Main Questionnaire Flashcards

Attachment 4f - Main Questionnaire Flashcards

54HIS-501(C) (2018)
NATIONAL
HEALTH
INTERVIEW
SURVEY
U.S. Department
of Commerce
BUREAU OF THE
CENSUS
Field
Representative’s
Flashcard and
Information
Booklet (CAPI)

CARD H1
You may choose more than one.
1.

Puerto Rican

2.

Cuban/Cuban American

3.

Dominican (Republic)

4.

Mexican

5.

Mexican American

6.

Central or South American

7.

Other Latin American

8.

Other Hispanic/Latino/Spanish

CARD H2
You may choose more than one.
1.

White

2.

Black/African American

3.

Indian (American)

4.

Alaska Native

5.

Native Hawaiian

6.

Guamanian or Chamorro

7.

Samoan

8.

Other Pacific Islander

9.

Asian Indian

10. Chinese
11. Filipino
12. Japanese
13. Korean
14. Vietnamese
15. Other Asian

CARD H3
2.

Spouse (husband/wife)

3.

Unmarried Partner

4.

Child (biological/adoptive/in-law/
step/foster)

5.

Child of Partner

6.

Grandchild

7.

Parent (biological/adoptive/in-law/
step/foster)

8.

Brother/Sister (biological/adoptive/in-law/
step/foster)

9.

Grandparent (Grandmother/Grandfather)

10. Aunt/Uncle
11. Niece/Nephew
12. Other relative
13. Housemate/Roommate
14. Roomer/Boarder
15. Other non-relative
16. Legal Guardian
17. Ward

CARD F1
You may choose more than one.
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)
Other impairment/problem

CARD F2
You may choose more than one.
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
Other impairment/problem

CARD F3
Beginning

Middle
Middle
Middle

1

2

3

8

9

10

15

16

17

4

5

6

7

11

12

13

14

18

19

20

21
End

22

23

24

29

30

31

25

26

27

28

CARD F4

You may choose up to four.

Insert drawing of injured body parts here

Insert drawing of face here.

CARD F5
You may choose up to two.

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)

CARD F6

1.
2.
3.
4.
5.
6.
7.
8.
9.

Passenger car
Passenger truck, such as a pickup truck, van, or
SUV
Bus
Large commercial truck, such as a semi-truck, big
rig, or 18-wheeler
Motorcycle (including mopeds, minibikes)
All terrain vehicle or ski/snow-mobile
Farm equipment (such as a tractor)
Industrial or construction vehicle
Other

CARD F7

You may choose up to two.
On, down, from, or into:
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

CARD F8

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

CARD F9

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)

CARD F10
You may choose up to two.
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)

CARD F11
You may choose up to two.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

Home (inside)
Home (outside)
School (not residential)
Child care center or preschool
Residential institution (excluding hospital)
Health care facility (including hospital)
Street or highway
Sidewalk
Parking lot
Sport facility, athletic field, or playground
Shopping center, restaurant, store, bank, gas
station, or other place of business
Farm
Park or recreation area (including bike or jog path)
River, lake, stream, or ocean
Industrial or construction area
Other public building
Other

CARD F12
You may choose more than one.
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
*EXCLUDE private plans that only provide
extra cash while hospitalized.

CARD F13

Insert picture of Medicare card here.

CARD F14
STATE NAMES FOR MEDICAID, CHIP, STATE-/LOCALSPONSORED, AND OTHER HEALTH INSURANCE
PROGRAMS

***FORTHCOMING***

CARD F15
You may choose more than one.
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)

CARD F16
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)

CARD F17
1.

6 months or less

2.

More than 6 months, but not more than
1 year ago

3.

More than 1 year, but not more than 3
years ago

4.

More than 3 years

5.

Never

CARD F18
You may choose up to five.
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.

Lost Medicaid (Other reason for losing Medicaid)

10. Other (specify)

CARD F19
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

CARD F20

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

CARD F21
0.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.

