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pdfAttachment 2a - Family Questionnaire
2017 Q1 NHIS Instrument Spec Report
Section name: HEALTH STATUS AND LIMITATION OF
ACTIVITIES
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.001
Variable Name
HLTH_BEG
Universe
FSTAT= empty or FSTAT=2
Universe-text
All families
Question Text
* Read the following introduction:
I am now going to ask about [fill1: your/the] general health [fill2: /of family members]
and the effects of any physical, mental, or emotional health problems.
* If refused enter CTRL-R.
Answer Codes
Enter 1 to Continue
Question Type
Text
Field Pane Description
Fill Instructions
Continue
fill1: if the subject=respondent fill "your" else fill "the".
fill2: if the subject=respondent fill an empty blank " " else, fill "of family members"
Special Instructions family level item; don’t store
do not allow
Skip Instructions
<1> [store <> in FSTAT; if AGE LE 4 goto FLAPLYLM; else goto FSPEDEIS]
goto [BCK.215_VISITCNT]
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Page 1 of 153
Module
04
Section Name
Family Health Ststus and Limitations of Activity
Part
Question ID
FHS.002
Variable Name
FAMDATE
Universe
HLTH_BEG = continue
Universe-text
Family Questionnaire has been started
Question Text
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions Set only if FAMDATE = empty
if HLTH_BEG = 1 (continue), set FAMDATE = CDATE (current date) (now called
ComputationDate)
This is an output variable that should be in the format 'MMDDYYYY'
Skip Instructions
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Page 2 of 153
Module
04
Section Name
Family Health Ststus and Limitations of Activity
Part
Question ID
FHS.003
Variable Name
FAMTIME
Universe
HLTH_BEG = continue
Universe-text
Family Questionnaire has been started
Question Text
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions Set only if FAMTIME = empty
if HLTH_BEG = 1 (continue), set FAMTIME = current time
This is an output variable that should be in the format "HH:MM [fill: a.m./p.m.]
Skip Instructions
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Page 3 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.005
Variable Name
FLAPLYLM
Universe
AGE<5
Universe-text
Families with one or more children age 0 to 4 years
Question Text
?[F1]
[fill1: Are/Is]
* Read names
(fill roster of persons age 0-4)
limited in the kind or amount of play activities [fill2: they/he/she] can do because of a
physical, mental, or emotional problem?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t Know
Yes/No
Field Pane Description
Fill Instructions
Limited in Play
fill1: For multi-person children age 0 to 4 years fill "Are", else fill "Is"
fill2: For multi-person children age 0 to 4 years fill "they", else fill "he/she"
Special Instructions family level item;
roster grid (display roster of children age 0 to 4)
Store this family level value to the person level.
Skip Instructions
<1> and only one child <5 store line number in PLAPLYLM and goto PLAPLYUN.
Else, goto [PLAPLYLM]
<2,D,R> [goto FSPEDEIS]
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Page 4 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.005_H
Variable Name
H_FLAPLYLM
Universe
Universe-text
Question Text
This question is only for children four years old or younger.
Physical, mental, and emotional problems are respondent defined.
The term "limited" is respondent defined.
Enter "1" if the respondent believes that any of the children four years old or younger
are limited in the kind or amount of
play activities they can do because of a physical, mental, or emotional problem.
Enter "2" if the respondent does not believe that any of the children four years old or
younger are limited in the kind or
amount of play activities they can do because of a physical, mental, or emotional
problem.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FLAPLYLM
Skip Instructions
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Page 5 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.010
Variable Name
PLAPLYLM
Universe
FLAPLYML=1
Universe-text
Persons <5 years and more than 1 child under 5
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions family level item; store at both family and at person level;
Eligible children with age 0-4 years
Store this family level value to the person level.
Skip Instructions
[Goto PLAPLYUN]
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Page 6 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.020
Variable Name
PLAPLYUN
Universe
FLAPLYLM =1 and persons selected in PLAPLYLM
Universe-text
Persons <5 yrs limited in play activities
Question Text
Is [fill: Alias listed in PLAPLYLM] able to take part AT ALL in
the usual kinds of play activities done by most children [Alias]’s age?
Answer Codes
1. Yes
2. No
Refused
Don’t Know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Can Play at All
fill: Alias listed in PLAPLYLM
Special Instructions person level item
Skip Instructions
<1,2,D,R> [Repeat this question to those children listed in PLAPLYLM, then [Goto
FSPEDEIS]
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Page 7 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.050
Variable Name
FSPEDEIS
Universe
AGE<18
Universe-text
Persons<18 years
Question Text
?[F1]
[fill: Do you/Does/Do any of the following family members,
* Read names
(fill roster of persons less than age 18)]
receive Special Educational or Early Intervention Services?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t Know
Yes/No
Field Pane Description
Fill Instructions
Special Ed/EIS
fill: for single-person household AGE<18 fill "Do you" (Emancipated minor), for multiperson houshold in which there is a single-person<18 years fill "Does" else fill "Do
any of the.."
Special Instructions family level item;
roster grid (display roster of persons<18 years)
Store this family level value to the person level.
Skip Instructions
<1> If only 1 child in the family, or if subject (child<18)=respondent
[store child’s person number in [PSPEDEIS]_1, goto PSPEDEM], else [goto
PSPEDEIS]
<2,D,R> [goto FLAADL]
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Page 8 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.050_H
Variable Name
H_FSPEDEIS
Universe
Universe-text
Question Text
This question is only for children 17 years old or younger.
Special Education is teaching designed to meet the needs of a child with special
needs and/or disabilities. They are designed for
children and youths aged 3 to 21. It is paid for by the public school system and may
take place at a regular school, a special
school, a private school, at home, or at a hospital.
Early Intervention Services are services designed to meet the needs of very young
children with special needs and/or disabilities. They
may include but are not limited to: medical and social services, parental counseling,
and therapy. They may be provided at the
child's home, a medical center, a day care center, or other place. They are provided
by the state or school system at no cost to the
parent.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FSPEDEIS
Skip Instructions
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Page 9 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.060
Variable Name
PSPEDEIS
Universe
FSPEDEIS=1 and more than 1 child less than 18
Universe-text
Persons < 18 receive Special Ed/EIS
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions family level item; store at both family and at person level
eligible children ages 0-17 years
Store this family level value to the person level.
Skip Instructions
[Goto PSPEDEM]
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Page 10 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.065
Variable Name
PSPEDEM
Universe
FSPEDEIS= 1 and persons selected in PSPEDEIS
Universe-text
Question Text
[fill: Do you/Does ALIAS] receive these services because of an emotional or
behavioral problem?
Answer Codes
1. Yes
2. No
Refused
Don’t Know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Due to Emotional/Behavioral Problem
fill: if the subject=respondent fill "Do you" else, fill "Does ALIAS"
Special Instructions person level item
Skip Instructions
<1,2,D,R> [goto FLAADL]
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Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.070
Variable Name
FLAADL
Universe
All families
Universe-text
Families with one or more persons ages 3 years and older
Question Text
Because of a physical, mental, or emotional problem, [fill1: do you/does anyone in the
family] need the help of other persons with PERSONAL CARE NEEDS, such as
eating, bathing, dressing, or getting around inside this home?
[fill2: Do not include family members age 2 and under.]
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t Know
Yes/No
Field Pane Description
Fill Instructions
Personal Care Needs
fill1: if one person family fill "do you" else, fill "does anyone in the family"
fill2: If there is a child < 3 years old in the family add "Do not include family members
age 2 and under."
Special Instructions family level item;
roster grid
Store this family level value to the person level.
Skip Instructions
<1>If one person family,
[store the respondent person number into PLAADL, [goto LABATH] , else [goto
PLAADL]
<2,D,R> [goto FLAIADL]
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Page 12 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.070_H
Variable Name
H_FLAADL
Universe
Universe-text
Question Text
This question is for all family members age 3 and over.
Physical, mental, and emotional problems are respondent defined.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FLAADL
Skip Instructions
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Page 13 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.080
Variable Name
PLAADL
Universe
FLAADL= 1 and more than 1 person age 3+ years
Universe-text
All families
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions family level item; store at both family and at person level
Eligible persons ages 3+ years
Store this family level value to the person level.
Skip Instructions
[Goto LABATH]
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Page 14 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.090_1
Variable Name
LABATH
Universe
FLAADL= 1 and person selected in PLAADL
Universe-text
Persons with a limitation
Question Text
[fill: Do you/Does Alias] need the help of other persons with...
Bathing or showering?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t Know
Repeating Series - Yes/No
Field Pane Description
Fill Instructions
Bathing
fill: if the subject= respondent fill "Do you" else, fill "Does Alias"
Special Instructions person level item;
Roster grid for all selected in PLAADL
Skip Instructions
<1, 2, D, R> [Repeat this question for family members listed in PLAADL, goto
LADRESS-LAHOME]
Else, [goto FLAIADL]
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Page 15 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.090_2
Variable Name
LADRESS
Universe
FLAADL= 1 and person selected in PLAADL
Universe-text
Persons with a limitation
Question Text
* Read if necessary.
[fill: Do you/Does Alias] need the help of other persons with...
Dressing?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t Know
Repeating Series - Yes/No
Field Pane Description
Fill Instructions
Dressing
fill: if the subject=respondent fill "Do you" else, fill "Does Alias"
Special Instructions person level item
Roster grid
Skip Instructions
<1, 2, D, R> [Repeat this question for family members listed in PLAADL, goto LAEATLAHOME
Else, [goto FLAIADL]
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Page 16 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.090_3
Variable Name
LAEAT
Universe
FLAADL= 1 and person selected in PLAADL
Universe-text
Persons with a limitation
Question Text
* Read if necessary.
[fill: Do you/Does Alias] need the help of other persons with...
Eating?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t Know
Repeating Series - Yes/No
Field Pane Description
Fill Instructions
Eating
fill: if the subject=respondent fill "Do you" else, fill "Does Alias"
Special Instructions person level item;
Roster grid
Skip Instructions
<1, 2, D, R> [Repeat this question for family members listed in PLAADL, goto LABEDLAHOME
Else [goto FLAIADL]
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Page 17 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.090_4
Variable Name
LABED
Universe
FLAADL= 1 and person selected in PLAADL
Universe-text
Persons with a limitation
Question Text
* Read if necessary.
[fill: Do you/Does Alias] need the help of other persons with...
Getting in or out of bed or chairs?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t Know
Repeating Series - Yes/No
Field Pane Description
Fill Instructions
In/out Bed/ Chairs
fill: if the subject=respondent fill "Do you" else, fill "Does Alias"
Special Instructions person level item;
Roster grid
Skip Instructions
<1, 2, D, R> [Repeat this question for family members listed in PLAADL, goto
LATOILT- LAHOME
Else [goto FLAIADL]
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Page 18 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.090_5
Variable Name
LATOILT
Universe
FLAADL= 1 and person selected in PLAADL
Universe-text
Persons with a limitation
Question Text
* Read if necessary.
[fill: Do you/Does Alias] need the help of other persons with...
Using the toilet, including getting to the toilet?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t Know
Repeating Series - Yes/No
Field Pane Description
Fill Instructions
Toileting
fill: if the subject=respondent fill "Do you" else, fill "Does Alias"
Special Instructions person level item;
Roster grid
Skip Instructions
<1, 2, D, R> [Repeat this question for family members listed in PLAADL, goto
LAHOME
Else [goto FLAIADL]
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Page 19 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.090_6
Variable Name
LAHOME
Universe
FLAADL= 1 and person selected in PLAADL
Universe-text
Persons with a limitation
Question Text
* Read if necessary.
[fill: Do you/Does Alias] need the help of other persons with...
Getting around inside the home?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t Know
Repeating Series - Yes/No
Field Pane Description
Fill Instructions
Get Around in Home
fill: if the subject=respondent fill "Do you" else, fill "Does Alias"
Special Instructions person level item;
Roster grid
Skip Instructions
<1, 2, D, R> [Repeat this question for family members listed in PLAADL,
Else [goto FLAIADL]
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Page 20 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.150
Variable Name
FLAIADL
Universe
AGE>=18
Universe-text
Families with one or more persons ages 18 years and older
Question Text
?[F1]
Because of a physical, mental, or emotional problem, do [fill: you/any of these family
members
* Read names
(fill roster of persons greater than or equal to age 18)]
need the help of other persons in handling ROUTINE NEEDS, such as everyday
household chores, doing necessary business, shopping, or getting around for other
purposes?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t Know
Yes/No
Field Pane Description
Fill Instructions
Routine needs
fill: if one person family fill "you" else, fill "any of these family members * (Read
names)"
Special Instructions family level item
new form pane
(display roster of persons AGE>=18)
Skip Instructions
<1> If one person family, store the respondent’s person number in PLAIADL, Goto
FLAWKNOW],
else [goto PLAIADL]
<2,D,R> [goto FLAWKNOW]
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Wednesday, July 06, 2016
Page 21 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.150_H
Variable Name
H_FLAIADL
Universe
Universe-text
Question Text
This question is for all family members age 18 and older.
Physical, mental, and emotional problems are respondent defined.
Enter "1" if the respondent believes that someone in the family needs the help of other
persons in handling routine needs, such
as everyday household chores, doing necessary business, shopping, or getting
around for other purposes.
Enter "2" if the respondent does not believe that anyone in the family needs the help
of other persons in handling routine needs,
such as everyday household chores, doing necessary business, shopping, or getting
around for other purposes.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FLAIADL
Skip Instructions
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Wednesday, July 06, 2016
Page 22 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.160
Variable Name
PLAIADL
Universe
FLAIADL= 1 and more than 1 person 18+
Universe-text
Families with limitations persons 18+yrs. and more than 1 persons 18+ yrs.
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions family level item; store at both family and at person level
Eligible persons age 18+
Skip Instructions
Family members not in delete status only.
Otherwise, [goto FLAWKNOW].
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Wednesday, July 06, 2016
Page 23 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.170
Variable Name
FLAWKNOW
Universe
AGE>= 18
Universe-text
Families with one or more persons ages 18 years and older
Question Text
?[F1]
Does a physical, mental, or emotional problem NOW keep [fill: you/any of these family
members
* Read names
(fill roster of persons greater than than or equal to age 18)]
from working at a job or business?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Unable to work
fill: if one person family fill "you" else, fill "any of these family members * (Read
names) (fill in names of family members aged 18 and older)"
Special Instructions family level item
display roster of persons 18 and older
Skip Instructions
<1>If one person family store in [PLAWKNOW] goto FLAWALK,
Else goto PLAWKNOW
<2,R,DK> [goto FLAWKLIM]
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H_FLAWKNOW
Wednesday, July 06, 2016
Page 24 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.170_H
Variable Name
H_FLAWKNOW
Universe
Universe-text
Question Text
This question is for family members 18 years old and older.
Physical, mental, and emotional problems are respondent defined.
Enter "1" if a physical, mental, or emotional problem NOW keeps any of the family
members 18 years old or older from working at a job
or business.
Enter "2" if a physical, mental, or emotional problem does not NOW keep any of the
family members 18 years old or older from working
at a job or business.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FLAWKNOW
Skip Instructions
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Wednesday, July 06, 2016
Page 25 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.180
Variable Name
PLAWKNOW
Universe
FLAWKNOW=1 and more than 1 person 18+
Universe-text
Families with more than 1 limited person 18+ years
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions family level item; store at both family and at person level
Eligible persons age 18+
Skip Instructions
All selected goto [FLAWALK],
Else goto [FLAWKLIM]
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Wednesday, July 06, 2016
Page 26 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.190
Variable Name
FLAWKLIM
Universe
AGE >= 18 and at least 1 person NOT selected in PLAWKNOW
Universe-text
Families with (one or more persons ages 18 years and older and not selected in
PLAWKNOW)
Question Text
?[F1]
[fill: Are you limited in the kind OR amount of work you/ Is Alias limited in the kind OR
amount of work he/she/ Are any of these family members,
* Read names
(fill roster of persons greater than or equal to age 18)]
limited in the kind OR amount of work they] can do because of a physical, mental or
emotional problem?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Limited in work
fill: if the subject=respondent fill "Are you.." If only 1 person not selected in
PLAWKNOW then fill " Is Alias.." else, fill "Are any of these family members, * (Read
names below) limited in the kind OR amount of work they"
Special Instructions family level item
(Read names below) display roster of persons AGE>=18 and not selected in
PLAWKNOW
Skip Instructions
<1> [ if one-person family, or only 1 person 18+ not selected in PLAWKNOW, store
person number in PLAWKLIM and goto [FLAWALK]; else goto [PLAWKLIM]
<2,R,DK> [goto FLAWALK]
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H_FLAWKLIM
Wednesday, July 06, 2016
Page 27 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.190_H
Variable Name
H_FLAWKLIM
Universe
Universe-text
Question Text
This question is for family members 18 years old or older that were not previously
identified as having a physical, mental, or emotional
problem that NOW keeps them from working at a job or business.
Physical, mental, and emotional problems are respondent defined.
Enter "1" if any of the family members 18 years old or older that were not previously
identified as having a physical, mental, or
emotional problem that NOW keeps them from working at a job or business are limited
in the kind OR amount of work they can do
because of a physical, mental, or emotional problem.
Enter "2" if none of the family members 18 years old or older that were not previously
identified as having a physical, mental, or
emotional problem that NOW keeps them from working at a job or business are limited
in the kind OR amount of work they can do
because of a physical, mental, or emotional problem.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screen:
FLAWKLIM
Skip Instructions
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Wednesday, July 06, 2016
Page 28 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.200
Variable Name
PLAWKLIM
Universe
FLAWKLIM = 1 and more than 1 person 18+ NOT selected in PLAWKNOW
Universe-text
More than 1 persons 18+ years and able to work
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions family level item; store at both family and at person level
Eligible persons age 18+ and NOT selected in PLAWKNOW
Skip Instructions
Family members not in delete status only.
[goto FLAWALK];
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Wednesday, July 06, 2016
Page 29 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.210
Variable Name
FLAWALK
Universe
All
Universe-text
All families
Question Text
?[F1]
Because of a health problem, [fill: do you/does anyone in the family] have difficulty
walking without using any special equipment?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Difficulty walking
fill: if one person family fill "do you" else, fill "does anyone.."
Special Instructions family level item
Skip Instructions
<1> if one person family store in PLAWALK and goto [FLAREMEM], else goto
[PLAWALK]
<2,R,DK> [goto FLAREMEM]
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H_FLAWALK
Wednesday, July 06, 2016
Page 30 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.210_H
Variable Name
H_FLAWALK
Universe
Universe-text
Question Text
This question is for all family members.
The term "health problem" is respondent defined.
Enter "1" if any family member, because of a health problem, has difficulty walking
without using any special equipment.
Enter "2" if no family member, because of a health problem, has difficulty walking
without using any special equipment.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FLAWALK
Skip Instructions
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Wednesday, July 06, 2016
Page 31 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.220
Variable Name
PLAWALK
Universe
FLAWALK = 1 and more than 1 person in family
Universe-text
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions family level item; store at both family and at person level
All non-deleted persons eligible
Skip Instructions
Family members not in delete status only.
Goto [FLAREMEM].
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Wednesday, July 06, 2016
Page 32 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.230
Variable Name
FLAREMEM
Universe
Universe-text
All families
Question Text
?[F1]
[fill1: Are you/Is anyone in the family] LIMITED IN ANY WAY because of difficulty
remembering or because [fill2: you/they] experience periods of confusion?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Difficulty remembering
fill1: if one person family fill "Are you" else, fill "Is anyone in the family"
fill2: if one person family fill "you" else, fill "they"
Special Instructions family level item
Skip Instructions
<1> if single-person family and age is less than 18, store person number in
PLAREMEM and goto [LAHCC]
Else, if single person family and age is 18+ store person # in [PLAREMEM] and goto
LAHCA.
Else goto [PLAREMEM]
<2,R,DK> [goto FLIMANY]
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H_FLAREMEM
Wednesday, July 06, 2016
Page 33 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.230_H
Variable Name
H_FLAREMEM
Universe
Universe-text
Question Text
This question is for all family members.
Consider a person to be "limited" if he/she can only partially perform an activity, or
can do it fully only part of the time,
or cannot do it at all.
Include only limitations related to difficulty remembering or experiencing periods of
confusion.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FLAREMEM
Skip Instructions
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AssocHelp
Wednesday, July 06, 2016
Page 34 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.240
Variable Name
PLAREMEM
Universe
FLAREMEM = 1 and more than 1 person in family
Universe-text
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions family level item; store at both family and at person level
All non-deleted persons eligible
Skip Instructions
Goto [FLIMANY]
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Wednesday, July 06, 2016
Page 35 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.250
Variable Name
FLIMANY
Universe
At least 1 person NOT selected in PLAPLYLM or in PSPEDEIS or in PLAADL or in
PLAIADL or in PLAWKNOW or in PLAWKLIM or in PLAWALK or in PLAREMEM
Universe-text
All families with any family members with no previously mentioned
limitations (NOT selected in PLAPLYLM or in PSPEDEIS or in PLAADL or in
PLAIADL or in PLAWKNOW or in PLAWKLIM or in PLAWALK or in PLAREMEM)
Question Text
?[F1]
[fill: Are you/ Is Alias/ Are any family members
* Read names
(fill roster of applicable persons.)]
LIMITED IN ANY WAY in any activities because of physical, mental or emotional
problems?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Any limitation
fill: if one person family fill "Are you" if more than 1 member not selected in
PLAPLYLM or in PSPEDEIS or in PLAADL or in PLAIADL or in PLAWKNOW or in
PLAWKLIM or in PLAWALK or in PLAREMEM, fill "Are any family members * (Read
names) (list names of persons without limitation)"
Else, fill "Is Alias"
Special Instructions family level item; Background validation using PLAPLYLM, PSPEDEIS, PLAADL,
PLAIADL, PLAWKNOW, PLAWKLIM, PLAWALK, and PLAREMEM. * Read names
below; Only display family members NOT selected in these items.
Skip Instructions
<1> [if 1 person family or respondent= only person NOT selected in [PLAPLYLM or in
PSPEDEIS or in PLAADL or in PLAIADL or in PLAWKNOW or in PLAWKLIM or in
PLAWALK or in PLAREMEM] fill "Are you". Else if only 1 person not selected in
[PLAPLYLM or in PSPEDEIS or in PLAADL or in PLAIADL or in PLAWKNOW or in
PLAWKLIM or in PLAWALK or in PLAREMEM] fill "Is Alias";
Else fill "Are any family members * Read names below (list names of person without
limitation)"
<2,R,DK> [goto LAHCC]
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H_FLIMANY
Wednesday, July 06, 2016
Page 36 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.250_H
Variable Name
H_FLIMANY
Universe
Universe-text
Question Text
This question is for those family members that have not been previously reported as
having a limitation due to a physical, mental, or emotional problem, or a limitation due
to difficulty remembering or experiencing periods of confusion.
Physical, mental, and emotional problems are respondent defined.
Consider a person to be "limited" if he/she can only partially perform an activity, or
can do it fully only part of the time, or cannot do it at all.
Include only limitations related to physical, mental, or emotional problems.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FLIMANY
Skip Instructions
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AssocHelp
Wednesday, July 06, 2016
Page 37 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.260
Variable Name
PLIMANY
Universe
FLIMANY = 1 and more than 1 person NOT selected in PLAPLYLM or in PSPEDEIS
or in PLAADL or in PLAIADL or in PLAWKNOW or in PLAWKLIM or in PLAWALK or
in PLAREMEM
Universe-text
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions family level item; store at both family and at person level
Eligible persons NOT selected in PLAPLYLM or in PSPEDEIS or in PLAADL or
in PLAIADL or in PLAWKNOW or in PLAWKLIM or in PLAWALK or in PLAREMEM.
Only display family members NOT selected in these items.
Skip Instructions
Goto LAHCC
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Wednesday, July 06, 2016
Page 38 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.270
Variable Name
LAHCC
Universe
Universe-text
age 0 to 17 years and (person selected in (PLAPLYLM or PSPEDEIS or PLAADL or
PLAWALK or PLAREMEM or PLIMANY))
Question Text
(book) F1
What conditions or health problems cause [fill: Alias]’s limitations?
* Enter all that apply, separate with commas.
* Do not probe except to clarify answer.
Answer Codes
Question Type
1. Vision/ problem seeing
2. Hearing problem
3. Speech problem
4. Asthma/breathing problem
5. Birth defect
6. Injury
7. Intellectual disability, also known as mental retardation
8. Other developmental problem (for example, cerebral palsy)
9. Other mental, emotional, or behavioral problem
10. Bone, joint, or muscle problem
11. Epilepsy or seizures
12. Learning disability
13. Attention Deficit/Hyperactivity Disorder (ADD/ADHD)
90. Other impairment/problem (LAHCC_S1)
91. Other impairment/problem (LAHCC_S2)
Refused
Don’t know
Enter All That Apply
Field Pane Description
Fill Instructions
Conditions/health problems
fill: [Alias]
Special Instructions person level item; store at person level
Condition Grid
Skip Instructions
<1-4, 6-13> selected entries goto appropriate follow up question LHCL##N [##= 0113, 90, 91]
<5> fill "96" in LHCL05N and fill "6" in LHCL05T
<90> goto LAHCC_S1
<91> goto LAHCC_S2
Roster through all selected in [PLAPLYLM or in PSPEDEIS or in PLAADL or
in PLAIADL or in PLAWKNOW or in PLAWKLIM or in PLAWALK or in PLAREMEM]
Once exhausted goto LAHCA.
For all selected LAHCC entries goto appropriate follow up question LHCL##N [##= 0113, 90,91]
Roster through all LAHCC entries. Roster through all selected in [PLAPLYLM or in
Wednesday, July 06, 2016
Page 39 of 153
PSPEDEIS or in PLAADL or in PLAIADL or in PLAWKNOW or in PLAWKLIM or in
PLAWALK or in PLAREMEM] Once exhausted goto LAHCA.
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H_LAHCC
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.270_H
Variable Name
H_LAHCC
Universe
Universe-text
Question Text
This question is for those family members less than 18 years old who were previously
reported as having a limitation.
The terms "conditions" and "health problems" are respondent defined.
Do not read the precoded categories to the respondent.
Enter "90 or 91" if the respondent mentions a condition or health problem not listed
and then specify the condition exactly as the respondent states it.
Consider a person to be "limited" if he/she can only partially perform an activity, or
can do it fully only part of the time, or
cannot do it at all.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
LAHCC
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 40 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.271_90
Variable Name
LAHCC_S1
Universe
If 90 selected in LAHCC
Universe-text
Other impairment selected in LAHCC
Question Text
* Read if necessary.
What is the other impairment or problem?
Answer Codes
Question Type
Text
Field Pane Description
Specify One
Fill Instructions
Special Instructions
Skip Instructions
<50 chars>
goto [LHCL90N]
Hard Edits
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AssocHelp
Wednesday, July 06, 2016
Page 41 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.271_91
Variable Name
LAHCC_S2
Universe
If 91 selected in LAHCC
Universe-text
Other impairment selected in LAHCC
Question Text
* Read if necessary.
What is the other impairment or problem?
Answer Codes
Question Type
Text
Field Pane Description
Specify One
Fill Instructions
Special Instructions
Skip Instructions
<50 chars>
goto [LHCL91N]
Hard Edits
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AssocHelp
Wednesday, July 06, 2016
Page 42 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.280_1
Variable Name
LHCL01N
Universe
LAHCC=1
Universe-text
Condition number 1 selected in LAHCC
Question Text
1 of 2
How long [fill: have you/has Alias] had a vision problem or problem seeing?
* Enter number for time with vision problem or problem seeing.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL01T
<96> then fill "6" in LHCL01T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL01T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
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Wednesday, July 06, 2016
Page 43 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.280_2
Variable Name
LHCL01T
Universe
LHCL01N=1-95, DK
Universe-text
Condition number 1 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with vision problem or problem seeing.
(LHCL01N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL01T
if (LHCL01T = 4 and LHCL01N > AGE) or (LHCL01T = 3 and LHCL01N > AGE
in months) or (LHCL01T = 2 and LHCL01N > AGE in weeks), goto [ERR1_LHCL01T]
Hard Edits
ERR1_LHCL01T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL01T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 44 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.282_1
Variable Name
LHCL02N
Universe
LAHCC=2
Universe-text
Condition number 2 selected in LAHCC
Question Text
1 of 2
How long [fill: have you/has Alias] had a hearing problem?
* Enter number for time with hearing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL02T
<96> then fill "6" in LHCL02T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL02T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
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Wednesday, July 06, 2016
Page 45 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.282_2
Variable Name
LHCL02T
Universe
LHCL02N=1-95, DK
Universe-text
Condition number 2 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with hearing problem.
(LHCL02N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL02T
if (LHCL02T = 4 and LHCL02N > AGE) or (LHCL02T = 3 and LHCL02N > AGE
in months) or (LHCL02T = 2 and LHCL02N > AGE in weeks), goto [ERR1_LHCL02T]
Hard Edits
ERR1_LHCL02T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL02T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 46 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.284_1
Variable Name
LHCL03N
Universe
LAHCC=3
Universe-text
Condition number 3 selected in LAHCC
Question Text
1 of 2
How long [fill: have you/has Alias] had a speech problem?
* Enter number for time with speech problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL03T
<96> then fill "6" in LHCL03T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL03T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
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AssocHelp
Wednesday, July 06, 2016
Page 47 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.284_2
Variable Name
LHCL03T
Universe
LHCL03N=1-95, DK
Universe-text
Condition number 3 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with speech problem.
(LHCL03N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL03T
if (LHCL03T = 4 and LHCL03N > AGE) or (LHCL03T = 3 and LHCL03N > AGE
in months) or (LHCL03T = 2 and LHCL03N > AGE in weeks), goto [ERR1_LHCL03T]
Hard Edits
ERR1_LHCL03T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL03T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 48 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.286_1
Variable Name
LHCL04N
Universe
LAHCC=4
Universe-text
Condition number 4 selected in LAHCC
Question Text
1 of 2
How long [fill: have you/has Alias] had asthma or a breathing problem?
* Enter number for time with asthma or breathing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL04T
<96> then fill "6" in LHCL04T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL04T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
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AssocHelp
Wednesday, July 06, 2016
Page 49 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.286_2
Variable Name
LHCL04T
Universe
LHCL04N=1-95, DK
Universe-text
Condition number 4 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with asthma or a breathing problem.
(LHCL04N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL04T
if (LHCL04T = 4 and LHCL04N > AGE) or (LHCL04T = 3 and LHCL04N > AGE
in months) or (LHCL04T = 2 and LHCL04N > AGE in weeks), goto [ERR1_LHCL04T]
Hard Edits
ERR1_LHCL04T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL04T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 50 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.287_1
Variable Name
LHCL05N
Universe
LAHCC=5
Universe-text
Condition number 5 selected in LAHCC
Question Text
Answer Codes
Question Type
Integer
Field Pane Description
Number
Fill Instructions
Special Instructions Storage variable for the line number of the Health Status and Limitation section birth
defect condition.
Question text not displayed
person level item; store at person level
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 51 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.287_2
Variable Name
LHCL05T
Universe
LHCL05N=1-95, DK
Universe-text
Condition number 5 selected in LAHCC
Question Text
Answer Codes
Question Type
Pick One - answer list pane
Field Pane Description
Units
Fill Instructions
Special Instructions Storage variable for the line number of the Health Status and Limitation section birth
defect condition.
Question text not displayed
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 52 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.288_1
Variable Name
LHCL06N
Universe
LAHCC=6
Universe-text
Condition number 6 selected in LAHCC
Question Text
1 of 2
How long [fill1: have you/has Alias] had the injury that caused [fill2:your/his/her]
limitation?
* Enter number for time with the injury.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill1: if the subject=respondent fill "have you" else, fill "has Alias"
fill2: if the subject=respondent fill "your" else, fill "his/her"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL06T
<96> then fill "6" in LHCL06T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL06T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 53 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.288_2
Variable Name
LHCL06T
Universe
LHCL06N=1-95, DK
Universe-text
Condition number 6 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with the injury that caused [fill: your/his/her] limitation.
(LHCL06N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Time period
fill: if the subject=respondent fill "your" else, fill "his/her"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL06T
if (LHCL06T = 4 and LHCL06N > AGE) or (LHCL06T = 3 and LHCL06N > AGE
in months) or (LHCL06T = 2 and LHCL06N > AGE in weeks), goto [ERR1_LHCL06T]
Hard Edits
ERR1_LHCL06T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL06T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 54 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.290_1
Variable Name
LHCL07N
Universe
LAHCC=7
Universe-text
Condition number 7 selected in LAHCC
Question Text
1 of 2
How long [fill: have you/has Alias] had intellectual disability, also known as mental
retardation?
* Enter number for time with intellectual disability/mental retardation.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL07T
<96> then fill "6" in LHCL07T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL07T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 55 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.290_2
Variable Name
LHCL07T
Universe
LHCL07N=1-95, DK
Universe-text
Condition number 7 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with intellectual disability/mental retardation.
(LHCL07N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL07T
if (LHCL07T = 4 and LHCL07N > AGE) or (LHCL07T = 3 and LHCL07N > AGE
in months) or (LHCL07T = 2 and LHCL07N > AGE in weeks), goto [ERR1_LHCL07T]
Hard Edits
ERR1_LHCL07T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL07T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 56 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.292_1
Variable Name
LHCL08N
Universe
LAHCC=8
Universe-text
Condition number 8 selected in LAHCC
Question Text
1 of 2
How long [fill: have you/has Alias] had a developmental problem (e.g. cerebral palsy)?
* Enter number for time with developmental problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL08T
<96> then fill "6" in LHCL08T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL08T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 57 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.292_2
Variable Name
LHCL08T
Universe
LHCL08N=1-95, DK
Universe-text
Condition number 8 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with developmental problem (e.g. cerebral palsy).
(LHCL08N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL08T
if (LHCL08T = 4 and LHCL08N > AGE) or (LHCL08T = 3 and LHCL08N > AGE
in months) or (LHCL08T = 2 and LHCL08N > AGE in weeks), goto [ERR1_LHCL08T]
Hard Edits
ERR1_LHCL08T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL08T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 58 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.294_1
Variable Name
LHCL09N
Universe
LAHCC=9
Universe-text
Condition number 9 selected in LAHCC
Question Text
1 of 2
How long [fill: have you/has Alias] had a mental, emotional, or behavioral problem?
* Enter number for time with mental, emotional, or behavioral problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL09T
<96> then fill "6" in LHCL09T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL09T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 59 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.294_2
Variable Name
LHCL09T
Universe
LHCL09N=1-95, DK
Universe-text
Condition number 9 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with mental, emotional, or behavioral problem.
(LHCL09N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL09T
if (LHCL09T = 4 and LHCL09N > AGE) or (LHCL09T = 3 and LHCL09N > AGE
in months) or (LHCL09T = 2 and LHCL09N > AGE in weeks), goto [ERR1_LHCL09T]
Hard Edits
ERR1_LHCL09T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL09T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 60 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.296_1
Variable Name
LHCL10N
Universe
LAHCC=10
Universe-text
Condition number 10 selected in LAHCC
Question Text
1 of 2
How long [fill: have you/has Alias] had a bone, joint, or muscle problem?
* Enter number for time with bone, joint, or muscle problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL10T
<96> then fill "6" in LHCL10T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL10T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 61 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.296_2
Variable Name
LHCL10T
Universe
LHCL10N=1-95, DK
Universe-text
Condition number 10 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with bone, joint, or muscle problem.
(LHCL10N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL10T
if (LHCL10T = 4 and LHCL10N > AGE) or (LHCL10T = 3 and LHCL10N > AGE
in months) or (LHCL10T = 2 and LHCL10N > AGE in weeks), goto [ERR1_LHCL10T]
Hard Edits
ERR1_LHCL10T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL10T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 62 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.298_1
Variable Name
LHCL11N
Universe
LAHCC=11
Universe-text
Condition number 11 selected in LAHCC
Question Text
1 of 2
How long [fill: have you/has Alias] had epilepsy or seizures?
* Enter number for time with epileplsy or seizures.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL11T
<96> then fill "6" in LHCL11T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL11T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 63 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.298_2
Variable Name
LHCL11T
Universe
LHCL11N=1-95, DK
Universe-text
Condition number 11 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with epilepsy or seizures.
(LHCL11N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL11T
if (LHCL11T = 4 and LHCL11N > AGE) or (LHCL11T = 3 and LHCL11N > AGE
in months) or (LHCL11T = 2 and LHCL11N > AGE in weeks), goto [ERR1_LHCL11T]
Hard Edits
ERR1_LHCL11T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL11T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 64 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.300_1
Variable Name
LHCL12N
Universe
LAHCC=12
Universe-text
Condition number 12 selected in LAHCC
Question Text
1 of 2
How long [fill: have you/has Alias] had a learning disability?
* Enter number for time with learning disability.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL12T
<96> then fill "6" in LHCL12T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL12T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 65 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.300_2
Variable Name
LHCL12T
Universe
LHCL12N=1-95, DK
Universe-text
Condition number 12 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with learning disability.
(LHCL12N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL12T
if (LHCL12T = 4 and LHCL12N > AGE) or (LHCL12T = 3 and LHCL12N > AGE
in months) or (LHCL12T = 2 and LHCL12N > AGE in weeks), goto [ERR1_LHCL12T]
Hard Edits
ERR1_LHCL12T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL12T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 66 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.302_1
Variable Name
LHCL13N
Universe
LAHCC=13
Universe-text
Condition number 13 selected in LAHCC
Question Text
1 of 2
How long [fill: have you/has Alias] had attention deficit/hyperactivity disorder?
* Enter number for time with attention deficit/hyperactivity disorder.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL13T
<96> then fill "6" in LHCL13T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL13T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 67 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.302_2
Variable Name
LHCL13T
Universe
LHCL13N=1-95, DK
Universe-text
Condition number 13 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with attention deficit/hyperactivity disorder.
(LHCL13N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL13T
if (LHCL13T = 4 and LHCL13N > AGE) or (LHCL13T = 3 and LHCL13N > AGE
in months) or (LHCL13T = 2 and LHCL13N > AGE in weeks), goto [ERR1_LHCL13T]
Hard Edits
ERR1_LHCL13T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL13T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 68 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.304_1
Variable Name
LHCL90N
Universe
LAHCC=90
Universe-text
Condition number 90 selected in LAHCC
Question Text
1 of 2
How long [fill1: have you/has Alias] had [fill2: problem in LAHCC_S1]?
* Enter number for time with [fill1: problem in LAHCC_S1]?
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill1: if the subject=respondent fill "have you" else, fill "has Alias"
fill2: problem LAHCC2_S1
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL90T
<96> then fill "6" in LHCL90T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL90T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 69 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.304_2
Variable Name
LHCL90T
Universe
LHCL90N=1-95, DK
Universe-text
Condition number 90 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with [fill: problem in LAHCC_S1].
(LHCL90N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Time period
fill: problem in LAHCC2_S1
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D>
if 91 selected in LAHCC, then goto LAHCC_S2,
Else, roster through all LAHCC entries and goto appropriate LHCL##N [##= 01-13,
90, 91]
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL90T
if (LHCL90T = 4 and LHCL90N > AGE) or (LHCL90T = 3 and LHCL90N > AGE
in months) or (LHCL90T = 2 and LHCL90N > AGE in weeks), goto [ERR1_LHCL90T]
Hard Edits
ERR1_LHCL90T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL90T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 70 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.306_1
Variable Name
LHCL91N
Universe
LAHCC=91
Universe-text
Condition number 91 selected in LAHCC
Question Text
1 of 2
How long [fill1: have you/has Alias] had [fill2: problem in LAHCC_S2]?
* Enter number for time with [fill1: problem in LAHCC_S2].
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill1: if the subject=respondent fill "have you" else, fill "has Alias"
fill2: problem in LAHCC2_S2
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-95, D> goto LHCL91T
<96> then fill "6" in LHCL91T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHCL##N and LHCL##T]; Roster through persons eligible in
LAHCC, else go to[LAHCA]
store "R" in [LHCL91T] goto next condition in [LAHCC]
Once exhausted goto [LAHCA]
Hard Edits
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Wednesday, July 06, 2016
Page 71 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.306_2
Variable Name
LHCL91T
Universe
LHCL91N=1-95, DK
Universe-text
Condition number 91 selected in LAHCC
Question Text
2 of 2
* Enter time period for time with [fill: problem in LAHCC_S2].
(LHCL91N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Time period
fill: problem in LAHCC_S2
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCC will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCC.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCC], continue to ask number and time
period for each subsequent condition; else go to LAHCA
Roster through all LAHCC entries, roster through next child. Once exhausted goto
LAHCA.
<6> goto ERR2_LHCL91T
if (LHCL91T = 4 and LHCL91N > AGE) or (LHCL91T = 3 and LHCL91N > AGE
in months) or (LHCL91T = 2 and LHCL91N > AGE in weeks), goto [ERR1_LHCL91T]
Hard Edits
ERR1_LHCL91T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL91T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 72 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.350
Variable Name
LAHCA
Universe
Universe-text
age 18+ and (person selected in (PLAADL or PLAIADL or PLAWKNOW or PLAWKLIM
or PLAWALK or PLAREMEM or PLIMANY))
Question Text
(book) F2 ?[F1]
What conditions or health problems cause [fill: your/Alias’s] limitations?
* Enter all that apply, separate with commas.
* Do not probe except to clarify answer.
Answer Codes
1. Vision/problem seeing
2. Hearing problem
3. Arthritis/rheumatism
4. Back or neck problem
5. Fracture or bone/joint injury
6. Other injury
7. Heart problem
8. Stroke problem
9. Hypertension/high blood pressure
10. Diabetes
11. Lung/breathing problem (for example, asthma and emphysema)
12. Cancer
13. Birth defect
14. Intellectual disability, also known as mental retardation
15. Other developmental problem (for example, cerebral palsy)
16. Senility
17. Depression/anxiety/emotional problem
18. Weight problem
19. Missing limbs (fingers, toes or digits), amputee
20. Kidney, bladder or renal problems
21. Circulation problems (including blood clots)
22. Benign tumors, cysts
23. Fibromyalgia, lupus
24. Osteoporosis, tendinitis
25. Epilepsy, seizures
26. Multiple Sclerosis (MS), Muscular Dystrophy (MD)
27. Polio(myelitis), paralysis, para/quadriplegia
28. Parkinson’s disease, other tremors
29. Other nerve damage, including carpal tunnel syndrome
30. Hernia
31. Ulcer
32. Varicose veins, hemorrhoids
33. Thyroid problems, Grave’s disease, gout
34. Knee problems (not arthritis (03), not joint injury(05))
35. Migraine headaches (not just headaches)
90. Other impairment/problem ( LAHCA_S1)
Wednesday, July 06, 2016
Page 73 of 153
91. Other impairment/problem ( LAHCA_S2)
Refused
Don’t know/not sure
Question Type
Enter All That Apply
Field Pane Description
Fill Instructions
Conditions/health problems
fill: if the subject=respondent fill "your" else, fill " Alias"
Special Instructions person level item; store at person level
Condition Grid
Skip Instructions
<1-12, 14-35, 90,91> selected entries goto appropriate follow up question LHAL##N
[##= 01-35, 90, 91]
<13> fill "96" in LHAL13N and fill "6" in LHAL13T
<90> goto LAHCA_S1
<91> goto LAHCA_S2
Roster through all selected in (PLAADL or PLAIADL or PLAWKNOW or
PLAWKLIM
or PLAWALK or PLAREMEM or PLIMANY)) Once exhausted goto PHSTAT
For all selected LAHCA entries goto appropriate followup question LHAL##N [##= 0135, 90, 91]
Roster through all LAHCA entries. Roster through all selected in (PLAADL or
PLAIADL or PLAWKNOW or PLAWKLIM or PLAWALK or PLAREMEM or PLIMANY))
Once exhausted goto PHSTAT.
Hard Edits
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H_LAHCA
Wednesday, July 06, 2016
Page 74 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.350_H
Variable Name
H_LAHCA
Universe
Universe-text
Question Text
This question is for those family members 18 years old or older who were previously
reported as having a limitation.
The terms [b]conditions[b] and [b]health problems[b] are respondent defined.
Do not read the precoded categories to the respondent.
Enter "90" or "91" if the respondent mentions a condition or health problem not listed
and then specify the condition exactly as the respondent states it.
Consider a person to be [b]limited[b] if he/she can only partially perform an activity, or
can do it fully only part of the time, or cannot do it at all.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
LAHCA
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 75 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.351_90
Variable Name
LAHCA_S1
Universe
If 90 selected in LAHCA
Universe-text
Other impairment selected in LAHCA
Question Text
* Read if necessary.
What is the other impairment or problem?
Answer Codes
Question Type
Text
Field Pane Description
Specify One
Fill Instructions
Special Instructions
Skip Instructions
<50 chars>
goto [LHAL90N]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 76 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.351_91
Variable Name
LAHCA_S2
Universe
If 91 selected in LAHCA
Universe-text
Other impairment selected in LAHCA
Question Text
* Read if necessary.
What is the other impairment or problem?
Answer Codes
Question Type
Text
Field Pane Description
Specify One
Fill Instructions
Special Instructions
Skip Instructions
<50 chars> Roster through all LAHCA entries and goto appropriate LHAL##N [##= 0135, 90, 91]
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Wednesday, July 06, 2016
Page 77 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.360_1
Variable Name
LHAL01N
Universe
LAHCA= 1
Universe-text
Condition number 1 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a vision problem or problem seeing?
* Enter number for time with vision problem or problem seeing.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject= respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL01T
<96> then fill "6" in LHAL01T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL01T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
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Wednesday, July 06, 2016
Page 78 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.360_2
Variable Name
LHAL01T
Universe
LHAL01N= 1-95, DK
Universe-text
Condition number 1 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with vision problem or problem seeing.
