program (FAP)
IF QD_FIPE4 = 2 THEN CONDITION_FILL = the Alaska Temporary Assistance Program (ATAP)
IF QD_FIPE4 = 3 THEN CONDITION_FILL = Cash Assistance (CA)
IF QD_FIPE4 = 4 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 5 THEN CONDITION_FILL = California Work Opportunity and Responsibility to
Kids (CalWorks)
IF QD_FIPE4 = 6 THEN CONDITION_FILL = Colorado Works
IF QD_FIPE4 = 7 THEN CONDITION_FILL = Temporary Family Assistance (TFA)
IF QD_FIPE4 = 8 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 9 THEN CONDITION_FILL = Temporary Cash Assistance for Needy Families
(TANF)
IF QD_FIPE4 = 10 THEN CONDITION_FILL =Temporary Assistance for Needy Families (TANF)
Maintenance of Effort (MOE)
IF QD_FIPE4 = 11 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 12 THEN CONDITION_FILL = Temporary Assistance to Needy Families (TANF)
or Temporary Assistance to Other Needy Families (TAONF)
IF QD_FIPE4 = 13 THEN CONDITION_FILL = Temporary Assistance for Families in Idaho (TAFI)
IF QD_FIPE4 = 14 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 15 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 16 THEN CONDITION_FILL = the Family Investment Program (FIP)
IF QD_FIPE4 = 17 THEN CONDITION_FILL = Cash Assistance
IF QD_FIPE4 = 18 THEN CONDITION_FILL = the Kentucky Transitional Assistance Program
(KTAP)
IF QD_FIPE4 = 19 THEN CONDITION_FILL = The Family Independence Temporary Assistance
Program (FITAP)
IF QD_FIPE4 = 20 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
or Additional Support for People in Retraining and Employment (ASPIRE)
IF QD_FIPE4 = 21 THEN CONDITION_FILL = The Family Investment Program (FIP) or
Temporary Cash Assistance (TCA)
IF QD_FIPE4 = 22 THEN CONDITION_FILL = Transitional Aid to Families with Dependent
Children (TAFDC)
IF QD_FIPE4 = 23 THEN CONDITION_FILL = the Family Independence Program (FIP)
IF QD_FIPE4 = 24 THEN CONDITION_FILL = the Minnesota Family Investment Program (MFIP)
IF QD_FIPE4 = 25 THEN CONDITION_FILL = Temporary Assistance to Needy Families (TANF)
IF QD_FIPE4 = 26 THEN CONDITION_FILL = Temporary Assistance
IF QD_FIPE4 = 27 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 28 THEN CONDITION_FILL = Aid to Dependent Children (ADC)
IF QD_FIPE4 = 29 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 30 THEN CONDITION_FILL = Financial Assistance to Needy Families
Version 4 – February 2017 (Post IRB Approval)
220
IF QD_FIPE4 = 31 THEN CONDITION_FILL = Work First New Jersey (WFNJ)
IF QD_FIPE4 = 32 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF),
or NMWorks
IF QD_FIPE4 = 33 THEN CONDITION_FILL = Family Assistance (FA)
IF QD_FIPE4 = 34 THEN CONDITION_FILL = Work First
IF QD_FIPE4 = 35 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
or Job Opportunities and Basic Skills (JOBS)
IF QD_FIPE4 = 36 THEN CONDITION_FILL = Ohio Works First (OWF) or Temporary Assistance
for Needy Families (TANF)
IF QD_FIPE4 = 37 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 38 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 39 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF),
Cash Assistance, or Moving to Independence
IF QD_FIPE4 = 40 THEN CONDITION_FILL = Rhode Island Works (RI Works)
IF QD_FIPE4 = 41 THEN CONDITION_FILL = Family Independence (FI)
IF QD_FIPE4 = 42 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 43 THEN CONDITION_FILL = Families First
IF QD_FIPE4 = 44 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 45 THEN CONDITION_FILL = the Family Employment Program (FEP)
IF QD_FIPE4 = 46 THEN CONDITION_FILL = Reach Up
IF QD_FIPE4 = 47 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 48 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
or WorkFirst
IF QD_FIPE4 = 49 THEN CONDITION_FILL = West Virginia Works (WV Works)
IF QD_FIPE4 = 50 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
IF QD_FIPE4 = 51 THEN CONDITION_FILL = Temporary Assistance for Needy Families (TANF)
ELSE CONDITION_FILL = BLANK
INC4
[IF NO FAMILY MEMBERS IN ROSTER] At any time during [CURRENT YEAR –
1], even for one month, did you receive any cash assistance from a state or [IF
QD_FIPE4 = 2, THEN “borough”] [IF QD_FIPE4 = 19 THEN “parish”] [IF
QD_FIPE4 NE 2 OR 19 THEN “county”] welfare program such as
[CONDITION_FILL]?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] At any time during
[CURRENT YEAR – 1], even for one month, did you or your [FAMILY
RELATIONSHIP FILL] receive any cash assistance from a state or [IF QD_FIPE4 = 2
THEN “borough”] [IF QD_FIPE4 = 19 THEN “parish”] [IF QD_FIPE4 NE 2 OR 19
THEN “county”] welfare program such as [CONDITION_FILL]?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] At any time during
[CURRENT YEAR – 1], even for one month, did [SAMPLE MEMBER] or you
receive any cash assistance from a state or [IF QD_FIPE4 = 2 THEN “borough”] [IF
QD_FIPE4 = 19 THEN “parish”] [IF QD_FIPE4 NE 2 OR 19 THEN “county”] welfare
program such as [CONDITION_FILL]?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] At any time during
[CURRENT YEAR – 1], even for one month, did [SAMPLE MEMBER] or any of
Version 4 – February 2017 (Post IRB Approval)
221
these same family members receive any cash assistance from a state or [IF QD_FIPE4
= 2 THEN “borough”] [IF QD_FIPE4 = 19 THEN “parish”] [IF QD_FIPE4 NE 2 OR
19 THEN “county”] welfare program such as [CONDITION_FILL]?
1
YES
2
NO
DK/REF
INC5
[IF NO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1], because of
low income, did you receive any other kind of non-monetary welfare or public
assistance, such as help with getting a job, placement in education or job training
programs, or help with transportation, child care, or housing?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] In [CURRENT
YEAR – 1], because of low income, did you or your [FAMILY RELATIONSHIP
FILL] receive any other kind of non-monetary welfare or public assistance, such as
help with getting a job, placement in education or job training programs, or help with
transportation, child care, or housing?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] In [CURRENT
YEAR – 1], because of low income, did [SAMPLE MEMBER] or you receive any
other kind of non-monetary welfare or public assistance, such as help with getting a
job, placement in education or job training programs, or help with transportation, child
care, or housing?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] In [CURRENT YEAR – 1],
because of low income, did [SAMPLE MEMBER] or any of these same family
members receive any other kind of non-monetary welfare or public assistance, such as
help with getting a job, placement in education or job training programs, or help with
transportation, child care, or housing?
1
YES
2
NO
DK/REF
INC6
[IF (INC4 = 1 OR INC5 = 1) AND INC3a = 2]
[IF NO FAMILY MEMBERS IN ROSTER] For how many months in [CURRENT
YEAR – 1] did you receive any type of welfare or public assistance?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] For how many
months in [CURRENT YEAR – 1] did you or your [FAMILY RELATIONSHIP FILL]
receive any type of welfare or public assistance?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] For how many
months in [CURRENT YEAR – 1] did [SAMPLE MEMBER] or you receive any type
of welfare or public assistance?
Version 4 – February 2017 (Post IRB Approval)
222
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] For how many months in
[CURRENT YEAR – 1] did [SAMPLE MEMBER] or any other family member living
here receive any type of welfare or public assistance?
[ALL] Please include:
• Cash assistance from a state or [IF QD_FIPE4 = 2 THEN “borough”] [IF QD_FIPE4
= 19 THEN “parish”] [IF QD_FIPE4 NE 2 OR 19 THEN “county”] welfare program
such as [CONDITION_FILL]
• Any other kind of non-monetary welfare or public assistance
__________ NUMBER OF MONTHS RECEIVED ASSISTANCE [RANGE: 1–12]
DK/REF
INC7
[IF (INC4 = 1 OR INC5 = 1) AND INC3a = (1, DK, OR REF)]
[IF NO FAMILY MEMBERS IN ROSTER] For how many months in [CURRENT
YEAR – 1] did you receive any type of welfare or public assistance, not including
SNAP benefits?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] For how many
months in [CURRENT YEAR – 1] did you or your [FAMILY RELATIONSHIP FILL]
receive any type of welfare or public assistance, not including SNAP benefits?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] For how many
months in [CURRENT YEAR – 1] did [SAMPLE MEMBER] or you receive any type
of welfare or public assistance, not including SNAP benefits?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER] For how many months in
[CURRENT YEAR – 1] did [SAMPLE MEMBER] or any other family member living
here receive any type of welfare or public assistance, not including SNAP benefits?
[ALL] Please include:
• Cash assistance from a state or [IF QD_FIPE4 = 2 THEN “borough”] [IF QD_FIPE4
= 19 THEN “parish”] [IF QD_FIPE4 NE 2 OR 19 THEN “county”] welfare program
such as [CONDITION_FILL]
• Any other kind of non-monetary welfare or public assistance
__________ NUMBER OF MONTHS RECEIVED ASSISTANCE [RANGE: 1–12]
DK/REF
INC7A
HAND R SHOWCARD 7 Here is a list of some other sources of income. When you
answer the next questions, please consider these income sources as well as those asked
about in earlier questions.