Never attended/kindergarten only
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade, no diploma
GED or equivalent
HIGH SCHOOL GRADUATE
Some college, no degree
Associate’s degree: occupational,
technical, or vocational program
Associate’s degree: academic program
Bachelor’s degree (Example: BA, AB, BS, BBA)
Master’s degree (Example: MA, MS, MEng, MEd,
MBA)
Professional School degree (Example: MD,
DDS, DVM, JD)
Doctoral degree (Example: Phd, EdD)

CARD F22
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

CARD C1
1. Parent (Biological, adoptive or step)
2. Grandparent
3. Aunt/Uncle
4. Brother/Sister
5. Other relative
6. Legal Guardian
7. Foster parent
8. Other non-relative

CARD C2
You may choose more than one.
1. Down syndrome
2. Cerebral palsy
3. Muscular dystrophy
4. Cystic fibrosis
5. Sickle cell anemia
6. Diabetes
7. Arthritis
8. Congenital heart disease
9. Other heart condition

CARD C3
0. Not true
1. Sometimes true
2. Often true

CARD C4
0. Never
1. 6 months or less
2. More than 6 months, but not more than 1 year ago
3. More than 1 year, but not more than 2 years ago
4. More than 2 years, but not more than 5 years ago
5. More than 5 years ago

CARD C5

0. None
1. 1
2. 2 - 3
3. 4 - 5
4. 6 - 7
5. 8 - 9
6. 10 - 12
7. 13 - 15
8. 16 or more

CARD C6
1. 1
2. 2 - 3
3. 4 - 5
4. 6 - 7
5. 8 - 9
6. 10 - 12
7. 13 - 15
8. 16 or more

CARD C7

1.

Not true

2.

Somewhat true

3.

Certainly true

CARD C8

Overall, do you think that this child has difficulties in any
of the following areas: emotions, concentration,
behavior, or being able to get along with other people?

1. No
2. Yes, minor difficulties
3. Yes, definite difficulties
4. Yes, severe difficulties

CARD A1
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

CARD A2
1. An employee of a PRIVATE company,
business, or individual for wages,
salary, or commission
2. A FEDERAL government employee
3. A STATE government employee
4. A LOCAL government employee
5. Self-employed in OWN business,
professional practice or farm
6. Working WITHOUT PAY in
family-owned business or farm

CARD A3
1. 1 employee
2. 2–9 employees
3. 10–24 employees
4. 25–49 employees
5. 50–99 employees
6. 100–249 employees
7. 250–499 employees
8. 500–999 employees
9.1000 employees or more

Card A4
You may choose more than one.

Place drawing of joints here.

CARD A5

0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity

CARD A6
You may choose more than one.
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
Other impairment/problem

CARD A7
0. Never
1. 6 months or less
2. More than 6 months, but not more than 1 year
ago.
3. More than 1 year, but not more than 2 years ago
4. More than 2 years, but not more than 5 years ago
5. More than 5 years ago

CARD A8
0. None
1. 1
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10-12
7. 13-15
8. 16 or more

CARD A9
1. 1
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10-12
7. 13-15
8. 16 or more

CARD ASI1

1.Gay
2.Straight, that is, not gay
3.Bisexual
4.Something else
5.I don’t know the answer

CARD ASI2

1. Lesbian or gay
2. Straight, that is, not lesbian or gay
3. Bisexual
4. Something else
5. I don’t know the answer

CARD ASI3
1. ALL of the time
2. MOST of the time
3. SOME of the time
4. A LITTLE of the time
5. NONE of the time

CARD ASI4
1. It’s unlikely you’ve been exposed to HIV
2. You were afraid to find out if you were HIV positive
(that you had HIV)
3. You didn’t want to think about HIV or about being HIV
positive
4. You were worried your name would be reported to
the government if you tested positive
5. You didn’t know where to get tested
6. You don’t like needles
7. You were afraid of losing your job, insurance,
housing, friends, family, if people knew you were
positive for
AIDS infection
8. Some other reason
9. No particular reason