(LHAL01N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL01T
if (LHAL01T = 4 and LHAL01N > AGE), goto [ERR1_LHAL01T]
Hard Edits
ERR1_LHAL01T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL01T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 79 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.362_1
Variable Name
LHAL02N
Universe
LAHCA= 2
Universe-text
Condition number 2 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a hearing problem?
* Enter number for time with hearing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL02T
<96> then fill "6" in LHAL02T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL02T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
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Wednesday, July 06, 2016
Page 80 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.362_2
Variable Name
LHAL02T
Universe
LHAL02N= 1-95, DK
Universe-text
Condition number 2 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with hearing problem.
(LHAL02N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL02T
if (LHAL02T = 4 and LHAL02N > AGE), goto [ERR1_LHAL02T]
Hard Edits
ERR1_LHAL02T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL02T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 81 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.364_1
Variable Name
LHAL03N
Universe
LAHCA= 3
Universe-text
Condition number 3 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had arthritis or rheumatism?
* Enter number for time with arthritis or rheumatism.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL03T
<96> then fill "6" in LHAL03T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL03T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
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Wednesday, July 06, 2016
Page 82 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.364_2
Variable Name
LHAL03T
Universe
LHAL03N= 1-95, DK
Universe-text
Condition number 3 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with arthritis or rheumatism.
(LHAL03N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL03T
if (LHAL03T = 4 and LHAL03N > AGE), goto [ERR1_LHAL03T]
Hard Edits
ERR1_LHAL03T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL03T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 83 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.366_1
Variable Name
LHAL04N
Universe
LAHCA= 4
Universe-text
Condition number 4 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a back or neck problem?
* Enter number for time with back or neck problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL04T
<96> then fill "6" in LHAL04T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL04T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
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Wednesday, July 06, 2016
Page 84 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.366_2
Variable Name
LHAL04T
Universe
LHAL04N= 1-95, DK
Universe-text
Condition number 4 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with back or neck problem.
(LHAL04N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL04T
if (LHAL014T = 4 and LHAL04N > AGE) , goto [ERR1_LHAL04T]
Hard Edits
ERR1_LHAL04T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL04T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 85 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.368_1
Variable Name
LHAL05N
Universe
LAHCA= 5
Universe-text
Condition number 5 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a fracture, bone, or joint injury?
* Enter number for time with fracture, bone or joint injury.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL05T
<96> then fill "6" in LHAL05T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL05T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
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Wednesday, July 06, 2016
Page 86 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.368_2
Variable Name
LHAL05T
Universe
LHAL05N= 1-95, DK
Universe-text
Condition number 5 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with fracture, bone, or joint injury.
(LHAL05N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL05T
if (LHAL05T = 4 and LHAL05N > AGE), goto [ERR1_LHAL05T]
Hard Edits
ERR1_LHAL05T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL05T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 87 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.370_1
Variable Name
LHAL06N
Universe
LAHCA= 6
Universe-text
Condition number 6 selected in LAHCA
Question Text
1 of 2
How long [fill1: have you/has Alias] had the [fill2: other] injury that caused [fill3:
your/his/her] limitation?
* Enter number for time with the injury.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill1: if the subject=respondent fill "have you" else, fill "has Alias"
fill2: if (LAHCA=5) fill "other"
fill3: if the subject=respondent fill "your" else, fill "his/her"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL06T
<96> then fill "6" in LHAL06T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL06T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 88 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.370_2
Variable Name
LHAL06T
Universe
LHAL06N= 1-95, DK
Universe-text
Condition number 6 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with [fill1: other] injury that caused [fill2: your/his/her]
limitation.
(LHAL06N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Time period
fill1: if (LAHCA=5) fill "other"
fill2: if the subject=respondent fill "your" else, fill "his/her"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL06T
if (LHAL06T = 4 and LHAL06N > AGE), goto [ERR1_LHAL06T]
Hard Edits
ERR1_LHAL06T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL06T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 89 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.372_1
Variable Name
LHAL07N
Universe
LAHCA= 7
Universe-text
Condition number 7 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a heart problem?
* Enter number for time with heart problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL07T
<96> then fill "6" in LHAL07T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL07T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 90 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.372_2
Variable Name
LHAL07T
Universe
LHAL07N= 1-95, DK
Universe-text
Condition number 7 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with heart problem.
(LHAL07N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL07T
if (LHAL07T = 4 and LHAL07N > AGE), goto [ERR1_LHAL07T]
Hard Edits
ERR1_LHAL07T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL07T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 91 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.374_1
Variable Name
LHAL08N
Universe
LAHCA= 8
Universe-text
Condition number 8 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a stroke problem?
* Enter number for time with stroke problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL08T
<96> then fill "6" in LHAL08T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL08T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 92 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.374_2
Variable Name
LHAL08T
Universe
LHAL08N= 1-95, DK
Universe-text
Condition number 8 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with stroke problem.
(LHAL08N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL08T
if (LHAL08T = 4 and LHAL08N > AGE) , goto [ERR1_LHAL08T]
Hard Edits
ERR1_LHAL08T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL08T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 93 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.376_1
Variable Name
LHAL09N
Universe
LAHCA= 9
Universe-text
Condition number 9 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had hypertension or high blood pressure?
* Enter number for time with hypertension or high blood pressure.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL09T
<96> then fill "6" in LHAL09T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL09T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 94 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.376_2
Variable Name
LHAL09T
Universe
LHAL09N= 1-95, DK
Universe-text
Condition number 9 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with hypertension or high blood pressure.
(LHAL09N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL09T
if (LHAL09T = 4 and LHAL09N > AGE) , goto [ERR1_LHAL09T]
Hard Edits
ERR1_LHAL09T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL09T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 95 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.378_1
Variable Name
LHAL10N
Universe
LAHCA= 10
Universe-text
Condition number 10 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had diabetes?
* Enter number for time with diabetes.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL10T
<96> then fill "6" in LHAL10T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL10T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 96 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.378_2
Variable Name
LHAL10T
Universe
LHAL10N= 1-95, DK
Universe-text
Condition number 10 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with diabetes.
(LHAL10N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL10T
if (LHAL10T = 4 and LHAL10N > AGE), goto [ERR1_LHAL10T]
Hard Edits
ERR1_LHAL10T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL10T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 97 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.380_1
Variable Name
LHAL11N
Universe
LAHCA= 11
Universe-text
Condition number 11 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a lung problem or breathing problem (e.g.,
asthma and emphysema)?
* Enter number for time with lung problem or breathing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL11T
<96> then fill "6" in LHAL11T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL11T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 98 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.380_2
Variable Name
LHAL11T
Universe
LHAL11N= 1-95, DK
Universe-text
Condition number 11 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with lung problem or breathing problem (e.g., asthma and
emphysema).
(LHAL11N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL11T
if (LHAL11T = 4 and LHAL11N > AGE), goto [ERR1_LHAL11T]
Hard Edits
ERR1_LHAL11T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL11T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 99 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.382_1
Variable Name
LHAL12N
Universe
LAHCA= 12
Universe-text
Condition number 12 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had cancer?
* Enter number for time with cancer.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL12T
<96> then fill "6" in LHAL12T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL12T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 100 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.382_2
Variable Name
LHAL12T
Universe
LHAL12N= 1-95, DK
Universe-text
Condition number 12 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with cancer.
(LHAL12N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL12T
if (LHAL12T = 4 and LHAL12N > AGE), goto [ERR1_LHAL12T]
Hard Edits
ERR1_LHAL12T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL12T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 101 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.383_1
Variable Name
LHAL13N
Universe
LAHCA=13
Universe-text
Condition number 13 selected in LAHCA
Question Text
Answer Codes
Question Type
Integer
Field Pane Description
Number
Fill Instructions
Special Instructions Storage variable for the line number of the Health Status and Limitation section birth
defect condition.
Question text not displayed
person level item; store at person level
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 102 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.383_2
Variable Name
LHAL13T
Universe
LHCL13N=1-95, DK
Universe-text
Condition number 13 selected in LAHCA
Question Text
Answer Codes
Question Type
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions Storage variable for the line number of the Health Status and Limitation section birth
defect condition.
Question text not displayed
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 103 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.384_1
Variable Name
LHAL14N
Universe
LAHCA= 14
Universe-text
Condition number 14 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had intellectual disability, also known as mental
retardation?
* Enter number for time with intellectual disability/mental retardation.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL14T
<96> then fill "6" in LHAL14T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL14T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 104 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.384_2
Variable Name
LHAL14T
Universe
LHAL14N= 1-95, DK
Universe-text
Condition number 14 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with intellectual disability/mental retardation.
(LHAL14N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL14T
if (LHAL14T = 4 and LHAL14N > AGE), goto [ERR1_LHAL14T]
Hard Edits
ERR1_LHAL14T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL14T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 105 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.386_1
Variable Name
LHAL15N
Universe
LAHCA= 15
Universe-text
Condition number 15 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a developmental problem (e.g. cerebral palsy)?
* Enter number for time with developmental problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL15T
<96> then fill "6" in LHAL15T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL15T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 106 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.386_2
Variable Name
LHAL15T
Universe
LHAL15N= 1-95, DK
Universe-text
Condition number 15 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with developmental problem (e.g. cerebral palsy).
(LHAL15N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL15T
if (LHAL15T = 4 and LHAL15N > AGE), goto [ERR1_LHAL15T]
Hard Edits
ERR1_LHAL15T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL15T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 107 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.388_1
Variable Name
LHAL16N
Universe
LAHCA= 16
Universe-text
Condition number 16 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had senility?
* Enter number for time with senility.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL16T
<96> then fill "6" in LHAL16T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL16T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 108 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.388_2
Variable Name
LHAL16T
Universe
LHAL16N= 1-95, DK
Universe-text
Condition number 16 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with senility.
(LHAL16N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL16T
if (LHAL16T = 4 and LHAL16N > AGE), goto [ERR1_LHAL16T]
Hard Edits
ERR1_LHAL16T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL16T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 109 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.390_1
Variable Name
LHAL17N
Universe
LAHCA= 17
Universe-text
Condition number 17 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had depression, anxiety, or an emotional problem?
* Enter number for time with depression, anxiety or an emotional problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL17T
<96> then fill "6" in LHAL17T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL17T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 110 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.390_2
Variable Name
LHAL17T
Universe
LHAL17N= 1-95, DK
Universe-text
Condition number 17 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with depression, anxiety, or an emotional problem.
(LHAL17N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL17T
if (LHAL17T = 4 and LHAL17N > AGE), goto [ERR1_LHAL17T]
Hard Edits
ERR1_LHAL17T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL17T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 111 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.392_1
Variable Name
LHAL18N
Universe
LAHCA= 18
Universe-text
Condition number 18 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a weight problem?
* Enter number for time with weight problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL18T
<96> then fill "6" in LHAL18T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL18T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 112 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.392_2
Variable Name
LHAL18T
Universe
LHAL18N= 1-95, DK
Universe-text
Condition number 18 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with weight problem.
(LHAL18N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL18T
if (LHAL18T = 4 and LHAL18N > AGE) , goto [ERR1_LHAL18T]
Hard Edits
ERR1_LHAL18T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL18T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 113 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.394_1
Variable Name
LHAL19N
Universe
LAHCA= 19
Universe-text
Condition number 19 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a missing limb (finger, toe, or digit)?
* Enter number for time with missing limb.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL19T
<96> then fill "6" in LHAL19T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL19T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 114 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.394_2
Variable Name
LHAL19T
Universe
LHAL19N= 1-95, DK
Universe-text
Condition number 19 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with missing limb (finger, toe, or digit).
(LHAL19N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL19T
if (LHAL19T = 4 and LHAL19N > AGE) , goto [ERR1_LHAL19T]
Hard Edits
ERR1_LHAL19T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL19T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 115 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.396_1
Variable Name
LHAL20N
Universe
LAHCA= 20
Universe-text
Condition number 20 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a kidney, bladder or renal problem?
* Enter number for time with kidney, bladder or renal problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL20T
<96> then fill "6" in LHAL20T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL20T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 116 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.396_2
Variable Name
LHAL20T
Universe
LHAL20N= 1-95, DK
Universe-text
Condition number 20 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with kidney, bladder or renal problem.
(LHAL20N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL20T
if (LHAL20T = 4 and LHAL20N > AGE), goto [ERR1_LHAL20T]
Hard Edits
ERR1_LHAL20T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL20T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 117 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.398_1
Variable Name
LHAL21N
Universe
LAHCA= 21
Universe-text
Condition number 21 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a circulation problem (including blood clots)?
* Enter number for time with circulation problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL21T
<96> then fill "6" in LHAL21T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL21T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 118 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.398_2
Variable Name
LHAL21T
Universe
LHAL21N= 1-95, DK
Universe-text
Condition number 21 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with circulation problem (including blood clots).
(LHAL21N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL21T
if (LHAL21T = 4 and LHAL21N > AGE), goto [ERR1_LHAL21T]
Hard Edits
ERR1_LHAL21T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL21T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 119 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.400_1
Variable Name
LHAL22N
Universe
LAHCA= 22
Universe-text
Condition number 22 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had benign tumors or cysts?
* Enter number for time with benign tumors or cysts.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL22T
<96> then fill "6" in LHAL22T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL22T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 120 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.400_2
Variable Name
LHAL22T
Universe
LHAL22N= 1-95, DK
Universe-text
Condition number 22 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with benign tumors or cysts.
(LHAL22N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL22T
if (LHAL22T = 4 and LHAL22N > AGE), goto [ERR1_LHAL22T]
Hard Edits
ERR1_LHAL22T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL22T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 121 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.402_1
Variable Name
LHAL23N
Universe
LAHCA= 23
Universe-text
Condition number 23 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had fibromyalgia or lupus?
* Enter number for time with fibromyalgia or lupus.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL23T
<96> then fill "6" in LHAL23T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL23T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 122 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.402_2
Variable Name
LHAL23T
Universe
LHAL23N= 1-95, DK
Universe-text
Condition number 23 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with fibromyalgia or lupus.
(LHAL23N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL23T
if (LHAL23T = 4 and LHAL23N > AGE) , goto [ERR1_LHAL23T]
Hard Edits
ERR1_LHAL23T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL23T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 123 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.404_1
Variable Name
LHAL24N
Universe
LAHCA= 24
Universe-text
Condition number 24 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had osteoporosis or tendinitis?
* Enter number for time with osteoporosis or tendinitis.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL24T
<96> then fill "6" in LHAL24T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL24T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 124 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.404_2
Variable Name
LHAL24T
Universe
LHAL24N= 1-95, DK
Universe-text
Condition number 24 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with osteoporosis or tendinitis.
(LHAL24N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL24T
if (LHAL24T = 4 and LHAL24N > AGE), goto [ERR1_LHAL24T]
Hard Edits
ERR1_LHAL24T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL24T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 125 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.406_1
Variable Name
LHAL25N
Universe
LAHCA= 25
Universe-text
Condition number 25 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had epilepsy or seizures?
* Enter number for time with epilepsy or seizures.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL25T
<96> then fill "6" in LHAL25T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL25T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 126 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.406_2
Variable Name
LHAL25T
Universe
LHAL25N= 1-95, DK
Universe-text
Condition number 25 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with epilepsy or seizures.
(LHAL25N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL25T
if (LHAL25T = 4 and LHAL25N > AGE), goto [ERR1_LHAL25T]
Hard Edits
ERR1_LHAL25T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL25T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 127 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.408_1
Variable Name
LHAL26N
Universe
LAHCA= 26
Universe-text
Condition number 26 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had multiple sclerosis (MS) or muscular dystrophy
(MD)?
* Enter number for time with multiple sclerosis (MS) or muscular dtstrophy (MD)?
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL26T
<96> then fill "6" in LHAL26T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL26T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 128 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.408_2
Variable Name
LHAL26T
Universe
LHAL26N= 1-95, DK
Universe-text
Condition number 26 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with multiple sclerosis (MS) or muscular dystrophy (MD).
(LHAL26N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL26T
if (LHAL26T = 4 and LHAL26N > AGE), goto [ERR1_LHAL26T]
Hard Edits
ERR1_LHAL26T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL26T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 129 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.410_1
Variable Name
LHAL27N
Universe
LAHCA= 27
Universe-text
Condition number 27 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had polio(myelitis), paralysis or para/quadriplegia?
* Enter number for time with polio (myelitis) paralysis or para/quadriplegia.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL27T
<96> then fill "6" in LHAL27T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL27T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 130 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.410_2
Variable Name
LHAL27T
Universe
LHAL27N= 1-95, DK
Universe-text
Condition number 27 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with polio(myelitis), paralysis or para/quadriplegia.
(LHAL27N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL27T
if (LHAL27T = 4 and LHAL27N > AGE), goto [ERR1_LHAL27T]
Hard Edits
ERR1_LHAL27T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL27T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 131 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.412_1
Variable Name
LHAL28N
Universe
LAHCA= 28
Universe-text
Condition number 28 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had Parkinson’s disease or tremors?
* Enter number for time with Parkinson's disease or tremors.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL28T
<96> then fill "6" in LHAL28T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL28T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 132 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.412_2
Variable Name
LHAL28T
Universe
LHAL28N= 1-95, DK
Universe-text
Condition number 28 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with Parkinson’s disease or tremors.
(LHAL28N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL28T
if (LHAL28T = 4 and LHAL28N > AGE) , goto [ERR1_LHAL28T]
Hard Edits
ERR1_LHAL28T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL28T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 133 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.414_1
Variable Name
LHAL29N
Universe
LAHCA= 29
Universe-text
Condition number 29 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had nerve damage (including carpal tunnel
syndrome)?
* Enter number for time with nerve damage.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL29T
<96> then fill "6" in LHAL29T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL29T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 134 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.414_2
Variable Name
LHAL29T
Universe
LHAL29N= 1-95, DK
Universe-text
Condition number 29 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with nerve damage (including carpal tunnel syndrome).
(LHAL29N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL29T
if (LHAL29T = 4 and LHAL29N > AGE) , goto [ERR1_LHAL29T]
Hard Edits
ERR1_LHAL29T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL29T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 135 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.416_1
Variable Name
LHAL30N
Universe
LAHCA= 30
Universe-text
Condition number 30 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a hernia?
* Enter number for time with hernia.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL30T
<96> then fill "6" in LHAL30T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL30T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 136 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.416_2
Variable Name
LHAL30T
Universe
LHAL30N= 1-95, DK
Universe-text
Condition number 30 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with hernia.
(LHAL30N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL30T
if (LHAL30T = 4 and LHAL30N > AGE), goto [ERR1_LHAL30T]
Hard Edits
ERR1_LHAL30T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL30T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 137 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.418_1
Variable Name
LHAL31N
Universe
LAHCA= 31
Universe-text
Condition number 31 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had an ulcer?
* Enter number for time with an ulcer.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL31T
<96> then fill "6" in LHAL31T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL31T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 138 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.418_2
Variable Name
LHAL31T
Universe
LHAL31N= 1-95, DK
Universe-text
Condition number 31 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with ulcer.
(LHAL31N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL31T
if (LHAL31T = 4 and LHAL31N > AGE), goto [ERR1_LHAL31T]
Hard Edits
ERR1_LHAL31T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL31T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 139 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.420_1
Variable Name
LHAL32N
Universe
LAHCA= 32
Universe-text
Condition number 32 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had varicose veins or hemorrhoids?
* Enter number for time with varicose veins or hemorrhoids.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL32T
<96> then fill "6" in LHAL32T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL32T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 140 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.420_2
Variable Name
LHAL32T
Universe
LHAL32N= 1-95, DK
Universe-text
Condition number 32 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with varicose veins or hemorrhoids.
(LHAL32N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL32T
if (LHAL32T = 4 and LHAL32N > AGE), goto [ERR1_LHAL32T]
Hard Edits
ERR1_LHAL32T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL32T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 141 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.422_1
Variable Name
LHAL33N
Universe
LAHCA= 33
Universe-text
Condition number 33 selected in LAHCA
Question Text
1 of 2
How long [fill: have you/has Alias] had a thyroid problem, Grave’s disease or gout?
* Enter number for time with thyroid problem, Grave's disease or gout.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent, fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL33T
<96> then fill "6" in LHAL33T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL33T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 142 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.422_2
Variable Name
LHAL33T
Universe
LHAL33N= 1-95, DK
Universe-text
Condition number 33 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with thyroid problem, Grave’s disease or gout.
(LHAL33N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL33T
if (LHAL33T = 4 and LHAL33N > AGE), goto [ERR1_LHAL33T]
Hard Edits
ERR1_LHAL33T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL33T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 143 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.424_1
Variable Name
LHAL34N
Universe
LAHCA= 34
Universe-text
Condition number 34 selected in LAHCA
Question Text
1 of 2
How long fill: have you/has Alias] had a knee problem?
* Enter number for time with knee problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL34T
<96> then fill "6" in LHAL34T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL34T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 144 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.424_2
Variable Name
LHAL34T
Universe
LHAL34N= 1-95, DK
Universe-text
Condition number 34 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with knee problem.
(LHAL34N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL34T
if (LHAL34T = 4 and LHAL34N > AGE), goto [ERR1_LHAL34T]
Hard Edits
ERR1_LHAL34T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL34T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 145 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.426_1
Variable Name
LHAL35N
Universe
LAHCA= 35
Universe-text
Condition number 35 selected in LAHCA
Question Text
1 of 2
How long {have you/has Alias} had migraine headaches?
* Enter number for time with migrane headaches.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill: if the subject=respondent fill "have you" else, fill "has Alias"
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL35T
<96> then fill "6" in LHAL35T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL35T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 146 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.426_2
Variable Name
LHAL35T
Universe
LHAL35N= 1-95, DK
Universe-text
Condition number 35 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with migraine headaches.
(LHAL35N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Time period
Fill Instructions
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL35T
if (LHAL35T = 4 and LHAL35N > AGE) , goto [ERR1_LHAL35T]
Hard Edits
ERR1_LHAL35T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL35T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 147 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.450_1
Variable Name
LHAL90N
Universe
LAHCA= 90
Universe-text
Condition number 90 selected in LAHCA
Question Text
1 of 2
How long [fill1: have you/has Alias] had [fill2: LAHCA_S1]?
* Enter number for time with [fill1: LAHCA_S1].
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill1: if the subject=respondent fill "have you" else, fill "has Alias"
fill2: LAHCA_S1
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL90T
<96> then fill "6" in LHAL90T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL90T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 148 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.450_2
Variable Name
LHAL90T
Universe
LHAL90N= 1-95, DK
Universe-text
Condition number 90 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with [fill: LAHCA_S1].
(LHAL90N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Time period
fill: LAHCA_S1
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D>
If 91 selected in LAHCA, then goto LAHCA_S2,
Else, roster through all LAHCA entries and goto appropriate LHAL##N [##= 01-35, 90,
91]
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL90T
if (LHAL90T = 4 and LHAL90N > AGE), goto [ERR1_LHAL90T]
Hard Edits
ERR1_LHAL90T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL90T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 149 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.452_1
Variable Name
LHAL91N
Universe
LAHCA= 91
Universe-text
Condition number 91 selected in LAHCA
Question Text
1 of 2
How long [fill1: have you/has Alias] had [fill2: LAHCA_S2]?
* Enter number for time with [fill1: LAHCA_S2].
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Number
fill1: if the subject=respondent fill "have you" else, fill "has Alias"
fill2: LAHCA_S2
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-95, D> goto LHAL91T
<96> then fill "6" in LHAL91T
If another condition selected, continue to ask number and time period for each
subsequent condition (LHAL##N and LHAL##T]; Roster through persons eligible in
LAHCA, else go to [PHSTAT]
store "R" in [LHAL91T] goto next condition in [LAHCA]
Once exhausted goto [PHSTAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 150 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.452_2
Variable Name
LHAL91T
Universe
LHAL91N= 1-95, DK
Universe-text
Condition number 91 selected in LAHCA
Question Text
2 of 2
* Enter time period for time with [fill: LAHCA_S2].
(LHAL91N..)
Answer Codes
Question Type
1. Day(s)
2. Week(s)
3. Month(s)
4. Year(s)
Since Birth
Refused
Don’t Know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Time period
fill: LAHCA_S2
Special Instructions person level item; store at person level.
The form pane for this item was redesigned for Q2, such that only conditions that were
selected at LAHCA will display. Also, the conditions will display in the order in which
the FR entered the data in LAHCA.
Skip Instructions
<1-4, R, D> [goto next condition selected in LAHCA], continue to ask number and time
period for each subsequent condition; else go to PHSTAT
Roster through all LAHCA entries, roster through next person 18+ Once exhausted
goto PHSTAT.
<6> goto ERR2_LHAL91T
if (LHAL91T = 4 and LHAL91N > AGE), goto [ERR1_LHAL91T]
Hard Edits
ERR1_LHAL91T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL91T
* "6" not selectable.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 151 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.500
Variable Name
PHSTAT
Universe
All persons
Universe-text
Question Text
Would you say [fill: your/Alias’s] health in general is excellent, very good, good, fair,
or poor?
Answer Codes
1. Excellent
2. Very good
3. Good
4. Fair
5. Poor
Refused
Don’t Know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
General Health
fill: if subject= respondent fill "your" else fill "Alias"
Special Instructions Associated Screens:
H_PHSTAT
Skip Instructions
Repeat for all people in the household
Every family member goto next section
Hard Edits
Soft Edits
AssocHelp
H_PHSTAT
Wednesday, July 06, 2016
Page 152 of 153
Module
04
Section Name
HEALTH STATUS AND LIMITATION OF ACTIVITIES
Part
Question ID
FHS.500_H
Variable Name
H_PHSTAT
Universe
Universe-text
Question Text
If the response is not one of the given categories (for example, "pretty good" or "up
and down"), repeat the question, emphasizing
"IN GENERAL" and clearly state the answer choices. In no instance should you
choose an answer for the respondent.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
PHSTAT
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 153 of 153
2017 Q1 NHIS Instrument Spec Report
Section name: Family Injuries & Poisonings
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.010
Variable Name
FINJ3M
Universe
All families
Universe-text
!Create input entry for FIJ.010_01!
Question Text
?[F1]
The next set of questions is about INJURIES AND POISONINGS. People can be
injured or poisoned unexpectedly, accidentally or on purpose. They may have hurt
themselves or others may have caused them to be hurt.
DURING THE PAST THREE MONTHS, that is since [fill 1: date (91 days before
today's date)], [fill 2: did you/did you or anyone in your family] have an injury where
any part of [fill 3: your/the] body was hurt, for example, with a [fill 4: (random set of
examples) cut or wound, broken bone, sprain or burn?]
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Injury
fill1: fill 91 days before today's date (which will be determined once FR has entered
FIJ section)
fill2: if single person household fill "did you" else, fill "did you or anyone.."
fill3: if the subject=respondent fill "your" else, fill "the"
fill4: fill random set of examples (mixed order: cut or wound, broken bone, sprain or
burn)
Formula for fill4= ?
Special Instructions 1. A random set of four injury examples (from a list of 10 sets) will be inserted into the
question text. The list of 10 example sets will be provided to the section author as
separate documentation. To ensure that the same list is used for a family when backups or break-offs occur, we suggest something like this:
IF (LISTNUM = a number) select a number between 1 and 10 at random, assign
LISTNUM that number,
and read list LISTNUM; ELSE read list LISTNUM. When FINJ3M is reached for the
first time, LISTNUM is assigned a number between 1 and 10. It will not be assigned a
different list number if the interviewer returns to FINJ3M, because LISTNUM will never
again be equal to zero for that case.
STORE RANDOMLY SELECTED NUMBER IN INJNUM AND INJLIST. IF EMPTY
SELECT RANDOM NUMBER
Wednesday, July 06, 2016
Page 1 of 87
Random List
1. cut or wound, dislocation, bruise, or sprain
2. bruise, cut or wound, sprain, or head injury
3. head injury, sprain, broken bone, or cut or wound
4. sprain, bruise, cut or wound, or scrape
5. cut or wound, broken bone, sprain, or burn
6. cut or wound, bruise, broken bone, or sprain
7. cut or wound, sprain, scrape, or broken bone
8. head injury, bruise, cut or wound, or sprain
9. bruise, insect bite, sprain, or cut or wound
10. cut or wound, sprain, broken bone, or bruise
2. If "yes" and a single-person family, store the person number in WFINJ3M and goto
TFINJ3M.
Skip Instructions
<1> [if single-person family, store person number in WFINJ3M and goto TFINJ3M;
else goto
WFINJ3M]
<2,R,DK> [goto FPOI3M]
Hard Edits
Soft Edits
AssocHelp
H_FINJ3M
Wednesday, July 06, 2016
Page 2 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.010_H
Variable Name
H_FINJ3M
Universe
Universe-text
Question Text
Injuries INCLUDE any physical trauma to the body such as
[blt] cuts,
wounds,
sprains,
bruises,
fractures (broken bones),
concussions and other head injuries,
scrapes,
burns,
dislocations,
insect stings,
animal bites,
foreign bodies (such as splinters or dirt in eye),
and anything else the respondent considers an injury. [blt]
EXCLUDE injuries resulting from repetitive trauma or cumulative injuries such as
carpal tunnel syndrome, tennis elbow, and trigger finger.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FINJ3M
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 3 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.012
Variable Name
WFINJ3M
Universe
AGE = All and FINJ3M = 1
Universe-text
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who was this?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members. If a single-person family, this
question should be skipped.
Skip Instructions
<1-25> [All family members. Avoid duplicate; goto TFINJ3M]
[goto FPOI3M]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 4 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.014
Variable Name
TFINJ3M
Universe
FINJ3M = 1 and person selected in WFINJ3M
Universe-text
Question Text
?[F1]
DURING THE PAST THREE MONTHS, how many different times [fill 1: were you/was
ALIAS] injured?
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
No. of times injured
fill1: if the subject=respondent fill "were you" else, fill "was ALIAS"
Special Instructions Complete loop of injury questions (including follow-ups) for current person before
returning to this question for the next person selected in WFINJ3M.
Skip Instructions
<01-10,DK> [goto MFINJ3M]
[goto TFINJ3M for next person with reported injuries; if
no more persons with injuries, goto FPOI3M]
<11-91> [goto ERR_TFINJ3M]
Hard Edits
Soft Edits
ERR_TFINJ3M
* ^TFINJ3M is unusually high. Please verify.
[goto MFINJ3M]
[reset TFINJ3M for new entry]
[reset TFINJ3M for new entry]
AssocHelp
H_TFINJ3M
Wednesday, July 06, 2016
Page 5 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.014_H
Variable Name
H_TFINJ3M
Universe
Universe-text
Question Text
This question is asking about the number of events that lead to an injury.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
TFINJ3M
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 6 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.016
Variable Name
MFINJ3M
Universe
TFINJ3M = 01-91 or DK
Universe-text
Question Text
?[F1]
Did [fill 1: you /ALIAS] talk to or see a medical professional about [fill 2: any of these
injuries/this injury/your injury or injuries/his injury or injuries/her injury or injuries]?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Consult medical professional
fill1: if the subject=respondent fill "you" else, fill "ALIAS"
fill2: if 01-91 in [TFINJ3M] and the subject has multiple injuries then fill "any of these
injuries" else, fill "this injury"
if "DK" in [TFINJ3M] and the subject=respondent then fill "your injury or injuries"
if "DK" in [TFINJ3M] and the subject is NOT the respondent then fill "his injury or
injuries/her injury or injuries" according to the subject's gender.
Special Instructions 1. Fill 2: ...your injury or injuries/his injury or injuries/her injury or injuries applies to
situations where a don’t know response was provided at TFINJ3M.
2. If TFINJ3M = 1 and MFINJ3M = 1, fill "1" in MTFINJ3M and goto IPDATEM.
Skip Instructions
<1> [if TFINJ3M eq 1, fill "1" in MTFINJ3M and goto IPDATEM; else goto MTFINJ3M]
<2,DK,R> [goto TFINJ3M for next person with reported injuries; if no more persons
with injuries,
goto FPOI3M]
Hard Edits
Soft Edits
AssocHelp
H_MFINJ3M
Wednesday, July 06, 2016
Page 7 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.016_H
Variable Name
H_MFINJ3M
Universe
Universe-text
Question Text
Talking to or seeing a trained medical professional can take place in a formal office
setting, over the phone, or in informal settings such as a dinner party. This includes
talking to or seeing a friend or relative that is a trained medical professional.
A trained medical professional includes anyone the respondent deems a medical
professional. Some examples may include:
a medical doctor,
an osteopath,
an ophthalmologist,
a physician assistant,
a nurse practitioner,
a nurse,
a physical or occupational therapist,
a podiatrist,
a chiropractor
an acupuncturist,
a naturopath,
and a homoeopathist.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
MFINJ3M
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 8 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.018
Variable Name
MTFINJ3M
Universe
MFINJ3M = 1
Universe-text
Question Text
?[F1]
Of [fill 1: the ^TFINJ3M/all the] times that [fill 2: you were/ALIAS was] injured, how
many of
those times was the injury serious enough that a medical professional was consulted?
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Times injured for which a medical professional consulted
fill1: if 01-91 in [TFINJ3M] fill that number in "the ^TFINJ3M"
fill2: if the subject=respondent fill "you were" else, fill "ALIAS was"
Special Instructions [If (MTIFNJ3M gt TFINJ3M)] display ERR1_MTFINJ3M
[If (TFINJ3M = 99 and MTFINJ3M gt 3) display ERR2_MTFINJ3M
Skip Instructions
<1-91> [If MTFINJ3M gt TFINJ3M, goto ERR1_MTFINJ3M; else, goto IPDATEM]
[goto TFINJ3M for next person with reported injuries; if no more persons with
injuries, goto FPOI3M]
[If MTIFNJ3M gt 3 and TFINJ3M= DK goto ERR2_MTFINJ3M]
Hard Edits
ERR1_MTFINJ3M
[If (MTIFNJ3M gt TFINJ3M), display ERR1_MTFINJ3M]:
[^MTFINJ3M] is greater than the total number of times you said [you were/ALIAS was]
injured, which is [^TFINJ3M]. For this question, we are asking about the number of
times [you were/ALIAS was] injured and a medical professional was consulted. For
example, if you were injured three different times but only sought medical advice or
treatment for one of those times, the answer would be one, even if you saw or talked
to a trained medical professional more than once about that injury event.
Goto
Close
Soft Edits
ERR2_MTFINJ3M
[If (TFINJ3M = 99 and MTFINJ3M gt 3), display ERR2_MTFINJ3M]:
^MTFINJ3M is an unusually high number of injuries for which a medical professional
was consulted. Please verify.
*Read if necessary.
Wednesday, July 06, 2016
Page 9 of 87
For this question, we are asking about the number of times [you were/ALIAS was]
injured and a medical professional was consulted. For example, if you were injured
three different times, but only sought medical advice or treatment for one of those
times, the answer would be one, even if you saw or talked to a trained medical
professional more than once about that injury event.
Suppress
Goto
Close
AssocHelp
H_MTFINJ3M
Wednesday, July 06, 2016
Page 10 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.018_H
Variable Name
H_MTFINJ3M
Universe
Universe-text
Question Text
This question is asking about the number of events that lead to an injury, for which a
trained medical professional was consulted.
[b]Consulting a trained medical professional[b] is seeking advice or treatment. This
advice may be given in a formal office setting, over the phone, or in informal settings
such as a dinner party. Advice or treatment may be received from a friend or relative
that is a trained medical professional.
A [b]trained medical professional[b] includes anyone the respondent deems a medical
professional. Some examples may include
[blt] a medical doctor,
an osteopath,
an ophthalmologist,
a physician assistant,
a nurse practitioner,
a nurse,
a physical or occupational therapist,
a podiatrist,
a chiropractor
an acupuncturist,
a naturopath,
and a homoeopath. [blt]
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associate Screens:
MTFINJ3M
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 11 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.020
Variable Name
FPOI3M
Universe
All families
Universe-text
Question Text
?[F1]
DURING THE PAST THREE MONTHS, that is since [fill 1: date (91 days before
today's date)], [fill 2: were you/ were you or anyone in your family] poisoned by
swallowing or breathing in a harmful substance such as bleach, carbon monoxide, or
too many pills or drugs? Do not include food poisoning, sun poisoning, or poison ivy
rashes.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Poisoning
fill1: fill 91 days before today's date (which will be determined once FR has entered
FIJ section)
fill2: if single person household fill "were you" else, fill "were you or anyone in your
family"
Special Instructions If <1> and a single-person family, store the person number in WFPOI3M and goto
TFPOI3M.
Skip Instructions
<1> [if single-person family, store person number in WFPOI3M and goto TFPOI3M;
else,
goto WFPOI3M]
<2,DK,R> [goto FDMED12M]
Hard Edits
Soft Edits
AssocHelp
H_FPOI3M
Wednesday, July 06, 2016
Page 12 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.020_H
Variable Name
H_FPOI3M
Universe
Universe-text
Question Text
Poisonings can be accidental or on purpose.
Poisonings INCLUDE substances such as
[blt] being bitten or stung by a poisonous animal or insect,
overdosing on any drug or medicine,
taking or being given the wrong drug,
and swallowing, breathing, injecting, or otherwise coming in contact with too much of a
harmful substance liquid, solid, or gas). [blt]
Poisonings EXCLUDE substances such as food poisoning, sun poisoning, poison ivy
rashes, and poison oak.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FPOI3M
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 13 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.022
Variable Name
WFPOI3M
Universe
AGE = All and FPOI3M = 1and more than 1 person
Universe-text
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who was this?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members. If a single-person family, this
question should be skipped.
Skip Instructions
<1-25> [All family members. Avoid duplicate; goto TFPOI3M]
[goto FDMED12M]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 14 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.024
Variable Name
TFPOI3M
Universe
FPOI3M = 1 and person selected in WFPOI3M
Universe-text
Question Text
?[F1]
DURING THE PAST THREE MONTHS, how many different times [fill 1: were you/was
ALIAS] poisoned? Do not include food poisoning, sun poisoning, or poison ivy rashes.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
No. of times poisoned
fill1: if the subject=respondent fill "were you" else, fill "was ALIAS"
Special Instructions Complete loop of poisoning questions (including follow-ups) for current person before
returning to this question for the next person selected in WFPOI3M.
Skip Instructions
<01-10, DK> [goto MFPOI3M]
[goto TFPOI3M for next person with reported poisoning; if
no more persons with a poisoning, goto FDMED12M]
<11-91> [goto ERR_TFPOI3M]
Hard Edits
Soft Edits
ERR_TFPOI3M
[If TFPOI3M gt 10, display ERR_TFPOI3M]
* ^TFPOI3M is unusually high. Please verify.
[goto MFPOI3M]
[goto TFPOI3M for new entry]
[goto TFPOI3M for new entry]
AssocHelp
H_TFPOI3M
Wednesday, July 06, 2016
Page 15 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.024_H
Variable Name
H_TFPOI3M
Universe
Universe-text
Question Text
This question is asking about the number of times the individual was poisoned.
Poisonings can be accidental or on purpose.
Poisonings include things such as:
being bitten or stung by a poisonous animal or insect,
overdosing on any drug or medicine,
taking or being given the wrong drug,
and swallowing, breathing, injecting, or otherwise coming in contact with too much of
a harmful substance (liquid, solid, or gas).
Poisonings exclude things such as:
food poisoning,
sun poisoning,
poison ivy rashes,
and poison oak.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
TFPOI3M
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 16 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.026
Variable Name
MFPOI3M
Universe
TFPOI3M = 01-91 or DK
Universe-text
Question Text
?[F1]
Did [fill 1: you /ALIAS] talk to or see a medical professional about [fill 2: any of these
poisonings/this poisoning/your poisoning or poisonings/his poisoning or
poisonings/her poisoning or poisonings]?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Consult medical professional
fill1: if the subject=respondent fill "you" else, fill "ALIAS"
fill2: if 01-91 in [TFPOI3M] and the subject has multiple injuries then fill "any of these
poisonings" else, fill "this poisoning"
if "DK" in [TFPOI3M] and the subject=respondent then fill "your poisoning or
poisonings"
if "DK" in [TFPOI3M] and the subject is NOT the respondent then fill "his poisoning or
poisonings/her poisoning or poisonings" according to the subject's gender.
Special Instructions 1. Fill 2: "...your poisoning or poisonings/his poisoning or poisonings/her poisoning or
poisonings" applies to situations where a "don’t know" response was provided at
TFPOI3M.
2. If TFPOI3M = 1 and MFPOI3M = 1, fill "1" in MTFINJ3M and goto IPDATEM.
Skip Instructions
<1> [if TFPOI3M eq 1, fill "1" in MTFPOI3M and goto IPDATEM; else goto MTFPOI3M]
<2,DK,R> [goto TFPOI3M for next person with reported poisoning; if no more persons
with a poisoning, goto FDMED12M]
Hard Edits
Soft Edits
AssocHelp
H_MFPOI3M
Wednesday, July 06, 2016
Page 17 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.026_H
Variable Name
H_MFPOI3M
Universe
Universe-text
Question Text
This question is asking about the number of times the individual was poisoned for
which a trained medical professional was consulted.
Poisonings can be accidental or on purpose.
Poisonings include things such as:
being bitten or stung by a poisonous animal or insect,
overdosing on any drug or medicine,
taking or being given the wrong drug,
and swallowing, breathing, injecting, or otherwise coming in contact with too much of
a harmful substance (liquid, solid, or gas).
Poisonings exclude things such as:
food poisoning,
sun poisoning,
poison ivy rashes,
and poison oak.
Talking to or seeing a trained medical professional can take place in a formal office
setting, over the phone, or in informal settings such as a dinner party. This includes
talking to or seeing a friend or relative that is a trained medical professional.
A trained medical professional includes anyone the respondent deems a medical
professional. Some examples may include:
a medical doctor,
an osteopath,
an ophthalmologist,
a physician assistant,
a nurse practitioner,
a nurse,
a physical or occupational therapist,
a podiatrist,
a chiropractor
an acupuncturist,
a naturopath,
and a homoeopathist.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
Wednesday, July 06, 2016
Page 18 of 87
MFPOI3M
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 19 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.028
Variable Name
MTFPOI3M
Universe
MFPOI3M = 1
Universe-text
Question Text
?[F1]
Of [fill 1: the ^TFPOI3M/all the] times that [fill 2: you were/ALIAS was] poisoned, how
many of
those times was the poisoning serious enough that a medical professional was
consulted?
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Times poisoned for which a medical professional consulted
fill1: see FIJ.018
fill2: if the subject=respondent fill "you were" else, fill "ALIAS was"
Special Instructions Fill 1: "...all the" would be used when a "don’t know" response was provided at
TFPOI3M.
Skip Instructions
<01-91> [If MTFPOI3M gt TFPOI3M, goto ERR1_MTFPOI3M; else, goto IPDATEM]
[goto TFPOI3M for next person with reported poisoning; if no more persons
with a
poisoning, goto FDMED12M]
If ((MTFPOI3M gt TFPOI3M) or (TFPOI3M eq DK and MTFPOI3M gt 3)), display
ERR_MTFPOI3M]:
Hard Edits
ERR1_MTFPOI3M
[If (MTFPOI3M gt TFPOI3M), display ERR1_MTFPOI3M]:
[^MTFPOI3M] is greater than the total number of times you said [you were/ALIAS
was] poisoned, which is [^TFPOI3M]. For this question, we are asking about the
number of times [you were/ALIAS was] poisoned and a medical professional was
consulted. For example, if you were poisoned three different times but only sought
medical advice or treatment for one of those times, the answer would be one, even if
you saw or talked to a trained medical professional more than once about that
poisoning event.
[goto MTFPOI3M for new entry]
[goto TFPOI3M or MTFPOI3M for new entry]
Soft Edits
ERR2_MTFPOI3M
[If TFPOI3M = 99 and MTFPOI3M gt 3), display ERR2_MTFINJ3M]:
* ^MTFINJ3M is an unusually high number.
Wednesday, July 06, 2016
Page 20 of 87
For this question, we are asking about the number of times [you were/ALIAS was]
poisoned and a medical professional was consulted. For example, if you were
poisoned three different times but only sought medical advice or treatment for one of
those times, the answer would be one, even if you saw or talked to a trained medical
professional more than once about that poisoning event.
Suppress
Goto
Close
AssocHelp
H_MTFPOI3M
Wednesday, July 06, 2016
Page 21 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.028_H
Variable Name
H_MTFPOI3M
Universe
Universe-text
Question Text
This question is asking about the number of times the individual was poisoned for
which a trained medical professional was consulted.
Consulting a trained medical professional is seeking medical advice or treatment.
This advice may be given in a formal office setting, over the phone, or in informal
settings such as a dinner party. Advice and treatment may be received from a friend
or relative that is a trained medical professional.
A trained medical professional includes anyone the respondent deems a medical
professional. Some examples may include:
a medical doctor,
an osteopath,
an ophthalmologist,
a physician assistant,
a nurse practitioner,
a nurse,
a physical or occupational therapist,
a podiatrist,
a chiropractor
an acupuncturist,
a naturopath,
and a homoeopathist.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
MTFPOI3M
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 22 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.050_1
Variable Name
IPDATEM
Universe
(MTFINJ3M = 01-91) OR (MTFPOI3M = 01-91)
Universe-text
Question Text
1 of 3
(calendar card)
* Please hand the calendar card to the respondent.
When did [fill 1: your/ALIAS’s] [fill 2: injury/poisoning] happen for which a medical
professional was consulted?
Now I’m going to ask a few questions about the [fill 3: ^MTFINJ3M/^MTFPOI3M] times
[fill 4:
you were/ALIAS was] [fill 5: injured/poisoned] for which a medical professional was
consulted. Starting with the most recent time, when did this [fill 6: injury/poisoning]
happen?