Income earned at a job or business
Retirement, disability, or survivor pension
Unemployment or worker's compensation
Veteran's administration payments
Version 4 – February 2017 (Post IRB Approval)
223
Child support
Alimony
Interest income
Dividends from stocks or mutual funds
Income from rental properties, royalties, estates or trusts
INC8
[IF NO FAMILY MEMBERS IN ROSTER] Before taxes and other deductions, was
your total personal income from all sources during [CURRENT YEAR – 1] more or
less than 20,000 dollars?
[IF AT LEAST ONE FAMILY MEMBER IN ROSTER] Now we are going to ask
about [SAMPLE MEMBER POSS] own personal income. Before taxes and other
deductions, was [SAMPLE MEMBER POSS] total personal income from all sources
during [CURRENT YEAR – 1] more or less than 20,000 dollars?
1
$20,000 OR MORE
2
LESS THAN $20,000
DK/REF
INC8A
[IF INC8 = DK OR REF] Income data are important in analyzing the health
information we collect. For example, the information helps us to learn whether persons
in one income group use certain types of medical care services or have conditions more
or less often than those in another group.
Before taxes and other deductions, was [SAMPLE MEMBER POSS] total personal
income from all sources during [CURRENT YEAR – 1] more or less than 20,000
dollars?
1
$20,000 OR MORE
2
LESS THAN $20,000
DK/REF
INC9
[IF INC8 = 2 OR IF INC8A = 2] HAND R SHOWCARD 8. Of these income groups,
which category best represents [SAMPLE MEMBER POSS] total personal income
during [CURRENT YEAR – 1]?
(Income data are important in analyzing the health information we collect. For
example, the information helps us to learn whether people in one income group use
certain types of medical care services or have conditions more or less often than those
in another group.)
1
2
3
4
5
6
7
8
LESS THAN $1,000
$1,000–$1,999
$2,000–$2,999
$3,000–$3,999
$4,000–$4,999
$5,000–$5,999
$6,000–$6,999
$7,000–$7,999
Version 4 – February 2017 (Post IRB Approval)
224
9
$8,000–$8,999
10
$9,000–$9,999
11
$10,000–$10,999
12
$11,000–$11,999
13
$12,000–$12,999
14
$13,000–$13,999
15
$14,000–$14,999
16
$15,000–$15,999
17
$16,000–$16,999
18
$17,000–$17,999
19
$18,000–$18,999
20
$19,000–$19,999
DK/REF
INC9A
[IF INC9 = DK OR REF] Income data are important in analyzing the health
information we collect. For example, the information helps us to learn whether persons
in one income group use certain types of medical care services or have conditions more
or less often than those in another group.
Of these income groups, which category best represents [SAMPLE MEMBER POSS]
total personal income during [CURRENT YEAR – 1]?
1
LESS THAN $1,000
2
$1,000–$1,999
3
$2,000–$2,999
4
$3,000–$3,999
5
$4,000–$4,999
6
$5,000–$5,999
7
$6,000–$6,999
8
$7,000–$7,999
9
$8,000–$8,999
10
$9,000–$9,999
11
$10,000–$10,999
12
$11,000–$11,999
13
$12,000–$12,999
14
$13,000–$13,999
15
$14,000–$14,999
16
$15,000–$15,999
17
$16,000–$16,999
18
$17,000–$17,999
19
$18,000–$18,999
20
$19,000–$19,999
DK/REF
INC10
[IF INC8 = 1 OR IF INC8A = 1] HAND R SHOWCARD 9 Of these income groups,
which category best represents [SAMPLE MEMBER POSS] total personal income
during [CURRENT YEAR – 1]?
Version 4 – February 2017 (Post IRB Approval)
225
(Income data are important in analyzing the health information we collect. For
example, the information helps us to learn whether people in one income group use
certain types of medical care services or have conditions more or less often than those
in another group.)
21
$20,000–$24,999
22
$25,000–$29,999
23
$30,000–$34,999
24
$35,000–$39,999
25
$40,000–$44,999
26
$45,000–$49,999
27
$50,000–$74,999
28
$75,000–$99,999
29
$100,000–$149,999
30
$150,000 OR MORE
DK/REF
INC10A
[IF INC10 = DK OR REF] Income data are important in analyzing the health
information we collect. For example, the information helps us to learn whether persons
in one income group use certain types of medical care services or have conditions more
or less often than those in another group.)
Of these income groups, which category best represents [SAMPLE MEMBER POSS]
total personal income during [CURRENT YEAR – 1]?
21
$20,000–$24,999
22
$25,000–$29,999
23
$30,000–$34,999
24
$35,000–$39,999
25
$40,000–$44,999
26
$45,000–$49,999
27
$50,000–$74,999
28
$75,000–$99,999
29
$100,000–$149,999
30
$150,000 OR MORE
DK/REF
INC11
[IF MORE THAN ONE FAMILY MEMBER IN ROSTER AND IF INC10 NE 30 OR
INC10A NE 30]
Next, we would like to know about the total family income from all sources during
[CURRENT YEAR – 1] before taxes and other deductions.
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] We would like you
to combine everyone’s income—that is, yours and that of your [FAMILY
RELATIONSHIP FILL].
Version 4 – February 2017 (Post IRB Approval)
226
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] We would like you
to combine everyone’s income—that is, [SAMPLE MEMBER POSS] and yours.
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN NE 1] We
would like you to combine everyone’s income—that is, yours and that of your
[FAMILY RELATIONSHIP FILLS].
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN = 1] We
would like you to combine everyone’s income—that is, yours, [SAMPLE MEMBER
POSS] and that of [IF QD01 = 5 FILL his, QD01 = 9 FILL her] [FAMILY
RELATIONSHIP FILLS] living here. [PROGRAMMER NOTE: THE PROXY
SHOULD NOT APPEAR IN [FAMILY RELATIONSHIP FILLS]. ALSO, USE
“other” AS A MODIFIER TO THE FAMILY RELATIONSHIP FILL WHEN THE
RELATIONSHIP TYPE IS EQUAL TO PROXY RELATIONSHIP TYPE AND ONE
OF THESE RELATIONSHIP TYPES IS STILL IN THE LIST.]
Please include all of the sources of income that we just talked about.
INC12
[IF MORE THAN ONE FAMILY MEMBER IN ROSTER AND (INC8 NE 1 OR
INC8A NE 1)] Before taxes and other deductions, was the total combined family
income during [CURRENT YEAR – 1] more or less than 20,000 dollars?
1
$20,000 OR MORE
2
LESS THAN $20,000
DK/REF
INC13
[IF INC12 = 2] HAND R SHOWCARD 8
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] Of these income
groups, which category best represents your total combined family income during
[CURRENT YEAR – 1]—that is, yours and that of your [FAMILY RELATIONSHIP
FILL].
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] Of these income
groups, which category best represents your total combined family income during
[CURRENT YEAR – 1]—that is, your [SAMPLE MEMBER POSS] and yours.
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN NE 1] Of
these income groups, which category best represents your total combined family
income during [CURRENT YEAR – 1]—that is, yours and that of your
[RELATIONSHIP FILLS].
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN = 1] Of
these income groups, which category best represents your total combined family
income during [CURRENT YEAR – 1]—that is, yours, [SAMPLE MEMBER POSS],
and that of [IF QD01 = 5 FILL his, QD01 = 9 FILL her] [FAMILY RELATIONSHIP
FILLS] living here? [PROGRAMMER NOTE: THE PROXY SHOULD NOT
APPEAR IN [FAMILY RELATIONSHIP FILLS]. ALSO, USE “other” AS A
Version 4 – February 2017 (Post IRB Approval)
227
MODIFIER TO THE FAMILY RELATIONSHIP FILL WHEN THE
RELATIONSHIP TYPE IS EQUAL TO PROXY RELATIONSHIP TYPE AND ONE
OF THESE RELATIONSHIP TYPES IS STILL IN THE LIST.]
1
LESS THAN $1,000
2
$1,000–$1,999
3
$2,000–$2,999
4
$3,000–$3,999
5
$4,000–$4,999
6
$5,000–$5,999
7
$6,000–$6,999
8
$7,000–$7,999
9
$8,000–$8,999
10
$9,000–$9,999
11
$10,000–$10,999
12
$11,000–$11,999
13
$12,000–$12,999
14
$13,000–$13,999
15
$14,000–$14,999
16
$15,000–$15,999
17
$16,000–$16,999
18
$17,000–$17,999
19
$18,000–$18,999
20
$19,000–$19,999
DK/REF
INC14
[IF (INC12 = 1 OR INC8 = 1 OR INC8A = 1) AND INC10 NE 30 OR INC10A NE 30]
HAND R SHOWCARD 9
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN NE 1] Of these income
groups, which category best represents your total combined family income during
[CURRENT YEAR – 1]—that is, yours and that of your [FAMILY RELATIONSHIP
FILL]?