You just told me about [fill 7: your/ALIAS’s] [fill 8: month, day of previous event]
[fill11:most recent/second most recent/third most recent/fourth most
recent][fill 9: injury/poisoning]. What was the date of the [fill 10: injury/poisoning]
before that for which a medical professional was consulted?
* Enter month.
Answer Codes
Question Type
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
Refused
Don’t know
Multi Part
Field Pane Description
Fill Instructions
Month
fill1: if the subject=respondent fill "your" else fill "ALIAS's"
fill2: if FINJ3M=1 then fill "injury", if FPOI3M =1 then fill "poisoning"
fill3: fill "MTFINJ3M/ MTFPOI3M"
Wednesday, July 06, 2016
Page 23 of 87
fill4: if the subject=respondent fill "you were" else fill "ALIAS was"
fill5: if FINJ3M=1 then fill "injured", if FPOI3M =1 then fill "poisoned"
fill6: if FINJ3M=1 then fill "injury", if FPOI3M =1 then fill "poisoning"
fill7: if the subject=respondent fill "your" else fill "ALIAS's"
fill8: fill moth, day of previous event
fill9: if FINJ3M=1 then fill "injury", if FPOI3M =1 then fill "poisoning"
fill10: if FINJ3M=1 then fill "injury", if FPOI3M =1 then fill "poisoning"
DO NOT ALLOW FUTURE DATE ENTRY TO WHAT IS IN FILL #8
fill11: when a person has multiple injury episodes but provides incomplete date
information, use the following fill "You just told me about [your/ALIAS’s] [most
recent/second most recent/third most recent/fourth most recent].." If the FR collects
complete date information on an injury or poisoning
episode, fill the date.
Special Instructions if (FINJ3M eq <1> and TFINJ3M eq <1> and MFINJ3M eq <1>) OR (FINJ3M eq
<1> and TFINJ3M eq <2-91,DK> and MFINJ3M eq <1> and MTFINJ3M eq <1>) OR
(FPOI3M eq <1> and TFPOI3M eq <1> and MFPOI3M eq <1>) OR (FPOI3M eq <1>
and TFPOI3M eq <2-91,DK> and MFPOI3M eq <1> and MTFPOI3M eq <1>)] then fill
"When did.."
[if (FINJ3M eq <1> and TFINJ3M eq <2-91,DK> and MFINJ3M eq <1> and MTFINJ3M
eq <2-91>) OR (FPOI3M eq <1> and TFPOI3M eq <2-91,DK> and MFPOI3M eq <1>
and MTFPOI3M eq <2-91>) AND the most recent injury/poisoning episode is being
asked about] then fill "Now I'm going to ask a few questions about the.."
[if (FINJ3M eq <1> and TFINJ3M eq <2-91,DK> and MFINJ3M eq <1> and MTFINJ3M
eq <2-91>) OR (FPOI3M eq <1> and TFPOI3M eq <2-91,DK> and MFPOI3M eq <1>
and MTFPOI3M eq <2-91>) AND the other injury/poisoning episodes are being asked
about] then fill "You just told me about.."
ONLY DISPLAY VALID MONTHS (91 days before today's date, which will be
determined once the FR enters FIJ for the first time).
Skip Instructions
<01-12> [goto IPDATED]
[goto IPHOW]
[goto IPDATENO]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 24 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.050_2
Variable Name
IPDATED
Universe
IPDATEM = 01-12
Universe-text
Question Text
2 of 3
* Enter day.
Answer Codes
Question Type
Multi Part
Field Pane Description
Day
Fill Instructions
Special Instructions (NOTE: Add invalid date messages.)
<1-31> Only allow valid days for month entered. If days not valid,
[goto ERR_IPDATED]
[then automatic blaise default error]
Skip Instructions
<01-31> [goto IPDATEY]
[goto IPHOW]
[goto IPDATEMT]
Hard Edits
ERR_IPDATED
[fill1: IPDATED] is not a valid day for [fill2: IPDATEM ].
[reset IPDATED for new entry]
[reset IPDATED for new entry]
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 25 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.050_3
Variable Name
IPDATEY
Universe
IPDATED = 01-31
Universe-text
Question Text
3 of 3
* Enter year.
Answer Codes
Question Type
Integer
Field Pane Description
Year
Fill Instructions
Special Instructions Allow 4 digits, Allow D, R.
Skip Instructions
If IPDATEM, IPDATED and IPDATEY result in a future date; then goto ERR_IPDATEY.
If IPDATEM, IPDATED, IPDATEMTresult in future date; the goto ERR_IPDATEY.
If IPDATEM, IPDATED and IPDATEY result in a date before the 91 day reference
period, then goto ERR1_IPDATEY.
If IPDATEM, IPDATED, IPDATEMT, and IPDATEY result in a date before the 91
day period, then do to ERR2_IPDATEY
If IPDATEM, IPDATED, IPDATEMT, and IPDATEY result in a date before
the 91 day period, then do to ERR3_IPDATEY
[goto IPHOW]
Hard Edits
ERR_IPDATEY
* Future date invalid.
* Please correct.
[reset IPDATED for new entry]
[reset IPDATED for new entry]
Soft Edits
ERR1_IPDATEY
* The reported date, [^IPDATEM(text)^IPDATED(numeric)^IPDATEY(4-digit year)],
falls outside the reference period beginning [fill date used in FIJ.010].
*Please verify the date and make any corrections.
Wednesday, July 06, 2016
Page 26 of 87
ERR2_IPDATEY
*The reported date, [^IPDATEM(text)^IPDATED(numeric)^IPDATEY(4-digit year)], falls
outside the reference period beginning [fill date used in FIJ.010]. NOTE: The start of
the reference period falls in the [beginning/middle/end] of [month used in FIJ.010].
*Please verify the date and make any corrections.
ERR3_IPDATEY
* The reported date, [^IPDATEM(text)^IPDATEY(4-digit year)], falls outside the
reference period beginning [fill date used in FIJ.010].
*Please verify the date and make any corrections.
AssocHelp
Wednesday, July 06, 2016
Page 27 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.051_1
Variable Name
IPDATENO
Universe
IPDATEM = DK
Universe-text
Question Text
1 of 2
Can you tell me approximately how long ago [fill 1: your/ALIAS’s] [fill 2:
injury/poisoning]
happened?
*Enter number for time since event.
Answer Codes
Question Type
Multi Part
Field Pane Description
Fill Instructions
Number
fill1: if the subject=respondent fill "your" else, fill "ALIAS's"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
***how/where do we cycle if both injury and poisoning?*****
Special Instructions This is part one of a question that is asked when a "don’t know" response is provided
to IPDATEM. In conjunction with IPDATETP, it is intended to capture an approximate
date of the injury/poisoning episode.
Skip Instructions
<001-996> [goto IPDATETP]
[goto IPHOW]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 28 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.051_2
Variable Name
IPDATETP
Universe
IPDATENO= 001-996
Universe-text
Question Text
2 of 2
*Enter number for time period since event.
^IPDATENO…
Answer Codes
Question Type
1. Days
2. Weeks
3. Months
Refused
Don’t know
Multi Part
Field Pane Description
Time period
Fill Instructions
Special Instructions This is part two of a question that is asked when a "don’t know" response is provided
to IPDATEM. In conjunction with IPDATENO, it is intended to capture an approximate
date of the injury/poisoning episode.
Skip Instructions
If IPDATEM, IPDATENO, and IPDATETP result in a date before the 91 day
period, then do to ERR1_IPDATETP
<1,2,3,R,DK> [goto IPHOW]
Hard Edits
If IPDATENO GT 91 days (1) or
IPDATENO GT 13 weeks (2) or
IPDATENO GT 4 months (3) then goto ERR_IPDATETP
ERR_IPDATETP
defaul blaise message for now "Out of range"
Soft Edits
ERR1_IPDATETP
*The approximate date falls outside the reference period beginning [fill date used in
FIJ.010].
*Please verify and make any corrections.
AssocHelp
Wednesday, July 06, 2016
Page 29 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.052
Variable Name
IPDATEMT
Universe
IPDATED = DK
Universe-text
Question Text
(book) F3
?[F1]
Was this in the beginning of [fill 1: ^IPDATEM (text)], the middle of [fill 2: ^IPDATEM
(text)],
or the end of [fill 3: ^IPDATEM (text)]?
Answer Codes
Question Type
1. Beginning
2. Middle
3. End
Refused
Don’t know
Pick One - answer list pane
Field Pane Description
Fill Instructions
What point in month
fill1/2/3: fill the entire name of the month selected in [IPDATEM]
Special Instructions This question is asked when a "don’t know" response is provided to IPDATED. It is
intended to capture an approximate date of the injury/poisoning episode.
Skip Instructions
<1,2,3,R,DK> [gotoIPHOW]
Hard Edits
Soft Edits
AssocHelp
H_IPDATEMT
Wednesday, July 06, 2016
Page 30 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.052_H
Variable Name
H_IPDATEMT
Universe
Universe-text
Question Text
The beginning of the month includes the 1st - 10th days of the month.
The middle of the month includes the 11th - 20th days of the month.
The end of the month includes the 21st - 31st days of the month.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IPDATEMT
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 31 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.060
Variable Name
IPHOW
Universe
(MTFINJ3M = 01-91) OR (MTFPOI3M = 01-91)
Universe-text
Question Text
?[F1]
[fill 7: How did [fill 1: your/ALIAS’s] [fill 2: injury/poisoning] on [fill 3: ^IPDATEM
^IPDATED (starting with most recent if multiple)] happen?] [fill 5: How did this [fill 6:
injury/poisoning] happen?] Please describe fully the circumstances or events leading
to the [fill 4: injury/poisoning], and any objects, substances, or other people involved.
* Enter the verbatim response, probing for as much detail as possible, including
specifically what the person was doing at the time and all circumstances surrounding
the
event. Record all volunteered information.
*Do not use proper names or language that will identify family members.
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
Description of injury/poisoning event
fill1: if the subject=respondent fill "your"; else, fill "ALIAS's"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1; then fill "poisoning" ***how/where do we
cycle if both injury and poisoning?*****
fill3: fill month and date selected in [IPDATEM] and [IPDATED]
fill4: if FINJ3M=1 fill "injury", or if FPOI3M=1; then fill "poisoning"
fill5: if IPDATEM, IPDATED, IPDATEY, IPDATENO, or IPDATEMPT= DK, then fill
"How did this [fill6: injury/poinsoning] happen?"; else use fill 7.
fill6: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
Special Instructions If injury and "refused" auto fill "R" for ICAUS; if injury and "don’t know" auto fill "DK" for
ICAUS.
Skip Instructions
[if injury, goto ICAUS1; else, if poisoning, goto PPCC]
[if injury, auto fill "R" for ICAUS1 and goto IJBODY; else, if poisoning, goto PPCC]
[if injury, auto fill "DK" for ICAUS1 and goto IJBODY; else, if poisoning, goto
PPCC]
Hard Edits
Soft Edits
Wednesday, July 06, 2016
Page 32 of 87
AssocHelp
H_IPHOW
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.060_H
Variable Name
H_IPHOW
Universe
Universe-text
Question Text
With as much detail as possible, type a description of the event that caused the
injury. This description is used to categorize the cause of injury.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IPHOW
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 33 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.065
Variable Name
ICAUS1
Universe
MTFINJ3M = 01-91 and IPHOW=NE to DK or R
Universe-text
Question Text
?[F1]
*Interviewer selects up to two categories that best describe the cause of the person’s
injury
Answer Codes
Question Type
1. Fall
2. Driver or passenger in a motor vehicle (such as car, truck, van, motorcycle, etc.)
3. Rider of a bicycle/tricycle/unicycle
4. Driver or passenger of other mode of transportation (boat, plane, train, golf cart,
etc.)
5. Pedestrian walking or on skateboard, skates, skis, etc. struck by vehicle or bike
6. Overexertion (includes twist, sprain, repetitive motion, whiplash, etc.)
7. Struck by or against something or someone, or struck by a falling object
8. Cutting or piercing by sharp object
9. Burned or scalded by fire or flame, hot objects, hot liquids, chemicals, etc.
10. Bite or sting (insect, animal, reptile, etc.)
11. Contact with machinery
12. Poisoning (excluding food poisoning)
13. Other
Refused
Don’t know
Pick Two - answer list pane
Field Pane Description
Cause of injury
Fill Instructions
Special Instructions
Skip Instructions
<01-13,R,D> [goto IJBODY]
Hard Edits
Soft Edits
AssocHelp
H_ICAUS1
Wednesday, July 06, 2016
Page 34 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.065_H
Variable Name
H_ICAUS1
Universe
Universe-text
Question Text
This question determines the skip pattern for follow-up questions.
[b]In a motor vehicle[b] includes events such as a rollover accident, a fall from the
motor vehicle, or any collision with a motor vehicle, an animal, or an object such as a
tree, car, pole, or water.
A [b]motor vehicle[b] is any mechanically or electrically powered device not
operated on rails. Any object such as a trailer, coaster, sled or wagon being towed by
a motor vehicle is considered a part of the motor vehicle. Examples of a motor vehicle
include a
[blt] motorcycle,
car,
truck,
ATV,
bus,
tractor,
semi-truck,
4 wheeler,
dirt bike,
snowmobile,
motorized scooter,
and any other vehicle with a motor except a boat, train, or plane. [blt]
[b]On a bike, scooter, skateboard, skates, skis, horse, etc.,[b] includes any injury or
fall to a person on a nonmotorized vehicle such as
[blt] a bike,
a skateboard,
in-line and ice skates,
skis,
snowboards,
a nonmotorized scooter,
or a horse.
[b]Pedestrian who was struck by a vehicle such as a car or bicycle[b] includes any
injury to a person involved in a collision with a vehicle or bike who was not, at the time
of the collision, riding in or on a motor vehicle, railway train, motorcycle, bicycle,
airplane, streetcar, animal-drawn vehicle, or other vehicle.
[b]Fall[b] includes any injury received when a person descends abruptly due to the
force of gravity and strikes an injury-producing surface at the same or lower level. DO
NOT SELECT THIS OPTION if the fall was from a motor vehicle, bike, skis,
skateboard, skates, horse, etc.
Wednesday, July 06, 2016
Page 35 of 87
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
ICAUS1
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 36 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.070
Variable Name
IJBODY
Universe
MTFINJ3M = '01'-'91'
Universe-text
All injury episodes for which a medical professional was consulted
Question Text
(book) F4
* Enter up to 4 responses, separate with commas.
* Ask or verify.
In this injury, what parts of [fill 1: your/ALIAS’s] body were hurt?
Answer Codes
Question Type
1. Ankle
2. Back
3. Buttocks
4. Chest
5. Ear
6. Elbow
7. Eye
8. Face
9. Finger/thumb
10. Foot
11. Forearm
12. Groin
13. Hand
14. Head (not face)
15. Hip
16. Jaw
17. Knee
18. Lower leg
19. Mouth
20. Neck
21. Nose
22. Shoulder
23. Stomach
24. Teeth
25. Thigh
26. Toe
27. Upper arm
28. Wrist
29. Other, please specify
Refused
Don’t know
Pick Four - answer list pane
Field Pane Description
Fill Instructions
Parts of body hurt
fill1: if the subject=respondent fill "your" else, fill "ALIAS's"
Wednesday, July 06, 2016
Page 37 of 87
Special Instructions
Skip Instructions
<01-28> [goto IJTYPE1]
<29> [goto IJBODYOS]
goto IPEV
Hard Edits
Soft Edits
AssocHelp
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.071
Variable Name
IJBODYOS
Universe
IJBODY = 29
Universe-text
All injury episodes where some "other" part of the body was hurt
Question Text
*Read if necessary.
What other parts of the body were hurt?
Answer Codes
Question Type
Text
Field Pane Description
Other
Fill Instructions
Special Instructions
Skip Instructions
[goto IJTYPE1]
[goto IJTYPE1]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 38 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.072
Variable Name
IJTYPE1
Universe
IJBODY= 01-29
Universe-text
All injury episodes where at least one part of the body was hurt
Question Text
(book) F5
*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill 1: your/ALIAS’s] [fill 2: first entry--^IJBODY (text) or ^IJBODYOS]
hurt?
Answer Codes
Question Type
1. Broken bone or fracture
2. Sprain, strain, or twist
3. Cut
4. Scrape
5. Bruise
6. Burn
7. Insect bite
8. Animal bite
9. Other (specify)
Refused
Don’t know
Pick Two - answer list pane
Field Pane Description
Fill Instructions
How was the first body part hurt
fill1: if the subject=respondent fill "your" else, fill "ALIAS's"
fill2: fill selection in IJBODY or IJBODYOS
Special Instructions 1. This question is asked for the first body part entered at IJBODY.
2. Fill 2: If one or more body parts were entered at IJBODY and the first body part
was recorded. Specify field, fill using the text from the other-specify. If "refused" or
"don’t know" was entered in the other-specify field, fill with "other body part".
Skip Instructions
<01-08, D> [goto IJTYPE2 for next body part entered at IJBODY; if no more body
parts, goto IPEV]
<9> [goto IJTYP1OS]
[goto IPEV]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 39 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.073
Variable Name
IJTYP1OS
Universe
IJTYPE1 = 09
Universe-text
All injury episodes where the first body part was hurt in some "other" way
Question Text
?[F1]
* Read if necessary.
How was [fill 1: your/ALIAS’s] [fill 2: first entry -- ^IJBODY (text) or ^IJBODYOS] hurt?
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
Other
fill1: if the subject=respondent fill "your" else, fill "ALIAS's"
fill2: fill selection in IJBODY or IJBODYOS
Special Instructions Fill 2: If one or more body parts were entered at IJBODY and the first body part was
recorded in the other-specify field, fill using the text from the other-specify. If
"refused" or "don’t know" was
entered in the other-specify field, fill with "other body part".
Skip Instructions
[goto IJTYPE2 for next body part; if no more body parts, goto
IPEV]
[goto IJTYPE2 for next body part; if no more body parts, goto IPEV]
Hard Edits
Soft Edits
AssocHelp
H_IJTYP1OS
Wednesday, July 06, 2016
Page 40 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.073_H
Variable Name
H_IJTYP1OS
Universe
Universe-text
Question Text
Please use specific descriptions such as crush and concussion. Avoid terms that
describe the cause (such as hit or punch) and symptoms (such as hurt and painful).
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IJTYP1OS
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 41 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.074
Variable Name
IJTYPE2
Universe
IJTYPE1 = 01-09, D and a second body part entered at IJBODY
Universe-text
All injury episodes where a second body part was entered at IJBODY and type of
injury or don’t know was entered for the first body part at IJTYPE1
Question Text
(book) F5
*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill 1: your/ALIAS’s] [fill 2: second entry--^IJBODY (text) or
^IJBODYOS] hurt?
Answer Codes
Question Type
1. Broken bone, or fracture
2. Sprain, strain, or twist
3. Cut
4. Scrape
5. Bruise
6. Burn
7. Insect bite
8. Animal bite
9. Other, please specify
Refused
Don’t know
Pick Two - answer list pane
Field Pane Description
Fill Instructions
How was the second body part hurt
fill1: if the subject=respondent fill "your" else, fill "ALIAS's"
fill2: fill selection in IJBODY or IJBODYOS
Special Instructions 1. This question is asked for the first body part entered at IJBODY.
2. Fill 2: If two or more body parts were entered at IJBODY and the second body part
was recorded in the other-specify field, fill using the text from the other-specify. If
"refused" or "don't know" was entered in the other-specify field, fill with "other body
part".
Skip Instructions
<01-08, D> [goto IJTYPE3 for next body part entered at IJBODY; if no more body
parts, goto IPEV]
<9> [goto IJTYP2OS]
[goto IPEV]
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Wednesday, July 06, 2016
Page 42 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.075
Variable Name
IJTYP2OS
Universe
IJTYPE2 = 09
Universe-text
All injury episodes where the second body part was hurt in some "other" way
Question Text
?[F1]
*Read if necessary.
How else was [fill 1: your/ALIAS’s] [fill 2: second entry -- ^IJBODY (text) or
^IJBODYOS] hurt?
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
Other
fill1: if the subject=respondent fill "your" else, fill "ALIAS's"
fill2: fill selection in IJBODY or IJBODYOS
Special Instructions Fill 2: If two or more body parts were entered at IJBODY and the first body part was
recorded in the other-specify field, fill using the text from the other-specify. If
"refused" or "don’t know" was
entered in the other-specify field, fill with "other body part".
Skip Instructions
[goto IJTYPE3 for next body part; if no more body parts, goto
IPEV]
[goto IJTYPE3 for next body part; if no more body parts, goto IPEV]
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H_IJTYP1OS
Wednesday, July 06, 2016
Page 43 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.076
Variable Name
IJTYPE3
Universe
IJTYPE2 = 01-09, D and a third body part entered at IJBODY
Universe-text
All injury episodes where a third body part was entered at IJBODY and type of injury
or don’t know was entered for the second body part at IJTYPE2
Question Text
(book) F5
*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill 1: your/ALIAS’s] [fill 2: third entry--^IJBODY (text) or ^IJBODYOS]
hurt?
Answer Codes
Question Type
1. Broken bone, or fracture
2. Sprain, strain, or twist
3. Cut
4. Scrape
5. Bruise
6. Burn
7. Insect bite
8. Animal bite
9. Other, please specify
Refused
Don’t know
Pick Two - answer list pane
Field Pane Description
Fill Instructions
How was the third body part hurt
fill1: if the subject=respondent fill "your" else, fill "ALIAS's"
fill2: fill selection in IJBODY or IJBODYOS
Special Instructions 1. This question is asked for the third body part entered at IJBODY.
2. Fill 2: If three or more body parts were entered at IJBODY and the third body part
was
recorded in the other-specify field, fill using the text from the other-specify. If
"refused" or
"don’t know" was entered in the other-specify field, fill with "other body part".
Skip Instructions
<01-08, D> [goto IJTYPE4 for next body part entered at IJBODY; if no more body
parts, goto IPEV]
<9> [goto IJTYP3OS]
[goto IPEV]
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Wednesday, July 06, 2016
Page 44 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.077
Variable Name
IJTYP3OS
Universe
IJTYPE3 = 09
Universe-text
All injury episodes where the third body part was hurt in some "other" way
Question Text
?[F1]
* Read if necessary.
How else was [fill 1: your/ALIAS’s] [fill 2: third entry -- ^IJBODY (text) or ^IJBODYOS]
hurt?
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
Other
fill1: if the subject=respondent fill "your" else, fill "ALIAS's"
fill2: fill selection in IJBODY or IJBODYOS
Special Instructions Fill 2: If three or more body parts were entered at IJBODY and the third body part was
recorded in the other-specify field, fill using the text from the other-specify. If
"refused" or "don’t know" was
entered in the other-specify field, fill with "other body part".
Skip Instructions
[goto IJTYPE4 for next body part; if no more body parts, goto
IPEV]
[goto IJTYPE4 for next body part; if no more body parts, goto IPEV]
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H_IJTYP1OS
Wednesday, July 06, 2016
Page 45 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.078
Variable Name
IJTYPE4
Universe
IJTYPE3 = 01-09, D and a fourth body part entered at IJBODY
Universe-text
All injury episodes where a fourth body part was entered at IJBODY and type of injury
or don’t know was entered for the third body part at IJTYPE3
Question Text
(book) F5
*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill 1: your/ALIAS’s] [fill 2: fourtht entry--^IJBODY (text) or
^IJBODYOS] hurt?
Answer Codes
Question Type
1. Broken bone, or fracture
2. Sprain, strain, or twist
3. Cut
4. Scrape
5. Bruise
6. Burn
7. Insect bite
8. Animal bite
9. Other, please specify
Refused
Don’t know
Pick Two - answer list pane
Field Pane Description
Fill Instructions
How was the fourth body part hurt
fill1: if the subject=respondent fill "your" else, fill "ALIAS's"
fill2: fill selection in IJBODY or IJBODYOS
Special Instructions 1. This question is asked for the fourth body part entered at IJBODY.
2. Fill 2: If four body parts were entered at IJBODY and the fourth body part was
recorded in the
ther-specify field, fill using the text from the other-specify. If "refused" or "don’t know"
was
entered in the other-specify field, fill with "other body part".
Skip Instructions
<01-08,D,R> [goto IPEV]
<09> [goto IJTYP4OS]
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Wednesday, July 06, 2016
Page 46 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.079
Variable Name
IJTYP4OS
Universe
IJTYPE4 = 09
Universe-text
All injury episodes where the fourth body part was hurt in some "other" way
Question Text
?[F1]
* Read if necessary.
How else was [fill 1: your/ALIAS’s] [fill 2: fourth entry -- ^IJBODY (text) or ^IJBODYOS]
hurt?
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
Other
fill1: if the subject=respondent fill "your" else, fill "ALIAS's"
fill2: fill selection in IJBODY or IJBODYOS
Special Instructions Fill 2: If four body parts were entered at IJBODY and the fourth body part was
recorded in the other-specify field, fill using the text from the other-specify. If
"refused" or "don’t know" was
entered in the other-specify field, fill with "other body part".
Skip Instructions
[goto IJTYPE2 for next body part; if no more body parts, goto
IPEV]
[goto IJTYPE2 for next body part; if no more body parts, goto IPEV]
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H_IJTYP1OS
Wednesday, July 06, 2016
Page 47 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.080_1
Variable Name
PPCC
Universe
MTFPOI3M = 01-91
Universe-text
Question Text
Did [fill 1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE
for this poisoning from...
A phone call to a poison control center?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Repeating Series - Yes/No
Field Pane Description
Fill Instructions
Poison control center
fill1: if the subject=respondent fill "you" else, fill "ALIAS"
Special Instructions This part of the repeating stem series is only asked of/about subjects for which a
poisoning(s) was reported.
Skip Instructions
<1,2,DK> [goto IPEV] [goto IPHOSP]
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Wednesday, July 06, 2016
Page 48 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.080_2
Variable Name
IPEV
Universe
(MTFINJ3M = 01-91) OR (MTFPOI3M = 01-91)
Universe-text
Question Text
Did [fill 1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE
for this [fill 2: injury/poisoning] from...
An emergency vehicle, such as an ambulance or fire truck?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Repeating Series - Yes/No
Field Pane Description
Fill Instructions
Emergency vehicle
fill1: if the subject=respondent fill "you" else, fill "ALIAS"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
Special Instructions The "read if necessary" instruction should only appear for poisoning episodes.
Skip Instructions
<1,2,DK> [goto IPER] [goto IPHOSP]
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Wednesday, July 06, 2016
Page 49 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.080_3
Variable Name
IPER
Universe
(MTFINJ3M = 01-91) OR (MTFPOI3M = 01-91)
Universe-text
Question Text
* Read if necessary.
Did [fill 1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE
for this [fill 2: injury/poisoning] from...
A visit to an emergency room?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Repeating Series - Yes/No
Field Pane Description
Fill Instructions
Emergency room
fill1: if the subject=respondent fill "you" else, fill "ALIAS"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
Special Instructions
Skip Instructions
<1,2,DK> [goto IPDO] [goto IPHOSP]
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Wednesday, July 06, 2016
Page 50 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.080_4
Variable Name
IPDO
Universe
(MTFINJ3M = 01-91) OR (MTFPOI3M = 01-91)
Universe-text
Question Text
?[F1]
* Read if necessary.
Did [fill 1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE
for this [fill 2: injury/poisoning] from...
A visit to a doctor’s office or other health clinic?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Repeating Series - Yes/No
Field Pane Description
Fill Instructions
Doctor’s office/health clinic
fill1: if the subject=respondent fill "you" else, fill "ALIAS"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
Special Instructions
Skip Instructions
<1,2,DK> [goto IPPCHCP] [goto IPHOSP]
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H_IPDO
Wednesday, July 06, 2016
Page 51 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.080_4_H
Variable Name
H_IPDO
Universe
Universe-text
Question Text
A visit to a doctor’s office or other health clinic includes an urgent care center.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IPDO
Skip Instructions
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Wednesday, July 06, 2016
Page 52 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.080_5
Variable Name
IPPCHCP
Universe
(MTFINJ3M = 01-91) OR (MTFPOI3M = 01-91)
Universe-text
Question Text
?[F1]
* Read if necessary.
Did [fill 1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP
CARE for this [fill 2: injury/poisoning] from...
A phone call to a doctor, nurse, or other health care professional?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Repeating Series - Yes/No
Field Pane Description
Fill Instructions
Phone call to health care professional
fill1: if the subject=respondent fill "you" else, fill "ALIAS"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
Special Instructions
Skip Instructions
<1,2,DK> [goto IPOTH] [goto IPHOSP]
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H_IPPCHCP
Wednesday, July 06, 2016
Page 53 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.080_5_H
Variable Name
H_IPPCHCP
Universe
Universe-text
Question Text
A [b]phone call to a doctor, nurse, or other health care professional[b] includes a call
to a nurse line, or a relative, friend, or acquaintance that is a trained medical
professional.
A [b]trained medical professional[b] includes anyone the respondent deems a medical
professional. Some examples may include:
[blt] a medical doctor,
an osteopath,
an ophthalmologist,
a physician assistant,
a nurse practitioner,
a nurse,
a physical or occupational therapist,
a podiatrist,
a chiropractor
an acupuncturist,
a naturopath,
and a homoeopath. [blt]
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IPPCHCP
Skip Instructions
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Wednesday, July 06, 2016
Page 54 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.080_6
Variable Name
IPOTH
Universe
(MTFINJ3M = 01-91) OR (MTFPOI3M = 01-91)
Universe-text
Question Text
* Read if necessary.
Did [fill 1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP
CARE for this [fill 2: injury/poisoning] from...
Any place else?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Repeating Series - Yes/No
Field Pane Description
Fill Instructions
Any place else
fill1: if the subject=respondent fill "you" else, fill "ALIAS"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
Special Instructions
Skip Instructions
<1> [goto IPOTHOS]
if [MTFINJ3M= 01-91 and IPEV=2] goto IPVER
<2,R,DK> [goto IPHOSP]
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Wednesday, July 06, 2016
Page 55 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.081
Variable Name
IPOTHOS
Universe
IPOTH = 1
Universe-text
Question Text
* Read if necessary.
Where else did [fill 1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOWUP CARE for this [fill 2: injury/poisoning]?
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
Other
fill1: if the subject=respondent fill "you" else, fill "ALIAS"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
Special Instructions
Skip Instructions
[goto IPHOSP]
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Wednesday, July 06, 2016
Page 56 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.082
Variable Name
IPVER
Universe
((MTFINJ3M = 01-91) and (IPEV = 2 and IPER = 2 and IPDO = 2 and IPPCHCP =2
and IPOTH = 2)) OR ((MTFPOI3M = 01-91) and (PPCC = 2 and IPEV = 2 and IPER =
2 and IPDO = 2 and IPPCHCP =2 and IPOTH = 2))
Universe-text
Question Text
* Please verify.
[fill 1: You/ALIAS] DID NOT receive any medical advice, treatment, or follow-up for
this [fill 2:
injury/poisoning]. Is that correct?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Verify
fill1: if the subject=respondent fill "You" else, fill "ALIAS"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
Special Instructions Treat this as a signal so that the FR may go back and make corrections.
Skip Instructions
<1>[If the subject HAS more injury/poisoning episodes, then go to FIJ.050_1for that
subject. If the subject DOES NOT HAVE more injury/poisoning episodes, then go to
FIJ.014/FIJ.024 for next person with an injury/poisoning. If no more family members
with an injury/poisoning, go to FPOI3M/FDMED12M.]
<2> [if poisoning, goto PPCC for new entries; else if injury, goto IPEV for new entries]
Hard Edits
ERR_IPVER
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Wednesday, July 06, 2016
Page 57 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.090
Variable Name
IPHOSP
Universe
(MTFINJ3M = 01-91) OR (MTFPOI3M = 01-91)
Universe-text
Question Text
?[F1]
[fill 1: Were you/Was ALIAS] hospitalized for at least one night as a result of this [fill 2:
injury/poisoning]?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Yes/No
Field Pane Description
Fill Instructions
Hospital overnight
fill1: if the subject=respondent fill "Were you" else, fill "Was ALIAS"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
Special Instructions
Skip Instructions
<1> [goto IPIHNO]
<2,R,DK> [if injury episode, goto IMTRAF; if poisoning episode, goto PPOIS]
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H_IPHOSP
Wednesday, July 06, 2016
Page 58 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.090_H
Variable Name
H_IPHOSP
Universe
Universe-text
Question Text
Hospitalized means a person is admitted and must stay one or more nights in a
hospital. Visits to an emergency room or outpatient clinic is not considered
hospitalized, even if they occur at night, unless the person is admitted and stays
overnight. Do not include stays in the hospital during which the person does not
spend at least one night, even though surgery may have been performed.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Assicated Screens:
IPHOSP
Skip Instructions
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Wednesday, July 06, 2016
Page 59 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.091
Variable Name
IPIHNO
Universe
IPHOSP = 1
Universe-text
Question Text
How many nights [fill 1: were you/was ALIAS] in the hospital?
* If still in hospital, ask how many nights up to today.
* Enter '95' for 95 or more nights.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Nights in hospital
fill1: if the subject=respondent fill "were you" else, fill "was ALIAS"
Special Instructions
Skip Instructions
<01-60,R,DK> if ICAUS1 eq 01, goto IFALL]]
[if ICAUS1 eq 02 or 03 or 05, goto IMTRAF]
if ICAUS1 eq 04 or 06-13 or R, or DK, goto IPWHAT]
<61-95> [goto ERR_IPIHNO]
Hard Edits
Soft Edits
[if IPIHNO gt 60, display ERR_IPIHNO]
* ^IPIHNO is unusually high. Please verify.
Suppress
Goto
Close
[if ICAUS eq 01 or 02 or 03, goto IMTRAF]
if ICAUS eq 04 or 06 or 07 or 97, or 99, goto IPWHAT]
if ICAUS eq 05, goto IFALL]]
[reset IPIHNO for new entry]
AssocHelp
H_IPIHNO
Wednesday, July 06, 2016
Page 60 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.091_H
Variable Name
H_IPIHNO
Universe
Universe-text
Question Text
Please enter the number of nights they were in the hospital and not the number of
days. For example, an answer of, "I was in for 7 days," could mean 6, 7, or 8 nights.
Probe further, emphasizing the word "nights."
Please include the total number of nights for all the hospital stays related to this
injury. If the person was transferred or had a repeat admission for the same injury add
up the number of nights.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IPIHNO
Skip Instructions
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Wednesday, July 06, 2016
Page 61 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.109
Variable Name
IMTRAF
Universe
ICAUS = 01-03
Universe-text
Question Text
?[F1]
* Ask or verify.
Did this accident occur on a public highway, street, or road?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Yes/No
Field Pane Description
Traffic-related
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R DK> [goto IMVWHO]
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H_IMTRAF
Wednesday, July 06, 2016
Page 62 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.109_H
Variable Name
H_IMTRAF
Universe
Universe-text
Question Text
Public highway, street, or road includes items such as:
a break down lane,
a shoulder,
a ditch,
or a median.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IMTRAF
Skip Instructions
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Wednesday, July 06, 2016
Page 63 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.110
Variable Name
IMVWHO
Universe
ICAUS = 01- 03
Universe-text
Question Text
* Ask or verify.
[fill 1: Were you/Was ALIAS] injured as:
* Read answer categories.
Answer Codes
Question Type
1. The driver of a motor vehicle
2. A passenger in a motor vehicle
3. A pedestrian
4. A bicycle rider or tricycle rider
5. The rider of a scooter, skateboard, skates, or other non-motorized vehicle
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Injured as
fill1: if the subject=respondent fill "Were you" else, fill "Was ALIAS"
Special Instructions
Skip Instructions
<1,2> [goto IMVTYP] <4,5> [goto IHELMT] <3,R,DK> [goto IPWHAT]
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Wednesday, July 06, 2016
Page 64 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.111
Variable Name
IMVTYP
Universe
IMVWHO = 01 or 02
Universe-text
Question Text
(book) F6
?[F1]
* Ask or verify.
What type of vehicle [fill 1: were you/was ALIAS] in?
Answer Codes
Question Type
1. Passenger car
2. Passenger truck, such as a pickup truck, van, or SUV
3. Bus
4. Large commercial truck, such as a semi-truck, big rig, or 18-wheeler
5. Motorcycle (including mopeds, minibikes)
6. All terrain vehicle or ski/snow-mobile
7. Farm equipment (such as a tractor)
8. Industrial or construction vehicle
9. Other
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Type of vehicle
fill1: if the subject=respondent fill "were you" else, fill "was ALIAS"
Special Instructions
Skip Instructions
<01,02,04> [goto ISBELT] <05,06> [goto IHELMT] <03,07,08,09,R,DK> [goto
IPWHAT]
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H_IMVTYP
Wednesday, July 06, 2016
Page 65 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.111_H
Variable Name
H_IMVTYP
Universe
Universe-text
Question Text
A [b]motorcycle[b], including mopeds and mini-bikes, is a two-wheeled motor vehicle
having one or two riding saddles and sometimes having a third wheel for the support
of a sidecar. The sidecar is considered part of the motorcycle.
An [b]all terrain vehicle or ski/snow-mobile[b] is a motor vehicle of special design, to
enable it to negotiate rough or soft terrain or snow. Examples of special design are
high construction, special wheels or tires, driven by treads, or support on a cushion of
air. Include hovercrafts (on land or swamp) in this category.
[b]Farm equipment[b] includes tractors and other farm machinery.
An [b]industrial or construction vehicle[b] includes industrial machinery, steamroller,
highway grader, etc.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IMVTYP
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 66 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.112
Variable Name
ISBELT
Universe
IMVTYP = 01, 02, 04
Universe-text
Question Text
?[F1]
* Ask or verify.
[fill 1: Were you/Was ALIAS] restrained at the time of the accident?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Restrained
fill1: if the subject=respondent fill "Were you" else, fill "Was ALIAS"
Special Instructions
Skip Instructions
<1,2,R,DK> [goto IPWHAT]
Hard Edits
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H_ISBELT
Wednesday, July 06, 2016
Page 67 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.112_H
Variable Name
H_ISBELT
Universe
Universe-text
Question Text
A safety belt is a seat belt.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
ISBELT
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 68 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.113
Variable Name
IHELMT
Universe
(IMVWHO = 04, 05) OR (IMVTYP = 05, 06)
Universe-text
Question Text
?[F1]
* Ask or verify.
[fill 1: Were you/Was ALIAS] wearing a helmet at the time of the accident?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
Wearing a helmet
fill1: if the subject=respondent fill "Were you" else, fill "Was ALIAS"
Special Instructions
Skip Instructions
<1,2,R,DK> [goto IPWHAT]
Hard Edits
Soft Edits
AssocHelp
H_IHELMT
Wednesday, July 06, 2016
Page 69 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.113_H
Variable Name
H_IHELMT
Universe
Universe-text
Question Text
Helmet includes:
a bike helmet,
a motorcycle helmet,
or a hard hat for horse back riding.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IHELMT
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 70 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.130
Variable Name
IFALL
Universe
ICAUS = 05
Universe-text
Question Text
(book) F7
* Enter up to 2 responses, separate with a comma.
* Ask or verify.
How did [fill 1: you/ALIAS] fall? Anything else?
Answer Codes
Question Type
1. Stairs, steps, or escalator
2. Floor or level ground
3. Curb (including sidewalk)
4. Ladder or scaffolding
5. Playground equipment
6. Sports field, court, or rink
7. Building or other structure
8. Chair, bed, sofa, or other furniture
9. Bathtub, shower, toilet, or commode
10. Hole or other opening
11. Other
Refused
Don’t know
Pick Two - answer list pane
Field Pane Description
Fill Instructions
Fall on, down, from, or into
fill1: if the subject=respondent fill "you" else, fill "ALIAS"
Special Instructions Allow up to two responses for this question
Skip Instructions
<01-11,R,DK> [goto IFALLWHY]
Hard Edits
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Wednesday, July 06, 2016
Page 71 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.131
Variable Name
IFALLWHY
Universe
IFALL = 01-11 or R or DK
Universe-text
Question Text
(book) F8
* Ask or verify.
What caused [fill 1: you/ALIAS] to fall?
Answer Codes
Question Type
1. Slipping or tripping
2. Jumping or diving
3. Bumping into an object or another person
4. Being shoved or pushed by another person
5. Losing balance or having dizziness (becoming faint or having a seizure)
6. Other
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Cause of fall
fill1: if the subject=respondent fill "you" else, fill "ALIAS"
Special Instructions
Skip Instructions
<1-6,R,DK> [goto IPWHAT]
Hard Edits
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Wednesday, July 06, 2016
Page 72 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.140
Variable Name
PPOIS
Universe
MTFPOI3M = 01-91
Universe-text
Question Text
(book) F9
?[F1]
* Ask or verify.
What did [fill 1: your/ALIAS’s] poisoning result from?
Answer Codes
Question Type
1. Swallowing a drug or medical substance mistakenly or in overdose
2. Swallowing or touching a harmful solid or liquid substance
3. Inhaling harmful gases or vapors
4. Eating a poisonous plant or other substance mistaken for food
5. Being bitten by a poisonous animal
6. Other (specify)
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Cause of poisoning
fill1: if the subject=respondent fill "your" else, fill "ALIAS's"
Special Instructions
Skip Instructions
<1-5,R,DK> [goto IPWHAT] <6> [goto PPOISOS]
Hard Edits
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AssocHelp
H_PPOIS
Wednesday, July 06, 2016
Page 73 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.140_H
Variable Name
H_PPOIS
Universe
Universe-text
Question Text
Poisonings can be accidental or on purpose.
Poisonings include things such as:
being bitten or stung by a poisonous animal or insect,
overdosing on any drug or medicine,
taking or being given the wrong drug,
and swallowing, breathing, injecting, or otherwise coming in contact with too much of
a harmful substance (liquid, solid, or gas).
Poisonings exclude things such as:
food poisoning,
sun poisoning,
poison ivy rashes,
and poison oak.
1. "Swallowing a drug or medical substance mistakenly or in overdose" includes items
such as:
over the counter drugs,
prescribed medications,
street drugs,
and herbs.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
PPOIS
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 74 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.141
Variable Name
PPOISOS
Universe
PPOIS = 6
Universe-text
Question Text
* Read if necessary.
How did [fill 1: your/ALIAS’s] poisoning occur?
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
Other
fill1: if the subject=respondent fill "your" else fill "ALIAS's"
Special Instructions
Skip Instructions
[goto IPWHAT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 75 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.150
Variable Name
IPWHAT
Universe
(MTFINJ3M = 01-91) OR (MTFPOI3M = 01-91)
Universe-text
Question Text
(book) F10
?[F1]
* Enter up to 2 responses, separate with a comma.
* Ask or verify.
What activity [fill 1: were you/was ALIAS] involved in at the time of the [fill 2:
injury/poisoning]?
Answer Codes
Question Type
1. Driving or riding in a motor vehicle
2. Working at a paid job
3. Working around the house or yard
4. Attending school
5. Unpaid work (such as volunteer work)
6. Sports and exercise
7. Leisure activity (excluding sports)
8. Sleeping, resting, eating, or drinking
9. Cooking
10. Being cared for (hands-on care from other person)
11. Other (specify)
Refused
Don’t know
Pick Two - answer list pane
Field Pane Description
Fill Instructions
Activity
fill1: if the subject=respondent fill "were you" else, fill "was ALIAS"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
Special Instructions Allow up to two responses for this question.
Skip Instructions
<01-10,R,DK> [goto IPWHER] <11> [goto IPWHATOT]
Hard Edits
Soft Edits
AssocHelp
H_IPWHAT
Wednesday, July 06, 2016
Page 76 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.150_H
Variable Name
H_IPWHAT
Universe
Universe-text
Question Text
PLEASE NOTE THAT THE RESPONDENT CAN PICK 2 ACTIVITIES.
[b]Driving or riding in a motor vehicle:[b] A motor vehicle is any mechanically or
electrically powered device not operated on rails including a
[blt] motorcycle,
car,
truck,
ATV,
bus,
tractor,
semi-truck,
4 wheeler,
dirt bike,
snow mobile,
and any other vehicle with a motor except a boat, train, or plane. [blt]
[b]Working at a paid job[b] includes doing work for pay or other compensation,
including in employer parking lots while working, arriving, or leaving; during
transportation between locations as a part of the job (excluding commuting to or from
home); and engaged in work activity where the vehicle is considered the work
environment (e.g., taxi driver, truck driver, etc.).
[b]Working around the house or yard[b] includes mowing the lawn, ironing, doing
laundry, and doing other house chores.
[b]Attending school (response category 4)[b] includes classroom activities, informal
activities during school hours, and school sponsored field trips.
[b]Unpaid work (response category 5)[b] includes caring for children or relatives and
volunteer work for an organized group.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IPWHAT
Skip Instructions
Hard Edits
Wednesday, July 06, 2016
Page 77 of 87
Soft Edits
AssocHelp
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.151
Variable Name
IPWHATOT
Universe
IPWHAT = 11
Universe-text
Question Text
* Read if necessary.
What other activity [fill 1: were you/was ALIAS] involved in at the time of the [fill 2:
injury/poisoning]?
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
Other
fill1: if the subject=respondent fill "were you" else, fill "was ALIAS"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
Special Instructions
Skip Instructions
[goto IPWHER]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 78 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.160
Variable Name
IPWHER
Universe
(MTFINJ3M = 01-91) OR (MTFPOI3M = 01-91)
Universe-text
Question Text
(book) F11
?[F1]
* Enter up to 2 responses, separate with a comma.
* Ask or verify.
Where [fill 1: were you/was ALIAS] when the [fill 2: injury/poisoning] happened?