[IF ONE FAMILY MEMBER IN ROSTER AND HASJOIN = 1] Of these income
groups, which category best represents your total combined family income during
[CURRENT YEAR – 1]—that is, [SAMPLE MEMBER POSS] and yours?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN NE 1] Of
these income groups, which category best represents your total combined family
income during [CURRENT YEAR – 1]—that is, yours and that of your [FAMILY
RELATIONSHIP FILLS]?
[IF AT LEAST TWO FAMILY MEMBERS IN ROSTER AND HASJOIN = 1] Of
these income groups, which category best represents your total combined family
income during [CURRENT YEAR – 1]—that is, yours, [SAMPLE MEMBER POSS],
and that of [IF QD01 = 5 FILL his, QD01 = 9 FILL her] [FAMILY RELATIONSHIP
FILLS] living here? [PROGRAMMER NOTE: THE PROXY SHOULD NOT
Version 4 – February 2017 (Post IRB Approval)
228
APPEAR IN [FAMILY RELATIONSHIP FILLS]. ALSO, USE “other” AS A
MODIFIER TO THE FAMILY RELATIONSHIP FILL WHEN THE
RELATIONSHIP TYPE IS EQUAL TO PROXY RELATIONSHIP TYPE AND ONE
OF THESE RELATIONSHIP TYPES IS STILL IN THE LIST.]
19
$20,000–$24,999
20
$25,000–$29,999
21
$30,000–$34,999
22
$35,000–$39,999
23
$40,000–$44,999
24
$45,000–$49,999
25
$50,000–$74,999
26
$75,000–$99,999
27
$100,000–$149,999
28
$150,000 OR MORE
DK/REF
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
229
37.
Health Insurance
BEGIN TIME STAMP
TOPROXY
[IF HASJOIN = 1] WHEN [HR3 FILL] HAS JOINED YOU:
The next questions are about [SAMPLE MEMBER POSS] health insurance coverage.
PRESS [ENTER] TO CONTINUE.
DEFINE H1_FILL
IF HASJOIN NE 1, THEN H1_FILL = The next questions are about health insurance.
ELSE HI_FILL = “’”
HI_1 [H1_FILL] 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.
[SAMPLE MEMBER A] covered by any kind of health insurance or some other kind of health
care plan?
1
YES
2
NO
DK/REF
DEFINE HI_2FILL
IF HASJOIN = 1, THEN HI_2FILL = does [SAMPLE MEMBER]
ELSE HI_2FILL = do you
HI_2 [IF HI_1 = 1 OR DK OR REF] What kind of health insurance or health care coverage
[HI_2FILL] have? Include those that pay for only one type of service, such as nursing home
care, accidents, or dental care. Exclude private plans that only provide extra cash while
hospitalized.
TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPANCE BAR BETWEEN
EACH CATEGORY YOU SELECT
1
2
3
4
5
6
7
8
Private health insurance
Medicare
Medi-Gap
Medicaid
SCHIP, also known as CHIP or Children's Health Insurance Program
Military health care, such as TRICARE, VA, or CHAMP-VA
Indian Health Service
State-sponsored health plan
Version 4 – February 2017 (Post IRB Approval)
230
9
Other government program
10
Single service plan, such as dental, vision, or prescriptions
11
No coverage of any type
DK/REF
DEFINE HI_3FILL
IF HASJOIN = 1, THEN HI_3FILL = [SAMPLE MEMBER]
ELSE HI_3FILL = you
HI_3 [IF HI_1 = 2 OR HI_2 = 11] About how long has it been since [HI_3FILL] last had health care
coverage?
1
2
3
4
5
6
DK/REF
6 months or less
More than 6 months, but less than 1 year
1 year
More than 1 year, but less than 3 years
3 years or more
Never had coverage
DEFINE WEREWAS
IF HR1 = 1 OR HASJOIN = BLANK OR 2 THEN WEREWAS = “were you”
ELSE WEREWAS = “was SAMPLE MEMBER”
HI14
[IF HI_3 = (1 OR 2 OR DK OR REF)] During the past 12 months, that is from [DATE
FILL] through today, about how many months [FILL WEREWAS] without any kind of
health insurance or coverage?
__________ NUMBER OF MONTHS [RANGE: 0–12]
DK/REF
GPS1
Finally, we are also interested in collecting GPS coordinates from this location. This
information will only be used for data quality and verification purposes. Do I have your
permission to collect this information?
1
2
YES
NO
DK/REF
[NOTE TO FI: IF CONSENT IS GIVEN, RECORD GPS ON TABLET ONCE YOU
ARE OUTSIDE OF THE HOME]
Version 4 – February 2017 (Post IRB Approval)
231
GPS2
[IF GPS1 = 2, DK OR REF] GPS coordinates will provide the latitude and longitude
of this address or location on a map. A researcher will use this information only to
verify that I conducted this interview at the correct address. Your name and interview
responses will be stored separately from the coordinates. May I collect the GPS
coordinates?
1
2
YES
NO
DK/REF
[NOTE TO FI: IF CONSENT IS GIVEN, RECORD GPS ON TABLET ONCE YOU
ARE OUTSIDE OF THE HOME]
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
232
38. Verification
BEGIN TIME STAMP
QCID
ENTER THE QC ID FROM THE QUALITY CONTROL FORM FOR THIS
INTERVIEW. THE QC ID IS LOCATED IN THE UPPER RIGHTHAND CORNER
OF THE QUALITY CONTROL FORM. THE HYPHEN MUST BE INCLUDED.
CASEID
ENTER THE CASE ID FOR THIS INTERVIEW. BE SURE TO INCLUDE A OR B
AT THE END OF THE CASE ID.
TOALLR3I It is important that I do my job correctly; therefore, my supervisors will be checking on
my work. Would you help me by printing your phone number and current address on
this form?
[GIVE QUALITY CONTROL FORM AND ENVELOPE TO RESPONDENT (OR
PARENT/GUARDIAN OF YOUTH RESPONDENT, IF AVAILABLE)]
Then place it in the postage-paid envelope so that my supervisor can write or call you
in several weeks to confirm that I did my job. When you are finished, please seal the
envelope and return it to me. As you can see, this is kept separate from the responses
that were entered so they will still be completely private.
PRESS [ENTER] TO CONTINUE.
INCENT01
HAND RESPONDENT $40 CASH.
MARK THE APPROPRIATE “CASH ACCEPTANCE” BOX ON THE INTERVIEW
INCENTIVE RECEIPT.
SIGN AND DATE INTERVIEW INCENTIVE RECEIPT AND GIVE TOP COPY TO
RESPONDENT.
I have signed this form to indicate that I have given you $40 for this interview. At the
bottom of this form, we have included national hotline numbers that you can call if you
ever feel you need to talk to someone about mental health or drug use issues.
IF NOT DONE EARLIER, GIVE ADULT RESPONDENT OR
PARENT/GUARDIAN OF YOUTH THE Q&A BROCHURE AND SAY:
For more details on the National Mental Health Study, this brochure includes answers
to common questions, website addresses, and other information.
PRESS [ENTER] TO CONTINUE.
THANKR2
Thank you for your time.
Version 4 – February 2017 (Post IRB Approval)
233
[ALL CASES] BE SURE YOU HAVE YOUR SHOWCARD BOOKLET, YUBIKEY,
AND INCENTIVE RECEIPT COPIES.
[ALL CASES] PRESS [ENTER] TO CONTINUE.
FIEXIT
END OF INTERVIEW REACHED.
PRESS 1 TO EXIT.
END TIME STAMP
Version 4 – February 2017 (Post IRB Approval)
234
39. Showcards
SHOWCARD 1
1
AMERICAN INDIAN OR ALASKA NATIVE
2
ASIAN
3
BLACK OR AFRICAN AMERICAN
4
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
5
WHITE
Version 4 – February 2017 (Post IRB Approval)
235
SHOWCARD 2
0
NO SCHOOLING COMPLETED
1
1ST GRADE COMPLETED
2
2ND GRADE COMPLETED
3
3RD GRADE COMPLETED
4
4TH GRADE COMPLETED
5
5TH GRADE COMPLETED
6
6TH GRADE COMPLETED
7
7TH GRADE COMPLETED
8
8TH GRADE COMPLETED
9
9TH GRADE COMPLETED
10
10TH GRADE COMPLETED
11
11TH GRADE COMPLETED
12
REGULAR HIGH SCHOOL DIPLOMA
13
12TH GRADE, NO DIPLOMA
14
GED CERTIFICATE OF HIGH SCHOOL COMPLETION
15
SOME COLLEGE CREDIT, BUT NO DEGREE
16
ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS)
17
BACHELOR’S DEGREE (FOR EXAMPLE, BA, BS)
18
MASTER’S DEGREE (FOR EXAMPLE, MA, MS, MENG, M.