Answer Codes
Question Type
1. Home (inside)
2. Home (outside)
3. School (not residential)
4. Child care center or preschool
5. Residential institution (excluding hospital)
6. Health care facility (including hospital)
7. Street or highway
8. Sidewalk
9. Parking lot
10. Sport facility, athletic field, or playground
11. Shopping center, restaurant, store, bank, gas station, or other place of business
12. Farm
13. Park or recreation area (including bike or jog path)
14. River, lake, stream, or ocean
15. Industrial or construction area
16. Other public building
17. Other
Refused
Don’t know
Pick Two - answer list pane
Field Pane Description
Fill Instructions
Place at time of injury/poisoning
fill1: if the subject=respondent fill "were you" else, fill "was ALIAS"
fill2: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
Special Instructions
Skip Instructions
<01-17,R,DK> [If AGE lt 5 and person HAS more injury/poisoning episodes, goto
IPDATEM
for that person; else if AGE lt 5 and person DOES NOT HAVE more
injury/poisoning episodes, goto TFINJ3M/TFPOI3M for next person with an
injury/poisoning; else if AGE lt 5 and no more family members with an
injury/poisoning, go to FPOI3M/FDMED12M;
Else [if AGE ge 13, goto IPEMP; else if AGE ge 5 and AGE le 12, goto IPSTU]
Hard Edits
Wednesday, July 06, 2016
Page 79 of 87
Soft Edits
AssocHelp
H_IPWHER
Wednesday, July 06, 2016
Page 80 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.160_H
Variable Name
H_IPWHER
Universe
Universe-text
Question Text
[b]Home inside[b] is any area that is under the roof of a residential structure or
anything that is attached to the structure INCLUDING a porch, deck, detached garage
(with roof and 4 walls), hallway or stairwell of an apartment building, and a crawl
space.
[b]Home outside[b] INCLUDES on top of the roof or on the exterior side of the home, a
garden, the yard, and a private playground.
[b]School (not residential)[b] EXCLUDES places such as dorm rooms.
[b]Child care center or preschool[b] INCLUDES places such as a home day care
facility.
[b]Residential institution (excluding hospitals)[b] INCLUDES places such as boarding
schools.
[b]Health care facility (including hospitals)[b] INCLUDES places such as a doctor’s
office, an outpatient facility, and an urgent care centers.
[b]Street/highway[b] INCLUDES places such as rural or dirt roads, and EXCLUDES
places such as sidewalks,
driveways, and parking lots.
[b]Sports facility, athletic field, or playground[b] INCLUDES places such as a baseball
diamond, a basketball or tennis court, a public swimming pool, and a skating rink.
[b]Park/recreation area (bike or jog path)[b] INCLUDES places and things such as a
picnic area and bike or jog path.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IPWHER
Skip Instructions
Hard Edits
Soft Edits
Wednesday, July 06, 2016
Page 81 of 87
AssocHelp
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.170
Variable Name
IPEMP
Universe
(MTFINJ3M = 01-91 and AGE >= 13) OR (MTFPOI3M = 01-91 and AGE >= 13)
Universe-text
Question Text
?[F1]
At the time of this [fill 1: injury/poisoning], [fill 2: were you/was ALIAS] employed fulltime, part-time, or not employed?
Answer Codes
Question Type
1. Full-time
2. Part-time
3. Not employed
Refused
Don’t know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Employed
fill1: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
fill2: if the subject=respondent fill "were you" else, fill "was ALIAS"
Special Instructions
Skip Instructions
<1,2> [goto IPWKLS] <3,R,DK> [goto IPSTU]
Hard Edits
Soft Edits
AssocHelp
H_IPEMP
Wednesday, July 06, 2016
Page 82 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.170_H
Variable Name
H_IPEMP
Universe
Universe-text
Question Text
The person is [b]employed[b] if they had a job when the injury happened. This
question is NOT asking if they were at work when the injury happened.
Volunteer work is included.
[b]Employed full-time[b] is defined as if the person works an average of 40 hours per
week.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IPEMP
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 83 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.171
Variable Name
IPWKLS
Universe
IPEMP = 1 or 2
Universe-text
Question Text
As a result of this [fill 1: injury/poisoning], how many days of work did [fill 2:
you/ALIAS] miss?
Answer Codes
1. None
2. Less than 1 day
3. One to five days
4. Six or more days
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Days of work missed
fill1: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
fill2: if the subject=respondent fill "you" else, fill "ALIAS"
Special Instructions
Skip Instructions
<1-4,R,DK> [goto IPSTU]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 84 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.180
Variable Name
IPSTU
Universe
(MTFINJ3M = 01-91 and AGE >= 5) OR (MTFPOI3M = 01-91 and AGE >= 5)
Universe-text
Question Text
?[F1]
At the time of this [fill 1: injury/poisoning], [fill 2: were you/was ALIAS] a full-time
student, part-time student or not a student?
Answer Codes
Question Type
1. Full-time
2. Part-time
3. Not a student
Refused
Don’t know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Student?
fill1: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
fill2: if the subject=respondent fill "were you" else, fill "was ALIAS"
Special Instructions
Skip Instructions
<1,2> [goto IPSCLS]
<3,R,DK> [If person HAS more injury/poisoning episodes, goto IPDATEM for that
person; else if person DOES NOT HAVE more injury/poisoning episodes, goto
TFINJ3M/TFPOI3M for next person with an injury/poisoning; else if no more family
members with an injury/poisoning, goto FDMED12M]
Hard Edits
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H_IPSTU
Wednesday, July 06, 2016
Page 85 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.180_H
Variable Name
H_IPSTU
Universe
Universe-text
Question Text
The person is a student if they are enrolled in school at the time of the injury. The
question is NOT asking if they were at school at the time of the injury.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
IPSTU
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 86 of 87
Module
05
Section Name
Family Injuries & Poisonings
Part
Question ID
FIJ.181
Variable Name
IPSCLS
Universe
IPSTU = 1 or 2
Universe-text
Question Text
As a result of this [fill 1: injury/poisoning], how many days of school did [fill 2:
you/ALIAS]
miss?
Answer Codes
1. None
2. Less than 1 day
3. One to five days
4. Six or more days
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Days of school missed
fill1: if FINJ3M=1 fill "injury", or if FPOI3M=1 then fill "poisoning"
fill2: if the subject=respondent fill "you" else, fill "ALIAS"
Special Instructions
Skip Instructions
<1-4,R,DK>[If person HAS more injury/poisoning episodes, goto IPDATEM for that
person; else
if person DOES NOT HAVE more injury/poisoning episodes, goto
TFINJ3M/TFPOI3M for next person with an injury/poisoning; else if no more family
members with an injury/poisoning, goto FDMED12M]
Hard Edits
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Wednesday, July 06, 2016
Page 87 of 87
2017 Q1 NHIS Instrument Spec Report
Section name: Family Food Security
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.010_00.000
Variable Name
FSRUNOUT
Universe
All
Universe-text
All families
Question Text
These next questions are about whether you were always able to afford the food you
needed in the last 30 days. I'm going to read you several statements that people have
made about their food situation. For these statements, please tell me whether the
statement was often true, sometimes true, or never true for [fill 1: you/your family] in
the last 30 days.
The first statement is "[fill 2: I/We] worried whether [fill 3: my/our] food would run out
before [fill 4: I/we] got money to buy more." Was that often true, sometimes true, or
never true for [fill 1: you/your family] in the last 30 days?
Answer Codes
Question Type
1 Often true
2 Sometimes true
3 Never true
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
fill 1: if single-person family, fill "you"; else fill "your family"
fill 2: if single-person family, fill "I"; else fill "We"
fill 3: if single-person family, fill "my"; else fill "our"
fill 4: if single-person family, fill "I"; else fill "we"
Special Instructions
Skip Instructions
<1-3,R,D> goto FSLAST
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Wednesday, July 06, 2016
Page 1 of 13
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.020_00.000
Variable Name
FSLAST
Universe
All
Universe-text
All families
Question Text
"The food that [fill 1: I/we] bought just didn't last, and [fill 1: I/we] didn't have money to
get more." Was that often true, sometimes true, or never true for [fill 2: you/your
family] in the last 30 days?
Answer Codes
1 Often true
2 Sometimes true
3 Never true
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
fill 1: if single-person family fill "I"; else fill "we"
fill 2: if single-person family, fill "you"; else fill "your family"
Special Instructions
Skip Instructions
<1-3,R,D> goto FSBALANC
Hard Edits
Soft Edits
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Wednesday, July 06, 2016
Page 2 of 13
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.024_00.000
Variable Name
QARNDM1
Universe
QAASK1 = 1
Universe-text
All families selected for QA question
Question Text
Random number generator
Answer Codes
(Allow 00-09)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 3 of 13
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.025_00.000
Variable Name
QACHK1
Universe
QAASK1 = 1
Universe-text
All families selected for QA question
Question Text
*Please enter [Fill1: QARNDM1 ] for quality assurance.
Answer Codes
(Allow 0-9)
Question Type
Procedure
Field Pane Description
Fill Instructions
QA Check
Fill1: QARNDM1 is the number that was randomly selected is filled in here
Special Instructions
Skip Instructions
[goto FSBALANC]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 4 of 13
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.026_00.000
Variable Name
QACHNG1
Universe
QACHK1=0-9
Universe-text
All families selected for QA question
Question Text
Flag field to indicate whether or not the value entered by the FR matched or not.
' ' (empty) - if the check was not asked or answered
0 - if the check was asked and the value entered matches the random value
1 - if the check was asked and the value entered does NOT match the random
value (cannot be undone)
Answer Codes
' ', 0,1
Question Type
Flag
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 5 of 13
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.030_00.000
Variable Name
FSBALANC
Universe
All
Universe-text
All families
Question Text
"[fill 1: I/We] couldn't afford to eat balanced meals." Was that often true, sometimes
true, or never true for [fill 2: you/your family] in the last 30 days?
Answer Codes
1 Often true
2 Sometimes true
3 Never true
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
fill 1: if single-person family, fill "I"; else fill "We"
fill 2: if single-person family, fill "you"; else fill "your family"
Special Instructions
Skip Instructions
<1,2> [goto FSSKIP]
<3,D,R> [if FSRUNOUT in(1,2) or FSLAST in(1,2), goto FSSKIP; else goto FINJ3M]
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Wednesday, July 06, 2016
Page 6 of 13
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.040_00.000
Variable Name
FSSKIP
Universe
FSRUNOUT in('1','2') or FSLAST in('1','2') or FSBALANC in('1','2')
Universe-text
Families for whom it was often or sometimes true in the last 30 days that they worried
that food would run out before they got money to buy more, or that food that was
bought didn't last and they didn't have money to get more, or they couldn't afford to
eat balanced meals
Question Text
In the last 30 days, did [fill 1: you/you or other adults in your family] ever cut the size
of your meals or skip meals because there wasn't enough money for food?
Answer Codes
1 Yes
2 No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
fill 1: if single-adult (18+) family, fill "you"; else fill "you or other adults in your family"
Special Instructions
Skip Instructions
<1> [goto FSSKDAYS]
<2,R,D> [goto FSLESS]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 7 of 13
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.050_00.000
Variable Name
FSSKDAYS
Universe
FSSKIP='1'
Universe-text
Adults in the family cut the size of their meals or skipped meals in the last 30 days
because there wasn't enough money for food
Question Text
In the last 30 days, how many days did this happen?
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-30,R,D> [goto FSLESS]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 8 of 13
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.060_00.000
Variable Name
FSLESS
Universe
FSRUNOUT in('1','2') or FSLAST in('1','2') or FSBALANC in('1','2')
Universe-text
Families for whom it was often or sometimes true in the last 30 days that they worried
that food would run out before they got money to buy more, or that food that was
bought didn't last and they didn't have money to get more, or they couldn't afford to
eat balanced meals
Question Text
In the last 30 days, did you ever eat less than you felt you should because there
wasn't enough money for food?
Answer Codes
1 Yes
2 No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto FSHUNGRY]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 9 of 13
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.070_00.000
Variable Name
FSHUNGRY
Universe
FSRUNOUT in('1','2') or FSLAST in('1','2') or FSBALANC in('1','2')
Universe-text
Families for whom it was often or sometimes true in the last 30 days that they worried
that food would run out before they got money to buy more, or that food that was
bought didn't last and they didn't have money to get more, or they couldn't afford to
eat balanced meals
Question Text
In the last 30 days, were you ever hungry but didn't eat because there wasn't enough
money for food?
Answer Codes
1 Yes
2 No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto FSWEIGHT]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 10 of 13
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.080_00.000
Variable Name
FSWEIGHT
Universe
FSRUNOUT in('1','2') or FSLAST in('1','2') or FSBALANC in('1','2')
Universe-text
Families for whom it was often or sometimes true in the last 30 days that they worried
that food would run out before they got money to buy more, or that food that was
bought didn't last and they didn't have money to get more, or they couldn't afford to
eat balanced meals
Question Text
In the last 30 days, did you lose weight because there wasn't enough money for food?
Answer Codes
1 Yes
2 No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto FSNOTEAT]
<2,R,D> [if FSSKIP=1 or FSLESS=1 or FSHUNGRY=1, goto FSNOTEAT; else goto
FINJ3M]
Hard Edits
Soft Edits
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Wednesday, July 06, 2016
Page 11 of 13
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.090_00.000
Variable Name
FSNOTEAT
Universe
FSSKIP='1' or FSLESS='1' or FSHUNGRY='1' or FSWEIGHT='1'
Universe-text
All families where adult(s) cut the size of meals or meals were skipped, ate less than
they felt they should, were hungry but didn't eat, or lost weight in the last 30 days
because there wasn't enough money for food
Question Text
In the last 30 days, did [fill 1: you/you or other adults in your family] ever not eat for a
whole day because there wasn't enough money for food?
Answer Codes
1 Yes
2 No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
fill 1: if single-adult (18+) family, fill "you"; else fill "you or other adults in your family"
Special Instructions
Skip Instructions
<1> [goto FSNEDAYS]
<2,R,D> [goto FINJ3M]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 12 of 13
Module
38
Section Name
Family Food Security
Part
Question ID
FFS.100_00.000
Variable Name
FSNEDAYS
Universe
FSNOTEAT='1'
Universe-text
All families where the adult(s) did not eat for a whole day, in the last 30 days, because
there wasn't enough money for food
Question Text
In the last 30 days, how many days did this happen?
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-30,R,D> [goto FINJ3M]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 13 of 13
2017 Q1 NHIS Instrument Spec Report
Section name: HEALTH CARE ACCESS AND UTILIZATION
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
A
Question ID
FAU.010
Variable Name
FDMED12M
Universe
AGE=All
Universe-text
All families
Question Text
?[F1]
The following questions are about the use of health care. Do not include dental care.
DURING THE PAST 12 MONTHS, [fill1: have you delayed seeking medical care/has
medical care been delayed for anyone in the family] because of worry about the cost?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Yes/No
Field Pane Description
Fill Instructions
Medical care delayed cost
fill1: For a 1 person family fill "have you delayed .. " For multi-person families, fill "
has medical care been delayed .. "
Special Instructions
Skip Instructions
<1> [If one person family, store the person number in
PDMED12M, goto FNMED12M; else, goto PDMED12M]
<2,D,R> goto FNMED12M
Hard Edits
Soft Edits
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H_FDMED12M
Wednesday, July 06, 2016
Page 1 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
Question ID
FAU.010_H
Variable Name
H_FDMED12M
Universe
Universe-text
Question Text
Includes all types of financial limitations that delayed a person in getting medical care.
[b]Delayed[b] assumes that medical care has been or will eventually be received.
[b]Medical Care[b] means medical care from a trained medical professional.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FDMED12M
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 2 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
A
Question ID
FAU.020
Variable Name
PDMED12M
Universe
AGE=All and FDMED12M= yes and family members > 1
Universe-text
1+ Persons had medical care delayed due to worry about cost during past 12 months
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
For which family member was medical care delayed?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members.
Skip Instructions
goto FNMED12M
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 3 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
A
Question ID
FAU.030
Variable Name
FNMED12M
Universe
AGE=All
Universe-text
All families
Question Text
?[F1]
DURING THE PAST 12 MONTHS, was there any time when [fill 1: you/someone in the
family] needed medical care, but did not get it because [fill 2: you/the family] couldn't
afford it?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Yes/No
Field Pane Description
Fill Instructions
Could not afford medical care
fill 1: for a 1 person family fill "you" For a multi-person family fill "someone in the
family"
fill 2: for a 1 person family fill "you" For a multi-person family fill "the family"
Special Instructions
Skip Instructions
<1> [If one person family, store the person number in
PNMED12M, goto FHOSPYR; else, goto PNMED12M]
<2,D,R> goto FHOSPYR
Hard Edits
Soft Edits
AssocHelp
H_FNMED12M
Wednesday, July 06, 2016
Page 4 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
Question ID
FAU.030_H
Variable Name
H_FNMED12M
Universe
Universe-text
Question Text
Include all types of financial limitations that prevented a person(s) from getting
medical care.
[b]Medical Care[b] means medical care from a trained medical professional.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FNMED12M
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 5 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
A
Question ID
FAU.040
Variable Name
PNMED12M
Universe
AGE=All and FNMED12M = yes and family members > 1
Universe-text
1+ Persons didn’t get med care due to cost during the past 12 months
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who didn't get needed care?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members.
Skip Instructions
go to FHOSPYR
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 6 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
B
Question ID
FAU.050
Variable Name
FHOSPYR
Universe
AGE=All
Universe-text
All families
Question Text
?[F1]
[fill1: Have you/Including all infants born in a hospital, has anyone in the family] been
hospitalized OVERNIGHT in the past 12 months? Do not include an overnight stay in
the emergency room.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Yes/No
Field Pane Description
Fill Instructions
In Hospital Overnight
fill1: for a 1 person family fill "Have you" For a multi-person family fill "Including all
infants born in a hospital, has anyone in the family"
Special Instructions Store this family level value to the person level.
Skip Instructions
<1> [If one person family, store the person number in PHOSPYR
goto HOSPNO; Else,goto PHOSPYR]
<2,D,R> goto FHCHM2W
Hard Edits
Soft Edits
AssocHelp
H_FHOSPYR
Wednesday, July 06, 2016
Page 7 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
Question ID
FAU.050_H
Variable Name
H_FHOSPYR
Universe
Universe-text
Question Text
INCLUDE as a patient in a hospital only persons who were admitted and stayed
overnight or longer.
EXCLUDE persons who visit emergency rooms or outpatient clinics, unless that
person was admitted and stayed overnight.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FHOSPYR
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 8 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
B
Question ID
FAU.060
Variable Name
PHOSPYR
Universe
AGE=All and FHOSPYR= yes and family members > 1
Universe-text
1+ Persons who were patients in a hospital OVERNIGHT during past 12 months
(Excl. ER)
Question Text
*Ask or verify. Enter applicable line number(s), separate with commas.
Who was in a hospital overnight?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members.
Store this family level value to the person level.
Skip Instructions
Go to HOSPNO.
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 9 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
B
Question ID
FAU.070
Variable Name
HOSPNO
Universe
Persons selected in PHOSPYR
Universe-text
Persons who stayed overnight in a hospital during past 12 months (Excl. ER)
Question Text
?[F1]
How many different times did [fill: you/Alias] stay in any hospital overnight or longer
DURING THE PAST 12 MONTHS?
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
How many different times
fill: for a 1 person family fill "you"
For a multi-person family fill "Alias"
Special Instructions Ask HOSPNO and HPNITE together for each person selected in PHOSPYR
Skip Instructions
<1-10> goto HPNITE <11-365> goto ERR_HOSPNO
goto HPNITE
Hard Edits
Soft Edits
ERR_HOSPNO
* [fill: HOSPNO] is unusually high.
* Verify entry.
* Make corrections if necessary.
AssocHelp
H_HOSPNO
Wednesday, July 06, 2016
Page 10 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
Question ID
FAU.070_H
Variable Name
H_HOSPNO
Universe
Universe-text
Question Text
This question refers to hospital stays, not the total number of nights spent in the
hospital. For example, if a person is admitted as a patient in the hospital and stays for
5 nights, this would count as 1 hospital stay.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
HOSPNO
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 11 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
B
Question ID
FAU.110
Variable Name
HPNITE
Universe
Persons selected in PHOSPYR and HOSPNO not empty
Universe-text
Persons who stayed overnight in a hospital during past 12 months (Excl. ER)
Question Text
?[F1]
Altogether how many nights [fill1: were you/was Alias] in the hospital DURING THE
PAST 12 MONTHS?
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Altogether how many nights
fill 1: for a 1 person family fill "were you" for a multi-person family fill "was Alias"
Special Instructions Ask HOSPNO and HPNITE together for each person selected in PHOSPYR
Set flag if instrument goes to ERR2_HPNITE.
Skip Instructions
<1-50,D,R> goto next person selected in [PHOSPYR], once exhausted goto
[FHCM2W]
<51-365> goto ERR1_HPNITE
[if HOSPNO le HPNITE goto the next person selected in PHOSPYR] else go to
ERR2_HPNITE once exhausted move to FHCM2W
Hard Edits
Soft Edits
ERR1_HPNITE
* [fill: HPNITE] is unusually high.
* Verify entry.
* Make corrections if necessary.
ERR2_HPNITE
* Do not read.
* [fill: HPNITE] night(s) is less than the total number of times in the hospital overnight.
* Please verify.
Note: If edit suppressed, store S in HPNITE_FLG
AssocHelp
H_HPNITE
Wednesday, July 06, 2016
Page 12 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
A
Question ID
FAU.110_FLG
Variable Name
HPNITE_FLG
Universe
Universe-text
Question Text
***OUT VARIABLE***
Answer Codes
S
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions If ERR2_HPNITE edit is suppressed, store S in HPNITE_FLG
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 13 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
Question ID
FAU.110_H
Variable Name
H_HPNITE
Universe
Universe-text
Question Text
If the respondent answers in terms of days, repeat the question so that it is
understood we are interested only in the number of nights. For example, a first
answer of, "I was in for 7 days", could mean 6, 7, or 8 nights. Always follow up such
answers by repeating the question, emphasizing the word "nights".
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
HPNITE
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 14 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
C
Question ID
FAU.120
Variable Name
FHCHM2W
Universe
AGE=All
Universe-text
All families
Question Text
?[F1]
These next questions are about health care received DURING THE LAST 2 WEEKS.
Include care from ALL types of medical doctors, such as dermatologists, psychiatrists,
ophthalmologists (AHF-thal-MOL-oh-jists), and general practitioners. Also include
care from OTHER health professionals such as nurses, physical therapists, and
chiropractors.
Do not include dental care. Do not include care while an overnight patient in a
hospital.
DURING THE LAST 2 WEEKS, did [fill: you/anyone in the family] receive care
AT HOME from a nurse or other health care professional?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Yes/No
Field Pane Description
Fill Instructions
Received Home Care
fill: for a 1 person family fill "you"
For a multi-person family fill "anyone in the family"
Special Instructions Store this family level value to the person level.
Skip Instructions
<1> [If one person family, store the person number in PHCHM2W
goto PHCHMN2W; Else, goto PHCHM2W]
<2,D,R> [goto FHCPH2W]
Hard Edits
Soft Edits
AssocHelp
H_FHCHM2W
Wednesday, July 06, 2016
Page 15 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
Question ID
FAU.120_H
Variable Name
H_FHCHM2W
Universe
Universe-text
Question Text
This question refers to health care received in the person's home by a trained medical
professional.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
FHCHM2W
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 16 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
C
Question ID
FAU.130
Variable Name
PHCHM2W
Universe
AGE=All and FHCHM2W=yes and family members > 1
Universe-text
1+ Persons received care AT HOME from hlth care professional during the past 2
weeks
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received care at home?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members.
Store this family level value to the person level.
Skip Instructions
go to PHCHMN2W
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 17 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
C
Question ID
FAU.140
Variable Name
PHCHMN2W
Universe
Persons selected in PHCHM2W
Universe-text
Persons who received care AT HOME from health care professional during the past 2
weeks (excl. dental care)
Question Text
How many home visits did [fill: you/ Alias] receive DURING THE LAST 2 WEEKS?
* Enter '50' for 50 or more visits.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
How Many Home Visits
fill: for a 1 person family fill "you"
For a multi-person family fill "Alias"
Special Instructions Roster through for every person marked in PHCHM2W
Skip Instructions
<1-14> [goto FHCPH2W] <15-50> [goto ERR_PHCPHMN2W]
[goto FHCPH2W]
Hard Edits
Soft Edits
ERR_PHCHMN2W
* [fill: PHCHMN2W] is unusually high.
* Verify entry.
* DO NOT PROBE. Make corrections if necessary.
AssocHelp
Wednesday, July 06, 2016
Page 18 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
C
Question ID
FAU.150
Variable Name
FHCPH2W
Universe
AGE=All
Universe-text
All families
Question Text
DURING THE LAST 2 WEEKS, did [fill: you/anyone in the family] get any medical
advice or test results over the PHONE from a doctor, nurse, or other health care
professional?
Do not include phone calls to make appointments, for billing questions or for
prescription refills.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Yes/No
Field Pane Description
Fill Instructions
Received Medical Advice/Test Results by Phone
fill: for a 1 person family fill "you"
For a multi-person family fill "anyone in the family"
Special Instructions Store this family level value to the person level.
Skip Instructions
<1> [If one person family, store the person number in PHCPH2W
goto PHCPHN2W; Else, goto PHCPH2W]
<2,D,R> [goto FHCDV2W]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 19 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
C
Question ID
FAU.160
Variable Name
PHCPH2W
Universe
AGE=All and FHCPH2W= yes and family members >1
Universe-text
1+ Persons for whom medical advise or test results were received over the phone
from a health care professional during the past 2 weeks (exclude calls for
appointments, billing questions, or prescription medicines)
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who was the phone call about?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members.
Store this family level value to the person level.
Skip Instructions
go to PHCPHN2W
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 20 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
C
Question ID
FAU.170
Variable Name
PHCPHN2W
Universe
Persons selected in PHCPH2W
Universe-text
Persons for whom medical advice or test results were received over the phone from a
health care professional during the past 2 weeks (exclude calls for appointments,
billing questions, or prescription refills)
Question Text
DURING THE LAST 2 WEEKS, how many telephone calls
[fill1: did you make?]
[fill2: were made about [fill: Alias]?
* Enter '50' for 50 or more phone calls.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
How Many Phone Calls Were Made
fill1: For a 1 person family fill "did you make?"
fill2: For a multi-person family fill "were made about '[fill: Alias]'"
Special Instructions Roster through for all persons marked in PHCPH2W
Skip Instructions
<1-14> [goto FHCDV2W] <15-50> [goto ERR_PHCPHN2W]
[goto FHCDV2W]
Hard Edits
Soft Edits
ERR_PHCPHN2W
* [fill: PHCPHN2W] is unusually high.
* Verify that all calls were within the two week period.
* Make corrections if necessary.
AssocHelp
Wednesday, July 06, 2016
Page 21 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
C
Question ID
FAU.180
Variable Name
FHCDV2W
Universe
AGE=All
Universe-text
All families
Question Text
DURING THE LAST 2 WEEKS, did [fill1: you/anyone in the family] see a doctor or
other health care professional at a doctor's OFFICE, a clinic, an emergency room, or
some other place?
[fill2: Do not include times during an overnight hospital stay.]
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Yes/No
Field Pane Description
Fill Instructions
Visit Doctor's Office, Etc.
fill1: For a 1 person family fill "you" For a multi-family fill "anyone in the family"
fill2: if FHOSPYR=1 then fill "Do not include times during an overnight hospital stay."
Special Instructions Store this family level value to the person level.
Skip Instructions
<1> [If one person family, store the person number in PHCDV2W
goto PHCDVN2W; Else, goto PHCDV2W]
<2,D,R> [goto F10DVYR]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 22 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
C
Question ID
FAU.190
Variable Name
PHCDV2W
Universe
AGE=All and FHCDV2W = yes and family members>1
Universe-text
1+ Persons who saw a health care professional in office, etc. during past 2 weeks
(exclude visits during overnight hospital stays)
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received care?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster including all non-deleted family members
Skip Instructions
goto PHCDVN2W
Hard Edits
Soft Edits
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Wednesday, July 06, 2016
Page 23 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
C
Question ID
FAU.200
Variable Name
PHCDVN2W
Universe
AGE=All and persons selected in PHCDV2W
Universe-text
Persons who had a visit to a health care professional during past 2 weeks (excl. Visits
during overnight hospital stays)
Question Text
How many times did [fill: you/ Alias] visit a doctor or other health care professional
DURING THE LAST 2 WEEKS?
* Enter '50' for 50 or more visits.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
How Many Visits to Health Professional
fill: for a 1 person family fill "you" For a multi-person family fill "Alias"
Special Instructions Roster through for all persons marked in PHCDV2W
Skip Instructions
<1-14> [goto F10DVYR] <15-50> [goto ERR_PHCDVN2W]
[goto F10DVYR]
Hard Edits
Soft Edits
ERR_PHCDVN2W
* [fill: PHCDVN2W] is unusually high.
* Verify that all visits were within the two week reference period.
* Make corrections if necessary.
AssocHelp
H_PHCDVN2W
Wednesday, July 06, 2016
Page 24 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
C
Question ID
FAU.210
Variable Name
F10DVYR
Universe
AGE=All
Universe-text
All families
Question Text
DURING THE PAST 12 MONTHS did [fill: you/any member of the family] receive care
from doctors or other health care professionals 10 or more times? Do not include
telephone calls.
Answer Codes
1. Yes
2. No
Refused
Don’t know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Received care 10 or more times
fill: For a 1 person family fill "you" For a multi-person family fill "any member of the
family"
Special Instructions
Skip Instructions
<1> [If one person family, store the person number in P10DVYR
goto FHICOV; Else, goto P10DVYR]
<2,D,R> [goto FHICOV] next section
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Wednesday, July 06, 2016
Page 25 of 26
Module
06
Section Name
HEALTH CARE ACCESS AND UTILIZATION
Part
C
Question ID
FAU.220
Variable Name
P10DVYR
Universe
AGE=All and F10DVYR= yes and family members >1
Universe-text
1+ Persons received care 10 or more times from health care professional during past
12 months (exclude telephone calls)
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received care 10 or more times?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster including all non-deleted family members
Skip Instructions
goto FHICOV
Hard Edits
Soft Edits
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Wednesday, July 06, 2016
Page 26 of 26
2017 Q1 NHIS Instrument Spec Report
Section name: Family Health Insurance
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.050
Variable Name
FHICOV
Universe
AGE=All
Universe-text
All families
Question Text
(book) F12 and (book) F14
The next questions are about health insurance. Include health insurance obtained
through employment or purchased directly as well as government programs like
Medicare and Medicaid that provide Medical care or help pay medical bills.
[fill 1:Are you/Is anyone in the family] covered by any kind of health insurance or some
other kind of health care plan?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't Know
Yes/No
Field Pane Description
Fill Instructions
Family Health Insurance
Fill 1: If single person family fill "Are you"; else fill "Is anyone in the family".
Special Instructions If FR enters 2, mark HIKIND = 11 for all persons in family
Skip Instructions
<1, D, R> [goto HIKIND]
<2> [if AGE ge 65, goto MCAREPRB; else goto MCAIDPRB]
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Wednesday, July 06, 2016
Page 1 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.070
Variable Name
HIKIND
Universe
AGE=All and FHICOV=1,D,R
Universe-text
All persons in the family where FHICOV= yes, Don't Know or Refused for that family
Question Text
(book) F12 and (book) F14
What kind of health insurance or health care coverage [fill 1: do you/does ALIAS]
have? INCLUDE those that pay for only one type of service (nursing home care,
accidents, or dental care). EXCLUDE private plans that only provide extra cash while
hospitalized.
* Enter all that apply, separate with commas.
Answer Codes
Question Type
1. Private health insurance
2. Medicare
3. Medi-Gap
4. Medicaid
5. CHIP (SCHIP/ Children’s Health Insurance Program)
6. Military health care (TRICARE/VA/CHAMP-VA)
7. Indian Health Service
8. State-sponsored health plan
9. Other government program
10. Single service plan (e.g., dental, vision, prescriptions)
11. No coverage of any type
Don't Know
Refused
Enter All That Apply
Field Pane Description
Fill Instructions
Coverage Type
Fill 1: If subject=respondent, fill [do you]; else fill [does ALIAS].
Special Instructions
Skip Instructions
[goto HCSPFYR]
<1-10> [if AGE ge 65 and HIKIND ne 2, goto MCAREPRB; else if HIKIND ne 10 goto
SINCOV; else goto HICHANGE]
<11> [if HIKIND = 1-10, goto ERR_HIKIND; else if AGE ge 65 goto MCAREPRB, else
goto MCAIDPRB]
Hard Edits
ERR_HIKIND:
* Cannot mark "No coverage of any kind" and another type.
* Please correct.
Soft Edits
AssocHelp
H_HIKIND
Wednesday, July 06, 2016
Page 2 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.070_H
Variable Name
H_HIKIND
Universe
Universe-text
Question Text
1. A [b]private health insurance plan[b] is any type of health insurance, including
Health Maintenance Organizations (HMOs), other than the programs in categories (2)
and (4-10). These plans may be provided in part or full by the person's employer or
union, or may be purchased directly by the individual.
2. [b] Medicare[b] refers to the Federal health insurance coverage for persons 65+
years of age and certain disabled persons under 65 years of age. [b]Medicare
Managed Care or Medicare + Choice[b] is a way of receiving your Medicare benefits.
These types of plans involve specific groups of doctors, hospitals, and other health
care providers who have agreed to provide care to Medicare beneficiaries in
exchange for a fixed payment from Medicare every month. In these plans, a person
must receive all of their care from the Medicare managed care plan, except for
emergencies.
3. [b]Medigap[b] insurance (also called Medicare Supplement Insurance, Medsup and
Medicare Select) is a private health insurance policy which provides reimbursement
for the out-of-pocket costs that are not covered by Medicare (for example:
prescription drugs, hearing aids, and foot care). There are ten standard Medigap
policies (A through J).
4. [b] Medicaid[b] refers to a medical assistance program that provides health care
coverage to low income and disabled persons. The Medicaid program is a joint
federal-state program which is administered by the states. In some states the
Medicaid programs have distinct names.
5. [b]Children's Health Insurance Program[b] (also called [b]SCHIP[b] or [b]CHIP[b])
refers to a joint federal and state program, administered by each state that offers
health care coverage to low-income, uninsured children. The program has recently
expanded in some states to include low income adults as well. This law was passed
in 1997. In some states, CHIP programs have distinct names.
6. [b]Military health care[b] includes health care available to active duty personnel
and their dependents ([b]TRICARE[b]) as well as [b]VA[b] (Veterans Administration)
which provides medical assistance to veterans of the Armed Forces, particularly those
with service-connected ailments and [b]CHAMP-VA[b] (Comprehensive Health and
Medical Plan of the Veterans Administration) provides health care for the spouse,
dependents, or survivors of a veteran who has a total, permanent service-connected
disability. TRICARE is a regionally managed health care program for active duty and
retired members of the uniformed services, their families, and survivors.
[b]TRICARE[b] offers eligible beneficiaries four choices for their health care:
TRICARE Prime, TRICARE Extra, TRICARE Standard and TRICARE for life.
TRICARE Standard is the new name for traditional [b]CHAMPUS[b] (Comprehensive
Health and Medical Plan for the Uniformed Services).
6. [b]Military health care[b] includes:
Wednesday, July 06, 2016
Page 3 of 117
[b]TRICARE[b] - a regionally managed health care program for active duty and
retired members of the uniformed services, their families, and survivors. TRICARE
offers eligible beneficiaries four choices for their health care: TRICARE Prime,
TRICARE Extra, TRICARE Standard and TRICARE for life. TRICARE Standard is the
new name for traditional CHAMPUS (Comprehensive Health and Medical Plan for the
Uniformed Services).
[b]VA[b] (Veterans Administration) - provides medical assistance to veterans of the
Armed Forces, particularly those with service-connected ailments.
[b]CHAMP-VA[b] (Comprehensive Health and Medical Plan of the Veterans
Administration) - provides health care for the spouse, dependents, or survivors of a
veteran who has a total, permanent service-connected disability.
7. [b]Indian Health Service[b] is the Federal health care program for Native Americans.
8. [b]State-sponsored health plan[b] refers to any other health care coverage run by a
specific state, including public assistance programs other than "Medicaid" that pay for
health care.
9. [b]Other Government Program[b] is a catch-all category for any public program
providing health care coverage other than those programs in categories 2, and 4-8.
10. [b]Single Service Plans[b] A Single Service Plan (SSP) is designed to provide
coverage for a specific type of service/care. This plan is usually limited to one type of
service or treatment for a specific condition and is frequently obtained to supplement
a comprehensive plan that may not provide that type of service. Examples of SSPs
are dental care, vision care, prescriptions, nursing home care, hospice care,
accidents, catastrophic care, cancer treatment, AIDS care, and/or hospitalization.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
HIKIND
Wednesday, July 06, 2016
Page 4 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.072
Variable Name
MCAREPRB
Universe
AGE ge 65 and (FHICOV ='2' or (HIKIND ne '2' and ne '3'))
Universe-text
All persons age 65 or older in the family where FHICOV is no, or where HIKIND is not
equal to Medicare for that person
Question Text
(book) F13
People covered by Medicare have a card that looks like this. [fill 1: Are you/Is ALIAS]
covered by Medicare?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Medicare Probe
Fill 1: If subject = respondent fill: [Are you]; else fill: [Is ALIAS].
Special Instructions If FR enters "1" add precode 2 to HIKIND;
If FR enters "1" and HIKIND=11, replace HIKIND with a 2.
Skip Instructions
<1,2,D,R> [if HIKIND ne 10 goto SINCOV; else goto HICHANGE]
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Wednesday, July 06, 2016
Page 5 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.073
Variable Name
MCAIDPRB
Universe
AGE lt 65 and (FHICOV='2' or HIKIND='11')
Universe-text
All persons in the family whose age is less than 65 where FHICOV is no, or where
HIKIND is not equal to Medicaid for that person
Question Text
(book F14)
* Refer to flashcard F14 for state Medicaid names.
There is a program called Medicaid that pays for health care for persons in need. In
this State it is also called [fill 2: State name]. [fill 1: Are you/Is ALIAS] covered by
Medicaid?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Medicaid Probe
Fill 1: If subject = respondent fill: [Are you]; else fill: [Is ALIAS].
Fill 2: State Name
Special Instructions If FR enters "1" add precode 4 to HIKIND;
If FR enters "1" and HIKIND=11, replace HIKIND with a 4.
Skip Instructions
<1,2,D,R> [if HIKIND ne 10 goto SINCOV; else goto HICHANGE]
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Wednesday, July 06, 2016
Page 6 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.074
Variable Name
SINCOV
Universe
AGE= All and (FHICOV='2', or HIKIND ne '10')
Universe-text
All persons in the family where FHICOV is no, or where HIKIND is not equal to single
service plan for that person
Question Text
[fill 1: Do you/Does ALIAS] have a separate insurance plan that pays for only one type
of service such as dental, vision, or prescriptions?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Single Service Probe
Fill 1: If subject = respondent fill: [Do you]; else fill: [Does ALIAS].
Special Instructions If FR enters "1" add precode "10" to HIKIND;
If FR enters "1", and HIKIND ='11', replace with a "10".
Skip Instructions
<1,2,D,R> [goto HICHANGE]
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Wednesday, July 06, 2016
Page 7 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.075
Variable Name
HICHANGE
Universe
AGE=All
Universe-text
All persons
Question Text
I have recorded [fill 1:you are/ALIAS is] [fill 2: covered by/not covered by health
insurance.]
[fill 3:^HIKIND]
Is this correct?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Other
Field Pane Description
Fill Instructions
Verification
Fill1: If subject=respondent, fill:"you are"; else, fill:" ALIAS is".
Fill 2: If (FHICOV=2 or HIKIND=11) and (MCAREPRB=2,R,D or MCAIDPRB=2,R,D)
and SINCOV=2,R,D fill "covered by"; else fill "not covered by health insurance".
Fill 3: fill coverage types from HIKIND, except HIKIND=11,
else if MCAREPRB=1, fill "Medicare";
else if SINCOV=1, fill "single service plan";
else if MCAIDPRB=1, fill "Medicaid".
Special Instructions If HIKIND=3, and HIKIND ne 2, add precode "2" to HIKIND (This is being done in the
post processing.)
Hard error should include variables HIKIND and HICHANGE. HIKIND should be listed
first.
Skip Instructions
[1, D, R] goto next person;
[2] goto ERR_HICHANGE
Hard Edits
ERR_HICHANGE
*Press enter to go back to HIKIND and update coverage.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 8 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.090
Variable Name
MCPART
Universe
Age=All and (HIKIND IN ('2','3') or MCAREPRB = '1')
Universe-text
All persons with Medicare
Question Text
Earlier I recorded that [fill 1: you are/ALIAS is] covered by Medicare. May I please
see [fill 2: your/ALIAS’s] Medicare card to determine the type of coverage?
* Reports from memory are acceptable if the Medicare card (or some other form of
documentation) is not available.
* Enter the coverage type.
Answer Codes
Question Type
1. Part A - Hospital Only
2. Part B - Medical Only
3. Both Part A & Part B
Refused
Don’t know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Coverage Type
Fill 1: If subject=respondent, fill:[you are]; else fill, [ALIAS is]
Fill 2: If subject=respondent, fill:[your]; else fill:[ALIAS’s]
Special Instructions
Skip Instructions
<1-3> [goto MCCARD]
[prefill MCCARD with a "2", goto MCCHOICE]
Hard Edits
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Wednesday, July 06, 2016
Page 9 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.092
Variable Name
MCCARD
Universe
MCPART = ('1', '2', '3')
Universe-text
All persons with Part A Medicare coverage, Part B Medicare coverage, or both
Question Text
* Do not read. Was the type of coverage obtained from a Medicare card or some
other form of documentation?
Answer Codes
1. Yes
2. No
Question Type
Yes/No
Field Pane Description
Plan Card
Fill Instructions
Special Instructions Do not allow D or R
Skip Instructions
<1,2> [If MCPART = 1, goto MCPARTD;
else if MCPART = 2,3, goto MCCHOICE]
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Wednesday, July 06, 2016
Page 10 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.095
Variable Name
MCCHOICE
Universe
MCPART IN ('2','3','R','D')
Universe-text
All persons with Medicare who have signed up for part B coverage or for whom it is
unknown if they have signed up for Part B coverage
Question Text
? [F1]
Medicare Advantage is the new name for Medicare Plus Choice plans. [fill 1: Are
you/Is ALIAS] enrolled in a Medicare Advantage plan?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Advantage
Fill 1: If subject= respondent, fill: [Are you]; else fill:[Is ALIAS]
Special Instructions
Skip Instructions
<1,2,R,D> goto MCHMO
Hard Edits
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H_MCCHOICE
Wednesday, July 06, 2016
Page 11 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.095_H
Variable Name
H_MCCHOICE
Universe
Universe-text
Question Text
[b]Medicare Plus Choice[b] is also known as Medicare+Choice, M Plus C, and
Medicare Part C. [b]Medicare Plus Choice[b] expands the Medicare Health Plan
options to include a broader range of plans in addition to the original fee-for-service
Medicare and Health Maintenance Organizations (HMO's). New Medicare Health
plans include: Preferred provider Organizations (PPO's), Health Maintenance
Organizations with a Point of Service Option, Point of Service plans, Private Fee-ForService (PFFS) plans (not the same as Medigap),
and Medical Savings Accounts (MSA).
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
MCCHOICE
Wednesday, July 06, 2016
Page 12 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.100
Variable Name
MCHMO
Universe
MCPART IN ('2','3','R','D')
Universe-text
All persons with Medicare who have signed up for part B coverage or for whom it is
unknown if they have signed up for Part B coverage
Question Text
? [F1]
[fill 1:Are you/Is ALIAS] under a Medicare managed care arrangement, such as an
HMO, that is, a Health Maintenance Organization?
(With an HMO, you must generally receive care from HMO doctors, otherwise the
expense is not covered unless you were referred by the HMO or there was a medical
emergency.)
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
HMO
Fill 1: If subject=respondent, fill:[ Are you]; else fill, [Is ALIAS]
Special Instructions
Skip Instructions
<1> [goto MCANAME]
<2,D,R> if MCCHOICE=1 [goto MCANAME];
else if MCCHOICE in(2,D,R) [goto MCREF]
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H_MCHMO
Wednesday, July 06, 2016
Page 13 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.100_H
Variable Name
H_MCHMO
Universe
Universe-text
Question Text
[b]Medicare Managed Care[b] is a way of receiving your Medicare benefits. These
types of plans involve specific groups of doctors, hospitals, and other health care
providers who have agreed to provide care to Medicare beneficiaries in exchange for
a fixed payment from Medicare every month. In these plans, a person must receive all
of their care from the Medicare managed care plan, except for emergencies.
[b]Health Maintenance Organization (HMO)[b] is a health care plan that delivers
comprehensive, coordinated medical services to enrolled members on a prepaid basis.
There are three basic types of HMOs:
1) Group/Staff HMO delivers services at one or more locations through a group of
physicians that contracts with the HMO to provide care or through its own physicians
who are employees of the HMO.
2) An Individual Practice Association (IPA) makes contractual arrangements with
doctors in the community, who treat HMO members out of their own offices.
3) Network HMO contracts with two or more group practices to provide health services.
Other managed care arrangements that may be available through Medicare include:
HMO's with Point of Service Options (POS), Provider sponsored Organizations
(PSO's), and Preferred Provider Organizations (PPO's).
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
MCHMO
Wednesday, July 06, 2016
Page 14 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.112
Variable Name
MCANAME
Universe
MCCHOICE='1' or MCHMO='1'
Universe-text
All persons who answered that they had either a Medicare Advantage plan or a
Medicare HMO plan
Question Text
? [F1]
What is the name of [fill 1: your/ALIAS’s] Medicare Advantage or Medicare HMO plan?