ED, MSW, MBA)
19
DOCTORATE DEGREE (FOR EXAMPLE, PHD, EDD)
20
PROFESSIONAL DEGREE BEYOND A BACHELOR’S
DEGREE (FOR EXAMPLE, MD, DDS, DVM, LLB, JD)
Version 4 – February 2017 (Post IRB Approval)
236
SHOWCARD 5
1
SELF
2
HUSBAND
3
SON (INCLUDES STEP, FOSTER, ADOPTIVE)
4
SON-IN-LAW
5
BROTHER (INCLUDES HALF, STEP, FOSTER,
ADOPTIVE)
6
BROTHER-IN-LAW
7
FATHER (INCLUDES STEP, FOSTER, ADOPTIVE)
8
FATHER-IN-LAW
9
UNCLE
10
NEPHEW
11
GRANDFATHER
12
GRANDSON
13
COUSIN
14
EX-HUSBAND
15
UNMARRIED PARTNER
16
HOUSEMATE OR ROOMMATE
17
TENANT, BOARDER, OR EXCHANGE STUDENT
18
OTHER RELATIVE
19
OTHER NON-RELATIVE
Version 4 – February 2017 (Post IRB Approval)
237
SHOWCARD 6
1
SELF
2
WIFE
3
DAUGHTER (INCLUDES STEP, FOSTER,
ADOPTIVE)
4
DAUGHTER-IN-LAW
5
SISTER (INCLUDES HALF, STEP, FOSTER,
ADOPTIVE)
6
SISTER-IN-LAW
7
MOTHER (INCLUDES STEP, FOSTER, ADOPTIVE)
8
MOTHER-IN-LAW
9
AUNT
10
NIECE
11
GRANDMOTHER
12
GRANDDAUGHTER
13
COUSIN
14
EX-WIFE
15
UNMARRIED PARTNER
16
HOUSEMATE OR ROOMMATE
17
TENANT, BOARDER, OR EXCHANGE STUDENT
18
OTHER RELATIVE
19
OTHER NON-RELATIVE
Version 4 – February 2017 (Post IRB Approval)
238
SHOWCARD 4
1
2
3
4
5
6
7
--------
ABILIFY
ABILIFY MAINTENA
ADDERAL
ADDERAL XR
ALPRAZOLAM
AMBIEN
AMITRIPTYLINE
8 -- AMPHETAMINE
9 -- ANAFRANIL
10 -- ARIPIPRAZOLE
11 -- ARMODAFINIL
12 -- ARTANE
13 -- ASENAPINE
14 -- ATIVAN
15
16
17
18
-----
ATOMOXETINE
BELSOMRA
BENZTROPINE
BRINTELLIX
19 -- BUDEPRION SR
20 -- BUDEPRION XL
21 -- BUPROPION
22
23
24
25
26
27
28
29
---------
BUSPAR
BUSPIRONE
CARBAMAZEPINE
CARBATROL
CATAPRES
CELEXA
CHLORDIAZEPOZIDE
CHLORPROMAZINE
Version 4 – February 2017 (Post IRB Approval)
30
31
32
33
34
35
36
--------
CITALOPRAM
CLOMIPRAMINE
CLONAZEPAM
CLONIDINE
CLOZAPINE
CLOZARIL
COGENTIN
37 -- CONCERTA
38-- CYMBALTA
39 -- CYTOMEL
40 -- DAYTRANA
41 -- DEPAKENE
42 -- DEPAKOTE
43 -- DEPAKOTE
SPRINKLES
44 -- DESOXYN
45 -- DESVENLAFAXINE
46 -- DESYREL
47 -- DEXEDRINE
48 -DEXMETHYLPHENIDATE
49 -DEXTROAMPHETAMINE
50 -DEXTROAMPHETAMINE/
AMPHETAMINE
51 -- DIAZEPAM
52 -- DIVALPROEX
53 -- DOXEPIN
54 -- DULOXETINE
55 -- EFFEXOR
56 -- ELAVIL
57 -- ESCITALOPRAM
58 -- ESKALITH
59
60
61
62
63
64
65
--------
66
67
68
69
70
71
72
ESZOPICLONE
EVEKEO
FANAPT
FETZIMA
FLUOXETINE
FLUPHENAZINE
FLUPHENAZINE
DECANOATE
-- FLUVOXAMINE
-- FOCALIN
-- FORFIVO XL
-- GABAPENTIN
-- GABITRIL
-- GEODON
-- GUANFACINE
73
74
75
76
-----
HALDOL
HALDOL DECANOATE
HALOPERIDOL
HALOPERIDOL
DECANOATE
77 -- HETLIOZ
78 -- ILOPERIDONE
79 -- INDERAL
80
81
82
83
84
85
86
87
---------
INTUNIV
INVEGA
INVEGA SUSTENNA
ISOCARBOXAZID
KLONOPIN
LAMICTAL
LAMOTRIGINE
LATUDA
239
88
89
90
91
92
93
94
95
96
97
-----------
LEVOMILNACIPRAN
LEXAPRO
LIBRIUM
LISDEXAMFETAMINE
LITHIUM
LITHOBID
LORAZEPAM
LUNESTA
LURASIDONE
LUVOX
98 -- LYRICA
99 -- MARPLAN
PARNATE
PAROXETINE
PAXIL
PHENELZINE
PRAZOSIN
PREGABALIN
PRISTIQ
PROCENTRA
PROLIXIN
PROLIXIN
DECANOATE
127 -- PROPRANOLOL
128 -- PROVIGIL
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
-----------------
MELATONIN
METADATE
METHAMPHETAMINE
METHYLIN
METHYLPHENIDATE
MINIPRESS
MIRTRAZAPINE
MODAFINIL
NARDIL
NEURONTIN
NORTRIPTYLINE
NUVIGIL
OLANZAPINE
OXCARBAZEPINE
PALIPERIDONE
PALIPERIDONE
PALMITATE
117
118
119
120
121
122
123
124
125
126
-----------
146
147
148
149
150
151
152
153
154
155
-----------------
156 -- TRIHEXYPHENIDYL
157 -- TRIIODOTHYRONINE
(T3)
158 -- TRILEPTAL
159 -- VALIUM
160 -- VALPROIC ACID
161 -- VENLAFAXINE
162 -- VIIBRYD
163 -- VILAZODONE
164 -- VORTIOXETINE
165 -- VYVANSE
166 -- WELLBUTRIN
167 -- XANAX
168 -- ZALEPLON
169 -- ZENZEDI
170 -- ZIPRASIDONE
171 -- ZOLOFT
172 -- ZOLPIDEM
173 -- ZOLPIMIST
PROZAC
QUETIAPINE
QUILLIVANT XR
RAMELTEON
REMERON
RESTORIL
RISPERDAL
RISPERDAL CONSTA
RISPERIDONE
RITALIN
ROZEREM
SAPHRIS
SEROQUEL
SERTRALINE
SILENOR
SONATA
-----------
SUVOREXANT
TASIMELTEON
TEGRETOL
TEMAZEPAM.
TENEX
THORAZINE
TOPAMAX
TOPIRAMATE
TRANYLCYPROMINE
TRAZODONE
(EXTENDED RELEASE
INJECTABLE)
116 -- PAMELOR
145 -- STRATTERA
174 -- ZYPREXA
175 -- ZYPREXA
RELPREVV
Version 4 – February 2017 (Post IRB Approval)
240
SHOWCARD Y2
1
The medicine was not helping
2
The child or one of his/her parents thought
the problem would get better without more
medicine
3
The child’s family couldn’t afford to pay for
the medicine
4
The child was too embarrassed to continue
taking the medicine
5
The child or one of his/her parents wanted to
solve the problem without medications
6
The medicine caused side effects that made
the child stop
7
The child was afraid that he/she would get
dependent on the medication
8
Someone in the child’s personal life
pressured him/her to stop
9
Any other reason for stopping
Version 4 – February 2017 (Post IRB Approval)
241
SHOWCARD Y3
1
The medicine was not helping
2
You thought the problem would get better
without more medicine
3
You couldn’t afford to pay for the medicine
4
You were too embarrassed to continue
taking the medicine
5
You wanted to solve the problem without
medications
6
The medicine caused side effects that made
you stop
7
You were afraid that you would get
dependent on the medication
8
Someone in your personal life pressured you
to stop
9
Any other reason for stopping
Version 4 – February 2017 (Post IRB Approval)
242
SHOWCARD 8
1
LESS THAN $1,000
2
$1,000 - $1,999
3
$2,000 - $2,999
4
$3,000 - $3,999
5
$4,000 - $4,999
6
$5,000 - $5,999
7
$6,000 - $6,999
8
$7,000 - $7,999
9
$8,000 - $8,999
10
$9,000 - $9,999
11
$10,000 - $10,999
12
$11,000 - $11,999
13
$12,000 - $12,999
14
$13,000 - $13,999
15
$14,000 - $14,999
16
$15,000 - $15,999
17
$16,000 - $16,999
18
$17,000 - $17,999
19
$18,000 - $18,999
20
$19,000 - $19,999
Version 4 – February 2017 (Post IRB Approval)
243
SHOWCARD 9
21
$20,000 - $24,999
22
$25,000 - $29,999
23
$30,000 - $34,999
24
$35,000 - $39,999
25
$40,000 - $44,999
26
$45,000 - $49,999
27
$50,000 - $74,999
28
$75,000 - $99,999
29
$100,000 - $149,999
30
$150,000 OR MORE
Version 4 – February 2017 (Post IRB Approval)
244
Appendix A
Summary of Module Content
Version 4 – February 2017 (Post IRB Approval)
245
Introduction
This document briefly summarizes the content of each National Mental Health Study (NMHS)
Adolescent Instrument module, provides a high-level overview of the changes made to the module, and
includes some topics the reader may wish to consider in reviewing the instrument. The way changes are
identified depends on the type of module:
•
Similar to Adult. If the adolescent module has a counterpart in the NMHS adult
instrument, this document lists the changes made to the adult module in order to create
the adolescent version.
•
Unique to Adolescent. If the adolescent module has no counterpart in the NMHS Adult
Instrument, this document lists changes made to adolescent source material provided
from the Substance Abuse and Mental Health Services Administration (SAMHSA) and
the National Institute of Mental Health (NIMH).
Changes
All modules were revised as follows.
•
Inclusion Logic. Checkpoint (CKPT) and “GO TO” logic instructions were translated
to question-by-question inclusion logic. This logic, which appears at the beginning of a
question, indicates which respondents should be asked each question. If no inclusion
logic appears in the specifications, the question will be asked of all adolescent
respondents.
•
Logic-Processing Variables. Where logic is complicated, it has been divided into
smaller units, each with its own variable name. Programmers and instrument testers
will use these variables to help ensure the instrument functions as intended. However,
respondents will not see the processing variables or their associated logic.
•
ACASI Adaptations. Most modules will be administered via audio computer-assisted
self-interviewing (ACASI). Where needed, items were revised to enable the automated
system to appropriately read text aloud.
•
– Removed parentheses and instead used other methods for setting text apart.
– Removed italicization.
– Removed underlining used to indicate text that should be emphasized and replaced
with bolding.
– Converted abbreviations to full words.
– Integrated most showcard booklet references into on-screen text.
– Revised language that suggested the question was being read to the respondent by
an interviewer (e.g., “Now I’d like to ask you about…” to “These next questions are
about…”).
Ranges. Wherever a question asks for an open-ended numerical answer, a specified
range is documented within which the respondents’ answers must fall in order to be
considered valid by the system. When a respondent enters a response outside the
allowable range, the system will generate a message alerting the respondent that the
response must be revised. Such range limits help to improve data quality by alerting
respondents to what are typically either keying errors or errors caused by the
respondent misunderstanding what information is being requested.
Version 4 – February 2017 (Post IRB Approval)
246
•
Yes/No Grids. Most check-all-that-apply questions were converted to grids of Yes/No
questions. The Yes/No format ensures that respondents consider each individual item
rather than skimming the list and, perhaps, only attending to one or two items. This
approach should be more effective in the ACASI environment where an interviewer is
not able to prompt a respondent to consider all items in the list.
•
Don’t Know and Refuse Responses.
•
– For each question, there is an explicit indication that a “don’t know” (DK) or refuse
(REF) is an option. Respondents will access these answer choices by using function
keys that have been labeled specifically for this purpose.
– Inclusion logic is provided where needed to clarify what should happen after a
respondent enters a “don’t know” answer or refuses a question.
Fills. Separate variables have been defined to create the text fills needed to tailor
questions based on a respondent’s answers to previous questions.
•
Renumbering. All items have been renumbered, in some cases several times, for logical
flow throughout the specifications. Renumbering will not be listed specifically in the
module-by-module summaries.
•
Module order. Modules were reordered several times during drafting. These changes
are not marked because the source documents were not specifically ordered when
received by RTI.
Because the changes noted above were made throughout the Adolescent Instrument, these categories of
changes are not repeated in the module-specific overviews that follow.
Key to Header Information Used in the Remaining Sections of this Document
The header for each section of this document contains the following information about the module.
•
Module Name
– There has been some renaming of CIDI modules as Dr. Kessler has worked to
create the CIDI 4.0 versions. The names included in this document are our best
understanding of how modules are now being referenced.
Version 4 – February 2017 (Post IRB Approval)
247
•
Mode
•
– CAPI = computer-assisted personal interviewing.
▪ Interviewers administer CAPI modules.
– ACASI = audio computer-assisted self-interviewing.
▪ Respondents read questions on their own or listen to the computer read the
questions to them through headphones.
▪ Interviewers remain nearby in order to provide showcards as requested by the
respondent and to answer any questions the respondent raises.
Coverage
– Part 1:
▪ All respondents will be administered at least one question from each module
assigned to Part 1.
– Part ½:
▪ All respondents will be randomly assigned to receive one or the other of the
paired modules assigned to Part ½.
– Screened +:
▪ Only respondents who screen positive for the disorder that is the subject of the
module will receive a “Screened +” module.
– Part 2:
▪ All respondents who screen positive to one or more of the disorder modules in
the CIDI Screener will receive “Part 2” modules.
▪ In addition, 25% of respondents who screen negative to all disorder modules
will also receive “Part 2” modules.
Version 4 – February 2017 (Post IRB Approval)
248
1.
Core Demographics | CAPI—Part 1
•
Overview
– Collects basic demographic information including age, race, ethnicity, marital
status, and educational attainment.
– Includes routing to ensure respondents who are younger than 13 are not interviewed
at all and that respondents younger than 18 are interviewed using the adolescent
instrument.
– Also asks for height, weight, country/state of origin, other languages spoken, and
how well the respondent speaks English.
•
Changes from Adult
– No high-level changes made. Beginning ACASI | CAPI—Part 1
•
Overview
– The interviewer introduces the respondent to audio computer-assisted selfinterviewing (ACASI).
•
Changes from Adult
– No high-level changes made.
Version 4 – February 2017 (Post IRB Approval)
249
2.
Tutorial | ACASI—Part 1
•
Overview
– The respondent follows instructions and completes practice questions, using
ACASI.
•
Changes from Adult
– No high-level changes made.
Version 4 – February 2017 (Post IRB Approval)
250
3.
Your Health | ACASI—Part 1
•
Overview
– Asks a variety of physical and mental health questions.
▪ general health
▪ impairment
▪ cancer history
▪ health condition history
▪ symptoms in past 30 days
▪ sleep problems
▪ basic categories of treatment in the past 12 months
– HHS impairment questions are included in this module, labeled as B8a–f.
•
Changes from Adult
– Removed B4, which asked about impairment. These topics are covered for the
adolescent in the Columbia Impairment Scale (Module 5).
– Removed B9, B9a1–B9a5, B9b, and B9c, which asked about cancer diagnoses.
– Revised B10 to include health conditions appropriate for adolescents.
– Revised wording in B14.
– Added B17A and B17B, which ask about being totally unable to go to school, work,
or carry out other usual activities because of physical or behavioral health.
– Replaced B17 with the B17C series, which asks about sleep problems.
– Removed the B22A series, IMWEEK1, IMDAYS, and LIAD68, which duplicated
impairment questions from disorder modules.
Version 4 – February 2017 (Post IRB Approval)
251
4.
Columbia Impairment Scale | ACASI—Part 1
•
Overview
– Asks 13 questions designed to assess impairment across four areas of functioning:
interpersonal relations, broad psychosocial domains, functioning in job or
schoolwork, and use of leisure time.
•
Changes from Original
– Grids were condensed into fewer screens.
– Item about siblings was removed from the grid and is asked as a stand-alone
question.
Version 4 – February 2017 (Post IRB Approval)
252
5.
CIDI Screener | ACASI—Part 1
•
Overview
– Includes questions designed to screen respondents into later modules for several
disorders.
▪ Depression
▪ Mania
▪ Panic
▪ Social Anxiety
▪ Agoraphobia
▪ Eating Disorders
▪ Separation Anxiety
▪ Attention and Concentration Problems
▪ Oppositional Defiant Disorder
•
Changes from Adult
–
–
–
–
–
–
Revised wording of SP1 and SP1a to be age appropriate.
Deleted SC8, SC8a, and SC8b, which asked about anger.
Deleted SC10 and SC11, which asked about OCD.
Added SC12, which asks about separation anxiety.
Added SC13 and SC13a, which ask about attention and concentration problems.
Added SC14, SC15, SC15a, and SC15b, which ask about getting in trouble with
adults and oppositional behavior.
Version 4 – February 2017 (Post IRB Approval)
253
6.
Depression | ACASI—Part 1
•
Overview
– Asks about depression symptoms in the past 30 days.
– Asks about depression symptoms in the worst period in life that lasted 2 weeks or
longer.
– If the respondent has experienced one or more of the initial set of worst-2-weeks
symptoms at least “most of the time,” asks follow-up questions about that 2-week
period.
▪ frequency experienced other symptoms
▪ degree of impairment
– If enough of the worst-2-weeks symptoms were experienced “some of the time” or
more frequently, follow-up questions are asked:
▪ age first time had depression episode
▪ whether first episode started in past 12 months
▪ years in life had an episode
▪ duration of longest episode
▪ how much episodes interfered with life
▪ number of months in past 12 months that had an episode
▪ age at time of most recent episode
•
Changes from Original
– Minor language changes for age appropriateness.
– Removed DE1d and DE1e, which asked about feeling irritable, grouchy, or in a bad
mood and feeling down on yourself, no good, or worthless.
– Added DEFINE DE4_COUNTA to count two items in a grid under different
conditions than the other items in that grid, which are counted in DEFINE
DE_COUNT.
– Edited logic throughout module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
254
7.
Mania | ACASI—Screened +
•
Overview
– Only administers the first question to respondents who have not already screened
positive for mania elsewhere in the instrument.