* Read if necessary: Do you have a health plan card or something with the plan name
on it?
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
HMO Name
Fill 1: If subject = respondent, fill: [your]; else fill:[ ALIAS's]
Special Instructions Allow 80 characters, Allow D, R
Display the text "Do you have a health plan card or something with the plan name on
it?" in BOLD GRAY text.
Skip Instructions
goto MCPREM
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H_MCANAME
Wednesday, July 06, 2016
Page 15 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.112_H
Variable Name
H_MCANAME
Universe
Universe-text
Question Text
Verify that the name given is the EXACT name of the Health Plan. Verify that you
have spelled it correctly.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
MCANAME
Wednesday, July 06, 2016
Page 16 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.113
Variable Name
MCPREM
Universe
MCCHOICE='1' or MCHMO='1'
Universe-text
All persons who answered that they had either a Medicare Advantage plan or a
Medicare HMO plan
Question Text
Besides [fill 1: your/ALIAS’s] Medicare Part B payment, [fill 2: are you/is ALIAS] paying
a premium for [fill 3: your/his/her] Medicare Advantage or Medicare HMO plan?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Additional Premium
Fill 1: If subject = respondent, fill: [your]; else fill:[ ALIAS's]
Fill 2: If subject = respondent, fill: [are you]; else fill: [is ALIAS]
Fill 3: if subject = respondent, fill: [your]; else if subject is not the respondent and is
male, fill: [his]; else fill: [her]
Special Instructions
Skip Instructions
<1,2,R,D> goto MCREF
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Wednesday, July 06, 2016
Page 17 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.114
Variable Name
MCREF
Universe
MCPART IN ('2','3','R','D')
Universe-text
All persons with Medicare who have signed up for part B coverage or
for whom it is unknown if they have signed up for Part B coverage
Question Text
? [F1]
Under [fill 1: your/ALIAS's] Medicare plan, if [fill 2: you need/he needs/she needs] to
go to a different doctor or place for special care, [fill 3: do you/does he/does she] need
approval or a referral? Do not include emergency care.
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Referral
Fill 1: If subject= respondent, fill: [your]; else, fill:[ALIAS's]
Fill 2: If subject= respondent, fill: [you need]; else if subject's SEX= male, fill: [he
needs]; else if subject's SEX= female, fill: [she needs]
Fill 3: If subject= respondent, fill: [do you]; else if subject's SEX= male, fill: [does he];
else if subject's SEX= female, fill: [does she]
Special Instructions
Skip Instructions
<1,2,R,D> goto MCPARTD
Hard Edits
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H_MCREF
Wednesday, July 06, 2016
Page 18 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.114_H
Variable Name
H_MCREF
Universe
Universe-text
Question Text
Most managed care plans require approval or a referral from one of the doctors
participating in the plan before the person can see a specialist who participates in the
plan or a doctor not participating in the plan.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
MCREF
Wednesday, July 06, 2016
Page 19 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.118
Variable Name
MCPARTD
Universe
AGE= ALL and (HIKIND IN ('2','3') or MCAREPRB = '1')
Universe-text
All persons with Medicare
Question Text
[Fill 1: Are you/Is ALIAS] enrolled in Medicare Part D, also known as the Medicare
Prescription Drug Plan?
Answer Codes
1. Yes
2. No
Refused
Don't Know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Medicare part D
Fill 1: If subject = respondent, fill: [Are you]; else fill:[Is ALIAS]
Special Instructions If more persons with Medicare, goto MCPART. If no more persons with Medicare, goto
next appropriate question.
Skip Instructions
If more persons with Medicare, goto MCPART. If no more persons with Medicare, goto
next appropriate question.
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Wednesday, July 06, 2016
Page 20 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.120
Variable Name
MACHMD
Universe
AGE= All and (HIKIND= '4' or MCAIDPRB = '1')
Universe-text
All persons with Medicaid coverage
Question Text
?[F1]
(book) F14
* Refer to flashcard F14 for state Medicaid name
The next questions are about Medicaid coverage. In this State it is also called [fill1:
State Name]. [fill 2: You are/ALIAS is] listed as having Medicaid coverage.
Can [fill 3: you/ALIAS] go to ANY doctor who will accept Medicaid or MUST [fill
4:you/he/she] choose from a list of doctors or is a doctor assigned?
Answer Codes
Question Type
1. Any doctor
2. Select from list
3. Doctor is assigned
Refused
Don’t know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Any Doctor
Fill 1: fill State Name
Fill 2: If subject= respondent, fill: [You are]; else fill: [ALIAS is]
Fill 3: If subject= respondent, fill: [you]; else fill: [ALIAS]
Fill 4: If subject= respondent, fill: [you]; else if subject's SEX= male, fill: [he]; else, if
subject's SEX = female, fill: [she]
Special Instructions
Skip Instructions
<1,R,D> [goto MXCHNG]
<2> [goto MACHMD1]
<3> [goto MACHMD2]
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AssocHelp
H_MACHMD
Wednesday, July 06, 2016
Page 21 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.120_H
Variable Name
H_MACHMD
Universe
Universe-text
Question Text
[b]Medicaid[b] refers to a medical assistance program that provides health care
coverage to low income and disabled persons. The Medicaid program is a joint
federal-state program which is administered by the States. The Medicaid program is
also often referred to as "Medical Assistance Program", "Medical Assistance", "Title
19" or "(State) Medicaid", such as "Alabama Medicaid". In the listing below are some
additional program names for Medicaid by state.
STATE NAMES FOR MEDICAID:
Alabama - Patients 1st; SOBRA
Arizona - AHCCS (Pronounced "Access") (Arizona Health Care Cost Containment
System); Healthy Arizona
Arkansas - ConnectCare
California - Medi-Cal
Colorado - Primary Care Physician Program (PCPP); BabyCare/KidsCare
Connecticut - Medical Assistance Program; HUSKY Part A
Delaware - Diamond State Health Plan
District of Columbia - Medical Assistance
Florida - MediPass
Georgia - Better Health Care; Right from the Start
Hawaii - Hawaii-QUEST
Idaho - Healthy Connections; Medical Assistance
Illinois - Medical Assistance; Healthy Start; Parent Assist; Kidcare Assist
Indiana - Hoosier Healthwise; Primestep; Risk Based Managed Care
Iowa - Medical Assistance; MediPASS; Iowa Plan
Kansas - HealthConnect; Healthwave 19
Kentucky - KenPAC (Kentucky Patient Access and Care System)
Louisiana - CommunityCARE; LaMoms
Maine - PrimeCare; Maine Care
Maryland - Medical Assistance Program; Healthchoice; REM Program
Massachusetts - MassHealth
Michigan - MICHOICE; Medical Assistance Program; Healthy Kids
Minnesota - Medical Assistance (MA)
Missouri - Missouri Managed Care Plus (MC+); MCPlus ; Sarah Lopez Waiver
Montana - Passport to Health
Nebraska - Nebraska Health Connection (NHC); Medical Assistance Program
New Hampshire - Medical Assistance Program; Healthy Kids Gold
New Jersey - New Jersey Care 2000+
New Mexico - SALUD!
New York - The Partnership Plan
North Carolina - Carolina Access; Health Care Connection; Access II; Access III
North Dakota - Medical Services; North Dakota Access and Care Program (NoDAC)
Ohio - Premier Care; Healthy Families, Healthy Start
Oklahoma - SoonerCare;
Oregon - Oregon Health Plan (OHP)
Wednesday, July 06, 2016
Page 22 of 117
Pennsylvania - Medical Assistance; Access Card; HealthChoices
Rhode Island - Rite Care; RI Medical Assistance; Katie Beckett
South Carolina - Healthy Options; Physicians Enhanced Program; South Carolina
Partners for Health Medicaid Insurance
South Dakota - Prime; Medical Assistance; M-CHIP
Tennessee - TennCare Medicaid
Texas - State of Texas Access Reform (STAR); Star+Plus
Virginia - Virginia Medallion; Medallion II
Washington - Basic Health Plus
West Virginia - Medical Assistance; Mountain Health Trust; Physicians Assured
Access System (PAAS)
Wisconsin Medical Assistance; Healthy Start
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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Soft Edits
AssocHelp
MACHMD
Wednesday, July 06, 2016
Page 23 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.130
Variable Name
MACHMD1
Universe
MACHMD= '2'
Universe-text
Persons with Medicaid who must select a doctor from a list of doctors
Question Text
* Ask or verify.
What is the name of the health plan that provided the list?
*Read if necessary: Do you have a health plan card or something with the plan name
on it?
Answer Codes
Question Type
Text
Field Pane Description
Plan with list
Fill Instructions
Special Instructions Allow 80 characters
Prefill the response of the 1st person for subsequent family members who get this
question, but still display question so FR can ask or verify.
Skip Instructions
goto MANAM
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Wednesday, July 06, 2016
Page 24 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.131
Variable Name
MACHMD2
Universe
MACHMD= '3'
Universe-text
Persons with Medicaid for whom a doctor is assigned
Question Text
* Ask or verify.
What is the name of the health plan that assigned the doctor?
*Read if necessary: Do you have a health plan card or something with the plan name
on it?
Answer Codes
Question Type
Text
Field Pane Description
Plan Assigned
Fill Instructions
Special Instructions allow 80 characters
prefill the response of the 1st person for subsequent family members who get this
question, but still display question so FR can ask or verify.
Skip Instructions
goto MANAM
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Wednesday, July 06, 2016
Page 25 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.132
Variable Name
MANAM
Universe
MACHMD= '2','3'
Universe-text
Persons with Medicaid who must select a doctor from a list or for whom a doctor is
assigned
Question Text
? [F1]
* Do not read. Was the Health Plan name obtained from a Health Plan Card or
something with the Health Plan name on it?
Answer Codes
Question Type
1. Yes
2. No
Yes/No
Field Pane Description
Name from Card
Fill Instructions
Special Instructions Do not allow D or R
Skip Instructions
<1, 2> goto MXCHNG
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H_MANAME
Wednesday, July 06, 2016
Page 26 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.132_H
Variable Name
H_MANAME
Universe
Universe-text
Question Text
Verify that the name given is the EXACT name of the Health Plan. Verify that you
have spelled it correctly.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
MANAM
Wednesday, July 06, 2016
Page 27 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.135_00.010
Variable Name
MXCHNG
Universe
AGE=All and (HIKIND='04' or MCAIDPRB='1')
Universe-text
All persons with Medicaid coverage
Question Text
Was [fill: your/ALIAS's] Medicaid obtained through Healthcare.gov or the [fill2: Health
Insurance Marketplace/state specific name fill]?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Medicaid from marketplace
Fill 1: If subject = respondent, fill [your]; else, fill [ALIAS's]
Fill 2: If no state specified below, fill Health Insurance Marketplace
If state specified below fill:
If CA then fill Health Insurance Marketplace, such as Covered California
If CO then fill Health Insurance Marketplace, such as Connect for Health Colorado
If CT then fill Health Insurance Marketplace, such as Access Health CT
If DC then fill Health Insurance Marketplace, such as DC Health Link
If HI then fill Health Insurance Marketplace, such as Hawaii Health Connector
If ID then fill Health Insurance Marketplace, such as Your Health Idaho
If KY then fill Health Insurance Marketplace, such as KYnect
If MA then fill Health Insurance Marketplace, such as Health Connector
If MD then fill Health Insurance Marketplace, such as Maryland Health Connection
If MN then fill Health Insurance Marketplace, such as MNsure
If NM then fill Health Insurance Marketplace, such as New Mexico Health
Connections
If MS then fill Health Insurance Marketplace, such as One, Mississippi
If NV then fill Health Insurance Marketplace, such as Nevada Health Link
If NY then fill Health Insurance Marketplace, such as New York State of Health
If OR then fill Health Insurance Marketplace, such as Cover Oregon
If RI then fill Health Insurance Marketplace, such as HealthSource RI
If VT then fill Health Insurance Marketplace, such as Vermont Health Connect
If WA then fill Health Insurance Marketplace, such as Washington Healthplanfinder
If UT then fill Health Insurance Marketplace, or through Avenue H
Special Instructions
Skip Instructions
<1, 2, R, D> goto MEDPREM
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Wednesday, July 06, 2016
Page 28 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.137_00.020
Variable Name
MEDPREM
Universe
AGE=All and (HIKIND(e)='04' or MCAIDPRB(e)='1'
Universe-text
All persons with Medicaid coverage
Question Text
A health insurance premium is the amount you or a family member pays each month
for health care coverage. Do you or a family member pay a premium for [Fill 1 :
your/ALIAS's] Medicaid plan?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Medicaid premium
Fill 1: If subject = respondent, fill [your]; else, fill [ALIAS's]
Special Instructions
Skip Instructions
<1> goto MDPRINC
<2,R,D> goto MAPCMD
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Wednesday, July 06, 2016
Page 29 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.137_00.030
Variable Name
MDPRINC
Universe
AGE=All and MEDPREM(e)='1'
Universe-text
All persons with Medicaid coverage who pay a premium for their plan
Question Text
Is the premium paid for this Medicaid plan based on income?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Premium based on income
Fill Instructions
Special Instructions
Skip Instructions
loop through all persons in the family with Medicaid, when roster is finished, goto next
appropriate group of questions.
If HIKIND=10 goto SSTYPE2; else goto If HIKIND=1 or 3, goto FHICCI6
If any person with HIKIND=1 or 3, but not in NEXTPNM*_B, goto HIVER1; else gotot
FHICC18
If any family member with HIKIND=5; goto STNAME, else if any member with
HIKIND=10,11, goto HILAST; else if HIKIND=1-9 goto HINOTYR, else goto HILAST
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Wednesday, July 06, 2016
Page 30 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.156
Variable Name
SSTYPE2
Universe
AGE=All and (HIKIND = '10' or SINCOV = '1').
Universe-text
All persons with single service plans
Question Text
(book) F15
* Enter all that apply, separate with commas.
You mentioned that [fill 1: you have/ALIAS has] a single-service plan - that is, an
insurance plan that provides one specific type of coverage. What type of service or
care does [fill 2: your/ALIAS's] single service plan or plans pay for?
Answer Codes
Question Type
1. Accidents
2. AIDS care
3. Cancer treatment
4. Catastrophic care
5. Dental care
6. Disability insurance (cash payments when unable to work for health reasons)
7. Hospice care
8. Hospitalization only
9. Long-term care (nursing home care)
10. Prescriptions
11. Vision care
12. Other (specify)
Refused
Don’t know
Enter All That Apply
Field Pane Description
Fill Instructions
Single Service Plan Type
Fill 1: If subject= respondent, fill: [you have]; Else fill: [ALIAS has]
Fill 2: If subject= respondent, fill: [your]; Else fill: [ALIAS's]
Special Instructions
Skip Instructions
1-11, D, R roster through for all people with single service plans, then goto next
appropriate question
12 goto SSOTHER
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Wednesday, July 06, 2016
Page 31 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.157
Variable Name
SSOTHER
Universe
SSTYPE= 12
Universe-text
Persons with "Other" Single service plan
Question Text
* Other type of single-service plan
Answer Codes
Question Type
Text
Field Pane Description
Other Single Service Plan
Fill Instructions
Special Instructions Allow 80 characters
Skip Instructions
if other persons with single service plan, goto SSTYPE2 until roster is exhausted.
Else goto next appropriate group of questions.
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Wednesday, July 06, 2016
Page 32 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.158
Variable Name
FHICCI6
Universe
AGE=All and HIKIND= '1','3' for any person in the family
Universe-text
All families with at least one person with private health insurance
Question Text
The next questions are about private health insurance plans [fill 2: including MediGap]. These plans can be obtained through work, purchased directly, or through a
state or local government program or community program.
[Fill 1: We have the following persons listed as being covered by such plans:
* Read names.
(Display roster of persons covered by private health insurance plans.)]
Answer Codes
Question Type
1. Enter 1 to Continue
Enter 1 to Continue
Field Pane Description
Fill Instructions
Continue
Fill 1: If more than 1 person has private health insurance, fill:
We have the following persons listed as being covered by such plans:
* Read names.
(Display roster of persons covered by private health insurance plans.)
Fill 2: When HIKIND = Medigap (3), fill: [including Medi-Gap].
Special Instructions If more than 1 person has private health insurance, display roster of family members
with private health insurance (HIKIND = 1 or 3)
Skip Instructions
goto HIPNAM1
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Wednesday, July 06, 2016
Page 33 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.160
Variable Name
HIPNAM1
Universe
AGE=All and HIKIND= '1','3' for any person in the family
Universe-text
All families with at least one person with private health insurance
Question Text
It is important that we record the complete and accurate name of each health
insurance plan. What is the COMPLETE name of the first plan?
Do NOT include plans that only provide extra cash while in the hospital or plans that
pay for only one type of service, such as nursing home care, accidents, or dental care.
* Read if necessary: Do you have your health plan card or something with the plan
name on it?
Answer Codes
Question Type
Text
Field Pane Description
First plan
Fill Instructions
Special Instructions Allow 80 characters
if HIPNAM1 = 'refused' or 'don't know' set plan name='Plan 1'
else set plan name =HIPNAM1 value
Skip Instructions
[prefill PCARD1 with a "2", goto HIPNAM1B]
else goto PCARD1
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Wednesday, July 06, 2016
Page 34 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.160_1
Variable Name
PCARD1
Universe
HIPNAM1 ne ' ', 'D', 'R'
Universe-text
Health plan name was collected in HIPNAM1
Question Text
* Do not read. Was the health plan name obtained from a health plan card or
something with the health plan name on it?
Answer Codes
1. Yes
2. No
Question Type
Yes/No
Field Pane Description
Plan card
Fill Instructions
Special Instructions Do not allow answer codes D, R
Skip Instructions
goto HIPNAM1B
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Wednesday, July 06, 2016
Page 35 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.170
Variable Name
HIPNAM1B
Universe
HIPNAM1 ne ' '
Universe-text
Health plan name was collected in HIPNAM1 or HIPNAM1 refused or don't know
Question Text
* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by this plan?
* Indicate each family member covered by this plan.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all persons with HIKIND=1 or 3 in answer pane. (Private health
insurance or MediGap.)
Please have the instrument automatically fill the person number if only one person is
covered by private health insurance or MediGap.
Skip Instructions
<1-25> if line number has FX='1' and le TOTPCNT and HHSTAT ne 'D' goto
MORPLAN
[if HIPNAM1= D, R, goto STNAME1 or STNAME2 or STNAME3 or MILSPC or
HILAST or HINOTYR
else, goto MORPLAN
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Wednesday, July 06, 2016
Page 36 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.171
Variable Name
MORPLAN
Universe
(HIPNAM1 ne 'R','D', ' ') or (HIPNAM1B ne 'R','D', ' ') or HIVER2='5' and
MORPLAN='2','R','D')
Universe-text
Health plan name was collected in HIPNAM1 or a person number was collected in
HIPNAM1B or another plan was mentioned at HIVER2 and MORPLAN='2','R','D'
Question Text
* Ask if necessary
Are there any more private health insurance plans?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
More plans
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto HIPNAM2]
<2,D,R> [(If all persons listed in HIPNAM1B goto FHICCI8); else
(If some or no persons listed in HIPNAM1B, but not all persons with
HIKIND=1,3 listed in HIPNAM1B, goto HIVER1)]
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Wednesday, July 06, 2016
Page 37 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.172
Variable Name
HIPNAM2
Universe
MORPLAN = '1'
Universe-text
All families with a second private health insurance plan
Question Text
What is the name of the next plan?
*Read if necessary: Do you have a health plan card or something with the plan name
on it?
Answer Codes
Question Type
Text
Field Pane Description
Second plan
Fill Instructions
Special Instructions Allow 80 characters
if HIPNAM2='refused' or 'don't know' set plan name='Plan 2'
else set plan name=HIPNAM2 value
Skip Instructions
[prefill PCARD2 with a "2", goto HIPNAM2B]
else goto PCARD2
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Wednesday, July 06, 2016
Page 38 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.172_1
Variable Name
PCARD2
Universe
HIPNAM2 ne ' ', D or R
Universe-text
Health plan name was recorded in HIPNAM2
Question Text
* Do not read. Was the health plan name obtained from a health plan card or
something with the health plan name on it?
Answer Codes
1. Yes
2. No
Question Type
Yes/No
Field Pane Description
Plan card
Fill Instructions
Special Instructions do not allow answer codes of D or R
Skip Instructions
goto HIPNAM2B
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Wednesday, July 06, 2016
Page 39 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.173
Variable Name
HIPNAM2B
Universe
HIPNAM2 ne ' '
Universe-text
Health plan name was collected in HIPNAM2 or HIPNAM2 = D, R
Question Text
* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by that plan?
* Indicate each family member covered by this plan.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all persons with HIKIND=1 or 3 in answer pane. (Private health
insurance or MediGap.)
Please have the instrument automatically fill the person number if only one person is
covered by private health insurance or MediGap.
Skip Instructions
<1-25> if line number has FX='1' and le TOTPCNT and HHSTAT ne 'D' goto
MORPLAN2
[if HIPNAM2 eq D or R and persons listed in HIPNAM1B, but not all persons
with HIKIND eq 1 or 3 listed in HIPNAM1B, goto HIVER1;
else if HIPNAM2 eq D or R and persons listed in HIPNAM1B, and all persons with
HIKIND eq 1 or 3 listed in HIPNAM1B, goto FHICCI8;
else if HIPNAM2 eq D or R and persons not listed in HIPNAM1B, goto HIVER1;
else if health plan name recorded in HIPNAM2, goto MORPLAN2]
else goto MORPLAN2
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Wednesday, July 06, 2016
Page 40 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.174
Variable Name
MORPLAN2
Universe
(HIPNAM2 ne 'R', 'D', ' ') or (HIPNAM2B ne 'R', 'D', ' ') or (HIVER2='5' and MORPLAN2
= '2','R','D')
Universe-text
Health plan name was collected in HIPNAM2 or a person number was collected in
HIPNAM2B or another plan was mentioned at HIVER2 and MORPLAN2='2','R','D'
Question Text
* Ask if necessary
Are there any more private health insurance plans?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
More plans
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto HIPNAM3]
<2,D,R> [if some or no persons listed in HIPNAM2B or HIPNAM1B, but not all persons
with HIKIND eq 1 or 3 listed in
HIPNAM2B or HIPNAM1B, goto HIVER1;
else goto FHICCI8]
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Wednesday, July 06, 2016
Page 41 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.175
Variable Name
HIPNAM3
Universe
MORPLAN2 = '1'
Universe-text
All families with a third private health insurance plan
Question Text
What is the name of the next plan?
*Read if necessary: Do you have a health plan card or something with the plan name
on it?
Answer Codes
Question Type
Text
Field Pane Description
Third plan
Fill Instructions
Special Instructions Allow 80 characters
if HIPNAM3 = 'refused' or 'don't know' set plan name = 'Plan 3' else set plan name =
HIPNAM3 value
Skip Instructions
[prefill PCARD3 with a "2", goto HIPNAM3B]
else goto PCARD3
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Wednesday, July 06, 2016
Page 42 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.175_1
Variable Name
PCARD3
Universe
HIPNAM3 ne ' ', 'D' or 'R'
Universe-text
Health plan name was recorded in HIPNAM3
Question Text
* Do not read. Was the health plan name obtained from a health plan card or
something with the health plan name on it?
Answer Codes
1. Yes
2.No
Question Type
Yes/No
Field Pane Description
Plan card
Fill Instructions
Special Instructions Do not allow answer codes of D or R
Skip Instructions
goto HIPNAM3B
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Wednesday, July 06, 2016
Page 43 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.176
Variable Name
HIPNAM3B
Universe
HIPNAM3 ne ' '
Universe-text
Health plan name was collected in HIPNAM3 or HIPNAM3 don't know or refused
Question Text
* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by that plan?
* Indicate each family member covered by this plan.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all persons with HIKIND=1 or 3 in answer pane. (Private health
insurance or MediGap.)
Please have the instrument automatically fill the person number if only one person is
covered by private health insurance or MediGap.
Skip Instructions
<1-25> if line number has FX='1' and le TOTPCNT and HHSTAT ne 'D' goto
MORPLAN3
[if HIPNAM3 eq D or R and persons listed in HIPNAM1B or HIPNAM2B, but not
all persons with HIKIND eq 1 or 3 listed in HIPNAM1B or HIPNAM2B, goto HIVER1;
else if HIPNAM3 eq D or R and persons listed in HIPNAM1B or HIPNAM2B, and
all persons with HIKIND eq 1 or 3 listed in HIPNAM1B or HIPNAM2B, goto FHICCI8;
else if HIPNAM3 eq D or R and persons not listed in HIPNAM1B and HIPNAM2B,
goto HIVER1;
else if health plan name recorded in HIPNAM3, goto MORPLAN3]
else goto MORPLAN3
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Wednesday, July 06, 2016
Page 44 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.177
Variable Name
MORPLAN3
Universe
(HIPNAM3 ne 'R', 'D', ' ') or (HIPNAM3B ne 'R', 'D', ' ') or (HIVER2='5' and
MORPLAN3='2','R','D')
Universe-text
Health plan name was collected in HIPNAM3 or a person number was collected in
HIPNAM3B or another plan was mentioned at HIVER2 and MORPLAN3='2','R','D'
Question Text
* Ask if necessary
Are there any more private health insurance plans?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
More plans
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto HIPNAM4]
<2,D,R> [if some or no persons listed in HIPNAM1B or HIPNAM2B or HIPNAM3B, but
not all persons with HIKIND eq 1 or 3 listed in HIPNAM1B or HIPNAM2B or
HIPNAM3B, goto HIVER1;
else goto FHICCI8]
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Wednesday, July 06, 2016
Page 45 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.178
Variable Name
HIPNAM4
Universe
MORPLAN3 = '1'
Universe-text
All families with a fourth private health insurance plan
Question Text
What is the name of the next plan?
*Read if necessary: Do you have a health plan card or something with the plan name
on it?
Answer Codes
Question Type
Text
Field Pane Description
Fourth plan
Fill Instructions
Special Instructions Allow 80 characters
if HIPNAM4 = 'refused' or 'don't know' set plan name = 'Plan 4' else set plan name =
HIPNAM4 value
Skip Instructions
[prefill PCARD4 with a "2", goto HIPNAM4B]
else goto PCARD4
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Wednesday, July 06, 2016
Page 46 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.178_1
Variable Name
PCARD4
Universe
HIPNAM4 ne ' ', D or R
Universe-text
Health plan name was recorded in HIPNAM4
Question Text
* Do not read. Was the health plan name obtained from a health plan card or
something with the health plan name on it?
Answer Codes
1. Yes
2.No
Question Type
Yes/No
Field Pane Description
Plan card
Fill Instructions
Special Instructions Do not allow answer codes of D or R
Skip Instructions
goto HIPNAM4B
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Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 47 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.179
Variable Name
HIPNAM4B
Universe
HIPNAM4 ne ' '
Universe-text
Health plan name was collected in HIPNAM4 or HIPNAM4 don't know or refused
Question Text
* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by that plan?
* Indicate each family member covered by this plan.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all persons with HIKIND=1 or 3 in answer pane. (Private health
insurance or MediGap.)
Please have the instrument automatically fill the person number if only one person is
covered by private health insurance or MediGap
Skip Instructions
<1-25> if line number has FX='1' and le TOTPCNT and HHSTAT ne 'D' but not all
persons with HIKIND eq 1 or 3 listed in HIPNAM1B or HIPNAM2B or HIPNAM3B or
HIPNAM4B goto HIVER1
else goto FHICCI8
[if persons listed in HIPNAM1B or HIPNAM2B or HIPNAM3B, but not all
persons with HIKIND eq 1 or 3 listed in HIPNAM1B or HIPNAM2B or HIPNAM3B, goto
HIVER1;
else if persons not listed in HIPNAM1B and HIPNAM2B and HIPNAM3B, goto
HIVER1;
else goto FHICCI8]
else goto FHICCI8
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Wednesday, July 06, 2016
Page 48 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.180
Variable Name
HIVER1
Universe
(HIKIND= '1','3') and (person not selected in HIPNAM1B and HIPNAM2B and
HIPNAM3B and HIPNAM4B)
Universe-text
Persons with private health insurance, but not listed under any of the mentioned plans
Question Text
? [F1]
[fill 1: You are/ALIAS is] listed as having private insurance but [fill 2: were/was] not
mentioned as being covered by any of the plans we just discussed. [fill 3: Are you/Is
ALIAS] covered by private insurance?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Covered
Fill 1: If subject= respondent, fill: [You are]; Else fill: [ALIAS is]
Fill 2: If subject= respondent, fill: [were]; Else fill: [was]
Fill 3: If subject= respondent, fill: [Are you]; Else fill: [Is ALIAS]
Special Instructions Loop through all persons with HIKIND=1 or 3, but not mentioned in HIPNAM1B or
HIPNAM2B or HIPNAM3B or HIPNAM4B
Hard error message should involve HIKIND and HIVER1, with HIKIND listed first.
Skip Instructions
<1> [goto HIVER2]
<2> [goto ERR_HIVER1]
goto FHICCI8 or STNAME1 or STNAME2 or STNAME3 or MILSPC or HILAST or
HINOTYR
if another person meets criteria goto HIVER1
else goto FHICCI8 or STNAME1 or STNAME2 or STNAME3 or MILSPC or
HILAST or HINOTYR
Hard Edits
ERR_HIVER1
*Press ENTER to go back to HIKIND to update health insurance coverage.
Soft Edits
AssocHelp
H_HIVER1
Wednesday, July 06, 2016
Page 49 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.180_H
Variable Name
H_HIVER1
Universe
Universe-text
Question Text
A private health insurance plan may be provided in part or full by the persons'
employer or union, may be purchased directly by the individual, or may be provided
through a state government or local community program.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
HIVER
Wednesday, July 06, 2016
Page 50 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.190
Variable Name
HIVER2
Universe
HIVER1= '1'
Universe-text
All persons who answered yes at HIVER1
Question Text
? [F1]
* Enter all that apply, separate with commas.
Is [fill 1: your/ALIAS's] health insurance plan the same as one of those already
mentioned?
Answer Codes
Question Type
Authors: fill names of plans, if not empty, for precodes 1-4 as follows:
1. [HIPNAM1 or 'Plan 1']
2. [HIPNAM2 or 'Plan 2'] (if available)
3. [HIPNAM3 or 'Plan 3'] (if available)
4. [HIPNAM4 or 'Plan 4'] (if available)
5. Some other plan not already mentioned
Refused
Don’t know
Enter All That Apply
Field Pane Description
Fill Instructions
Which Plan
Fill 1: If subject= respondent, fill: [your]; Else fill: [ALIAS's]
Special Instructions if HIVER2 = '1' add person's line number to HIPNAM1B or replace 'Don’t know' or
'Refused' answer
if HIVER2 = '2' add person's line number to HIPNAM2B or replace 'Don’t know' or
'Refused' answer
if HIVER2 = '3' add person's line number to HIPNAM3B or replace 'Don’t know' or
'Refused' answer
if HIVER2 = '4' add person's line number to HIPNAM4B or replace 'Don’t know' or
'Refused' answer
If HIVER2 = '5' and less than 4 plan names entered, change MORPLAN or
MORPLAN2 or MORPLAN3, as appropriate, to '1' (Yes)
Skip Instructions
<1-4> [Update any inputs into the appropriate list (HIPNAM1B, HIPNAM2B,
HIPNAM3B, HIPNAM4B),
if another person meets criteria, goto HIVER1,
else goto FHICCI8 or STNAME1 or STNAME2 or STNAME3 or MILSPC or
HILAST or HINOTYR]
<5> [If 4 plan names were given, ignore this 5th plan and if another person meets
criteria, goto HIVER1,
else goto FHICCI8 or FHI200 or STNAME1 or STNAME2 or STNAME3 or
MILSPC or HILAST or HINOTYR]
If less than 4 plan names, goto MORPLAN or MORPLAN2 or MORPLAN3, as
appropriate, to add more private health insurance plans]
goto FHICCI8 or STNAME1 or STNAME2 or STNAME3 or MILSPC or HILAST or
Wednesday, July 06, 2016
Page 51 of 117
HINOTYR
if another person meets criteria goto HIVER1
else goto FHICCI8 or STNAME1 or STNAME2 or STNAME3 or MILSPC or
HILAST or HINOTYR
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H_FHIVER2
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.190_H
Variable Name
H_FHIVER2
Universe
Universe-text
Question Text
A private health insurance plan may be provided in part or full by the persons'
employer or union, may be purchased directly by the individual, or may be provided
through a state government or local community program.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 52 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.195
Variable Name
FHICCI8
Universe
(HIPNAM1 ne ' ') and (HIPNAM1 ne 'D', 'R' or HIPNAM1B ne 'D', 'R')
Universe-text
If there is a private health insurance plan mentioned
Question Text
[Fill 1]
Answer Codes
1. Enter 1 to Continue
Question Type
Enter 1 to Continue
Field Pane Description
Fill Instructions
Continue
Fill 1: If this is the first plan in the roster (i.e. from HIPNAM1), then fill: [Now I am
going to ask some questions about the [fill 2] you just told me about [fill 3].]; Else fill:
[Next I would like to ask you about [fill 5].]
Fill 2: If only one plan mentioned, fill: [plan], else fill: [plans]
Fill 3: If more than one plan mentioned, fill: [, starting with [fill 4]]; else no fill
Fill 4: Fill name of plan mentioned in HIPNAM1 or if HIPNAM1= D, R, fill: [Plan 1]
Fill 5: Fill name of next plan from roster. (HIPNAM2, HIPNAM3, HIPNAM4)
if HIPNAM2=D,R, fill [Plan 2] or if HIPNAM3=D,R, fill [Plan 3] or If HIPNAM4=D,R fill
[Plan 4]
Special Instructions This begins the roster of private health insurance detail questions.
Do not allow answer codes D, R
Skip Instructions
<1> [goto FHI200]
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Wednesday, July 06, 2016
Page 53 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.200
Variable Name
FHI200
Universe
All private health insurance plans - FHICCI8='1'
Universe-text
asked of all private health insurance plans
Question Text
? [F1]
Health insurance plans are usually obtained in one person's name even if other family
members are covered. That person is called the policyholder. In whose name is this
plan?
* Enter line number of family member (from list below) in whose name this plan is held.
* Enter 0 if the policyholder is not on the family roster."
Answer Codes
Question Type
Pick One - answer list pane
Field Pane Description
Policyholder
Fill Instructions
Special Instructions Allow "0" response for "Policyholder outside of the family"
Skip Instructions
If <00> goto PRPOLH
if <1-25> goto PRCOOH
if goto PLNWRK
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H_PLNNAM
Wednesday, July 06, 2016
Page 54 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.200_H
Variable Name
H_PLNNAM
Universe
Universe-text
Question Text
This refers to (1) the person who purchased the policy, or (2) the person whose
employment or membership in a particular group makes
the person or the family eligible for coverage under the health insurance plan.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
FHI200
Wednesday, July 06, 2016
Page 55 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.202_01.010
Variable Name
PRPOLH
Universe
FHI200(e)='0'
Universe-text
All persons on each plan where the policyholder is outside of the family roster
Question Text
How [fill1:are you/is ALIAS] related to the policyholder for [fill2:
plan1/plan2/plan3/plan4]?
*Read if Necessary…
[fill3:You are/ALIAS is} the policyholder’s…
Answer Codes
Question Type
1. Child (including stepchildren)
2. Spouse
3. Former spouse
4. Some other relationship
Refused
Don’t know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Fill 1: If subject = respondent, fill: [are you]; else fill:[is ALIAS]
Fill 2: If subject = respondent, fill: name of plan being asked about
[plan1/plan2/plan3/plan4]
Fill 3: If subject = respondent, fill: [You are]; else fill:[ALIAS is]
Special Instructions Looped for each person per plan mentioned in fill 2.
Skip Instructions
<1-4,R,D> [goto PLNWRK]
NOTE: Detailed questions about private health insurance plans are looped through for
each plan mentioned in a family. Information on up to 4 plans per family is collected.
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Wednesday, July 06, 2016
Page 56 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.204_01.010
Variable Name
PRCOOH
Universe
('01'<=FHI200(e)<='25')
Universe-text
All private health insurance plans with policyholder on family roster
Question Text
Does this plan cover anyone who does not live here?
Answer Codes
1. Yes
2. No
Refused
Don’t know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto PLNWRK]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 57 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.210
Variable Name
PLNWRK
Universe
All private health insurance plans - FHICCI8='1'
Universe-text
asked of all private health insurance plans
Question Text
? [F1]
(book) F16
Which one of these categories best describes how this plan was obtained?
Answer Codes
Question Type
1. Through employer
2. Through union
3. Through workplace, but don't know if employer or union
4. Through workplace, self-employed or professional association
5. Purchased directly
6. Through Healthcare.gov or the Affordable Care Act, also known as Obamacare
7. Through a state/local government or community program
8. Other (specify)
Don't Know
Refused
Pick One - answer list pane
Field Pane Description
How plan obtained
Fill Instructions
Special Instructions
Skip Instructions
<1-4, 6> goto PLNPAY
<5,7,R,D> goto PLNEXCHG
<8> goto PLNWKSP
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H_PLNWRK
Wednesday, July 06, 2016
Page 58 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.210_1
Variable Name
PLNWKSP
Universe
PLNWRK= '08'
Universe-text
All private health insurance plans where the plan was obtained through an other
source
Question Text
*Read if necessary.
How was this plan obtained?
Answer Codes
Question Type
Text
Field Pane Description
Other
Fill Instructions
Special Instructions Allow 80 characters.
Skip Instructions
Goto PLNEXCHG
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AssocHelp
Wednesday, July 06, 2016
Page 59 of 117
Module
07
Section Name
Family Health insurance
Part
Question ID
FHI.210_H
Variable Name
H_PLNWRK
Universe
Universe-text
Question Text
A private health insurance plan may be provided in part or full by the persons'
employer or union, may be purchased directly by the individual, or may be provided
through a state or local government or community program.
A private health insurance plan through a state or local government program or
community program is a type of private insurance for which state or local government
or community effort pays part or all of the cost of a private insurance plan, such as
Blue Cross/Blue Shield. The individual may also contribute to the cost of the health
insurance and may receive a card such as a Blue Cross/Blue Shield card.
A community program or effort may include a variety of mechanisms to achieve health
insurance for persons who would otherwise be uninsured. An example would be a
private company giving a grant to an HMO to pay for health insurance coverage.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
PLNWRK
Wednesday, July 06, 2016
Page 60 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.215_00.010
Variable Name
PLNEXCHG
Universe
PLNWRK(e) IN ('05', '07', ‘08’, 97, 99)
Universe-text
All private health insurance plans that are not employer based (or of unknown origins)
Question Text
Was the plan obtained through the Healthcare.gov or the [fill 1: Health Insurance
Marketplace/state specific name fill]?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Purchased through marketplace
Fill 1: If no state specified below, fill Health Insurance Marketplace
If state specified below fill:
If CA then fill Health Insurance Marketplace, such as Covered California
If CO then fill Health Insurance Marketplace, such as Connect for Health Colorado
If CT then fill Health Insurance Marketplace, such as Access Health CT
If DC then fill Health Insurance Marketplace, such as DC Health Link
If HI then fill Health Insurance Marketplace, such as Hawaii Health Connector
If ID then fill Health Insurance Marketplace, such as Your Health Idaho
If KY then fill Health Insurance Marketplace, such as KYnect
If MA then fill Health Insurance Marketplace, such as Health Connector
If MD then fill Health Insurance Marketplace, such as Maryland Health Connection
If MN then fill Health Insurance Marketplace, such as MNsure
If NM then fill Health Insurance Marketplace, such as New Mexico Health
Connections
If MS then fill Health Insurance Marketplace, such as One, Mississippi
If NV then fill Health Insurance Marketplace, such as Nevada Health Link
If NY then fill Health Insurance Marketplace, such as New York State of Health
If OR then fill Health Insurance Marketplace, such as Cover Oregon
If RI then fill Health Insurance Marketplace, such as HealthSource RI
If VT then fill Health Insurance Marketplace, such as Vermont Health Connect
If WA then fill Health Insurance Marketplace, such as Washington Healthplanfinder
If UT then fill Health Insurance Marketplace, or through Avenue H
Special Instructions
Skip Instructions
<1,2,R,D> goto PLNPAY
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Wednesday, July 06, 2016
Page 61 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.220
Variable Name
PLNPAY
Universe
All private health insurance plans - FHICCI8='1'
Universe-text
asked of all private health insurance plans
Question Text
? [F1]
* Enter all that apply, separate with commas.
Who pays for this health insurance plan?
* If government program is reported, probe for Medicare or Medicaid or CHIP before
entering code 7. If government is the employer, enter code 2.
Answer Codes
Question Type
1. Self or Family (living in the household)
2. Employer or Union
3. Someone outside the household
4. Medicare
5. Medicaid
6. CHIP (SCHIP/Children’s Health Insurance Program)
7. State or local government or community program
Refused
Don’t know
Enter All That Apply
Field Pane Description
Who pays
Fill Instructions
Special Instructions
Skip Instructions
<1-7,R,D> if includes '1' [goto PLNPRE]
else [goto PLNMGD]
Hard Edits
Soft Edits
AssocHelp
H_PLNPAY
Wednesday, July 06, 2016
Page 62 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.220_H
Variable Name
H_PLNPAY
Universe
Universe-text
Question Text
This refers to the payment of premiums, not health care services or out-of-pocket
expenditures. Premiums are regular payments for health insurance coverage.
Frequently, these payments are made by payroll deduction.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 63 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.225_00.000
Variable Name
PLNPRE
Universe
PLNPAY includes '1'
Universe-text
Private plan paid for by self or family
Question Text
Is the premium paid for this plan based on income?
Answer Codes
1. Yes
2. No
Refused
Don’t know
Question Type
Yes/No
Field Pane Description
Premium paid
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto HICOSTN]
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Wednesday, July 06, 2016
Page 64 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.230_1
Variable Name
HICOSTN
Universe
PLNPAY includes '1'
Universe-text
Plans payed for by self or family
Question Text
?[F1]
1 of 2
How much [fill 1: do you/does your family] currently spend for health insurance
premiums for [fill 2: fill plan name/fill name of Plan 1]? Please include payroll
deductions for premiums.
*Enter dollar amount for premium payments.
Answer Codes
Question Type
Multi Part
Field Pane Description
Fill Instructions
Amount
fill 1: If single person family, fill: [do you]; else fill: [does your family]
fill 2: fill plan name from HIPNAM1 or HIPNAM2 or HIPNAM3 or HIPNAM4 depending
upon which sequence in the roster you are in. If HIPNAM1, HIPNAM2, HIPNAM3, or
HIPNAM4=D,R, fill [Plan 1], etc. as appropriate.
Special Instructions allow 1-99995, D, R
part 1 of 2 part question
if HICOSTN = 'D' store 'D' in HICOSTT
if HICOSTN = 'R' store 'R' in HICOSTT
Skip Instructions
<1-99995> [goto HICOSTT]
[store "R" in HICOSTT and goto PLNMGD]
[store "D" in HICOSTT and goto PLNMGD]
Hard Edits
Soft Edits
ERR_HICOSTN
* [fill # from HICOSTN] is unusually high. Please verify.
Make corrections if necessary.
AssocHelp
H_HICOST
Wednesday, July 06, 2016
Page 65 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.230_1_H
Variable Name
H_HICOST
Universe
Universe-text
Question Text
This refers to the payment of premiums, not health care services or out-of-pocket
expenditures. Premiums are regular payments for health insurance coverage.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
HICOSTN
HICOSTT
Wednesday, July 06, 2016
Page 66 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.230_2
Variable Name
HICOSTT
Universe
HICOSTN = 1-99995
Universe-text
All private health insurance plans with a valid response to HICOSTN
Question Text
?[F1]
2 of 2
* Enter time period for premium payments.
Answer Codes
Question Type
1. Once a week
2. Once every 2 weeks
3. Once a month
4. Twice a month
5. Every two months
6. Quarterly (every 3 months)
7. Once a year
8. Twice a year
Refused
Don’t know
Multi Part
Field Pane Description
Time period
Fill Instructions
Special Instructions part 2 of 2 part question
Skip Instructions
<1-8,R,D> [goto PLNMGD]
Hard Edits
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AssocHelp
H_HICOST
Wednesday, July 06, 2016
Page 67 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.240
Variable Name
PLNMGD
Universe
all private health insurance plans - FHICCI8='1'
Universe-text
asked of all private health insurance plans
Question Text
? [F1]
Is [fill 1: fill plan name/fill name of Plan 1] an HMO (Health Maintenance
Organization), an IPA (Individual Practice Association), a PPO (Preferred Provider
Organization), a POS (Point-Of-Service), fee-for-service or is it some other kind of
plan?
Answer Codes
Question Type
1. HMO/IPA
2. PPO
3. POS
4. Fee-for-service
5. Other
Refused
Don’t know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Type of plan
fill 1: [fill plan name from HIPNAM1 or HIPNAM2 or HIPNAM3 or HIPNAM4] or [if
HIPNAM1, HIPNAM2, HIPNAM3, or HIPNAM4=D,R, fill [Plan 1], etc. as appropriate.
Special Instructions Add an answer tag for this question.
Skip Instructions
<1-5,D,R> [goto HDHP]
Hard Edits
Soft Edits
AssocHelp
H_PLNMGD
Wednesday, July 06, 2016
Page 68 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.240_H
Variable Name
H_PLNMGD
Universe
Universe-text
Question Text
[b]HMO[b] - Health Maintenance Organizations are health delivery systems that offer
comprehensive health coverage for hospital and physician services for a prepaid,
fixed fee.
[b]IPA[b] - type of HMO which contracts directly with physicians in independent
practices, and/or contracts with one or more associations of physicians in independent
practices, or multi-specialties. The plan is predominantly organized around
solo/single practices.
[b]PPO[b] - Preferred Provider Organizations are a form of managed care although
not a "traditional" HMO. Enrollees in PPOs are encouraged to use designated or
"preferred" health providers. Financial incentives for individuals include lower
payments or coinsurance and maximum limits on out-of-pocket costs for in-network
use. PPOs are less restrictive than HMO's in that visits to specialists are not
dependent on the authorization by a member’s primary care physician. Unlike HMOs,
out-of-network usage is allowed by PPOs though at a higher cost to enrollee.
[b]POS[b] - Point-of-Service plans are a form of managed care although not a
"traditional" HMO. POS plans allow for "opt-out" or out-of-network coverage, but
accompanied by strong economic incentives to the enrollees to use network providers.
POS plans generally use gatekeepers for referrals to specialists in the network. It is
this attribute that most readily distinguishes a POS plan from a PPO.
[b]Fee-for-Service[b] - This is the traditional kind of health care policy. Insurance
companies pay fees for the services provided to the insured people covered by the
policy. This type of health insurance offers the most choices of doctors and hospitals.
You can choose any doctor you wish and change doctors any time. You can go to any
hospital in any part of the country. With fee-for-service, the insurer only pays for part
of your doctor and hospital bills. A fee-for-service plan pays for covered services after
services have been received.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
Wednesday, July 06, 2016
Page 69 of 117
AssocHelp
PLNMGD
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.241
Variable Name
HDHP
Universe
All Private Health Insurance Plans - FHICCI8='1'
Universe-text
Asked of All Private Health Insurance Plans
Question Text
?[F1]
[If only one person covered by this plan:]
Is the annual deductible for medical care for this plan less than $1,300 or $1,300 or
more? If there is a separate deductible for prescription drugs, hospitalization, or outof-network care, do not include those deductible amounts here.
[If two or more persons in the family are covered by this plan:]
Is the family annual deductible for medical care for this plan less than $2,600 or
$2,600 or more? If there is a separate deductible for prescription drugs,
hospitalization, or out-of-network care, do not include those deductible amounts here.
Answer Codes
Question Type
1. Less than [fill 1: $1,300/$2,600]
2. [fill 1: $1,300/$2,600] or more
Refused
Don’t know
Pick One - answer list pane
Field Pane Description
Fill Instructions
HDHP Plan
fill 1: if one person covered by the plan, fill $1,300;
else, if two or more persons covered by the plan, fill $2,600
Special Instructions
Skip Instructions
<1,R,D> [goto MGCHMD]
<2> [goto HSAHRA]
Hard Edits
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AssocHelp
H_HSAHRA
Wednesday, July 06, 2016
Page 70 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.242
Variable Name
HSAHRA
Universe
HDHP=2
Universe-text
Asked of All High Deductible Private Health Plans
Question Text
?[F1]
With this plan, is there a special account or fund that can be used to pay for medical
expenses? The accounts are sometimes referred to as Health Savings Accounts
(HSAs), Health Reimbursement Accounts (HRAs), Personal Care accounts, Personal
Medical funds, or Choice funds, and are different from Flexible Spending Accounts.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don’t know
Yes/No
Field Pane Description
HSAHRA
Fill Instructions
Special Instructions
Skip Instructions
1,2,R,D [goto MGCHMD]
Hard Edits
Soft Edits
AssocHelp
H_HSAHRA
Wednesday, July 06, 2016
Page 71 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.242_H
Variable Name
H_HSAHRA
Universe
Universe-text
Question Text
[b]Health Savings Account[b] - A Health Savings Account or HSA is an account that is
used to pay for medical expenses not covered by one’s insurance plan. HSAs require
a companion high deductible insurance policy. The employer may fund them or the
employee and balances may rollover from year to year. Features of a HSA include:
tax-deductible deposits, tax deferred interest earned on the account, tax-free
withdrawals for qualified medical expenses, carryover of unused funds and interest
from year to year, and portability. A HSA qualified insurance policy must have a
deductible of at least $1300 for individuals and $2600 for families.
[b]Health Reimbursable Agreement[b] - A Health Reimbursable Agreement or HRA is
an account that is used to pay for medical expenses. HRAs are an employer-funded
account with the following features: tax free withdrawals for qualified medical
expenses, carryover of unused credits from year to year, credits in a HRA do not earn
interest, credits in a HRA are forfeited if health insurance plan is switched.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 72 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.243
Variable Name
MGCHMD
Universe
all private health insurance plans - FHICCI8='1'
Universe-text
asked of all private health insurance plans
Question Text
Under this plan, can [fill 1:you/ALIAS/the family members with this plan] choose ANY
doctor or MUST [fill2:you/he/she/they] choose one from a specific group or list of
doctors?
Answer Codes
1. Any doctor
2. Select from group/list
Refused
Don’t know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Any doctor
Fill 1: If single person family, or if respondent is the only person covered, fill: [you];
else, if only one person is covered, and that person is not the respondent, fill :[
ALIAS]; else, fill: [the family members with this plan]
Fill 2: If single person family, or if respondent is the only person covered, fill: [you];
else, if only one person is covered, and that person is not the respondent and SEX =
1, fill :[ he]; else, if only one person is covered, and that person is not the respondent
and SEX = 2, fill :[ she]; else, fill: [they]
Special Instructions
Skip Instructions
<1> [goto MGPRMD]
<2> [goto MGPYMD]
[goto PCPREQ]
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Wednesday, July 06, 2016
Page 73 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.244
Variable Name
MGPRMD
Universe
MGCHMD = '1'
Universe-text
All private health insurance plans where covered persons can choose any doctor
Question Text
[fill 1:Do you/Does ALIAS/Do the family members with this plan] have the option of
choosing a doctor from a preferred or select list at a lower cost?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Choose from list
Fill 1: If single person family, or if respondent is the only person covered, fill: [Do
you]; else if only one person is covered, and that person is not the respondent, fill :[
Does ALIAS]; else fill: [Do the family members with this plan]
Special Instructions
Skip Instructions
[goto PCPREQ]
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Wednesday, July 06, 2016
Page 74 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.246
Variable Name
MGPYMD
Universe
MGCHMD = '2'
Universe-text
All private health insurance plans where covered persons must select from a group or
list of doctors
Question Text
If [fill 1: you select/ALIAS selects/the family members with this plan select] a doctor
who is not in the plan, will [fill 2:^HIPNAM1/ ^HIPNAM2/^HIPNAM3/^ HIPNAM4/Plan
1/Plan 2/Plan 3/Plan 4] pay for any part of the cost?
Answer Codes
1. Yes
2. No
Refused
Don’t know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Pay for cost
Fill 1: If single person family, or if respondent is the only person covered, fill: [you
select]; else if only one person is covered, and that person is not the respondent, fill :[
ALIAS selects]; else fill: [the family members with this plan select]
fill 2: Fill the plan name from HIPNAM1 or HIPNAM2 or HIPNAM3 or HIPNAM4
depending upon the sequence in the roster. If HIPNAM, HIPNAM2 or HIPNAM3 or
HIPNAM4= D, R, fill [Plan 1], etc. as appropriate.
Special Instructions
Skip Instructions
[goto PCPREQ]
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Wednesday, July 06, 2016
Page 75 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.248_05.000
Variable Name
PCPREQ
Universe
All private health insurance plans - FHICCI8 = '1'
Universe-text
Asked of all private health insurance plans
Question Text
Does this plan REQUIRE [fill1: you/ALIAS/the family members with this plan] to have a
primary care doctor who approves all [fill2: your/their] care?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Fill 1: If single person family, or if respondent is the only person covered, fill: [you];
else if only one person is covered, and that person is not the respondent, fill :[ ALIAS];
else fill: [the family members with this plan]
Fill 2: if single person family or if respondent is the only person covered, fill: [your];
else fill: [their]
Special Instructions
Skip Instructions
<1,2,R,D> [goto PRRXCOV]
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Wednesday, July 06, 2016
Page 76 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.249_01
Variable Name
PRRXCOV
Universe
All private health insurance plans - FHICCI8='1'
Universe-text
All private health insurance plans
Question Text
Does [fill 1: ^HIPNAM1 or ^HIPNAM2, or ^HIPNAM3, or ^HIPNAM4 or Plan 1 or Plan 2
or Plan 3 or Plan 4] pay for any of the costs for medicines prescribed by a doctor?
* Read if necessary: Does this plan have a drug benefit?
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't Know
Yes/No
Field Pane Description
Fill Instructions
Pays for Drugs Private
Fill 1: ^HIPNAM1 or ^HIPNAM2, or ^HIPNAM3, or ^HIPNAM4 or Plan 1 or Plan 2 or
Plan 3 or Plan 4
Special Instructions Loop through from FHICCI8 for any other private plans. When roster is exhausted,
goto next appropriate question.
Skip Instructions
goto PRDNCOV
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Wednesday, July 06, 2016
Page 77 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.249_02
Variable Name
PRDNCOV
Universe
All private health insurance plans - FHICCI8='1'
Universe-text
All private health insurance plans
Question Text
Does [fill 1: ^HIPNAM1 or ^HIPNAM2, or ^HIPNAM3, or ^HIPNAM4 or Plan 1 or Plan 2
or Plan 3 or Plan 4] pay for any of the costs for dental care?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Dental insurance
Fill 1: ^HIPNAM1 or ^HIPNAM2, or ^HIPNAM3, or ^HIPNAM4 or Plan 1 or Plan 2 or
Plan 3 or Plan 4
Special Instructions
Skip Instructions
Loop through from FHICCI8 for any other private plans. When roster is exhausted,
if any PLNWRK in ('1','2','3','4') goto FCOVCONF
else goto STNAME1 or STNAME2 or STNAME3 or MILSPC or HILAST or HINOTYR
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Wednesday, July 06, 2016
Page 78 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.249_03
Variable Name
FCOVCONF
Universe
PLNWRK(e) IN('1','2','3','4')
Universe-text
All families with an employer-based health plan
Question Text
If [fill1: you/your family] had to buy a health plan on [fill 2: your/its] own with no help
from [fill 3: your/an] employer, how confident are you that [fill 1: you/your family] would
be able to obtain affordable coverage Would you say…
*Read categories below.
Answer Codes
Question Type
1. Very confident
2. Somewhat confident
3. Not too confident
4. Not confident at all
Don’t know
Refused
Pick One - answer list pane
Field Pane Description
Fill Instructions
Fill 1: if single person family fill "you"; else fill "your family"
Fill 2: if single person family fill "your"; else fill "its"
Fill 3: if single person family fill "your"; else fill "an"
Special Instructions
Skip Instructions
<1-4,R,D> goto STNAME1 or STNAME2 or STNAME3 or MILSPC or HILAST or
HINOTYR
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Wednesday, July 06, 2016
Page 79 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.250
Variable Name
STNAME1
Universe
AGE = All and HIKIND = '05'
Universe-text
All persons with CHIP
Question Text
Earlier I recorded that [fill 1: you are/ALIAS is] covered by the Children’s Health
Insurance Program (CHIP/SCHIP). What is the name of the plan?
* Read if necessary: Do you have a health plan card or something with the plan name
on it?
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
Name of CHIP Plan
Fill 1:If subject = respondent, fill: [you are]; else, fill: [ALIAS is]
Special Instructions Loop through STNAME1 - STREF1 on a person basis.
Allow 80 characters, D, R
Skip Instructions
[goto CHXCHNG]
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Wednesday, July 06, 2016
Page 80 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.250_00.010
Variable Name
CHXCHNG
Universe
AGE = All and HIKIND(e)='05'
Universe-text
All persons with CHIP
Question Text
Was [fill 1: your/ALIAS's] CHIP plan obtained through the [fill 2: Health Insurance
Marketplace/ fill state specific fill]?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
CHIP through marketplace
Fill 1: If subject = respondent, fill [your]; else, fill [ALIAS's]
Fill 2: If no state specified below, fill Health Insurance Marketplace
If state specified below fill:
If CA then fill Health Insurance Marketplace, such as Covered California
If CO then fill Health Insurance Marketplace, such as Connect for Health Colorado
If CT then fill Health Insurance Marketplace, such as Access Health CT
If DC then fill Health Insurance Marketplace, such as DC Health Link
If HI then fill Health Insurance Marketplace, such as Hawaii Health Connector
If ID then fill Health Insurance Marketplace, such as Your Health Idaho
If KY then fill Health Insurance Marketplace, such as KYnect
If MA then fill Health Insurance Marketplace, such as Health Connector
If MD then fill Health Insurance Marketplace, such as Maryland Health Connection
If MN then fill Health Insurance Marketplace, such as MNsure
If NM then fill Health Insurance Marketplace, such as New Mexico Health
Connections
If MS then fill Health Insurance Marketplace, such as One, Mississippi
If NV then fill Health Insurance Marketplace, such as Nevada Health Link
If NY then fill Health Insurance Marketplace, such as New York State of Health
If OR then fill Health Insurance Marketplace, such as Cover Oregon
If RI then fill Health Insurance Marketplace, such as HealthSource RI
If VT then fill Health Insurance Marketplace, such as Vermont Health Connect
If WA then fill Health Insurance Marketplace, such as Washington Healthplanfinder
If UT then fill Health Insurance Marketplace, or through Avenue H
Special Instructions
Skip Instructions
<1,2,R,D> [goto STRFPRM1]
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Wednesday, July 06, 2016
Page 81 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.250_00.020
Variable Name
STRFPRM1
Universe
AGE = All and HIKIND(e)='05'
Universe-text
All persons with CHIP
Question Text
A health insurance premium is the amount you or a family member pays each month
for health care coverage. Do you or a family member pay a premium for this CHIP
plan?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
CHIP premium
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto CHPRINC]
<2,R,D> [goto STDOC1]
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Wednesday, July 06, 2016
Page 82 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.250_00.030
Variable Name
CHPRINC
Universe
AGE = All and STRFPRM1(e)='01'
Universe-text
Those with CHIP coverage who pay a premium for their plan
Question Text
Is the premium paid for [fill 1: ^STNAME1/this CHIP plan] based on income?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Premium based on income
Fill 1: [fill: ^STNAME1], else if STNAME1 = to D or R, fill: [this CHIP plan]
Special Instructions
Skip Instructions
<1,2,R,D> goto STDOC1
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Wednesday, July 06, 2016
Page 83 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.251
Variable Name
STDOC1
Universe
AGE = All and HIKIND = '05'
Universe-text
All persons with SCHIP
Question Text
Under the [fill 1:^STNAME1/CHIP PLAN] can [fill 2: you/ALIAS] go to ANY doctor who
will accept this plan or MUST [fill 3: you/he/she] choose from a list of doctors or is the
doctor assigned?
Answer Codes
1. Any doctor
2. Select from list
3. Doctor is assigned
Refused
Don’t know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Any Doctor
Fill 1: fill: [^STNAME1]; else, if STNAME1 = D or R, fill: [CHIP Plan]
Fill 2: If subject = respondent, fill [you]; else fill: [ALIAS]
Fill 3: If subject = respondent, fill [you]; else if sex = 1, fill: [he]; else, if sex = 2, fill:
[she]
Special Instructions
Skip Instructions
<1, 2, D, R> goto next person in roster, else [goto STNAME2]
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Wednesday, July 06, 2016
Page 84 of 117
Module
07
Section Name
Part
Question ID
FHI.257
Variable Name
STNAME2
Universe
AGE = All and HIKIND = '08'
Universe-text
All persons with a state sponsored health plan
Question Text
Earlier I recorded that [fill 1: you are/ALIAS is] covered by a state sponsored health
plan. What is the name of the plan?
* Read if necessary: Do you have a health plan card or something with the plan name
on it?
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
Name of State Sponsored Plan
Fill 1:If subject = respondent, fill: [you are]; else, fill: [ALIAS is]
Special Instructions Loop through STNAME2 - STREF2 on a person basis.
Skip Instructions
goto OPXCHNG
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Wednesday, July 06, 2016
Page 85 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.257_00.010
Variable Name
OPXCHNG
Universe
AGE = All and HIKIND(e) = '08'
Universe-text
All persons with a state sponsored health plan
Question Text
Was [fill 1: your/ALIAS's] state sponsored health plan obtained through
Healthcare.gov or the [fill 2: Health Insurance Marketplace/ fill state specific name]?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
State plan through marketplace
Fill 1: If subject = respondent, fill [your]; else, fill [ALIAS's]
Fill 2: If no state specified below, fill Health Insurance Marketplace
If state specified below fill:
If CA then fill Health Insurance Marketplace, such as Covered California
If CO then fill Health Insurance Marketplace, such as Connect for Health Colorado
If CT then fill Health Insurance Marketplace, such as Access Health CT
If DC then fill Health Insurance Marketplace, such as DC Health Link
If HI then fill Health Insurance Marketplace, such as Hawaii Health Connector
If ID then fill Health Insurance Marketplace, such as Your Health Idaho
If KY then fill Health Insurance Marketplace, such as KYnect
If MA then fill Health Insurance Marketplace, such as Health Connector
If MD then fill Health Insurance Marketplace, such as Maryland Health Connection
If MN then fill Health Insurance Marketplace, such as MNsure
If NM then fill Health Insurance Marketplace, such as New Mexico Health
Connections
If MS then fill Health Insurance Marketplace, such as One, Mississippi
If NV then fill Health Insurance Marketplace, such as Nevada Health Link
If NY then fill Health Insurance Marketplace, such as New York State of Health
If OR then fill Health Insurance Marketplace, such as Cover Oregon
If RI then fill Health Insurance Marketplace, such as HealthSource RI
If VT then fill Health Insurance Marketplace, such as Vermont Health Connect
If WA then fill Health Insurance Marketplace, such as Washington Healthplanfinder
If UT then fill Health Insurance Marketplace, or through Avenue H
Special Instructions
Skip Instructions
<1,2,R,D> goto STRFPRM2
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Wednesday, July 06, 2016
Page 86 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.257_00.020
Variable Name
STRFPRM2
Universe
AGE = All and HIKIND(e) = '08'
Universe-text
All persons with a state sponsored health plan
Question Text
A health insurance premium is the amount you or a family member pays each month
for health
care coverage. Do you or a family member pay a premium for [fill : your/ALIAS's]
state-sponsored health plan?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
State plan premium
Fill 1: If subject = respondent, fill [your]; else, fill [ALIAS's]
Special Instructions
Skip Instructions
<1> goto SSPRINC
<2,R,D> goto STDOC2
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Wednesday, July 06, 2016
Page 87 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.257_00.030
Variable Name
SSPRINC
Universe
AGE = All and STRFPRM2(e)='1'
Universe-text
Those with state sponsored health plan who pay a premium for their plan
Question Text
Is the premium paid for [fill 1: ^STNAME2/this state sponsored plan] based on income?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Premium based on income
Fill 1: [fill: ^STNAME2], else if STNAME2 = to D or R, fill: [this state sponsored plan]
Special Instructions
Skip Instructions
<1,2,R,D> goto STDOC2
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Wednesday, July 06, 2016
Page 88 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.258
Variable Name
STDOC2
Universe
AGE = All and HIKIND = '08'
Universe-text
All persons with state sponsored health care
Question Text
Under the [fill 1:^STNAME2/state sponsored plan] can [fill 2: you/ALIAS] go to ANY
doctor who will accept this plan or MUST [fill 3: you/he/she] choose from a list of
doctors or is the doctor assigned?
Answer Codes
1. Any doctor
2. Select from list
3. Doctor is assigned
Refused
Don’t know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Any Doctor
Fill 1: [fill: ^STNAME2], else; if STNAME2 = to D or R, fill: [state sponsored plan]
Fill 2: If subject = respondent, fill [you]; else fill: [ALIAS]
Fill 3: If subject = respondent, fill [you]; else if sex = 1, fill: [he]; else, if sex = 2, fill:
[she]
Special Instructions
Skip Instructions
<1, 2, D, R> [goto STNAME3]
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Wednesday, July 06, 2016
Page 89 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.264
Variable Name
STNAME3
Universe
AGE = All and HIKIND = '09'
Universe-text
All persons with an other government plan
Question Text
Earlier I recorded that [fill 1: you are/ALIAS is] covered by an other government
program. What is the name of the plan?
* Read if necessary: Do you have a health plan card or something with the plan name
on it?
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
Name of Other Government Plan
Fill 1:If subject = respondent, fill: [you are]; else, fill: [ALIAS is]
Special Instructions Loop through STNAME3 - STREF3 on a person basis.
Allow 80 characters, D, R
Skip Instructions
[goto OGXCHNG]
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Wednesday, July 06, 2016
Page 90 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.264_00.010
Variable Name
OGXCHNG
Universe
AGE = All and HIKIND(e)='09'
Universe-text
All persons with an other government program
Question Text
Was [fill1: your/ALIAS's] other government program obtained through Healthcare.gov
or the [fill2]?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Other plan through marketplace
Fill 1: If subject = respondent, fill [your]; else, fill [ALIAS's]
Fill 2: If no state specified below, fill Health Insurance Marketplace
If state specified below fill:
If CA then fill Health Insurance Marketplace, such as Covered California
If CO then fill Health Insurance Marketplace, such as Connect for Health Colorado
If CT then fill Health Insurance Marketplace, such as Access Health CT
If DC then fill Health Insurance Marketplace, such as DC Health Link
If HI then fill Health Insurance Marketplace, such as Hawaii Health Connector
If ID then fill Health Insurance Marketplace, such as Your Health Idaho
If KY then fill Health Insurance Marketplace, such as KYnect
If MA then fill Health Insurance Marketplace, such as Health Connector
If MD then fill Health Insurance Marketplace, such as Maryland Health Connection
If MN then fill Health Insurance Marketplace, such as MNsure
If NM then fill Health Insurance Marketplace, such as New Mexico Health
Connections
If MS then fill Health Insurance Marketplace, such as One, Mississippi
If NV then fill Health Insurance Marketplace, such as Nevada Health Link
If NY then fill Health Insurance Marketplace, such as New York State of Health
If OR then fill Health Insurance Marketplace, such as Cover Oregon
If RI then fill Health Insurance Marketplace, such as HealthSource RI
If VT then fill Health Insurance Marketplace, such as Vermont Health Connect
If WA then fill Health Insurance Marketplace, such as Washington Healthplanfinder
If UT then fill Health Insurance Marketplace, or through Avenue H
Special Instructions
Skip Instructions
<1,2,R,D> goto STRFPRM3
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Wednesday, July 06, 2016
Page 91 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.264_00.020
Variable Name
STRFPRM3
Universe
AGE = All and HIKIND(e)='09'
Universe-text
All persons with an other government program
Question Text
A health insurance premium is the amount you or a family member pays each month
for health care coverage. Do you or a family member pay a premium for [fill :
your/ALIAS's] other government program?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Other plan premium
Fill 1: If subject = respondent, fill [your]; else, fill [ALIAS's]
Special Instructions
Skip Instructions
<1> goto OGPRINC
<2,R,D> goto STDOC3
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Wednesday, July 06, 2016
Page 92 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.264_00.030
Variable Name
OGPRINC
Universe
AGE = All and STRFPRM3(e)='01'
Universe-text
Those with other government health plan who pay a premium for their plan
Question Text
Is the premium paid for [fill 1: ^STNAME3/this other government plan] based on
income?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Premium based on income
Fill 1: [fill: ^STNAME3], else if STNAME3 = to D or R, fill: [this other government plan]
Special Instructions
Skip Instructions
<1,2,R,D> goto STDOC3
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Wednesday, July 06, 2016
Page 93 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.265
Variable Name
STDOC3
Universe
AGE = All and HIKIND = '09'
Universe-text
All persons with an other government plan
Question Text
Under the [fill 1:^STNAME3/other government plan] can [fill 2: you/ALIAS] go to ANY
doctor who will accept this plan or MUST [fill 3:you/he/she] choose from a list of
doctors or is the doctor assigned?
Answer Codes
1. Any doctor
2. Select from list
3. Doctor is assigned
Refused
Don’t know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Any Doctor
Fill 1: [^STNAME3]; else, if STNAME3= to D or R, fill: [other government plan]
Fill 2: If subject = respondent, fill [you]; else fill: [ALIAS]
Fill 3: If subject = respondent, fill [you]; else if sex = 1, fill: [he]; else, if sex = 2, fill:
[she]
Special Instructions
Skip Instructions
<1,2,D,R> [goto STNAME3] *see flowchart
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Wednesday, July 06, 2016
Page 94 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.270
Variable Name
MILSPC
Universe
AGE = All and HIKIND = '06'
Universe-text
All persons with military health care
Question Text
? [F1]
* Enter all that apply, separate with commas.
Earlier I recorded that [fill 1] covered by military health care. What types of military
health care [fill 2:] covered by?
Answer Codes
Question Type
1. TRICARE
2. VA
3. CHAMP-VA
4. Other military coverage (specify)
Don’t know
Refused
Enter All That Apply
Field Pane Description
Fill Instructions
Type of Military Coverage
Fill 1: If subject = respondent, fill: [you are]; Else fill: [ALIAS is]
Fill 2: If subject = respondent, fill: [are you]; Else fill: [is ALIAS]
Special Instructions
Skip Instructions
<1> [goto MILMAN]
<4> [goto MILSPCOT]
<2,3,D,R> [loop through for all persons in roster, when exhausted, goto next
appropriate question.]
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Wednesday, July 06, 2016
Page 95 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.270_H
Variable Name
H_MILSPC
Universe
Universe-text
Question Text
[b]TRICARE[b] is a regionally managed health care program for active duty and
retired members of the uniformed services, their families, and survivors. TRICARE for
military dependents was previously known as CHAMPUS.
[b]VA[b] (Veterans Administration) provides medical assistance to veterans of the
Armed Forces, particularly those with service-connected ailments.
[b]CHAMP-VA[b] (Comprehensive Health and Medical Plan of the Veterans
Administration) provides health care for the spouse, dependents, or survivors of a
veteran who has a total, permanent service-connected disability.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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MILSPC
Wednesday, July 06, 2016
Page 96 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.271
Variable Name
MILSPCOT
Universe
MILSPC = '04'
Universe-text
All persons with other military coverage
Question Text
* Other military coverage
Answer Codes
Question Type
Text
Field Pane Description
Other
Fill Instructions
Special Instructions Allow 80 characters
Skip Instructions
if MILSPC eq 1, goto MILMAN;
else, goto next appropriate question
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Wednesday, July 06, 2016
Page 97 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.275
Variable Name
MILMAN
Universe
MILSPC = '01'
Universe-text
All persons with TRICARE coverage
Question Text
? [F1]
Is [fill 1: your/ALIAS's] TRICARE plan, TRICARE prime, TRICARE Extra, TRICARE
Standard or TRICARE for Life?
Answer Codes
Question Type
1. TRICARE Prime
2. TRICARE Extra
3. TRICARE Standard
4. TRICARE for Life
5. TRICARE other (specify)
Refused
Don’t know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Type of TRICARE
Fill 1:If subject = respondent, fill: [your]; Else, fill: [ALIAS’s]
Special Instructions
Skip Instructions
<1-4,D,R> [goto next appropriate question]
<5> [goto MILMANOT]
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H_MILMAN
Wednesday, July 06, 2016
Page 98 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.275_H
Variable Name
H_MILMAN
Universe
Universe-text
Question Text
[b]TRICARE[b] is a regionally managed health care program for active duty and
retired members of the uniformed services, their families, and survivors. TRICARE
offers eligible beneficiaries four choices for their health care:
[b]TRICARE Prime[b] - Under this TRICARE option, Military Treatment Facilities are
the principal source of health
care. Active duty military personnel are automatically enrolled in TRICARE Prime.
Family members and
survivors of active duty personnel and retirees and their family members and survivors
under age 65 are also
eligible for TRCARE prime.
[b]TRICARE Extra[b] - Under this TRICARE option you choose a doctor, hospital, or
other medical provider listed in
the TRICARE Provider Directory. Anyone who is CHAMPUS (Comprehensive Health
and Medical Plan for the
Uniformed Services) eligible may use TRICARE Extra.
[b]TRICARE Standard[b] - This is the new name for traditional CHAMPUS. Under
this plan, you can see the
authorized provider of your choice. Treatment may also be available at a Military
Treatment Facility. Anyone
who is CHAMPUS (Comprehensive Health and Medical Plan for the Uniformed
Services) eligible may use
TRICARE Standard.
[b]TRICARE for Life (TFL)[b] - This option is available to all Medicare-eligible
uniformed services retirees,
Medicare-eligible family members, and Medicare-eligible widows/widowers and certain
former spouses who
were eligible for TRICARE before age 65. Beneficiaries are required to purchase
Medicare Part B and MUST
pay the appropriate Medicare Part B monthly premiums. TRICARE for Life pays
secondary to Medicare.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Wednesday, July 06, 2016
Page 99 of 117
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MILMAN
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.276
Variable Name
MILMANOT
Universe
MILMAN = '5'
Universe-text
All persons with other type of TRICARE coverage
Question Text
* Other type of TRICARE coverage
Answer Codes
Question Type
Text
Field Pane Description
Other TRICARE
Fill Instructions
Special Instructions Allow 80 characters
Skip Instructions
Loop through from MILSPC for all persons with this coverage. When exhausted, goto
next appropriate question.
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Wednesday, July 06, 2016
Page 100 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.280
Variable Name
HILAST
Universe
AGE = All and HIKIND = '10','11'
Universe-text
All persons without known health insurance or with only single service plans
Question Text
(book) F17
? [F1]
Not including Single Service Plans, about how long has it been since [fill 1:
you/ALIAS] last had health care coverage?
Answer Codes
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
Refused
Don’t know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Time Since Last Covered
Fill 1: If subject = respondent, fill: [you]; Else fill: [ALIAS]
Special Instructions
Skip Instructions
[goto HISTOP]
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H_HILAST
Wednesday, July 06, 2016
Page 101 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.280_H
Variable Name
H_HILAST
Universe
Universe-text
Question Text
Single Service Plans do not count for this item. A Single Service Plan is designed to
provide coverage for a specific type of service/care. This plan is usually limited to one
type of service or treatment for a specific condition and is frequently obtained to
supplement a comprehensive plan that may not provide that type of service.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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HILAST
Wednesday, July 06, 2016
Page 102 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.290
Variable Name
HISTOP
Universe
AGE = All and HIKIND = '10','11'
Universe-text
All persons without known health insurance or with only single service plans
Question Text
(book) F18
[Fill 1: [Which of these are reasons [fill 2:you/ALIAS] stopped being covered?/Which
of these are reasons [fill 3: you do/ALIAS does] not have health insurance?]
* Enter up to 5 reasons, separate with commas.
Answer Codes
Question Type
1. Person in family with health insurance lost job or changed employers
2. Got divorced or separated/death of spouse or parent
3. Became ineligible because of age/left school
4. Employer does not offer coverage/or not eligible for coverage
5. Cost is too high
6. Insurance company refused coverage
7. Medicaid/Medical plan stopped after pregnancy
8. Lost Medicaid/Medical plan because of new job or increase in income
9. Other reason for losing Medicaid
10. Other (specify)
Refused
Don’t know
Enter All That Apply
Field Pane Description
Fill Instructions
Why No Coverage
Fill 1: If HILAST eq <1-5>, fill: [Which of these are reasons [fill 2] stopped being
covered?]; else if HILAST eq <6,R,D>, fill: [Which of these are reasons [fill 3] not have
health insurance?]
Fill 2: If subject = respondent, fill: [you]; else fill: [ALIAS]
Fill 3: If subject = respondent, fill: [you do]; else fill: [ALIAS does]
Special Instructions
Skip Instructions
<1-9,D,R> [goto FHIKDB]
<10> [goto HISTOPOT]
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Wednesday, July 06, 2016
Page 103 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.291
Variable Name
HISTOPOT
Universe
HISTOP = '10'
Universe-text
All persons without known health insurance and other reason for stopping or not
having coverage
Question Text
? [F1]
* Other reason for not having coverage
Answer Codes
Question Type
Text
Field Pane Description
Other
Fill Instructions
Special Instructions Allow 80 characters
Skip Instructions
Goto FHIKDB
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H_HISTOPO
Wednesday, July 06, 2016
Page 104 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.291_H
Variable Name
H_HISTOPO
Universe
Universe-text
Question Text
Enter exactly what the respondent tells you, in their own words.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
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HISTOPOT
Wednesday, July 06, 2016
Page 105 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.300
Variable Name
HINOTYR
Universe
HIKIND= '1','2','3','4','5','6','7','8','9'
Universe-text
All persons with known health insurance, except single service plans
Question Text
In the PAST 12 MONTHS, was there any time when [fill 1: you/ALIAS] did NOT have
ANY health insurance or coverage?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Without Coverage
Fill 1: If subject = respondent, fill: [you]; Else fill: [ALIAS]
Loop through HINOTYR and PWRKBSP for each person in universe.
<1> [goto HINOTMYR]
<2,D,R> [goto FHICHNG]
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Wednesday, July 06, 2016
Page 106 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.310
Variable Name
HINOTMYR
Universe
HINOTYR = '1'
Universe-text
All persons who currently have health insurance who did not have
health insurance/coverage for some period of time in the past 12 months
Question Text
In the PAST 12 MONTHS, about how many months [fill 1: were you/was ALIAS]
without coverage?
* If less than 1 month, enter '1'.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Months Without Coverage
Fill 1: If subject = respondent, fill: [were you]; Else fill: [was ALIAS]
Special Instructions Allow 1-12, D, R
Insert answer tag "months to the right of answer field.
When roster is exhausted, goto FHIKDB
Skip Instructions
<1-12,D,R>
When roster is exhausted, goto FHIKDB
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Wednesday, July 06, 2016
Page 107 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.312_00.010
Variable Name
FHICHNG
Universe
HINOTYR(e)='2','D','R'
Universe-text
All persons who are currently insured who were continuously covered in the past year
Question Text
Did [fill1: you/ALIAS] have [fill2: type of health insurance coverage] for the past 12
months?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Fill1: If single person family fill "you"; else fill "ALIAS"
Fill 2: fill with [HIKIND] and separate with a comma for multiple plans, when
applicable. If MCAREPRB=1 or MCAIDPRB=1, add a fill of 'Medicare' or 'Medicaid' to
any other plans mentioned in HIKIND. If HIKIND=11 (No coverage of any type), do
not fill this text in the fill variable (tempHIKIND).
Special Instructions
Skip Instructions
<1,R,D> [goto HCSPFYR]
<2> [goto FHIKDB]
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Wednesday, July 06, 2016
Page 108 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.315_00.010
Variable Name
FHIKDB
Universe
HISTOP = '1','2','3','4','5','6','7','8','9','10','D', 'R' or HINOTYR = '1' or FHICHNG = '2'
Universe-text
All persons except those with continuous coverage who are currently uninsured for
more than 1 year with no changes
Question Text
(book) F12 and (book) F14
If person is currently uninsured:
{Think about the last time [fill1: you/ALIAS] had health insurance or health care
coverage. What type did [fill1: you/ALIAS] have?}
If person had a period without coverage in the past year:
{I recorded that [fill1: you/ALIAS] had a period without health insurance in the past
year. What type of health insurance or coverage did [fill1: you/ALIAS] have before
this period?}
If person had a change in coverage type in the past year:
{What other types of health insurance or health care coverage did [fill1: you/ALIAS]
have?}
*Enter all that apply, separate with commas.
Answer Codes
Question Type
1. Private health insurance
2. Medicare
3. Medi-Gap
4. Medicaid
5. CHIP (SCHIP/Children's Health Insurance Program)
6. Military health care (TRICARE/VA/CHAMP-VA)
7. Indian Health Service
8. State-sponsored health plan
9. Other government program
10. Single service plan (e.g., dental, vision, prescriptions)
11. No coverage of any type
Refused
Don't know
Enter all that apply
Field Pane Description
Fill Instructions
If HISTOP <1-10, D, R> for currently uninsured fill: [Think about the last time [fill1:
you/ALIAS] had health insurance or health care coverage. What type(s) did [fill 1:
you/ALIAS] have?]
If HINOTMYR not = to empty, for period without coverage in the past year fill: {I
recorded that [fill1: you/ALIAS] had a period without health insurance in the past year.
What type of health insurance or coverage did [fill1:you/ALIAS] have before this
Wednesday, July 06, 2016
Page 109 of 117
period?}
If FHICHNG=2, for a change in coverage type in the last year fill: {What other types
of health insurance or health care coverage did [fill1: you/ALIAS] have?}
Special Instructions
Skip Instructions
<1> [goto PWRKB]
<2-11,R,D> [goto HCSPFYR]
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Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.316_00.010
Variable Name
PWRKB
Universe
FHIKDB(e)='01'
Universe-text
All persons who had private health insurance previously
Question Text
Which one of these categories best describes how [fill1: your/ALIAS’s] private health
insurance was obtained?
Answer Codes
1. Through employer
2. Through union
3. Through workplace, but don't know if employer or union
4. Through workplace, self-employed or professional association
5. Purchased directly
6. Through a state/local government or community program
7. Other, specify
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Fill 1: If subject = respondent, fill: [your]; else fill:[ALIAS's]
Special Instructions
Skip Instructions
<1-6,R,D> [goto HCSPFYR] <7> [goto PWRKBSP]
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Wednesday, July 06, 2016
Page 110 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.317_00.010
Variable Name
PWRKBSP
Universe
PWRKBSP(e)='07'
Universe-text
All persons who had private health insurance obtained from other source previously
Question Text
*Enter how private health insurance was obtained.
Answer Codes
Question Type
Verbatim
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
[goto HCSPFYR]
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Wednesday, July 06, 2016
Page 111 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.320
Variable Name
HCSPFYR
Universe
All families
Universe-text
All families
Question Text
(book) F19
The next question is about money that [fill 1:you have/your family has] spent out of
pocket on medical care. We do NOT want you to count health insurance premiums,
over the counter drugs, or costs that you will be reimbursed for. In the PAST 12
MONTHS, about how much did [fill 2: you/your family] spend for medical care and
dental care?
Answer Codes
Question Type
0. Zero
1. Less than $500
2. $500-$1,999
3. $2,000-$2,999
4. $3,000-$4,999
5. $5,000 or more
Refused
Don’t know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Out of pocket costs
Fill 1: If single person family, fill: [you have]; Else, fill; [your family has]
Fill 2: If single person family, fill: [you]; Else, fill; [your family]
Special Instructions
Skip Instructions
goto MEDBILL
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Wednesday, July 06, 2016
Page 112 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.325_00.010
Variable Name
MEDBILL
Universe
All families
Universe-text
All families
Question Text
In the past 12 months did [fill1: you/anyone in the family] have problems paying or
were unable to pay any medical bills? Include bills for doctors, dentists, hospitals,
therapists, medication, equipment, nursing home or home care.
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Fill1: if single person family fill "you"; else fill "anyone in the family"
Special Instructions
Skip Instructions
<1,2,7,9> [goto MEDBPAY]
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Wednesday, July 06, 2016
Page 113 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.327_00.010
Variable Name
MEDBPAY
Universe
All families
Universe-text
All families
Question Text
[fill 1: Do you/Does anyone in your family] currently have any medical bills that are
being paid off over time? This could include medical bills being paid off with a credit
card, through personal loans, or bill paying arrangements with hospitals or other
providers. The bills can be from earlier years as well as this year.
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Fill1: if single person family, fill "Do you"; else fill "Does anyone in your family"
Special Instructions
Skip Instructions
<1,2,7,9> if MEDBILL=2 [goto FSA]; else [goto MEDBNOP]
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Wednesday, July 06, 2016
Page 114 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.327_00.020
Variable Name
MEDBNOP
Universe
MEDBILL='1','R','D'
Universe-text
All families but those who said they don’t have problems paying their medical bills
Question Text
[fill 1: Do you/Does anyone in your family] currently have any medical bills that you
are unable to pay at all?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Fill1: if single person family fill "Do you"; else fill "Does anyone in your family"
Special Instructions
Skip Instructions
<1,2,7,9> [goto FSA]
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Wednesday, July 06, 2016
Page 115 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.330
Variable Name
FSA
Universe
All Families
Universe-text
All Families
Question Text
? [F1]
[fill 1: Do you/Does anyone in your family] have a Flexible Spending Account for
health expenses? These accounts are offered by some employers to allow employees
to set aside pre-tax dollars of their own money for their use throughout the year to
reimburse themselves for their out-of-pocket expenses for health care. With this type
of account, any money remaining in the account at the end of the year, following a
short grace period, is lost to the employee.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
FSAs
fill 1: If single person family, fill: [Do you]; else, fill; [Does anyone in your family]
Special Instructions
Skip Instructions
goto PLBORN
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H_FSA
Wednesday, July 06, 2016
Page 116 of 117
Module
07
Section Name
Family Health Insurance
Part
Question ID
FHI.330_H
Variable Name
H_FSA
Universe
Universe-text
Question Text
[b]Flexible Spending Accounts (FSAs)[b] - Health care flexible spending accounts are
employer-established benefit plans that reimburse employees for specified medical
expenses as they are incurred. These accounts are allowed under section 125 of the
Internal Revenue Code. The employee contributes funds to the account through a
salary reduction agreement and is able to withdraw the funds set aside to pay for
medical bills. The salary reduction agreement means that any funds set aside in a
FSA escape both income tax and Social Security tax. Employers may contribute to
these accounts as well.
Once the amount of contribution has been designated during an open enrollment
period that occurs once each year, the employee is not allowed to change the amount
or drop out of the FSA during the year unless he or she experiences a change in
family status. By law, the employee forfeits any unspent funds in the account at the
end of the year other than the 2.5-month grace period. There is no requirement to
have a private health insurance plan with a FSA.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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AssocHelp
Wednesday, July 06, 2016
Page 117 of 117
2017 Q1 NHIS Instrument Spec Report
Section name: Socio-Demographic
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.001
Variable Name
PLBORN
Universe
All
Universe-text
All persons
Question Text
[fill 1: Were you/Was ALIAS] born in the United States?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Born US
1. If subject = respondent, fill: [ Were you], else fill: [Was ALIAS]
Special Instructions
Skip Instructions
<1> [store 1 in CITIZEN and goto PLBORN1]
<2> [goto PLBORN2]
[goto CITIZEN]
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Wednesday, July 06, 2016
Page 1 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.002
Variable Name
PLBORN1
Universe
PLBORN='1'
Universe-text
All persons born in the U.S.
Question Text
In what state [fill 1:were you/was ALIAS] born?
Answer Codes
1. Alabama
19. Louisiana
37. Oklahoma
2. Alaska
20. Maine
38. Oregon
3. Arizona
21. Maryland
39. Pennsylvania
4. Arkansas
22. Massachusetts 40. Rhode Island
5. California
23. Michigan
41. South Carolina
6. Colorado
24. Minnesota
42. South Dakota
7. Connecticut
25. Mississippi
43. South Dakota
8. Delaware
26. Missouri
44. Texas
9. Dist. Of Columbia 27. Montana
45. Utah
10. Florida
28. Nebraska
46. Vermont
11. Georgia
29. Nevada
47. Virginia
12. Hawaii
30. New Hampshire 48. Washington
13. Idaho
31. New Jersey
49. West Virginia
14. Illinois
32. New Mexico
50. Wisconsin
15. Indiana
33. New York
51. Wyoming
16. Iowa
34. North Carolina
17. Kansas
35. North Dakota
Refused
18. Kentucky
36. Ohio
Don't Know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
State of Birth
1. If subject = respondent, fill: [were you], else, fill [was alias]
Special Instructions <1-51,52> [store 1 in CITIZEN]
Make this a look-up table.
No D/R allowed.
Insert answer name.
****(NCHS wants this to be output as 2 variables. Does this go in output specs?)
Skip Instructions
<1-51, D, R> [goto HEADST]
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Wednesday, July 06, 2016
Page 2 of 36
Module
08
Section Name
Family Socio Demographic
Part
Question ID
FSD.002_01
Variable Name
STATECODE
Universe
Universe-text
Question Text
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions Created in the instrument. State name from PLBORN1 stored in this variable.
Skip Instructions
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Wednesday, July 06, 2016
Page 3 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.003
Variable Name
PLBORN2
Universe
PLBORN = '2'
Universe-text
All persons not born in the US
Question Text
In what country [fill: 1] born?
* Please record country of birth. If country not found, type "ZZ"
Answer Codes
Question Type
Pick One - popup window
Field Pane Description
Fill Instructions
Country of Birth
1. If subject = respondent, fill: [were you], else, fill [was alias]
Special Instructions Display list of all countries in a lookup table.
Should allow 40 characters.
Skip Instructions
<60-85> [store 2 in CITIZEN; goto USYR]
<100-696> [goto USYR]
[goto USYR]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 4 of 36
Module
08
Section Name
Family Socio Demographic
Part
Question ID
FSD.003_01
Variable Name
COUNTRYCODE
Universe
Universe-text
Question Text
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions Created in the instrument. Country name from PLBORN2 stored in this variable.
Should allow 40 characters.
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 5 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.004
Variable Name
USYR
Universe
PLBORN='2'
Universe-text
All persons not born in the US
Question Text
[Fill: 1]
In what year did [fill: 3] come to the United States to stay?
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Year Came to US
1. If AGEDOB@3 and AGEDOB 4 and AGEDOB 5 are valid, fill [* Read if necessary.
Earlier I recorded [fill: 2] date of birth as [month in words, 2-digit day, 4-digit year]. ]
2. If subject = respondent, fill [your], else fill [alias's]
3. If subject = respondent, fill [you], else fill [alias]
Special Instructions Allow answers of [1880-current year]
Skip Instructions
goto USLONG
<1880-2220> If USYR > CURYEAR THEN
Goto ERR1_USYR
Elseif AGEDOB_5 not IN('REFUSAL','DONTKNOW') THEN
If AGEDOB_5 > USYR THEN
Goto ERR2_USYR
Endif
Elseif AGE < (CURYEAR - USYR - 1) THEN
Goto ERR2_USYR
Else
Goto CITIZEN
Endif
Hard Edits
ERR1_USYR
*Future year invalid: [fill: USYR]. Please correct.