– If screened positive on the first question or already screened positive for mania
elsewhere in the instrument, follow-up questions are asked:
▪ whether other people ever noticed or commented on high mood
▪ for each of several symptoms, frequency during a typical intense episode
If key symptoms from a typical intense episode were frequent enough, asks
follow-up questions:
o for each of several additional symptoms, frequency during a typical
intense episode
o how often the episode interfered with life
– If screened positive when considering the full set of key symptoms from a typical
intense episode, asks more follow-up questions:
▪ age first time had episode
▪ whether first episode started in past 12 months
▪ years in life had an episode
▪ duration of longest episode
▪ how much episodes interfered with life
▪ whether ever hospitalized as a result of an episode
▪ number of months in past 12 months that had an episode
▪ whether had episode in the past 30 days
▪ age at time of most recent episode
•
Changes from Adult
– Minor language changes for age appropriateness.
Version 4 – February 2017 (Post IRB Approval)
255
8.
Anxiety and Worry (GAD) | ACASI—Part 1
•
Overview
– Asks all respondents frequency of experiencing a first set of symptoms in the past
30 days.
▪ If experienced a sufficient number of the first set of symptoms frequently, then
asks frequency of experiencing a second set of symptoms in the past 30 days.
– If 30-day symptoms were not frequent, asks for frequency of symptoms in the most
intense 6-month period in life.
– If had several symptoms frequently either in the past 30 days or in the most intense
6-month period in life, asks follow-up questions.
▪ age first time had an anxiety or worry episode
▪ whether started in past 12 months
▪ number of years in life had episode
▪ duration of longest episode
▪ number of days in a typical week during the episodes when anxious or worried
at least a little of the time
▪ how much episodes ever interfered with life
▪ number of months in past 12 months had an episode
▪ age had most recent episode
•
Changes from Adult
– Minor language changes for age appropriateness.
Version 4 – February 2017 (Post IRB Approval)
256
9.
Social Anxiety | ACASI—Screened +
•
Overview
– Module administered to respondents who endorse either SC4 or SC4a in the CIDI
Screener module.
– For each of five social situations, asks if there was ever a time in the respondent’s
life when he or she was very afraid, anxious, or extremely shy in that situation.
– For each of five performance situations, asks if there was ever a time in the
respondent’s life when he or she was very afraid, anxious, or extremely
uncomfortable in that situation.
– If the respondent reports problems in three or more situations, asks about the
intensity of reactions when at their worst.
– If intensity was high, asks whether respondent had each of five fears.
– If had at least one of the five listed fears, asks how often got very upset.
– If had at least one of the five listed fears and got very upset in problematic
situations, asks follow-up questions about the period in life with the most intense
reactions:
▪ how often tried to avoid the situations
▪ how much fears or avoidance interfered with life
▪ age when first had reactions
▪ whether reactions started in past 12 months
▪ years in life had reactions
▪ number of months in past 12 months that would have had reactions
▪ whether would have had reactions in the past 30 days
▪ age most recent time would have had reactions
•
Changes from Adult
– No high-level changes.
Version 4 – February 2017 (Post IRB Approval)
257
10.
Agoraphobia | ACASI—Screened +
•
Overview
– Module administered to respondents who endorse SC5 in the CIDI Screener
module.
– For each of five situations, asks if there was ever a time in the respondent’s life
when he or she feared escape might be difficult or help might not be available when
in the situation.
– If reported fear in at least two situations, asks follow-up questions:
▪ what was feared most in the situations
▪ how upset the respondent got during time in life when symptoms were most
severe
– If would get very or extremely upset, asks how often would get very upset when in
situations where might be unable to escape or get help.
– If almost always got very upset when in situations where might be unable to escape
or get help, asks follow-up questions.
▪ Regarding the time when fear was most severe…
how soon after entered situation the respondent would usually get very upset
how often would try to avoid situations
how much interfered with life
age when fear started
whether started in past 12 months
years in life had the fear
number of months in past 12 months that would have gotten very upset if
were in one of the situations
whether would have had the reaction in the past 30 days
age most recent time would have become upset
•
Changes from Adult
– Minor language changes for age appropriateness.
Version 4 – February 2017 (Post IRB Approval)
258
11.
Panic Disorder | ACASI—Screened +
•
Overview
– Only administers the first question to respondents who have not already screened
positive for panic disorder elsewhere in the instrument.
– If screened positive on the first question or already screened positive for panic
disorder elsewhere in the instrument, asks whether attacks occurred “out of the
blue” versus when the respondent had a strong fear or was in real danger.
– If at least some of the attacks occurred “out of the blue”, follow-up questions are
asked:
▪ proportion of “out of the blue” attacks that occurred when under the influence of
alcohol or drugs
▪ proportion of “out of the blue” attacks that occurred when asleep
▪ total number of “out of the blue” attacks in lifetime
▪ whether had each of 14 symptoms
▪ If at least some of the 14 listed symptoms reported, asks more follow-up
questions.
whether had a month or longer when worried due to symptoms
whether respondent had a month or longer when he or she changed everyday
activities due to symptoms
age at first “out of the blue” attack
If previous answers left uncertainty, asks one or more of the following as
well:
o whether respondent’s first attack was in past 12 months
o whether had first attack in the past 30 days
o years in life had at least one attack
o number of months in past 12 months that had an attack
o age at time of most recent attack
o number of days out of the past 30 days that had an attack
•
Changes from Adult
– No high-level changes.
Version 4 – February 2017 (Post IRB Approval)
259
12.
Eating Disorders | ACASI—Screened +
•
Overview
– If reported in CIDI Screener that there was ever a time in life when had a great deal
of concern about or strongly feared being too fat or overweight but weighed less
than other people (SC6 and SC6a both answered “yes”), asks several follow-up
questions:
▪ lowest body weight had on purpose after age of 12
▪ height when at lowest weight
▪ whether respondent feared he or she would gain weight, when at lowest weight
if feared would gain weight, asks whether did things to keep weight low
if did things to keep weight low, asks whether:
o felt too heavy
o thought some parts of body were too fat
o felt self-esteem or confidence dependent on staying thin or losing more
weight
o anyone told respondent that their low weight was bad for own health
– If reported in CIDI Screener that ever have had a time in life when went on eating
binges at least once a week for 3 three months or longer (SC7), asks several followup questions:
▪ whether felt loss of control during time when binged
▪ If felt loss of control during time when binged, asks follow-up questions.
whether respondent experienced each of five symptoms.
o If experienced three of the five symptoms, asks about four other
symptoms.
whether did each of six actions in order to control weight
o If took one or more of the weight control actions, asks if ever did it/them
at least once a week for 3 three months or longer.
o If did weight control action(s) for 3 three months or longer, asks followup questions about the long episode(s).
age first time had an episode
whether episode started in the past 12 months
number of years in life had such episodes
duration of the longest episode ever had
how much the episodes interfered with life
number of episodes in the past 12 months
age at time of most recent episode
•
Changes from Adult
– No high-level changes.
Version 4 – February 2017 (Post IRB Approval)
260
13.
Suicidality | ACASI—Part 1
•
Overview
– Asks if the respondent ever seriously thought about killing himself or herself. If the
respondent answers yes, asks several questions about suicidality:
▪ age first time seriously thought about killing self
▪ occurrence in the past 12 months
▪ age last time
▪ whether made plan
age first time
occurrence in the past 12 months
age last time
▪ if ever tried to kill self, asks:
number of attempts
age first time (if more than once)
description of intent first time (if more than once)
occurrence in the past 12 months
age at (last) time
injuries or poisoning
medical attention required
overnight hospitalization required
description of intent (last) time
method
– Asks whether ever hurt self on purpose without wanting to die. If so, asks follow-up
questions:
▪ age first time
▪ occurrence in the past 12 months
▪ age last time
•
Changes from Adult
– No high-level changes made.
Version 4 – February 2017 (Post IRB Approval)
261
14.
Unusual Experiences | ACASI—Part 1
•
Overview
– For each of seven psychotic experiences, asks whether the respondent ever had that
experience.
– Asks follow-up questions about each psychotic experience reported:
▪ age of first experience
▪ lifetime count of experiences
▪ years in life had experiences at least one time
▪ duration of the experience(s)—where applicable
▪ whether had the experience in the past 12 months
▪ age most recent time had the experience
▪ level of belief about reality of experience(s)
▪ how distressing experiences were/experience was
– If one or more types of psychotic experience reported, asks about help in dealing
with the experiences:
▪ ever talked to doctor or mental health professional
▪ cause, per doctor or mental health professional
▪ whether medication was taken for experiences and, if so, which medication
▪ interference with life
•
Changes from Adult
– No high-level changes made.
Version 4 – February 2017 (Post IRB Approval)
262
15.
Psychosis | ACASI—Part ½
•
Overview
– Module removed.
Version 4 – February 2017 (Post IRB Approval)
263
16.
Treatment of Emotional Problems | ACASI—Part 1
•
Overview
– Asks whether respondent stayed overnight or longer in a hospital or other facility to
receive treatment for problems with emotion, nerves, or mental health. If yes,
follow-up questions are asked about each facility where the respondent stayed:
▪ number of times hospitalized
▪ age (first) time
▪ started in past 12 months or not
▪ number of nights in the past 12 months
▪ age most recent time
– For each of six sources, asks if ever received counseling or medication:
▪ mental health professional
▪ general medical care provider
▪ spiritual advisor
▪ Certified Peer Counselor
▪ self-help or support group
▪ computerized or internet-based mental health treatment program
– For each source reported, asks follow-up questions:
▪ type of help received, if unclear given source
▪ age (first) time
▪ whether started in past 12 months
▪ years in life received help from that source
▪ help in past 12 months
▪ kind of sessions in past 12 months, if from mental health professional
▪ age most recent time
▪ whether help is still being received (categories collapsed)
if not, why stopped
– If did not receive professional help in the past 12 months, asks whether there was
ever a time in past 12 months when respondent felt such help was needed.
– Asks whether received each of three school services.
– If did not receive professional help in the past 12 months and there was a time when
the respondent felt such help was needed, then asks why professional help was not
obtained.
•
Changes from Adult
– Minor wording changes for age appropriateness.
– Added TR1A and TR1A_OTH, which ask about types of facilities.
– Removed items that ask about hospitalization generally and replaced them with
questions about each type of facility endorsed in TR1A.
Version 4 – February 2017 (Post IRB Approval)
264
– Removed TR5, which asked about night hospitalized in the past 12 months, to avoid
redundancy.
– Added TR52Ha–d, which ask about special school services.
– Removed TR54a–g, TR54h, and TR54_OTH, which asked about reasons for
stopping treatment.
Version 4 – February 2017 (Post IRB Approval)
265
17.
Trait Fear | ACASI—Part ¼
•
Overview
– Asks 20 questions related to trait fear.
– Respondents will be randomly assigned to receive either the Trait Fear,
Disinhibition, Personality, or Affective Reactive Index module.
•
Changes from Adult
– No high-level changes made.
Version 4 – February 2017 (Post IRB Approval)
266
18.
Disinhibition | ACASI—Part ¼
•
Overview
– Asks 20 questions related to disinhibition.
– Respondents will be randomly assigned to receive either to receive either the Trait
Fear, Disinhibition, Personality, or Affective Reactive Index module.
•
Changes from Adult
– No high-level changes made.
Version 4 – February 2017 (Post IRB Approval)
267
19.
Personality | ACASI—Part ¼
•
Overview
– Asks 26 personality questions.
– Respondents will be randomly assigned to receive either the Trait Fear,
Disinhibition, Personality, or Affective Reactive Index module.
•
Changes from Adult
– No high-level changes made.
Version 4 – February 2017 (Post IRB Approval)
268
20.
Affective Reactive Index | ACASI—Part ¼
•
Overview
– Asks seven questions comparing the respondent’s behavior to that of his or her
peers.
– Respondents will be randomly assigned to receive either the Trait Fear,
Disinhibition, Personality, or Affective Reactive Index module.
•
Changes from Original
– No high-level changes made.
Version 4 – February 2017 (Post IRB Approval)
269
21.
BPD Screen | ACASI—Part 1
•
Overview
– Asks a single grid of 12 Yes/No questions of all respondents.
•
Changes from Adult
– No high-level changes made.
Version 4 – February 2017 (Post IRB Approval)
270
22.
Attention and Concentration | ACASI—Screened +
•
Overview
– If reported in CIDI Screener that there were concentration problems before the age
of 12 that lasted 6 months or longer (SC13 = yes), asks a series of follow-up items:
– Asks how often concentration and attention problems occurred.
– If had six or more attention or concentration symptoms, asks about:
▪ Impairment
▪ Age of onset
▪ Total number of years had problems with concentration or attention
▪ How many months in the past 12 had problems with concentration or attention
▪ If had problems in the past 30 days
▪ If did not have problems in the past 30 days, age at most recent problems
– If reported in CIDI Screener that there were problems being restless and fidgety
before the age of 12 that lasted 6 months or longer (SC11a = yes), asks a series of
follow-up items.
▪ Asks how often feelings of restlessness or impatience occurred.
▪ If had six or more inattention symptoms, asks about:
Impairment
Age of onset
Total number of years had problems with restlessness and impatience
How many months in the past 12 had problems with restlessness and
impatience
If had problems in the past 30 days
If did not have problems in the past 30 days, age at most recent problems
•
Changes from Original
– Edited logic throughout module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
271
23.
Oppositional-Defiant Disorder | ACASI—Screened +
•
Overview
– If reported in CIDI Screener that there were problems getting in trouble with adults
because of losing your temper, arguing or talking back, or refusing to do what you
were told that lasted 6 months or longer (SC12 = yes), asks how often each of
several oppositional-defiant behavioral problems occurred.
– If reported high frequency for four or more oppositional-defiant symptoms, asks
about:
▪ Age of onset
▪ Impairment
▪ How many months in the past 12 had problems with oppositional-defiant
disorder
▪ If had problems in the past 30 days
▪ If did not have problems in the past 30 days, age at time of most recent
problems
•
Changes from Original
– Edited logic throughout module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
272
24.
Conduct Disorder | ACASI—Screened +
•
Overview
– If reported in CIDI Screener that there were problems getting in trouble with adults
because of lying, stealing, breaking rules, breaking into cars, setting fires,
destroying property on purpose, running away from home, playing hooky, or
staying out late (SC15, SC15a, or SC15b = yes), asks a series of follow-up items:
▪ how often certain behavioral problems occurred
▪ age of onset
▪ If had three or more conduct disorder symptoms, asks about:
Impairment
How many months in the past 12 had problems with conduct disorder
Whether had problems in the past 6 months
If did not have problems in the past 6 months, age at time of most recent
problems
•
Changes from Original
– Edited logic throughout module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
273
25.
Separation Anxiety Disorder | ACASI—Screened +
•
Overview
– If reported in CIDI Screener that there was anxiety about separation (SC12 = yes),
asks a series of follow-up items:
▪ Asks how often each of several issues with separation symptoms occurred.
▪ If had three or more symptoms, asks about:
Impairment
Age of onset
Whether started in the past 12 months
How many years total separation anxiety occurred
How many months in the past 12 had problems with separation anxiety
Recency of problems
Age at time of most recent problems
•
Changes from Original
– Minor wording changes for age appropriateness.
– Edited logic throughout module for DSM5 compliance.
Version 4 – February 2017 (Post IRB Approval)
274
26.
Juvenile Justice and Detention | ACASI—Part1
•
Overview
– Begins by asking respondents if they have ever been arrested. Those who have
continue; those who have not skip to the next module.
– Asks respondents if they were ever in a jail, detention center, or any other juvenile
justice or adult criminal justice facility, as well as the amount of time during in
these facilities.
– Asks respondents age the first time they were sent to a justice facility.
– Asks if they were in a facility, and how long in that facility, in the past 12 months.
– Asks about being on probation, parole, supervised release, or other conditional
release, or in another kind of special program during the past 12 months.
•
Changes from Original
– Minor wording changes for age appropriateness.
– Removed AP06–AP09 and AP11, which ask about committing crimes but not
getting caught or arrested.
– Added JJ14, which asks about special justice programs.
Version 4 – February 2017 (Post IRB Approval)
275
27.
Homelessness | ACASI—Part 1
•
Overview
– Begins by asking respondents if they have ever been homeless. Those who have
continue; those who have not skip to the next module.
– Asks respondents when they were homeless, where they slept while homeless, and
how much of their life they have been homeless.
•
Changes from Adult
– No high-level changes.
Version 4 – February 2017 (Post IRB Approval)
276
28.
Head Injuries | ACASI—Part 1
•
Overview
– Asks number of lifetime head or neck injuries that:
▪ resulted in lost consciousness
▪ caused “seeing stars” or other confusion
▪ caused memory lapse
– If memory lapse reported, asks number of times a head or neck injury caused
memory loss lasting less than 30 minutes, between 30 minutes and 24 hours, and
more than 24 hours.
•
Changes from Adult
– Minor wording changes for age appropriateness.
Version 4 – February 2017 (Post IRB Approval)
277
29.
Stressful Experiences (Post-Traumatic Stress Disorder) | ACASI—Part 2
•
Overview
– Asks whether respondent ever had each of 18 stressful experiences.
– For each stressful experience ever experienced, asks follow-up questions:
▪ number of times or months/years had the experience
▪ age (first) time
– Asks how much bothered by each of eight symptoms in the past 30 days.
– Asks how much bothered by each of eight symptoms in the worst month in life.
▪ If at least moderately bothered by two or more symptoms, asks how much
bothered by each of an additional set of 15 symptoms.
▪ If bothered enough by key sets of symptoms, asks follow-up questions:
age first time had symptoms
years in life had at least a month with symptoms
number of months had symptoms
age most recent time had symptoms
how much episodes interfered with life
•
Changes from Adult
– Minor language changes for age appropriateness.
– Removed P1d, P6, P7a, and P7b, which asked about experience in a war or combat
zone.
– Removed P30, P31, and P32, which asked about stressful life experiences.
Version 4 – February 2017 (Post IRB Approval)
278
30.
Family Medical History (ACE) | ACASI—Part 2
•
Overview
– Asks questions about biological mother and father, including:
▪ if still living
▪ current age or age at time of death
▪ education
▪ has or had Autism spectrum disorder, bipolar disorder, an anxiety disorder,
depression, or schizophrenia
– Asks about siblings, alive and living, followed by total number of siblings, total
number of full siblings, number of older full siblings, total number of half siblings,
and number of older half siblings.
▪ If any siblings are reported, asks if any of them has or had Autism spectrum
disorder, bipolar disorder, an anxiety disorder, depression, or schizophrenia.
▪ If any of the above disorders are reported, asks if full siblings, half siblings, or
both had each disorder (Autism, bipolar, anxiety, depression, schizophrenia).
•
Changes from Adult
– Removed AFM16–AMF18, which asked about lifetime events.