ERR2_USYR: * [fill year from USYR] is prior to the person's birth year.
*Please correct.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 6 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.005
Variable Name
USLONG
Universe
USYR = D or R
Universe-text
All persons not born in the US and refused or did not know USYR
Question Text
About how long [fill: 1] been in the United States?
* Read if necessary: Earlier I recorded that [fill: 2] [fill: AGE] years old.
*Enter 95 for 95 or more years.
*If less than 1 year given as a response, code the answer as "0".
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
How Long in US
1. If subject = respondent, fill: [have you]; else fill: [has alias].
2. If subject = respondent, fill: [you are]; else fill: [alias is].
Special Instructions Allow answers of [0-95]
Skip Instructions
[goto CITIZEN]; else [if gt AGE goto ERR_USLONG]; else goto CITIZEN
Hard Edits
ERR_LONG: * In US longer than alive!
* Please correct.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 7 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.006
Variable Name
CITIZEN
Universe
PLBORN2 ge 100 or (PLBORN in (R,D)) or (
Universe-text
All persons not born in the US or US territory
Question Text
(book) F20
?[F1]
[Fill: 1] a CITIZEN of the United States?
Answer Codes
Question Type
1. Yes, born in one of the 50 United States or the District of Columbia
2. Yes, born in Puerto Rico, Guam, American Virgin Islands, or other U.S. territory
3. Yes, born abroad to American parent(s)
4. Yes, U.S. citizen by naturalization
5. No, not a citizen of the United States
Refused
Don't Know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Citizen Status
1. If subject = respondent fill [Are you]; else fill [Is alias]
Special Instructions All persons born in the US (PLBORN1 eq 1-52) should automatically get 1 on
CITIZEN, and should NOT be asked this question;
All persons born in a US territory (PLBORN2 eq 60-99) should automatically get 2 on
CITIZEN, and should NOT be asked this question
Error meesages involving CITIZEN and PLBORN1
Skip Instructions
<1> (If PLBORN eq 2 and CITIZEN eq 1): goto ERR1_CITIZEN; [If PLBORN eq R and
CITIZEN eq 1]; goto ERR3_CITIZEN [If PLBORN eq D and CITIZEN eq 1]; goto
ERR4_CITIZEN
<2> goto ERR2_CITIZEN
else goto HEADST
Hard Edits
ERR1_CITIZEN
*Already indicated birth outside the United States.
*Please correct.
ERR2_CITIZEN
*Already indicated birth outside United States territory.
*Please correct.
Soft Edits
ERR3_CITIZEN: Refused
Previously, you refused to say if [usted/ALIAS] was born in the United States.
Would you like to change your answer to the question?
ERR4_CITIZEN: Don't Know
Previosuly, you didn't know if [you/ALIAS] were born in the United States.
Would you like to change your answer to the question?
Wednesday, July 06, 2016
Page 8 of 36
AssocHelp
H_CITIZEN
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.006_H
Variable Name
H_CITIZEN
Universe
Universe-text
Question Text
Information about citizenship is being collected by the Department of Health and
Human Services to perform health-related research pertaining to place of birth and
length of time in the United States. Providing this information is voluntary and is
collected under the authority of the Public Health Service Act. There will be no effect
on pending immigration or citizenship petitions.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
CITIZEN
Wednesday, July 06, 2016
Page 9 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.007
Variable Name
HEADST
Universe
AGE le 6
Universe-text
All persons age 6 and under
Question Text
?[F1]
Is [alias] now attending Head Start?
Answer Codes
Question Type
1. Yes
2. No
Don't know
Refused
Yes/No
Field Pane Description
Now Attend Head Start
Fill Instructions
Special Instructions
Skip Instructions
<2, D, R> [ goto HEADSTEV]
<1> [goto EDUC]
Hard Edits
Soft Edits
AssocHelp
H_HEADST
Wednesday, July 06, 2016
Page 10 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.007_H
Variable Name
H_HEADST
Universe
Universe-text
Question Text
Headstart programs are designed to provide services for children living in families with
incomes below poverty. These services may include but are not limited to: medical,
dental, social, and education services. If a child who is eligible for these services has
special needs or disabilities, the child may receive both Headstart and Early
Intervention Services or Special Education Services. Although many children begin
Headstart at age three or four, in some areas Headstart services begin with prenatal
care and infant care.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
HEADST
HEADSTEV
Wednesday, July 06, 2016
Page 11 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.008
Variable Name
HEADSTEV
Universe
AGE lt 18 and HEADST ne 1
Universe-text
All persons under age 18 and not currently enrolled in Head Start
Question Text
?[F1]
Has [alias] ever attended Head Start?
Answer Codes
Question Type
1. Yes
2. No
Don't know
Refused
Yes/No
Field Pane Description
Ever Attended Head Start
Fill Instructions
Special Instructions
Skip Instructions
<1, 2, D, R> [if no more AGE le 18, goto EDUC]
Hard Edits
Soft Edits
AssocHelp
H_HEADST
Wednesday, July 06, 2016
Page 12 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.010
Variable Name
EDUC
Universe
AGE= 5+
Universe-text
All persons 5 years of age and older
Question Text
(book) F21
?[F1]
What is the HIGHEST level of school [fill:1] completed or the highest degree [fill:1]
received? Please tell me the number from the card.
* Enter highest level of school completed.
Answer Codes
Question Type
0. Never attended/kindergarten only 12. 12th grade, no diploma
1. 1st grade
13. GED or equivalent
2. 2nd grade
14. HIGH SCHOOL GRADUATE
3. 3rd grade
15. Some college, no degree
4. 4th grade
16. Associate's degree: occupational, technical
or vocational program
5. 5th grade
17. Associate's degree: academic program
6. 6th grade
18. Bachelor's degree (Example: BA, AB, BS,
BBA)
7. 7th grade
19. Master's degree (Example: MA, MS, MEng,
MEd, MBA)
8. 8th grade
20. Professional School degree (Example: MD,
DDS, DVM, JD)
9. 9th grade
21. Doctoral degree ( Example: PhD, EdD)
10. 10th grade
Refused
11. 11th grade
Don't know
Long List
Field Pane Description
Fill Instructions
Highest Level School Completed
1. If subject = respondent, fill "you have"; else fill "alias has"
Special Instructions If AGE lt <5> [Do not ask this question, store <96> in EDUC]
if MARK [goto ARMFFC] <2,R,D> [goto ARMFEV]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 16 of 36
Module
08
Section Name
Family Socio-Demographic
Part
Question ID
FSD.021_00.000
Variable Name
ARMFEV
Universe
AGE GE '018' and AGE not IN('997','999') and (ARMFVER(e) IN(‘2’,’7’,’9’) or
HHSTAT3 ne 'A')
Universe-text
All families with a person age 18 or older who is not currently on active duty or said
R,D to active duty question
Question Text
[fill1: Have you/Has alias] ever served on active duty in the U.S. Armed Forces,
military Reserves, or National Guard?
*Read if necessary. Active duty does not include training for the Reserves or National
Guard, but DOES include activation, for example, for service in the US or in a foreign
country, in support of military or humanitarian operations.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
fill1: if subject=respondent fill “Have you” else fill “Has alias”
Special Instructions Roster through all applicable persons 18+. If ARMFVER=1 fill ARMFEV=1
Skip Instructions
<1> [goto ARMFFC] <2,R,D> [goto DOINGLW]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 17 of 36
Module
08
Section Name
Family Socio-Demographic
Part
Question ID
FSD.022_00.000
Variable Name
ARMFFC
Universe
AGE GE '018' and AGE not IN('997','999') and ARMFEV(e)=’1’
Universe-text
All families with a person age 18 or older who has ever served in the armed forces
Question Text
Did [fill1: you/alias] ever serve in a foreign country during a time of armed conflict or
on a humanitarian or peace-keeping mission?
*Read if necessary. This would include National Guard or reserve or active duty
monitoring or conducting peace keeping operations in Bosnia Kosovo, in the Sinai
between Egypt and Israel, or in response to the 2004 tsunami, or Haiti in 2010.
Answer Codes
Question Type
1. Yes
2. No
Refused
Don't know
Yes/No
Field Pane Description
Fill Instructions
fill1: if subject=respondent fill “you” else fill “alias”
Special Instructions Roster through all applicable persons 18+.
Skip Instructions
<1,2,R,D> [goto ARMFTMP]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 18 of 36
Module
08
Section Name
Family Socio-Demographic
Part
Question ID
FSD.023_00.000
Variable Name
ARMFTMP
Universe
AGE GE '018' and AGE not IN('997','999','') and ARMFEV(e)=’1’
Universe-text
All families with a person age 18 or older who has ever served in the armed forces
Question Text
When did [fill1: you/alias] serve on ACTIVE DUTY in the U.S. Armed Forces?
*Enter all that apply, separate with commas.
*Enter all periods in which this person served. Enter the item even if the person
served for just part of that period.
Answer Codes
Question Type
1. Sept 2001 or later
2. August 1990 to August 2001 (including Persian Gulf War)
3. May 1975 to July 1990
4. Vietnam era (August 1964 to April 1975)
5. February 1955 to July 1964
6. Korean War (July 1950 to January 1955)
7. January 1947 to June 1950
8. December 1946 or earlier
Refused
Don’t know
Enter all that apply
Field Pane Description
Fill Instructions
fill1: if subject=respondent fill “you” else fill “alias”
Special Instructions Roster through all applicable persons 18+. (NOTE: YEARLY UPDATES NEEDED TO
ADJUST YEAR NUMBER, BECAUSE EACH YEAR ADDS '1' YEAR AWAY FROM
THE WARS/CONFLICTS SHOWN IN THE ANSWER CODES)
If AGE > = 81, gray out answer code 1
if AGE < = 31 or AGE > = 92, gray out answer code 2
if AGE < = 42 or AGE > = 107, gray out answer code 3
if AGE < = 57 or AGE > = 118, gray out answer code 4
if AGE < = 68, gray out answer code 5
if AGE < = 77, gray out answer code 6
if AGE < = 82, gray out answer code 7
if AGE < = 86, gray out answer code 8
Skip Instructions
<1,3-11,R,D> [goto DOINGLW] <2> [goto ARMFDS]
Hard Edits
If gray answer code is selected please display:
That selection is not valid at this time.
Pleae correct.
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 19 of 36
Module
08
Section Name
Family Socio-Demographic
Part
Question ID
FSD.024_00.000
Variable Name
ARMFDS
Universe
AGE GE '018' and AGE not IN('997','999','') and ARMFTMP(e)=’2’
Universe-text
All families with a person age 18 or older who served from August 1990 to August
2001
Question Text
Did [fill1: you/alias] serve in the Persian Gulf during Operation Desert Shield or
Operation Desert Storm between August 1990 and April 1991?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
fill1: if subject=respondent fill “Have you” else fill “Has alias”
Special Instructions Roster through all applicable persons 18+.
**9.13.10 - Spanish Translation: Desert Shield and Desert Storm were left as is. No
translation is needed for these two concepts.**
Skip Instructions
<1,2,R,D> [goto DOINGLW]
Hard Edits
Soft Edits
AssocHelp
Wednesday, July 06, 2016
Page 20 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.050
Variable Name
DOINGLW
Universe
AGE=18+
Universe-text
All persons age 18+
Question Text
(book) F22 ? [F1]
The next few questions are about employment status.
Which of the following [fill: 1] doing last week?
* Read answer categories.
Answer Codes
Question Type
1. Working for pay at a job or business
2. With a job or business but not at work
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.
Refused
Don't know
Pick One - answer list pane
Field Pane Description
Fill Instructions
Doing last week
1. If subject = respondent fill: [were you]; else fill: [was alias]
Special Instructions
Skip Instructions
<1,4> [go to WRKHRS1]
<2,5> [go to WHYNOWRK]
<3,D,R> [go to WRKLYR]
Hard Edits
Soft Edits
AssocHelp
H_DOINGLW
Wednesday, July 06, 2016
Page 21 of 36
Module
08
Section Name
Family Socio Demographic
Part
Question ID
FSD.050_H
Variable Name
H_DOINGLW
Universe
Universe-text
Question Text
A [b]job[b] exists when there is a definite arrangement for regular work on a continuing
basis, and the person holding the job receives pay or other compensation for his/her
work. The schedule of hours or days can be irregular as long as there is a definite
arrangement to work on a continuing basis.
A [b]business[b] exists when machinery or equipment of substantial value is used in
conducting the business; an office, store, or other place of business is maintained; or
the business is advertised to the public.
An individual is [b]working for pay[b] if he or worked for wages, salary, commission,
tips, piece-rates, or pay-in-kind (e.g., room-and-board); worked for profit in his/her
own business, practice or farm; worked as a civilian for the National Guard or Dept. of
Defense; or performed exchange or share work on a farm.
[b]Have a job or business but not at work[b] includes individuals on annual leave or
vacation (paid or unpaid); on maternity or family leave (paid or unpaid); at jury duty;
involved in a labor dispute that is taking place at his/her place of employment; on sick
leave (paid or unpaid); on a temporary lay-off (lasting less than 30 days), and the
person expects to be called back within that time period.
An individual is [b]looking for work[b] if he or she is conducting an active job search,
which includes filling out applications or sending out resumes; placing or answering
classified ads; checking union/professional registers; bidding on a contract or
auditioning for a part in a play; contacting friends or relatives about possible jobs;
contacting school/college university employment offices; contacting prospective
employers directly; contacting public or private employment offices.
Include as [b]working, but not for pay[b] at least 15 hours of work per week without
pay in a business or farm operated by a related household member. Volunteer efforts
should NOT be considered as working. Likewise, unpaid internships are not
considered as working.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
Wednesday, July 06, 2016
Page 22 of 36
AssocHelp
DOINGLW
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.060
Variable Name
WHYNOWRK
Universe
(AGE= 18+) and (DOINGLW = with a job or business but not at work, or not working at
a job or business and not looking for work)
Universe-text
All persons age 18 + who were either with a job or business but not at work, or not
working at a job or business and not looking for work.
Question Text
?[F1]
What is the main reason [fill: 1] did not [fill: 2]
Answer Codes
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
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Reason for not Working
1. If subject = respondent, fill: [you]; else fill: [alias]
2. If DOINGLW = with a job or business but not at work, fill: [work last week?]; else
fill: [have a job or business last week?]
Special Instructions
Skip Instructions
<01-03, 08-10,D,R> [goto WRKLYR] else <04-07> [goto WRKHRS1]
Hard Edits
Soft Edits
AssocHelp
H_WHYNOWRK
Wednesday, July 06, 2016
Page 23 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.060_H
Variable Name
H_WHYNOWRK
Universe
Universe-text
Question Text
[b]Taking care of house or family[b] is any type of work around the house such as
cleaning, cooking, maintaining the yard, caring for children or family, etc.
[b]Going to school[b] means attending any type of public or private educational
establishment both in and out of the regular school system.
[b]Retired, Unable to work for health reasons[b], and [b]Disabled[b] are respondent
defined.
[b]Layoff[b] means that the person is waiting to be called back to a job from which they
have been temporarily laid-off or furloughed. Layoffs can be due to slack work, plant
retooling or remodeling, inventory taking, and the like. Do not consider a person who
was not working because of a labor dispute at his/her own place of employment as
being on layoff.
[b]Have job/contract and off-season[b] includes school personnel (teachers,
administrators, custodians, etc.) on summer vacation who have a definite
arrangement, either written or oral, to return to work in the fall, are not considered to
be on layoff during the summer. They may, however, be laid off from a summer job or
looking for work for the summer months (but this would NOT be considered their main
job or employment activity).
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
WHYNOWRK
Wednesday, July 06, 2016
Page 24 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.070
Variable Name
WRKHRS1
Universe
(AGE=18+ ) and [(DOINGLW = Working for pay at a job or business or working, but
not for pay, at a family owned job or business) or (WHYNOWRK = on a planned
vacation from work, or on family or maternity leave, or temporarily unable to work for
health reasons, or have job/contract and off-season)]
Universe-text
All persons aged 18+ who were working for pay at a job or business or working, but
not for pay, at a job or business last week or on a planned vacation from work, or on
family or maternity leave, or temporarily unable to work for health reasons, or have
job/contract and off-season
Question Text
?[F1]
How many hours [fill: 1]
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Hours Worked
1. If DOINGLW = (working for pay at a job or business) or (working, but not for pay, at
a family-owned job or business) fill: [did [fill:2] work LAST WEEK at ALL jobs or
businesses?]; else, fill: [do [fill: 2] USUALLY work at ALL jobs or businesses?]
2. If subject = respondent, fill: [you]; else, fill: [alias]
Special Instructions Allow 1-168, D, R
Display "Hours" answer tag in form pane.
Skip Instructions
<1-34, D, R> [goto WRKFTALL]
<95-168> goto soft error message
<35-168> [goto WRKLYR]
Hard Edits
Soft Edits
* [Fill: WRKHRS] is an unusually high number.
* Please verify.
AssocHelp
H_WRKHRS
Wednesday, July 06, 2016
Page 25 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.070_H
Variable Name
H_WRKHRS
Universe
Universe-text
Question Text
Include only the actual hours spent on the job last week. Exclude time off for any
reason, even if they were paid for the time off. For example, exclude the half hour paid
lunch break, any "sick leave" used due to illness or to see a doctor, and any
"vacation" time or "personal days".
Enter Hours in whole numbers, rounding 30 minutes or more UP to the next whole
number and dropping 29 or fewer minutes.
For persons with businesses, include hours spent setting up a new business or
profession, even if it is not opened yet. Also, include hours worked at a person's
business, even if he/she actually transacted no business.
Include extra hours worked last week, even if they were without compensation. For
example: include the time a teacher spent at home grading papers.
Include hours spent doing unpaid work on a family farm or business owned by a
related household member.
Do NOT include hours spent on jury duty or on the National Guard duty.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
WRKHRS
Wednesday, July 06, 2016
Page 26 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.080
Variable Name
WRKFTALL
Universe
AGE=18+ and WRKHRS1 = 1-34, D, R
Universe-text
All persons aged 18+ who worked less than 35 hours last week or did not know/refuse
to answer how many hours they worked last week
Question Text
?[F1]
[Fill: 1] USUALLY work 35 hours or more per week in total at ALL jobs or businesses?
Answer Codes
Question Type
1. Yes
2. No
Don't know
Refused
Yes/No
Field Pane Description
Fill Instructions
Usually Work Full Time
1. If subject = respondent, fill: [Do you]; else fill: [Does ALIAS]
Special Instructions
Skip Instructions
[goto WRKLYR]
Hard Edits
Soft Edits
AssocHelp
H_WRKFTALL
Wednesday, July 06, 2016
Page 27 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.080_H
Variable Name
H_WRKFTALL
Universe
Universe-text
Question Text
Include only the actual hours spent on the job last week. Exclude time off for any
reason, even if they were paid for the time off. For example, exclude the half hour paid
lunch break, any sick leave used due to illness or to see a doctor, and any "vacation"
time or "personal days".
Enter Hours in whole numbers, rounding 30 minutes or more UP to the next whole
number and dropping 29 or fewer minutes.
For persons with businesses, include hours spent setting up a new business or
profession, even if it is not opened yet. Also, include hours worked at a person's
business, even if he/she actually transacted no business.
Include extra hours worked last week, even if they were without compensation. For
example: include the time a teacher spent at home grading papers.
Include hours spent doing unpaid work on a family farm or business owned by a
related household member.
Do NOT include hours spent on jury duty or on the National Guard duty.
Consider the [b]usual number of hours worked[b] (more or less than 35 hours) to be
those worked in 50 percent or more of the weeks in which the person works. If exactly
half are 35+ and half are less than 35, enter "yes". If a new job began last week,
"usual" means what the person expects to work.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
WRKFTALL
Wednesday, July 06, 2016
Page 28 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.100
Variable Name
WRKLYR
Universe
AGE = 18+
Universe-text
All persons age 18+
Question Text
?[F1]
Did [fill: 1] work for pay at any time in [last year in 4 digit format]?
Answer Codes
Question Type
1. Yes
2. No
Don't know
Refused
Yes/No
Field Pane Description
Fill Instructions
Work for Pay Last Year
1. If subject = respondent, fill: [you]; else if SEX = male, fill: [he]: else if SEX = female,
fill: [she]
Special Instructions
Skip Instructions
<1> [goto WRKMYR]
<2, D, R> [goto HIEMPOF]
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H_WRKLYR
Wednesday, July 06, 2016
Page 29 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.100_H
Variable Name
H_WRKLYR
Universe
Universe-text
Question Text
Include as working:
[blt]Work for pay.
Work for profit in one's own business, practice or farm.
Work without pay in a business or farm operated by a related household
member.
Work as a civilian for the National Guard or Dept. of Defense.
Exchange or share work on a farm.[blt]
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
WRKLYR
WRKMYR
Wednesday, July 06, 2016
Page 30 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.110
Variable Name
WRKMYR
Universe
AGE = 18+ and WRKLYR = yes
Universe-text
All persons age 18+ who worked last year
Question Text
?[F1]
How many months in [last year in 4 digit format] did [fill: 1] have at least one job or
business?
*If less than one month, enter '1'.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Months Worked Last Year
1. If subject = respondent, fill: [you]; else fill [ALIAS]
Special Instructions Allow 1-12, D, R
Display "months" answer tag in form pane.
Skip Instructions
[goto ERNYR]
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H_WRKLYR
Wednesday, July 06, 2016
Page 31 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.120
Variable Name
ERNYR
Universe
AGE = 18+ and WRKLYR = yes
Universe-text
All persons age 18+ who worked last year
Question Text
?[F1]
What is your best estimate of [fill: 1] earnings before taxes and deductions from ALL
jobs and businesses in [fill: last year in 4 digit format]?
Include hourly wages, salaries, tips and commissions.
* Enter '999,995' if the reported income is greater than $999,995.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Earnings Last Year
1. If subject = respondent, fill: [you]; else fill: [ALIAS]
Special Instructions Allow 1-999995, D, R
Display "$" tag in form pane and digit grouping.
Skip Instructions
[goto HIEMPOF]
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H_ERNYR
Wednesday, July 06, 2016
Page 32 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.120_H
Variable Name
H_ERNYR
Universe
Universe-text
Question Text
Earnings includes:
[blt]Wages and salaries including tips, commissions, Armed Forces pay and cash
bonuses, as well as subsistence
allowances.
Net income from unincorporated businesses, professional practices, farms, or from
rental property. ("Net" means after deducting business expenses, but before
deducting personal taxes.)
Unemployment or workman's compensation.[blt]
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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ERNYR
Wednesday, July 06, 2016
Page 33 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.130
Variable Name
HIEMPOF
Universe
(AGE = 18+) and (DOINGLW = working for pay at a job or business, or with a job or
business, but not at work, or working, but not for pay, at a family-owned job or
business.)
Universe-text
persons who are age 18+ and working for pay at a job or business or with a job or
business, but not at work, or working, but not for pay, at a family-owned job or
business.
Question Text
?[F1]
Regarding [fill:1] job or work last week, was health insurance offered to [fill: 2] through
[fill:3] workplace?
Answer Codes
Question Type
1. Yes
2. No
Don't know
Refused
Yes/No
Field Pane Description
Fill Instructions
Health Insurance Offered
1. If subject = respondent, fill: [your]; else fill: [alias's]
2.. If subject = respondent, fill: [you]; else fill: [alias]
3. If subject = respondent, fill: [your]; else if SEX = male, fill: [his]; else if SEX =
female, fill: [her]
Special Instructions
Skip Instructions
If roster is exhausted, [goto next section]
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H_HIEMPOF
Wednesday, July 06, 2016
Page 34 of 36
Module
08
Section Name
Socio-Demographic
Part
Question ID
FSD.130_H
Variable Name
H_HIEMPOF
Universe
Universe-text
Question Text
Health Insurance may be provided in part or full by the persons' employer. Enter
"yes" even if the person must pay part of the cost of the insurance.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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HIEMPOF
Wednesday, July 06, 2016
Page 35 of 36
Module
08
Section Name
Family Socio-Demographic
Part
Question ID
FSD.135
Variable Name
FERNTOT
Universe
(for all family members 18+ WRKLYR not in ('7' '9')) and (for all family members 18+
ERNYR not in ('999997' '999999')) and (WRKLYR = '1' for at least one family member
18+)
Universe-text
Families with WRKLYR not equal to Don't Know or Refused for any adult in the family
and ERNYR not equal to "Don't Know" or "Refused" for any adult in the family and at
least one family member reports working in the past year.
Question Text
***This item sums the reported personal earnings (ERNYR) for each person in the
family where all earnings information is known and at least one family member reports
working in the past year. Where the sum of personal earnings is greater than
$999,994, use $999,995 . ***
Answer Codes
Question Type
Procedure
Field Pane Description
Fill Instructions
Special Instructions ***This variable requires summing values across persons within a family.***
Skip Instructions
<000001-999995> goto next section
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Wednesday, July 06, 2016
Page 36 of 36
2017 Q1 NHIS Instrument Spec Report
Section name: Family Sources of Income
Module
09
Section Name
Family Sources of Income
Part
Question ID
FIN.010
Variable Name
FINCINT
Universe
All
Universe-text
All
Question Text
* Read the following.
The next questions are about [fill1: your total/your total family] income in [fill2: last
calendar year in 4-digit format] BEFORE TAXES.
Income is important in analyzing the health information we collect. For example, with
this information, we can learn whether persons in one income group use certain types
of medical services more or less often than those in another group. Please be
assured that, like all other information you have provided, these answers will be kept
strictly confidential.
Answer Codes
Question Type
1. Enter 1 to Continue
Enter 1 to Continue
Field Pane Description
Fill Instructions
Continue
Fill1: If one person family, fill [your total]; else, fill:[your total family]
Fill2: variable for last calander year
Special Instructions Do Not Allow D/R.
Skip Instructions
goto FSAL
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Wednesday, July 06, 2016
Page 1 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.030
Variable Name
FSAL
Universe
AGE GE18
Universe-text
Any person in the family is 18+
Question Text
?[F1]
[fill Did you receive income in [fill: last calendar year in 4 digit format] from wages and
salaries?]
[fill: When answering these questions, please remember that by "combined family
income," I mean your income PLUS the income of all family members living in this
household (including cohabiting partners, and armed forces members living at home).
Did any family members 18 and older, that is * Read names
[fill roster of people GE 18 in column format, in bold black]
receive income in [fill: last calendar year in 4 digit format] from wages and salaries?]
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Wages and Salaries
1. If 1 person in the family, fill: [Did you receive...]; Else fill: [When answering...]
Special Instructions If all family members are emancipated minors, this question should be skipped.
Skip Instructions
<1> [If 1 person family, store person number in PSAL and skip to FSEINC; Else goto
PSAL]
<2, D, R,> [Goto FSEINC]
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H_FSAL
Wednesday, July 06, 2016
Page 2 of 64
Module
09
Section Name
Family Sources of Income
Part
Question ID
FIN.030_H
Variable Name
H_FSAL
Universe
Universe-text
Question Text
Include:
Wages and salaries including tips, commissions, Armed Forces pay and cash
bonuses, as well as subsistence allowances.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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Wednesday, July 06, 2016
Page 3 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.040
Variable Name
PSAL
Universe
AGE GE18 and FSAL=yes and family members > 1
Universe-text
If the respondent answered yes to FSAL and there is more than one person 18+ in the
family.
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions display roster of all non-deleted family members GE 18
Skip Instructions
Goto FSEINC
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Wednesday, July 06, 2016
Page 4 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.050
Variable Name
FSEINC
Universe
AGE GE18
Universe-text
Any person in the family 18+
Question Text
[fill: Did you receive income in [fill: last calendar year in 4-digit format] from selfemployment including business and farm income?/ Did ALIAS receive income in [fill:
last calendar year in 4-digit format] from self-employment including business and farm
income?/Did any family members 18 and older, that is
*Read names
[fill roster of people GE 18 in column format and bold black]
receive income in [fill: last calendar year in 4-digit format] from...self-employment
including business and farm income?]
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Self Employment
If only one person in the roster and that person = respondent, then
[fill 1: Did you receive income in [fill: last calendar year in 4-digit format] from...selfemployment including business and farm income?]
If only one person in the roster, and that person ne respondent, then
[fill 2: Did ALIAS receive income in [fill: last calendar year in 4-digit format]
from...self-employment including business and farm income?]
If multiple names in the roster, then
[fill 3: Did any family members 18 and older, that is *Read names
[fill roster of people GE 18 in column format and bold black]
receive income in [fill: last calendar year in 4-digit format] from...self-employment
including business and farm income?]
Special Instructions If all family members are emancipated minors, this question should be skipped.
Skip Instructions
<1> [If 1 person family, store person number in PSEINC and skip to FSSRR; Else goto
PSEINC]
<2, D, R> [Goto FSSRR]
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Wednesday, July 06, 2016
Page 5 of 64
AssocHelp
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.060
Variable Name
PSEINC
Universe
AGE GE 18 and FSEINC=yes and family members > 1
Universe-text
If the respondent answered yes to FSEINC and there is more than one person 18+ in
the family.
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members GE age 18
Skip Instructions
Goto FSSRR
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Wednesday, July 06, 2016
Page 6 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.070
Variable Name
FSSRR
Universe
AGE=ALL
Universe-text
All families
Question Text
?[F1]
Did [fill: you/any family members living here] receive income in [fill: last year in 4 digit
format] from Social Security or Railroad Retirement?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
SS/ RR
1. If one person family fill: [you]; Else fill: [ any family members...]
Special Instructions
Skip Instructions
<1> If 1 person family, store person number in PSSRR and skip to FSSRRD; Else,
goto PSSRR.
<2, D, R> [Goto FPENS]
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H_FSSRR
Wednesday, July 06, 2016
Page 7 of 64
Module
09
Section Name
Family Sources of Income
Part
Question ID
FIN.070_H
Variable Name
H_FSSRR
Universe
Universe-text
Question Text
[b]U. S. Government Railroad Retirement Benefits[b] are based on a person's longterm employment in the railroad industry.
[b]Social Security (SS)[b] payments are received by persons who have worked long
enough in employment which had SS deductions taken from their salary in order to be
entitled to payments. Payments may be made to the spouse or dependent children of
the covered workers. SS also pays benefits to student dependents (under 19 years of
age) of eligible social security recipients.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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Wednesday, July 06, 2016
Page 8 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.080
Variable Name
PSSRR
Universe
AGE= ALL and FSSRR = yes and family members > 1
Universe-text
If respondent answered yes to FSSRR and there is more than one person in the family
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all persons in the family.
Skip Instructions
Goto FSSRRD
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Wednesday, July 06, 2016
Page 9 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.082
Variable Name
FSSRRD
Universe
Families with person selected in PSSRR and AGE LE 64
Universe-text
If person selected in PSSRR and age is less than or equal to 64 years old
Question Text
?[F1]
Was [fill: your/any family member's *Read names
[fill roster of all non-deleted family members selected in PSSRR and AGE LE 64 in
column format in bold black]]
Social Security or Railroad Retirement income received as a disability benefit?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Disability Benefit
1. If only one person in the family, fill: [your]; Else fill: [any family member's....] Also fill
a list of the names of the persons in the family (in bold black) into the info pane before
"Social Security..."
Special Instructions
Skip Instructions
<1> [If only one person in the roster, fill the person number in PSSRRDB, and skip to
PSSRRD; Else goto PSSRRDB]
<2, D, R> [Go to FPENS]
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H_FSSRR
Wednesday, July 06, 2016
Page 10 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.084
Variable Name
PSSRRDB
Universe
FSSRRD=yes and family members > 1
Universe-text
If respondent answered yes to FSSRRD and there is more than one person in the
family less than or equal to 64
Question Text
*Ask or verify. Enter applicable line number(s), separate with commas.
Who received Social Security or Railroad Retirement as a disability benefit?
(Anyone else?)
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all persons marked in PSSRR and age is than or equal to 64
Skip Instructions
Goto PSSRRD.
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Wednesday, July 06, 2016
Page 11 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.086
Variable Name
PSSRRD
Universe
Person selected in PSSRRDB
Universe-text
Ask for everyone listed in PSSRRDB.
Question Text
Did [fill: you/alias] receive this benefit because [fill: you are/he is/she is] disabled?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Disabled
1. If subject=respondent, fill: [you]; else fill [alias].
2. If subject=respondent, fill: [you are]; else if subject sex =male, fill: [he is] else if
subject sex=female, fill: [she is]
Special Instructions
Skip Instructions
<1, 2, D, R> [after rostering through everyone listed in PSSRRDB, goto FPENS]
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Wednesday, July 06, 2016
Page 12 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.090
Variable Name
FPENS
Universe
AGE=All
Universe-text
All families
Question Text
Did [fill: you/any family members living here] receive income in [fill:variable for last
calander year] from any disability pension [fill: other than Social Security or Railroad
Retirement]?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Disability Pension
1. If one person in the family, fill: [you] else, fill: [any family...]
2. If FSSRRD=yes, fill: [other than...] else, no fill.
Special Instructions
Skip Instructions
<1> If only one person in the family, fill the person number in PPENS, and skip to
FOPENS; Else goto PPENS
<2, D, R> [Goto FOPENS]
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Wednesday, July 06, 2016
Page 13 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.100
Variable Name
PPENS
Universe
AGE=All and FPENS=yes and family members > 1
Universe-text
If respondent answered yes to FPENS and there is more than one person in the family
Question Text
*Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
*Indicate each family member with this income.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members.
Skip Instructions
Goto FOPENS
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Wednesday, July 06, 2016
Page 14 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.102
Variable Name
FOPENS
Universe
AGE=All
Universe-text
All families
Question Text
Did [fill 1] receive income from any retirement or survivor pension [fill 2] [fill 3] [fill 4]?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Survivor pension
1. If one person in the family, fill: [you] else, fill: [any family...]
2. If FSSRR=yes and FPENS ne yes, fill [other than Social Security or Railroad
Retirement]
3. If FPENS=yes and FSSRR ne yes, fill [other than disability pension]
4. If FSSRR=yes and FPENS=yes, fill [other than Social Security, Railroad Retirement
or other disabilty pension]
5. If FSSRR ne yes and FPENS ne yes, then no fill.
Special Instructions
Skip Instructions
<1> [If only one person in the family, fill line number into POPENS, and skip to FSSI;
Else goto POPENS]
<2, D, R> Goto FSSI
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Wednesday, July 06, 2016
Page 15 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.104
Variable Name
POPENS
Universe
AGE=All and FOPENS=yes and family members > 1
Universe-text
If anyone in the family received income from retirement or survivor pension.
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members.
Skip Instructions
Goto FSSI
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Wednesday, July 06, 2016
Page 16 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.110
Variable Name
FSSI
Universe
AGE=All
Universe-text
All families
Question Text
?[F1]
Did [fill: 1] receive Supplemental Security Income (SSI) ?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Supplemental Security Income
1. If one person in the family, fill: [you] else, fill: [any family...]
Special Instructions
Skip Instructions
<1> If only one person in the family, fill person number in PSSI and skip to PSSID;
else goto PSSI
<2, D, R> [goto FTANF]
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H_FSSI
Wednesday, July 06, 2016
Page 17 of 64
Module
09
Section Name
Part
Question ID
FIN.110_H
Variable Name
H_FSSI
Universe
Universe-text
Question Text
SSI pays monthly benefits to aged, disabled, and blind people who have limited
income and assets, regardless of age. A person may be eligible for SSI payments
even if they have never worked.
SSI is NOT the same as Social Security. A person can get SSI in addition to Social
Security.
The SSI program is issued by the Social Security Administration. Each state may add
to the Federal payment from its own funds. This additional money may be included in
the federal payment or it may be received as a separate check. If it is combined with
the Federal payment, the words "STATE PAYMENT INCLUDED" will appear on the
Federal check. A few states make SSI payments to individuals who do not receive a
Federal payment.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
FSSI, PSSID, FSSAPL, FSDAPL
Skip Instructions
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Wednesday, July 06, 2016
Page 18 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.120
Variable Name
PSSI
Universe
AGE=all and FSSI=yes and family members > 1
Universe-text
If respondent answered yes to FSSI and there is more than one person in the family
Question Text
*Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family received this?
(Anyone else?)
*Indicate each family member with this income.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members.
Skip Instructions
Goto PSSID.
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Wednesday, July 06, 2016
Page 19 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.122
Variable Name
PSSID
Universe
Persons selected in PSSI
Universe-text
roster through this for all persons listed in PSSI
Question Text
?[F1]
Did [fill: 1] receive SSI because [fill: 2] a disability?
Answer Codes
Question Type
1. Yes
2. No
Don't know
Refused
Yes/No
Field Pane Description
Fill Instructions
Because of a disability
1. If subject=respondent, fill: [you]; else, fill: [alias]
2. If subject=respondent, fill: [you have]; else, if SEX=male fill: [he has]; if
SEX=female, fill: [she has]
Special Instructions
Skip Instructions
<1, 2, D, R> [After rostering through for each family member listed in PSSI, goto
FTANF]
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H_FSSI
Wednesday, July 06, 2016
Page 20 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.150
Variable Name
FTANF
Universe
AGE=All
Universe-text
All families
Question Text
?[F1]
At any time during [fill 1: last year in 4 digit format], even for one month, did [fill 2:
you/any family members living here] receive any CASH assistance from a state or
county welfare program, such as [fill 3: state-specific program name]?
* Please do not include food stamps, SSI, energy assistance, or medical assistance
payments.
Answer Codes
Question Type
1. Yes
2. No
Don't know
Refused
Yes/No
Field Pane Description
Fill Instructions
Cash Assistance
1. Fill the last calendar year in 4-digit format.
2. If one person in the family, fill: [you] else, fill: [any family...]
3. Fill the state program name(s) for the family's state of residence (VERADD
(COV.010) for variable ST). For those states, fill both names separated by "or" as
listed below.
If AL then fill "Alabama Family Assistance Program or JOBS"
If AK then fill "Alaska Temporary Assistance Program (ATAP)"
If AZ then fill "Arizona Cash Assistance or EMPOWER (Employing and Moving People
Off Welfare and Encouraging Responsibility)"
If AR then fill "Arkansas Temporary Assistance for Needy Families (TANF) or
Arkansas Work Pays"
If CA then fill "California Work Opportunity and Responsibility to Kids (CALWORKS)"
If CO then fill "Colorado Works"
If CT then fill "Temporary Family Assistance (TFA) or Jobs First"
If DE then fill "Temporary Assistance for Needy Families (TANF)"
If DC then fill "District of Columbia Temporary Assistance for Needy Families (TANF)"
If FL then fill "Florida Temporary Cash Assistance or Welfare Transition Program or
ACCESS Florida"
If GA then fill "Georgia Temporary Assistance for Needy Families (TANF)"
If HI then fill "Hawaii Temporary Assistance for Needy Families (TANF) or Temporary
Assistance for Other Needy Families (TAONF)"
If ID then fill "Temporary Assistance for Families in Idaho (TAFI)"
If IL then fill "Illinois Temporary Assistance for Needy Families (TANF)"
If IN then fill "Indiana Temporary Assistance for Needy Families (TANF) or Indiana
Manpower Placement and Comprehensive Training (IMPACT)"
If IA then fill "Iowa Family Investment Program (FIP) or PROMISE JOBS"
If KS then fill "Successful Families Program - Temporary Assistance for Needy
Families (TANF) or KansasWorks"
Wednesday, July 06, 2016
Page 21 of 64
If KY then fill "Kentucky Transitional Assistance Program (K-TAP)"
If LA then fill "Louisiana Family Independence Temporary Assistance Program
(FITAP) or Strategies to Empower People (STEP)"
If ME then fill "Maine Temporary Assistance for Needy Families (TANF) or Additional
Support for People in Retraining and Employment (ASPIRE)"
If MD then fill "Temporary Cash Assistance"
If MA then fill "Transitional Aid to Families with Dependent Children (TAFDC) or
Employment Services Program (ESP)"
If MI then fill "Family Independence Program (FIP)"
If MN then fill "Minnesota Family Investment Program (MFIP)"
If MS then fill "Mississippi Temporary Assistance for Needy Families (TANF)"
If MO then fill "Temporary Assistance or Beyond Welfare"
If MT then fill "Montana Temporary Assistance for Needy Families (TANF) or FAIM
(Families Achieving Independence in Montana)"
If NE then fill "Aid to Dependent Children (ADC) or Employment First"
If NV then fill "Nevada Temporary Assistance for Needy Families (TANF) or New
Employees of Nevada (NEON)"
If NH then fill "New Hampshire Financial Assistance to Needy Families (FANF) or New
Hampshire Employment Program (NHEP)"
If NJ then fill "Work First New Jersey (WFNJ)"
If NM then fill "NMWorks"
If NY then fill "Family Assistance (FA) Program or Safety Net Assistance (SNA)"
If NC then fill "Work First"
If ND then fill "Temporary Assistance for Needy Families (TANF) or Job Opportunities
and Basic Skills (JOBS)"
If OH then fill "Ohio Works First (OWF) or Prevention, Retention and Contingency
(PRC)"
If OK then fill "Oklahoma Temporary Assistance for Needy Families (TANF)"
If OR then fill "Oregon Temporary Assistance for Needy Families (TANF) or JOBS
Plus"
If PA then fill "Pennsylvania Temporary Assistance for Needy Families (TANF)"
If RI then fill "Rhode Island Works"
If SC then fill "South Carolina Family Independence Program"
If SD then fill "South Dakota Temporary Assistance for Needy Families (TANF)"
If TN then fill "Tennessee Families First"
If TX then fill "Texas Temporary Assistance for Needy Families (TANF)"
If UT then fill "Family Employment Program (FEP and FEPTP)"
If VT then fill "Reach UP (TANF) or Reach Ahead (transition program)"
If VA then fill "Virginia Temporary Assistance for Needy Families (TANF) or Virginia
Initiative for Employment not Welfare (VIEW)"
If WA then fill "Washington Temporary Assistance for Needy Families (TANF) or
WorkFirst"
If WV then fill "West Virginia Works Program (WV WORKS)"
If WI then fill "Wisconsin Works (W-2) Program"
If WY then fill "Wyoming TANF or Personal Opportunities with Employment
Responsibility (POWER)"
Special Instructions <1> [If one person in the family, fill person number into PTANF and skip to FOWBEN;
Else goto PTANF.
<2, D, R> [goto FOWBEN]
Skip Instructions
<1> [If one person in the family, fill person number into PTANF and skip to FOWBEN;
Else goto PTANF.
<2, D, R> [goto FOWBEN]
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Wednesday, July 06, 2016
Page 22 of 64
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H_FTANF
Wednesday, July 06, 2016
Page 23 of 64
Module
09
Section Name
Part
Question ID
FIN.150_H
Variable Name
H_FTANF
Universe
Universe-text
Question Text
Include in this question any CASH assistance from a state or county welfare program,
and not other types of non-cash welfare assistance. Non-cash assistance (such as
job training, job placement, child care, various kinds of vouchers, or transportation
help) should be included in the question FOWBEN.
Cash assistance state or county welfare programs may come through program types
such as [b] Welfare or Welfare-to-Work, General Assistance/Emergency Assistance,
Refugee Cash Assistance, General Assistance from the Bureau of Indian Affairs, or
Tribal Administered General Assistance [b].
Generally, cash assistance comes in the form of a check, but some states give
recipients a debit card which is linked to an account containing their monies. Debit
cards and welfare-subsidized wages are considered cash assistance.
The following is a list of state-specific program names:
Alabama - Alabama Family Assistance (FA) Program, JOBS
Alaska - Alaska Temporary Assistance Program (ATAP)
Arizona – Arizona Cash Assistance Program, EMPOWER (Employing and Moving
People Off Welfare and Encouraging Responsibility)
Arkansas – Arkansas Temporary Assistance for Needy Families (TANF), Arkansas
Work Pays
California - California Work Opportunity and Responsibility to Kids (CALWORKS)
Colorado - Colorado Works
Connecticut - Temporary Family Assistance (TFA), Jobs First
Delaware - Temporary Assistance for Needy Families (TANF), DABC (Delaware's A
Better Chance)
District of Columbia - Temporary Assistance for Needy Families (TANF)
Florida - Temporary Assistance for Needy Families (TANF) or Welfare Transition
Program or ACCESS Florida
Georgia - Temporary Assistance for Needy Families (TANF)
Hawaii - Temporary Assistance for Needy Families (TANF), Temporary Assistance for
Other Needy Families (TAONF)
Idaho - Temporary Assistance for Families in Idaho (TAFI)
Illinois - Temporary Assistance for Needy Families (TANF)
Indiana - Temporary Assistance for Needy Families (TANF), Indiana Manpower
Placement and Comprehensive Training (IMPACT)
Iowa - Family Investment Program (FIP), PROMISE JOBS
Kansas - Successful Families Program - Temporary Assistance for Needy Families
(TANF), KansasWorks
Kentucky - Kentucky Transitional Assistance Program (K-TAP)
Louisiana - Family Independence Temporary Assistance Program (FITAP), Strategies
to Empower People (STEP)
Maine - Temporary Assistance for Needy Families (TANF), Additional Support for
People in Retraining and Employment (ASPIRE)
Wednesday, July 06, 2016
Page 24 of 64
Maryland - Family Investment Program (FIP) or Maryland RISE (Reaching
Independence and Stability through Employment
Massachusetts - Transitional Aid to Families with Dependent Children (TAFDC),
Employment Services Program (ESP)
Michigan - Family Independence Program (FIP)
Minnesota - Minnesota Family Investment Program (MFIP)
Mississippi - Temporary Assistance for Needy Families (TANF)
Missouri - Temporary Assistance, Beyond Welfare
Montana - Temporary Assistance for Needy Families (TANF), FAIM (Families
Achieving Independence in Montana)
Nebraska - Aid to Dependent Children (ADC), Employment First
Nevada - Temporary Assistance for Needy Families (TANF), New Employees of
Nevada (NEON)
New Hampshire - Financial Assistance to Needy Families (FANF), New Hampshire
Employment Program (NHEP)
New Jersey - Work First New Jersey (WFNJ)
New Mexico - NMWorks
New York - Family Assistance (FA) Program and Safety Net Assistance (SNA)
North Carolina - Work First
North Dakota - Temporary Assistance for Needy Families (TANF), Job Opportunities
and Basic Skills (JOBS)
Ohio - Ohio Works First (OWF), Prevention, Retention and Contingency (PRC)
Oklahoma - Temporary Assistance for Needy Families (TANF)
Oregon - Temporary Assistance for Needy Families (TANF), JOBS Plus
Pennsylvania - Temporary Assistance for Needy Families (TANF)
Rhode Island - Rhode Island Works
South Carolina - Family Independence Program
South Dakota - Temporary Assistance for Needy Families (TANF)
Tennessee - Families First
Texas - Temporary Assistance for Needy Families (TANF), Texas Works (Department
of Human Services), cash assistance Choices (Texas Workforce Commission), TANF
work program
Utah - Family Employment Program (FEP)
Vermont - Reach UP (TANF), Reach Ahead (transition program)
Virginia - Temporary Assistance for Needy Families (TANF), Virginia Initiative for
Employment not Welfare (VIEW)
Washington - Temporary Assistance for Needy Families (TANF), WorkFirst
West Virginia - West Virginia Works Program (WV WORKS)
Wisconsin - Wisconsin Works (W-2) Program
Wyoming - Wyoming TANF or Personal Opportunities with Employment Responsibility
(POWER)
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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FTANF
Wednesday, July 06, 2016
Page 25 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.160
Variable Name
PTANF
Universe
AGE=All and FTANF=yes and family members > 1
Universe-text
If respondent answered yes to FTANF and there is more than one person in the family
Question Text
*Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family received this?
(Anyone else?)
*Indicate each family member with this income.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members.
Skip Instructions
Goto FOWBEN
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Wednesday, July 06, 2016
Page 26 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.164
Variable Name
FOWBEN
Universe
AGE=All
Universe-text
All families
Question Text
At any time during [fill: variable for calculating last calander year], did [fill: 1] receive
any OTHER kind of welfare assistance such as help with getting a job, placement in
education or job training programs, or help with transportation or child care?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Other Welfare
1. If one person in the family, fill: [you] else, fill: [anyone in...]
Special Instructions
Skip Instructions
<1> [if 1 person family, store line number in POWBEN, goto FINTRST]; else goto
POWBEN
<2, D, R> [goto FINTRST]
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Wednesday, July 06, 2016
Page 27 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.166
Variable Name
POWBEN
Universe
AGE=All and FOWBEN=yes and familiy members > 1
Universe-text
If the respondent answered yes to FOWBEN and there is more than one person in the
family
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members.
Skip Instructions
Goto FINTRST
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Wednesday, July 06, 2016
Page 28 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.170
Variable Name
FINTRST
Universe
AGE=All
Universe-text
All families
Question Text
Did [fill: 1] receive income from interest bearing checking accounts, savings accounts,
IRAs or certificates of deposit, money market funds, treasury notes, bonds, or any
other investments that earn interest?
* Do not include dividends
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Interest Accounts
1. If one person in the family, fill: [you] else, fill: [any family...]
Special Instructions
Skip Instructions
<1> [if 1 person family, store line number in PINTRST, goto FDIVD]; Else goto
PINTRST.
<2, D, R> [goto FDIVD]
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Wednesday, July 06, 2016
Page 29 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.180
Variable Name
PINTRST
Universe
AGE=All and FINTRST=1 and family members > 1
Universe-text
If respondent answered yes to FINTRST and there is more than one person in the
family
Question Text
*Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display a roster of all non-deleted family members.
Skip Instructions
Goto FDIVD
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Wednesday, July 06, 2016
Page 30 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.190
Variable Name
FDIVD
Universe
AGE=All
Universe-text
All families
Question Text
Did [fill: 1] receive income from dividends from stocks or mutual funds, or net rental
income from property, royalties, estates or trusts?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Dividends
1. If one person in the family, fill: [you] else, fill: [any family members living here]
Special Instructions
Skip Instructions
<1> [If one person in family, store person number in PDIVD skip to FCHLDSP; else
goto PDIVD]
<2, D, R> [goto FCHLDSP]
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Wednesday, July 06, 2016
Page 31 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.200
Variable Name
PDIVD
Universe
AGE=All and FDIVD=yes and family members > 1
Universe-text
If respondent answered yes to FDIVD and there is more than one person in the family
Question Text
* Ask or verify. Enter applicable line number(s). Separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
Answer Codes
Question Type
Display roster of all non-deleted family members
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members.
Skip Instructions
Goto FCHLDSP
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Wednesday, July 06, 2016
Page 32 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.210
Variable Name
FCHLDSP
Universe
AGE=All
Universe-text
All families
Question Text
?[F1]
Did [fill: 1] receive income from child support?
Answer Codes
Question Type
1. Yes
2. No
Dont Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Child Support
1. If one person in the family, fill: [you] else, fill: [any family members living here]
Special Instructions
Skip Instructions
<1> [If 1 person family, store person number in PCHLDSP goto FINCOT; else goto
PCHLDSP]
<2, D, R> [goto FINCOT]
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H_CHLDPSP
Wednesday, July 06, 2016
Page 33 of 64
Module
09
Section Name
Part
Question ID
FIN.210_H
Variable Name
H_CHLDSP
Universe
Universe-text
Question Text
An adult in the family may have received child support income on behalf of a minor
child (or children) present in the household. If this was the case, you should then
indicate in PCHLDSP the line number OF THE CHILD for whom the money was
intended. Although the mother may have received the money, it was only received
because of a child or children.
There may be instances where a child receiving support in the last calendar year is
not living in the household at the time of the interview. As a result, the child will not be
included in either the household or family rosters. In such a case, you should use the
person number of the custodial parent.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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AssocHelp
Associated screens:
FCHLDSP, PCHLDSP
Wednesday, July 06, 2016
Page 34 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.220
Variable Name
PCHLDSP
Universe
AGE=All and FCHLDSP=yes and family members > 1
Universe-text
If respondent answered yes to FCHLDSP and there is more than one person in the
family
Question Text
?[F1]
*Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate which child in the family this is for. If that child is no longer residing with this
family, enter line number of custodial parent.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display a roster of all non-deleted family members.
Skip Instructions
Goto FINCOT
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H_CHLDSP
Wednesday, July 06, 2016
Page 35 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.230
Variable Name
FINCOT
Universe
AGE=All
Universe-text
All families
Question Text
Did [you/any family member living here] receive income from any other source such as
alimony, contributions from family/others, VA payments, Workers' Compensation, or
unemployment compensation?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Other Income
1. If one person in the family, fill: [you] else, fill: [any family...]
Special Instructions
Skip Instructions
<1> [If one person in the family, store person number in PINCOT, goto FINCTOT];
else goto PINCOT.
<2, D, R> goto FINCTOT
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Wednesday, July 06, 2016
Page 36 of 64
Module
09
Section Name
Family Sources of Income
Part
A
Question ID
FIN.240
Variable Name
PINCOT
Universe
AGE=All and FINCOT=yes and family members > 1
Universe-text
Respondent answered yes to FINCOT, and there is more than one person in the family
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of non-deleted family members.
Skip Instructions
Goto FINCTOT
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Wednesday, July 06, 2016
Page 37 of 64
Module
09
Section Name
Family Income Amounts and Home Ownership
Part
B
Question ID
FIN.250
Variable Name
FINCTOT
Universe
AGE= ALL
Universe-text
All families
Question Text
[fill1: When answering this next question, please remember to include your income
PLUS the income of all family members living in this household.]
What is your best estimate of [fill2: your total income/the total income of all family
members] from all sources, before taxes, in [fill3: last calendar year in 4 digit format]?
* Enter ‘999,995’ if the reported income is greater than $999,995.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Family Income
fill1: If more than one person in the family
fill2: If one person in the family, fill: [your total income]; else, fill: [the total income of all
family members]
Special Instructions
Skip Instructions
<0-999> goto ERR1_FINCTOT
<250001-999995> goto ERR2_FINCTOT
<1000-250000> goto HOUSEOWN
goto FPOV250
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ERR1_FINCTOT:
* Do not read to the respondent.
* $[fill: FINCTOT] is unusually low. Make corrections if necessary.
ERR2_FINCTOT:
* Do not read to the respondent.
* $[fill: FINCTOT] is unusually high. Make corrections if necessary.
AssocHelp
Wednesday, July 06, 2016
Page 38 of 64
Module
09
Section Name
Family Income Amounts and Home Ownership
Part
B
Question ID
FIN.255
Variable Name
FPOV250
Universe
FINCTOT=R,D
Universe-text
Respondents who don't know or refuse their total family income
Question Text
Was your total [fill1: family/ ] income from all sources less than [fill2: 250% of poverty
threshold] or [fill2: 250% of poverty threshold] or more?
Answer Codes
1. Less than [fill2: 250% of poverty threshold]
2. [fill2: 250% of poverty threshold] or more
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
250% of poverty
fill1: If more than one person in the family, fill "family"; else leave blank
fill2: fill 250% of poverty threshold value based on family size
Special Instructions Use the following thresholds (2016 survey year) based on family size:
1 person, age < 66: $31,000
1 person, age >= 66: $28,000
2 persons, age of all < 66: $40,000
2 persons, age of one >= 66: $36,000
3 persons: $47,000
4 persons: $61,000
5 persons: $72,000
6 persons: $81,000
7 persons: $92,000
8 persons: $103,000
9+ persons: $122,000
Please store the filled amount in POV250.
Skip Instructions
<1> goto FPOV138
<2> if PCNT in('01','02') then goto FINC75;
else if (PCNT ='04' or PCNT>='07') then goto FPOV400;
else if PCNT in('03','05','06') then goto FINC100
goto HOUSEOWN
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Wednesday, July 06, 2016
Page 39 of 64
Module
09
Section Name
Family Income Amounts and Home Ownership
Part
B
Question ID
FIN.258
Variable Name
FPOV138
Universe
FPOV250='1'
Universe-text
The respondent answered less than 250% of poverty at FPOV250
Question Text
Was your total [fill1: family/ ] income from all sources less than [fill2: 138% of poverty
threshold] or [fill2: 138% of poverty threshold] or more?
Answer Codes
1. Less than [fill2: 138% of poverty threshold]
2. [fill2: 138% of poverty threshold] or more
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
138% of poverty
fill1: If more than one person in the family, fill "family"; else leave blank
fill2: fill 138% of poverty threshold value based on family size
Special Instructions Use the following thresholds (2016 survey year) based on family size:
1 person, age < 66: $17,000
1 person, age >= 66: $16,000
2 persons, age of all < 66: $22,000
2 persons, age of one >= 66: $20,000
3 persons: $26,000
4 persons: $34,000
5 persons: $40,000
6 persons: $45,000
7 persons: $51,000
8 persons: $57,000
9+ persons: $67,000
Please store the filled amount in POV138.
Skip Instructions
<1> goto FPOV100
<2> goto FPOV200
goto HOUSEOWN
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Wednesday, July 06, 2016
Page 40 of 64
Module
09
Section Name
Family Income Amounts and Home Ownership
Part
B
Question ID
FIN.261
Variable Name
FPOV100
Universe
FPOV138='1'
Universe-text
The respondent answered less than 138% of poverty at FPOV138
Question Text
Was your total [fill1: family/ ] income from all sources less than [fill2: 100% poverty
threshold] or [fill2: 100% poverty threshold] or more?
Answer Codes
1. Less than [fill2: 100% of poverty threshold]
2. [fill2: 100% poverty threshold] or more
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
100% of poverty
fill1: If more than one person in the family, fill "family"; else leave blank
fill2: fill 100% of poverty threshold value based on family size
Special Instructions Use the following thresholds (2016 survey year) based on family size:
1 person, age < 66: $12,000
1 person, age >= 66: $11,000
2 persons, age of all < 66: $16,000
2 persons, age of one >= 66: $14,000
3 persons: $19,000
4 persons: $24,000
5 persons: $29,000
6 persons: $33,000
7 persons: $37,000
8 persons: $41,000
9+ persons: $49,000
Please store the filled amount in POV100.
Skip Instructions
<1,2,R,D> goto HOUSEOWN
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Wednesday, July 06, 2016
Page 41 of 64
Module
09
Section Name
Family Income Amounts and Home Ownership
Part
B
Question ID
FIN.264
Variable Name
FPOV200
Universe
FPOV138='2'
Universe-text
The respondent answered 138% of poverty or more at FPOV138
Question Text
Was your total [fill1: family/ ] income from all sources less than [fill2: 200% of poverty
threshold] or [fill2: 200% of poverty threshold] or more?
Answer Codes
1. Less than [fill2: 200% of poverty threshold]
2. [fill2: 200% of poverty threshold] or more
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
200% of poverty
fill1: If more than one person in the family, fill "family"; else leave blank
fill2: fill 200% of poverty threshold value based on family size
Special Instructions Use the following thresholds (2016 survey year) based on family size:
1 person, age < 66: $25,000
1 person, age >= 66: $23,000
2 persons, age of all < 66: $32,000
2 persons, age of one >= 66: $29,000
3 persons: $38,000
4 persons: $49,000
5 persons: $58,000
6 persons: $65,000
7 persons: $74,000
8 persons: $82,000
9+ persons: $98,000
Please store the filled amount in POV200.
Skip Instructions
<1,2,R,D> goto HOUSEOWN
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Wednesday, July 06, 2016
Page 42 of 64
Module
09
Section Name
Family Income Amounts and Home Ownership
Part
B
Question ID
FIN.267
Variable Name
FINC75
Universe
FPOV250='2' and PCNT in('01','02')
Universe-text
The respondent answered 250% of poverty threshold or more at FPOV250 and he/she
is from a 1 or 2 person family
Question Text
Was your total [fill: family/ ] income from all sources less than $75,000 or $75,000 or
more?
Answer Codes
1. Less than $75,000
2. $75,000 or more
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
$75,000
fill: If more than one person in the family, fill "family"; else leave blank
Special Instructions
Skip Instructions
<1> goto FPOV400
<2> goto FINC100
goto HOUSEOWN
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Wednesday, July 06, 2016
Page 43 of 64
Module
09
Section Name
Family Income Amounts and Home Ownership
Part
B
Question ID
FIN.270
Variable Name
FINC100
Universe
(FINC75='2' and PCNT in('01','02')) or (FPOV250='2' and PCNT in('03','05','06'))
Universe-text
The respondent answered $75,000 or more at FINC75 and he/she is from a 1 or 2
person family; or the respondent answered 250% of poverty or more at FPOV250 and
he/she is from a 3, 5, or 6 person family
Question Text
Was your total [fill: family/ ] income from all sources less than $100,000 or $100,000
or more?
Answer Codes
1. Less than $100,000
2. $100,000 or more
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
$100,000
fill: If more than one person in the family, fill "family"; else leave blank
Special Instructions
Skip Instructions
<1> if PCNT in(‘01’,’02’,’05’,’06’) then goto HOUSEOWN;
else if PCNT=’03’ then goto FPOV400
<2> > if PCNT in(‘01’,’02’,’03’) then goto FINC150;
else if PCNT in (‘05’,’06’) then goto FPOV400
[goto HOUSEOWN]
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Wednesday, July 06, 2016
Page 44 of 64
Module
09
Section Name
Family Income Amounts and Home Ownership
Part
B
Question ID
FIN.273
Variable Name
FPOV400
Universe
(FINC75=’1’ and PCNT in(‘01’,’02’)) or (FINC100=’1’ and PCNT=’03’) or (FINC100=’2’
and PCNT in(’05’,’06’)) or (F250POV=’2’ and (PCNT=’04’ or PCNT >=’07’))
Universe-text
The respondent answered less than $75,000 at FINC75 and he/she is from a 1 or 2
person family; or the respondent answered less than $100,000 at FINC100 and
he/she is from a 3 person family; or the respondent answered $100,000 or more at
FINC100 and he/she is from a 5 or 6 person family; or the respondent answered 250%
of poverty or more at FPOV250 and he/she is from a 4, 7, 8, or 9+ person family
Question Text
Was your total [fill1: family/ ] income from all sources less than [fill2: 400% of poverty
threshold] or [fill2: 400% of poverty threshold] or more?
Answer Codes
1. Less than [fill2: 400% of poverty threshold]
2. [fill2: 400% of poverty threshold] or more
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
400% of poverty
fill1: If more than one person in the family, fill "family"; else leave blank
fill2: fill 400% of poverty threshold value based on family size
Special Instructions Use the following thresholds (2016 survey year) based on family size:
1 person, age < 66: $49,000
1 person, age >= 66: $46,000
2 persons, age of all < 66: $64,000
2 persons, age of one >= 66: $57,000
3 persons: $76,000
4 persons: $97,000
5 persons: $115,000
6 persons: $130,000
7 persons: $148,000
8 persons: $164,000
9+ persons: $196,000
Please store the filled amount in POV400.
Skip Instructions
<1> if PCNT >= '09' then goto FINC150;
else goto HOUSEOWN
<2> if PCNT in(‘01’,’02’,’03’,’07','08' ) goto HOUSEOWN;
else if PCNT in('04','05','06') goto FINC150
goto HOUSEOWN
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Wednesday, July 06, 2016
Page 45 of 64
Module
09
Section Name
Family Income Amounts and Home Ownership
Part
B
Question ID
FIN.276
Variable Name
FINC150
Universe
(FINC100=’2’ and PCNT in(‘01’,’02’,’03’)) or (FPOV400=’2’ and PCNT in(‘04’,’05’,’06’))
or (FPOV400=’1’ and PCNT >= '09’)
Universe-text
The respondent answered $100,00 or more at FINC100 and he/she is from a 1, 2, or 3
person family; or the respondent answered 400% of poverty or more at FPOV400 and
he/she is from a 4, 5, or 6 person family; or the respondent answered less than 400%
of poverty at FPOV400 and he/she is from a family of 9 or more persons
Question Text
Was your total [fill: family/ ] income from all sources less than $150,000 or $150,000
or more?
Answer Codes
1. Less than $150,000
2. $150,000 or more
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
$150,000
fill: If more than one person in the family, fill "family"; else leave blank
Special Instructions
Skip Instructions
<1,2,R,D> goto HOUSEOWN
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Wednesday, July 06, 2016
Page 46 of 64
Module
09
Section Name
Family Income Amounts and Home Ownership
Part
B
Question ID
FIN.280
Variable Name
HOUSEOWN
Universe
AGE = ALL
Universe-text
All Families
Question Text
Is this house/apartment owned or being bought, rented, or occupied by some other
arrangement by you [fill: /or someone in your family]?
Answer Codes
1. Owned or being bought
2. Rented
3. Other arrangement
Don't Know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Owned or Rent
1. If family members> 1, fill: [... or someone in your family?]
Special Instructions place answer name to the right
Skip Instructions
<1,3,R,D> [goto FSSAPL]
<2> [goto FGAH]
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Wednesday, July 06, 2016
Page 47 of 64
Module
09
Section Name
Family Income Amounts and Home Ownership
Part
B
Question ID
FIN.282
Variable Name
FGAH
Universe
HOUSEOWN= rented
Universe-text
Families who rent
Question Text
?[F1]
[fill: 1] paying lower rent because the Federal, State, or local government is paying
part of the cost?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Lower Rent
1. If one person in the family, fill:[Are you], Else fill: [Is anyone in your family]
Special Instructions
Skip Instructions
<1, 2, D, R> [goto FSSAPL to see if family fits into the universe for this question]
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H_FGAH
Wednesday, July 06, 2016
Page 48 of 64
Module
09
Section Name
Family Income Amounts and Home Ownership
Part
Question ID
FIN.282_H
Variable Name
H_FGAH
Universe
Universe-text
Question Text
Federal, State, or Local government housing programs for persons with low income
may take many forms. Government housing assistance could come from:
[blt]monetary assistance to help pay rent,
a program called "Section 8,"
direct payments to landlords,
vouchers,
or other types of assistance from a local housing authority.[blt]
Living in public housing is considered housing assistance from the government.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screen:
FGAH
Skip Instructions
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Wednesday, July 06, 2016
Page 49 of 64
Module
09
Section Name
Family Income Program Participation
Part
C
Question ID
FIN.300
Variable Name
FSSAPL
Universe
AGE=All
Universe-text
All
Question Text
?[F1]
[fill: Have you EVER applied for Supplemental Security Income or SSI, even if the
claim was denied?/Have any family members living here EVER applied for
Supplemental Security Income (SSI)? This includes people who applied for benefits,
even if the claim was denied.]
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Applied SSI
1. If one person in the family, fill: [Have you EVER applied for Supplemental Security
Income or SSI, even if the claim was denied?] else, fill: [Have any family members
living here EVER applied for Supplemental Security Income (SSI)? This includes
people who applied for benefits, even if the claim was denied.]
Special Instructions
Skip Instructions
<1> [If one person family, store line number in PSSAPL. Goto FSDAPL to see if family
fits into universe for this question; Else goto PSSAPL]
<2, D, R> [goto FSDAPL to see if family fits into universe for this question]
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H_FSSI
Wednesday, July 06, 2016
Page 50 of 64
Module
09
Section Name
Family Income Program Participation
Part
C
Question ID
FIN.310
Variable Name
PSSAPL
Universe
AGE=All and familiy members > 1
Universe-text
If respondent said yes to FSSAPL and there is more than one person in the family
Question Text
*Ask or verify. Enter applicable line number(s), separate with a comma.
Who in the family applied for it?
(Anyone else?)
* Indicate each family member who applied for SSI benefits.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of all non-deleted family members.
Skip Instructions
Goto FSDAPL
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Wednesday, July 06, 2016
Page 51 of 64
Module
09
Section Name
Family Income Program Participation
Part
C
Question ID
FIN.330
Variable Name
FSDAPL
Universe
AGE= ALL
Universe-text
All Families
Question Text
?[F1]
[fill: Have you EVER APPLIED for disability benefits from Social Security even if the
claim was denied?/Have any family members living here EVER applied for disability
benefits from Social Security? This includes people who applied for benefits, even if
the claim was denied.]
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Applied Disability Benefits
1. If one person in the family, fill: [Have you EVER APPLIED for disability benefits
from Social Security even if the claim was denied?] else, fill: [Have any family
members living here EVER applied for disability benefits from Social Security? This
includes people who applied for benefits, even if the claim was denied.]
Special Instructions
Skip Instructions
<1> [If one person family, store line number in PSDAPL. Goto TANFMYR to see if the
family fits in the universe for TANFMYR; Else goto PSDAPL]
<2, D, R> [goto TANFMYR to see if family fits into the universe for this question]
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H_FSSRR
Wednesday, July 06, 2016
Page 52 of 64
Module
09
Section Name
Family Income Program Participation
Part
C
Question ID
FIN.340
Variable Name
PSDAPL
Universe
AGE=All and FSDAPL=yes and family members > 1
Universe-text
Respondent answered yes to FSDAPL and there is more than one person in the
family.
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family applied for it?
(Anyone else?)
* Indicate each family member who applied for Social Security Disability benefits.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display a roster of all non-deleted family members.
Skip Instructions
Goto TANFMYR to see if family fits into the universe for this question.
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Wednesday, July 06, 2016
Page 53 of 64
Module
09
Section Name
Family Income Program Participation
Part
C
Question ID
FIN.350
Variable Name
TANFMYR
Universe
AGE=All and person selected in PTANF
Universe-text
Persons who received AFDC or General Assistance
Question Text
?[F1]
Earlier I recorded that [fill: you/alias] received cash assistance from programs such as
welfare or public assistance in [fill: last year in 4 digit format]. During [fill: last year in
4 digit format], about how many months did [fill: you/alias] receive this assistance?
*Enter "1" if less than one month.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
# of Months of Cash Assistance
1. If one person family, fill: [you] else fill: [alias]
Special Instructions This is asked for all persons listed in PTANF. Roster through for each person.
Skip Instructions
<1-12, D, R> Repeat this question for all persons listed in PTANF, then goto FSNAP
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H_TANFMYR
Wednesday, July 06, 2016
Page 54 of 64
Module
09
Section Name
Part
Question ID
FIN.350_H
Variable Name
H_TANFMYR
Universe
Universe-text
To answer this question:
Question Text
1 = 1 month or less
2 = more than 1, but not more than 2 months
3 = more than 2, but not more than 3 months
4 = more than 3, but not more than 4 months
5 = more than 4, but not more than 5 months
6 = more than 5, but not more than 6 months
7 = more than 6, but not more than 7 months
8 = more than 7, but not more than 8 months
9 = more than 8, but not more than 9 months
10 = more than 9, but not more than 10 months
11 = more than 10, but not more than 11 months
12 = more than 11, but not more than 12 months
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
TANFMYR, FSNAPMYR
Skip Instructions
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Wednesday, July 06, 2016
Page 55 of 64
Module
09
Section Name
Family Income Program Participation
Part
C
Question ID
FIN.360
Variable Name
FSNAP
Universe
AGE=All
Universe-text
All families
Question Text
?[F1]
At any time during [fill 1: last calendar year in 4-digit format], did [fill 2: you/any family
members living here] receive [fill 3: food stamp benefits/SNAPNAME or food stamp
benefits]?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
Food Stamps/SNAP
1. Fill the last calendar year in 4-digit format.
2. If one person in the family, fill: [you]; else fill: [any family members living here]
3. If the state program name is "Food Stamp Program", then just fill "food stamp
benefits";
else, fill state name for the family's state of residence (VERADD (COV.010) for
variable ST) along with "or food stamp benefits" as listed below.
If AL then fill "Food Assistance Program or food stamp benefits"
If AK then fill "food stamp benefits"
If AZ then fill "Nutrition Assistance or food stamp benefits"
If AR then fill "SNAP or food stamp benefits"
If CA then fill "CalFresh"
If CO then fill "Food Assistance Program or food stamp benefits"
If CT then fill "SNAP or food stamp benefits"
If DE then fill "Food Supplement Program or food stamp benefits"
If DC then fill "SNAP or food stamp benefits"
If FL then fill "Food Assistance Program or food stamp benefits"
If GA then fill "SNAP or food stamp benefits"
If HI then fill "SNAP or food stamp benefits"
If ID then fill "food stamp benefits"
If IL then fill "SNAP or food stamp benefits"
If IN then fill "SNAP or food stamp benefits"
If IA then fill "Food Assistance Program and food stamp benefits"
If KS then fill "Food Assistance Program and food stamp benefits"
If KY then fill "SNAP or food stamp benefits"
If LA then fill "SNAP or food stamp benefits"
If ME then fill "Food Supplement Program or food stamp benefits"
If MD then fill "Food Supplement Program or food stamp benefits"
If MA then fill "SNAP or food stamp benefits"
If MI then fill "Food Assistance Program or food stamp benefits"
If MN then fill "SNAP or food stamp benefits"
Wednesday, July 06, 2016
Page 56 of 64
If MS then fill "SNAP or food stamp benefits"
If MO then fill "food stamp benefits"
If MT then fill "SNAP or food stamp benefits"
If NE then fill "SNAP or food stamp benefits"
If NV then fill "SNAP or food stamp benefits"
If NH then fill "SNAP"
If NJ then fill "SNAP"
If NM then fill "SNAP or food stamp benefits"
If NY then fill "SNAP or food stamp benefits"
If NC then fill "Food and Nutrition Services or food stamp benefits"
If ND then fill "SNAP or food stamp benefits"
If OH then fill "Food Assistance Program or food stamp benefits"
If OK then fill "SNAP or food stamp benefits"
If OR then fill "SNAP or food stamp benefits"
If PA then fill "SNAP or food stamp benefits"
If RI then fill "SNAP or food stamp benefits"
If SC then fill "SNAP or food stamp benefits"
If SD then fill "SNAP or food stamp benefits"
If TN then fill "SNAP"
If TX then fill "SNAP or food stamp benefits"
If UT then fill "SNAP"
If VT then fill "3SquaresVT or food stamp benefits"
If VA then fill "SNAP or food stamp benefits"
If WA then fill "Basic Food or food stamp benefits"
If WV then fill "SNAP or food stamp benefits"
If WI then fill "FoodShare Wisconsin or food stamp benefits"
If WY then fill "SNAP or food stamp benefits"
Special Instructions
Skip Instructions
<1> [goto FSNAPMYR]
<2, D, R> [Goto FINWIC to see if family falls into the universe for this question.]
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H_FSNAP
Wednesday, July 06, 2016
Page 57 of 64
Module
09
Section Name
Part
Question ID
FIN.360_H
Variable Name
H_FSNAP
Universe
Universe-text
Question Text
SNAP or Food Stamp benefits are coupons that can be used to purchase food. The
SNAP or Food Stamp program is a joint federal-state program which is administered
by the state and local governments.
The following is a list of state-specific program names:
Alabama - Food Assistance Program
Alaska - Food Stamp Program (FSP)
Arizona - Nutrition Assistance
Arkansas - SNAP
California - CalFresh
Colorado - Food Assistance Program
Connecticut - SNAP
Delaware - Food Supplement Program
District of Columbia - SNAP
Florida - Food Assistance Program
Georgia - SNAP
Hawaii - SNAP
Idaho - Food Stamp Program (FSP)
Illinois - SNAP
Indiana - SNAP
Iowa - Food Assistance Program
Kansas - Food Assistance Program
Kentucky - SNAP
Louisiana - SNAP
Maine - Food Supplement Program
Maryland - Food Supplement Program
Massachusetts - SNAP
Michigan - Food Assistance Program
Minnesota - SNAP
Mississippi - SNAP
Missouri - Food Stamp Program (FSP)
Montana - SNAP
Nebraska - SNAP
Nevada - SNAP
New Hampshire - SNAP
New Jersey - SNAP
New Mexico - SNAP
New York - SNAP
North Carolina - Food and Nutrition Services
North Dakota - SNAP
Ohio - Food Assistance Program
Oklahoma - SNAP
Oregon - SNAP
Pennsylvania - SNAP
Wednesday, July 06, 2016
Page 58 of 64
Rhode Island - SNAP
South Carolina - SNAP
South Dakota - SNAP
Tennessee - SNAP
Texas - SNAP
Utah - SNAP
Vermont - 3SquaresVT
Virginia - SNAP
Washington - Basic Food
West Virginia - SNAP
Wisconsin - FoodShare Wisconsin
Wyoming - SNAP
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
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FSNAP
Wednesday, July 06, 2016
Page 59 of 64
Module
09
Section Name
Family Income Program Participation
Part
C
Question ID
FIN.380
Variable Name
FSNAPMYR
Universe
FSNAP=1
Universe-text
Family received food stamp/SNAP benefits in previous calendar year
Question Text
?[F1]
During [fill 1: last year in 4 digit format], about how many months were [fill 2: food
stamp benefits/SNAPNAME or food stamp benefits] received?
* Enter "1" if less than 1 month
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
months of Food Stamps/SNAP
1. Fill last calendar year in 4-digit format.
2. If the state program name is "Food Stamp Program", then just fill "food stamp
benefits";
else fill state program name for the family's state of residence along with "or food
stamp benefits" as shown below.
If AL then fill Food Assistance Program or food stamp benefits
If AK then fill food stamp benefits
If AZ then fill Nutrition Assistance or food stamp benefits
If AR then fill SNAP or food stamp benefits
If CA then fill CalFresh
If CO then fill Food Assistance Program or food stamp benefits
If CT then fill SNAP or food stamp benefits
If DE then fill Food Supplement Program or food stamp benefits
If DC then fill SNAP or food stamp benefits
If FL then fill Food Assistance Program or food stamp benefits
If GA then fill SNAP or food stamp benefits
If HI then fill SNAP or food stamp benefits
If ID then fill food stamp benefits
If IL then fill SNAP or food stamp benefits
If IN then fill SNAP or food stamp benefits
If IA then fill Food Assistance Program and food stamp benefits
If KS then fill Food Assistance Program and food stamp benefits
If KY then fill SNAP or food stamp benefits
If LA then fill SNAP or food stamp benefits
If ME then fill Food Supplement Program or food stamp benefits
If MD then fill Food Supplement Program or food stamp benefits
If MA then fill SNAP or food stamp benefits
If MI then fill Food Assistance Program or food stamp benefits
If MN then fill SNAP or food stamp benefits
If MS then fill SNAP or food stamp benefits
If MO then fill food stamp benefits
If MT then fill SNAP or food stamp benefits
Wednesday, July 06, 2016
Page 60 of 64
If NE then fill SNAP or food stamp benefits
If NV then fill SNAP or food stamp benefits
If NH then fill SNAP
If NJ then fill SNAP
If NM then fill SNAP or food stamp benefits
If NY then fill SNAP or food stamp benefits
If NC then fill Food and Nutrition Services or food stamp benefits
If ND then fill SNAP or food stamp benefits
If OH then fill Food Assistance Program or food stamp benefits
If OK then fill SNAP or food stamp benefits
If OR then fill SNAP or food stamp benefits
If PA then fill SNAP or food stamp benefits
If RI then fill SNAP or food stamp benefits
If SC then fill SNAP or food stamp benefits
If SD then fill SNAP or food stamp benefits
If TN then fill SNAP
If TX then fill SNAP or food stamp benefits
If UT then fill food stamp benefits
If VT then fill 3SquaresVT or food stamp benefits
If VA then fill SNAP or food stamp benefits
If WA then fill Basic Food or food stamp benefits
If WV then fill SNAP or food stamp benefits
If WI then fill FoodShare Wisconsin or food stamp benefits
If WY then fill SNAP or food stamp benefits
Special Instructions
Skip Instructions
Goto FINWIC to see if family fits into universe for this question.
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H_FSNAP
Wednesday, July 06, 2016
Page 61 of 64
Module
09
Section Name
Family Income Program Participation
Part
C
Question ID
FIN.384
Variable Name
FINWIC
Universe
(SEX= female and AGE=12-55) or (AGE=0-5)
Universe-text
Families with females aged 12-55 or children age 0-5
Question Text
?[F1]
At any time during [fill: last year in 4 digit format] did [you/anyone in your family]
receive benefits from the WIC program, that is, the Women, Infants and Children
program?
Answer Codes
Question Type
1. Yes
2. No
Don't Know
Refused
Yes/No
Field Pane Description
Fill Instructions
WIC
1. If one person in the family, fill: [you] else, fill: [anyone in your family...]
Special Instructions
Skip Instructions
<1> [If 1 person family, store person number in PWIC. [Goto end of section];
Else [goto PWIC]
<2, D, R> [Goto end of section.]
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H_FINWIC
Wednesday, July 06, 2016
Page 62 of 64
Module
09
Section Name
Part
Question ID
FIN.384_H
Variable Name
H_FINWIC
Universe
Universe-text
Question Text
WIC or the Supplemental Food Program for Women, Infants and Children (WIC)
provides food and/or vouchers which can be exchanged for food. Pregnant women
without children may also qualify for this program. Children are eligible for WIC
benefits until their 5th birthday (although the parent/guardian receives the
food/vouchers).
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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Wednesday, July 06, 2016
Page 63 of 64
Module
09
Section Name
Family Income Program Participation
Part
C
Question ID
FIN.385
Variable Name
PWIC
Universe
FINWIC=yes and family members > 1
Universe-text
Respondent answered yes to FINWIC
Question Text
* Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family received this?
(Anyone else?)
* Indicate family members who were authorized to receive WIC benefits.
Answer Codes
Question Type
Enter All That Apply
Field Pane Description
Who
Fill Instructions
Special Instructions Display roster of non-deleted family members.
Skip Instructions
Goto end of section
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Wednesday, July 06, 2016
Page 64 of 64
2017 Q1 NHIS Instrument Spec Report
Section name: Language of Interview
Module
55
Section Name
Language of Interview
Part
Question ID
FLG.010_00.000
Variable Name
ENGLANG
Universe
AGE >= 5
Universe-text
All persons age 5 or older
Question Text
How well [fill: do you/does ALIAS] speak English? Would you say…
Answer Codes
1. Very well
2. Well
3. Not well
4. Not at all
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
English language
if respondent fill "do you" else fill "does ALIAS"
Special Instructions Repeat question for all persons on roster age 5+
Question should come after FIN section but before FSD section.
Skip Instructions
<1-4> goto next section,
If FDRN_FLG=2, then goto S.C. section if sample child in the family;
Else If not, then goto S.A. secton;
Else no S.C. nor S.A., then goto RECONTACT section
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Wednesday, July 06, 2016
Page 1 of 1
2017 Q1 NHIS Instrument Spec Report
Section name: Family Disability: Version 2
Module
36
Section Name
Family Disability: Version 2
Part
Question ID
FDB.020_00.000
Variable Name
P2DFHEAR
Universe
AGE >= 1 and FDRN_FLG=2
Universe-text
All persons age 1 or older and random number generator=2
Question Text
With this next set of questions, we want to learn about people who have physical,
mental, or emotional conditions that cause serious difficulties with their daily activities.
Though different, these questions may sound similar to ones I asked earlier.
[fill 1: Are you/Is ALIAS] deaf or [fill 2: do you/does ALIAS] have serious difficulty
hearing?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Difficulty hearing
1. If subject=respondent fill: [Are you]; else fill: [Is ALIAS]
2. If subject=respondent fill: [do you]; else fill: [does ALIAS]
Special Instructions Loop through FDB.020--FDB.135 for one person and then repeat for next person on the
roster.
Skip Instructions
<1,2,D,R> goto P2DFSEE
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Wednesday, August 03, 2016
Page 1 of 11
Module
36
Section Name
Family Disability: Version 2
Part
Question ID
FDB.040_00.000
Variable Name
P2DFSEE
Universe
AGE >= 1 and FDRN_FLG=2
Universe-text
All persons age 1 or older
Question Text
[fill 1: Are you/Is ALIAS] blind or [fill 2: do you/does ALIAS] have serious difficulty seeing
even when wearing glasses?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Difficulty seeing
1. If subject=respondent fill: [Are you]; else fill: [Is ALIAS]
2. If subject=respondent fill: [do you]; else fill: [does ALIAS]
Special Instructions Loop through FDB.020--FDB.135 for one person and then repeat for next person on the
roster.
Skip Instructions
<1,2,D,R> if no more persons age 5 or older, goto next section;
else goto P2DFCON
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Wednesday, August 03, 2016
Page 2 of 11
Module
36
Section Name
Family Disability: Version 2
Part
Question ID
FDB.060_00.000
Variable Name
P2DFCON
Universe
AGE >= 5 and FDRN_FLG=2
Universe-text
All persons 5 or older
Question Text
Because of a physical, mental, or emotional condition, [fill 1: do you/does ALIAS] have
serious difficulty concentrating, remembering, or making decisions?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Difficulty concentrating
1. If subject=respondent fill: [do you]; else fill: [does ALIAS]
Special Instructions Loop through FDB.020--FDB.135 for one person and then repeat for next person on the
roster.
Skip Instructions
<1,2,D,R> goto P2DFWALK
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Wednesday, August 03, 2016
Page 3 of 11
Module
36
Section Name
Family Disability: Version 2
Part
Question ID
FDB.080_00.000
Variable Name
P2DFWALK
Universe
AGE >= 5 and FDRN_FLG=2
Universe-text
All persons 5 or older
Question Text
[fill 1: Do you/Does ALIAS] have serious difficulty walking or climbing stairs?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Difficulty walking
1. If subject=respondent fill: [Do you]; else fill: [Does ALIAS]
Special Instructions Loop through FDB.020--FDB.135 for one person and then repeat for next person on the
roster.
Skip Instructions
<1,2,D,R> goto P2DFDRES
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Wednesday, August 03, 2016
Page 4 of 11
Module
36
Section Name
Family Disability: Version 2
Part
Question ID
FDB.100_00.000
Variable Name
P2DFDRES
Universe
AGE >= 5 and FDRN_FLG=2
Universe-text
All persons 5 or older
Question Text
[fill 1: Do you/Does ALIAS] have difficulty dressing or bathing?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Difficulty dressing
1. If subject=respondent fill: [Do you]; else fill: [Does ALIAS]
Special Instructions Loop through FDB.020--FDB.135 for one person and then repeat for next person on the
roster.
Skip Instructions
<1,2,D,R> if age GE 5 and AGE LE 14 and PDFCON=1 [goto PDFCAUSE]; else if no
more persons age 15 or older, goto next section; else goto P2DFERR
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Wednesday, August 03, 2016
Page 5 of 11
Module
36
Section Name
Family Disability
Part
Question ID
FDB.105_00.000
Variable Name
QARNDM2
Universe
QAASK2 = 1
Universe-text
All families selected for QA question
Question Text
Random number generator
Answer Codes
(Allow 00-09)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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Wednesday, August 03, 2016
Page 6 of 11
Module
36
Section Name
Family Disability
Part
Question ID
FDB.110_00.000
Variable Name
QACHK2
Universe
QAASK2 = 1 AND ( (AGE >= 5 AND P2DFDRES <> EMPTY) OR (AGE < 5 AND
P2DFSEE <> EMPTY))
Universe-text
All persons age 1 or older and random number generator=2 where QA question was
selected
Question Text
*Please enter [Fill1: QARNDM2 ] for quality assurance.
Answer Codes
(Allow 0-9)
Question Type
Procedure
Field Pane Description
Fill Instructions
QA Check
Fill1: QARNDM2 is the number that was randomly selected is filled in here
Special Instructions
Skip Instructions
[goto P2DFERR]
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Wednesday, August 03, 2016
Page 7 of 11
Module
36
Section Name
Family Disability
Part
Question ID
FDB.115_00.000
Variable Name
QACHNG2
Universe
QACHK2=0-9
Universe-text
All families selected for QA question
Question Text
Flag field to indicate whether or not the value entered by the FR matched or not.
' ' (empty) - if the check was not asked or answered
0 - if the check was asked and the value entered matches the random value
1 - if the check was asked and the value entered does NOT match the random
value (cannot be undone)
Answer Codes
' ', 0,1
Question Type
Flag
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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Wednesday, August 03, 2016
Page 8 of 11
Module
36
Section Name
Family Disability: Version 2
Part
Question ID
FDB.120_00.000
Variable Name
P2DFERR
Universe
AGE >= 15 and FDRN_FLG=2
Universe-text
All persons 15 or older
Question Text
Because of a physical, mental, or emotional condition, [fill 1: do you/does ALIAS] have
difficulty doing errands alone such as visiting a doctor's office or shopping?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Difficulty doing errands
1. If subject=respondent fill: [do you]; else fill: [does ALIAS]
Special Instructions Loop through FDB.020--FDB.135 for one person and then repeat for next person on the
roster.
Skip Instructions
<1,2,D,R> if PDFCON=1 then goto PDFCAUSE; else if no more persons age 1 or
older, goto next section;
else return to P2DFHEAR for next person age 1 or older
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Wednesday, August 03, 2016
Page 9 of 11
Module
36
Section Name
Family Disability: Version 2
Part
Question ID
FDB.130_00.000
Variable Name
PDFCAUSE
Universe
AGE >= 5 and FDRN_FLG=2 and PDFCON(e)='1'
Universe-text
All persons 5 or older who have difficulty concentrating or remembering
Question Text
What is the MAIN reason for [fill 1: your/ALIAS's] difficulty concentrating, remembering
or making decisions?
Answer Codes
1. Intellectual disability (formerly known as mental retardation)
2. Developmental disability (such as cerebral palsy or autism)
3. Dementia or Alzheimer’s disease
4. Learning disability or ADHD
5. Education level
6. Mental illness (such as depression, anxiety, post-traumatic stress disorder,
emotional problem)
7. Traumatic brain injury or stroke
8. Age-related changes
9. Chronic health condition (such as diabetes, high blood pressure, heart disease,
cancer, multiple sclerosis, Parkinson’s disease, epilepsy)
10. Drugs or medications
11. Other (specify)
Refused
Don't know
2. No
Don't know
Refused
Question Type
Pick one answer list pane
Field Pane Description
Fill Instructions
Cause of difficulty
1. If subject=respondent fill: [your]; else fill: [ALIAS'S]
Special Instructions Loop through FDB.020--FDB.135 for one person and then repeat for next person on the
roster.
Skip Instructions
<1-10,D,R> if no more persons age 15 or older, goto next section; <11> [goto
PDFSPEC];
else return to P2DFHEAR for next person age 1 or older
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Wednesday, August 03, 2016
Page 10 of 11
Module
36
Section Name
Family Disability: Version 2
Part
Question ID
FDB.135_00.000
Variable Name
PDFSPEC
Universe
AGE >= 5 and FDRN_FLG=2 and PDFCAUSE(e)='11'
Universe-text
All persons 5 or older who have difficulty concentrating or remembering and the cause
was given as other
Question Text
*Enter the other reason for difficulty with concentrating, remembering or making
decisions?
Answer Codes
Verbatim
Refused
Don’t know
Question Type
Verbatim
Field Pane Description
Other cause
Fill Instructions
Special Instructions Loop through FDB.020--FDB.135 for one person and then repeat for next person on the
roster.
Skip Instructions
<1-10,D,R> if no more persons age 15 or older, goto next section; <11> [goto
PDFOTHER];
else return to P2DFHEAR for next person age 1 or older
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Wednesday, August 03, 2016
Page 11 of 11
| File Type | application/pdf |
| File Modified | 2016-11-14 |
| File Created | 2016-07-07 |