Version 4 – February 2017 (Post IRB Approval)
279
31.
Tobacco, Alcohol, and Drugs | ACASI—Part 2
•
Overview
– Asks about age of first use (if ever) of alcohol, tobacco, marijuana, and various
prescription and non-prescription drugs.
▪ If ever used, asks for frequency of use in the past 12 months.
▪ Also asks for number of uses per day for tobacco products and number of drinks
per day for alcohol.
– Respondents reporting a higher quantity/frequency of alcohol use are asked for
more information about their alcohol use, including any resulting problems.
– Respondents reporting drug use are asked for more information about their use,
including any resulting problems.
– Asks about hospitalizations resulting from drug or alcohol use.
– Asks about treatment for problematic drug or alcohol use.
•
Changes from Adult
– No high-level changes.
Version 4 – February 2017 (Post IRB Approval)
280
32.
Relationships and Social Networks | ACASI—Part 2
•
Overview
– Asks about relationship status/marital status.
▪ If ever married, asks about marital history including number of marriages, age
at time of first marriage, and if applicable, duration of marriage and how the
marriage ended.
▪ If married or in a steady relationship, asks questions about the quality of the
relationship (e.g., how much your partner cares about you, how much your
partner understands you, etc.).
– Asks for number and ages of biological children, as well as adoptive or stepchildren.
– Asks if respondent or his or her partner is currently pregnant.
– Asks about respondent’s social life including time spent with friends, attending
meetings or recreational groups, and role of religion or spiritual beliefs in the
respondent’s life.
– Asks about number of people the respondent can rely on for comfort or support as
well as whether the respondent believes he or she is a burden to others.
– Asks about use of internet for social networking and playing games and whether
these activities are relaxing or frustrating.
•
Changes from Adult
– Removed U2 and U3, which asked about marital status.
– Removed U1A, U1B, and U1C, which asked sexual orientation and gender identity.
– Removed U9, which asked about living with someone in a marriage like
relationship.
– Added introduction text to U10.
– Removed U18, U19, and U20, which asked about step and adoptive children.
Version 4 – February 2017 (Post IRB Approval)
281
33.
Childhood Demographics | ACASI—Part 2
•
Overview
– Asks primarily about the respondent’s experience in school, including learning
disorders, mental or emotional problems, school engagement, participation in sports
and other extracurricular activities, and exercise.
•
Changes from Adult
–
–
–
–
–
Minor wording changes for age appropriateness.
Removed DE20_11, which asked about where a respondent was raised.
Added DE20, which asks about school enrollment.
Added DE20B, which asks about expected educational attainment.
Removed Q18–Q22, which asked about mental or emotional problems and
disorders and events that happened in high school.
– Removed Q26a, which asked whether participated in an organized sport during
middle or high school years.
– Removed Q27–Q28c, which asked about participation in physical activities after the
age of 18.
Version 4 – February 2017 (Post IRB Approval)
282
34.
Childhood Experiences | ACASI—Part 2
•
Overview
– All respondents are asked about their experiences, including
▪ major life events involving the respondent’s parents, such as divorce, suicide,
incarceration, and problems with drugs/alcohol or mental illness.
▪ frequency of troublesome behaviors, such as bullying, fighting, lying, skipping
school, arguing with adults, and disobeying rules.
▪ frequency of homelessness, time on welfare, and familial support.
– Respondents are asked if they have ever been bullied and if they themselves have
bullied someone. If yes, they are asked if it happened during the past 12 months.
The same questions are asked about electronic bullying.
– Respondents are asked a series of questions about physical abuse, sexual abuse,
emotional abuse, and neglect.
•
Changes from Adult
– Minor wording changes for age appropriateness.
– Removed X3a–X3g, which asked about bullying.
– Removed X4a–X4e, which asked about behavioral problems that are covered in
other modules.
– Removed X5d–X5h and X6a–X6e, which asked about experiences that are covered
in other modules or by later questions.
– Added ACES1–ACES9 from the CDC ACES, which ask about adults and their
behavior in a respondent’s life.
Version 4 – February 2017 (Post IRB Approval)
283
35.
Employment | ACASI—Part 1
•
Overview
– Asks if respondent worked at a job or business last week.
▪ If respondent did not work last week, asks if respondent had a job.
▪ Hours worked at job or business last week and whether usually works 35 hours
or more per week.
▪ If did not work last week, asks reason.
▪ If did not have a job, asks main reason for this and if respondent was making
specific efforts to find work.
– Asks if respondent worked at a job or business in past 12 months.
– Asks if respondent was self-employed in past 12 months.
▪ If worked at a job or business, asks number of employers in past 12 months
(including self if self-employed).
▪ Was there ever a time in the past 12 months without a job or business.
▪ Number of days in the past 30 missed due to personal illness or injury and
number of days in the past 30 missed because “just didn’t want to be there”.
– ACASI closeout/end of audio.
•
Changes from Adult
– Removed QD38, which asked about total number of weeks without working at a job
or business.
– Removed QD39a and QD39b, which asked about the last month and year a
respondent worked.
Version 4 – February 2017 (Post IRB Approval)
284
36.
Household Roster | CAPI—Part 1
•
Overview
– Asks about total number of people living in household.
– For each person reported, asks age on last birthday, gender, and relationship to
respondent.
•
Changes from Adult
– No high-level changes.
Version 4 – February 2017 (Post IRB Approval)
285
37.
Proxy Information | CAPI—Part 1
•
Overview
– Determines whether proxy (adult household member or person present) would be
better able to answer questions about income and insurance.
•
Changes from Adult
– Added reference to medication, because pharmacoepidemiology questions asked via
proxy for adolescents.
– Added definitions for SAMPLE MEMBER C, SAMPLE MEMBER CC, SAMPLE
MEMBER D, SAMPLE MEMBER E, AND SAMPLE MEMBER E PRO, which
are needed for correct verb conjugation in the Pharmacoepidemiology module when
using a proxy.
Version 4 – February 2017 (Post IRB Approval)
286
38.
Pharmacoepidemiology | ACASI—Part 1
•
Overview
– Asks total number of different kinds of prescription and non-prescription
medications taken in past 7 days.
– Asks if over the past 12 months any of the following prescription medications taken
for emotions, substance use, energy, concentration, sleep, or ability to cope with
stress: sleeping pills/sedatives, anti-depressants, tranquilizers,
amphetamines/stimulants, or antipsychotics.
▪ If none of the above, asks if any type of prescription medication was taken for
emotions, substance use, energy, concentration, sleep, or ability to cope with
stress over the past 12 months.
▪ If any of the above reported, asks which medications were taken in the past 12
months.
– For up to 20 medications reported, asks the following:
▪ Number of days taken in past 30 days and past 12 months and best estimate of
first date taken in past 12 months
– For up to three medications reported, asks the following.
▪ Problem medication was taken for and effectiveness of medication
▪ If medication was taken with health professional’s supervision or without, and
who prescribed the medication
▪ Number of days in the past 30 forgot to take or took less than instructed
▪ If still taking the medication
If no longer taking, asks if health professional instructed respondent to stop
taking
If health professional did not instruct to stop taking the medication, asks if
the health professional agreed with decision to stop
If medication was stopped because felt better
Other reason for stopping the medication
If side effects were the reason for stopping, asks about the nature of the side
effects
•
Changes from Adult
– Updated language for CAPI administration to a proxy or self-report, which included
the use of three showcards not needed in the adult.
– Included showcards when necessary for CAPI administration.
– Added APH0, which asks if a respondent has ever taken a prescription medication
for mental health reasons.
– Added APH4a and APH5a, which ask what was the first prescription medication a
respondent took for mental health reasons.
Version 4 – February 2017 (Post IRB Approval)
287
39.
Income | CAPI—Part 1
•
Overview
– Asks if any of the following were received last year.
▪ Social Security or Railroad Retirement
▪ Supplemental Security Income
▪ Supplemental Nutrition Assistance Program
▪ Cash assistance
▪ Other non-monetary assistance
– If any received, asks number of months received last year.
– Asks if income from other sources including a job or business.
– Total personal income and total family income last year.
•
Changes from Adult
– No high-level changes.
Version 4 – February 2017 (Post IRB Approval)
288
40.
Health Insurance | CAPI—Part 1
•
Overview
– Asks if received Medicare, Medicaid, state CHIP, military health insurance (e.g.,
TRICARE or CHAMPUS/CHAMPVA), or private health insurance.
– Covered by any health insurance.
– Any time in past 12 months without health insurance, and how many months if so.
– Length of time since last covered.
•
Changes from Adult
– No high-level changes.
Version 4 – February 2017 (Post IRB Approval)
289
41.
Verification | CAPI—Part 1
•
Overview
– Covers the closeout of the interview. Information is collected to assist RTI
International in verifying a portion of each interviewer’s work.
– The interviewer is instructed to provide the incentive payment, sign the incentive
receipt form, provide a copy of the receipt form to the respondent, and thank him or
her for participating in the study.
– The Quality Control Form is now an electronic form on the tablet. Added
instructions to the interviewer on how to access and complete this form.
•
Changes from Adult
No high-level changes.
Version 4 – February 2017 (Post IRB Approval)
290
| File Type | application/pdf |
| Author | allewis |
| File Modified | 2017-04-13 |
| File Created | 2017-04-13 |