Form 0920-1061 Even-Numbered Year BRFSS Core Questionnaire

Attachment 3a

Even - numbered Year

2020, 2022 Core Questionnaire

Table of Contents

OMB Header and Introductory Text 3

Landline Introduction 4

Cell Phone Introduction 9

Core Section 1: Health Status 14

Core Section 2: Healthy Days 15

Core Section 3: Healthcare Access 16

Core Section 4: Exercise 18

Core Section 5: Inadequate Sleep 18

Core Section 6: Chronic Health Conditions 19

Core Section 7: Oral Health 22

Core Section 8: Demographics 22

Core Section 9: Tobacco Use 29

Core Section 10: Alcohol Consumption 32

Core Section 11: Immunization 34

Core Section 12: Falls 36

Core Section 13: Seat Belt Use and Drinking and Driving 36

Core Section 14: Breast and Cervical Cancer Screening 38

Core Section 15: Prostate Cancer Screening 41

Core Section 16: Colorectal Cancer Screening 44

Core Section 17: H.I.V./AIDS 47

Closing Statement/ Transition to Modules 51

OMB Header and Introductory Text

Read if necessary	Read	Interviewer instructions (not read)
Public reporting burden of this collection of information is estimated to average 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).		Form Approved OMB No. 0920-1061 Exp. Date 3/31/2018 Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at ivk7@cdc.gov.
	HELLO, I am calling for the (health department). My name is (name). We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.

Landline Introduction

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
LL01.	Is this [PHONE NUMBER]?	CTELENM1	1 Yes	Go to LL02		63
			2 No	TERMINATE	Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time.
LL02.	Is this a private residence?	PVTRESD1	1 Yes	Go to LL04	Read if necessary: By private residence we mean someplace like a house or apartment. Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.	64
			2 No	Go to LL03	If no, business phone only: thank you very much but we are only interviewing persons on residential phones lines at this time. NOTE: Business numbers which are also used for personal communication are eligible.
			3 No, this is a business		Read: Thank you very much but we are only interviewing persons on residential phones at this time.
LL03.	Do you live in college housing?	COLGHOUS	1 Yes	Go to LL04	Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.	65
			2 No	TERMINATE	Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
LL04.	Do you currently live in__(state)____?	STATERE1	1 Yes	Go to LL05		66
			2 No	TERMINATE	Thank you very much but we are only interviewing persons who live in [STATE] at this time.
LL05.	Is this a cell phone?	CELPHONE	1 Yes, it is a cell phone	TERMINATE	Read: Thank you very much but we are only interviewing by landline telephones in private residences or college housing at this time.	67
			2 Not a cell phone	Go to LL06	Read if necessary: By cell phone we mean a telephone that is mobile and usable outside your neighborhood. Do not read: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).
LL06.	Are you 18 years of age or older?	LADULT1	1 Yes	[CATI NOTE: IF COLLEGE HOUSING = “YES,” CONTINUE; OTHERWISE GO TO ADULT RANDOM SELECTION]		68
			2 No	TERMINATE	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
LL07.	Are you male or female?	COLGSEX	1 Male 2 Female	ONLY for respondents who are LL and COLGHOUS= 1.		69
			7 Don’t know/Not sure 9 Refused	TERMINATE	Thank you for your time, your number may be selected for another survey in the future.
LL08.	I need to randomly select one adult who lives in your household to be interviewed. Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older?	NUMADULT	1	Go to Transition to Section 1. Go to LL09	Read: Are you that adult? If yes: Then you are the person I need to speak with. If no: May I speak with the adult in the household?	70-71
			2-6 or more	Go to LL10.
LL09.	Are you male or female?	LANDSEX	1 Male 2 Female	GO to Transition Section 1.		72
			7 Don’t know/Not sure 9 Refused	TERMINATE	Thank you for your time, your number may be selected for another survey in the future.
LL10.	How many of these adults are men?	NUMMEN	_ _ Number 77 Don’t know/ Not sure 99 Refused			73-74
LL11.	So the number of women in the household is [X]. Is that correct?	NUMWOMEN			Do not read: Confirm the number of adult women or clarify the total number of adults in the household. Read: The persons in your household that I need to speak with is [Oldest/Youngest/ Middle//Male /Female].	75-76
LL12	The person in your household that I need to speak with is [Oldest/Youngest/ Middle//Male /Female]. Are you the [Oldest/Youngest/ Middle//Male /Female] in this household?	RESPSLCT	1 Male 2 Female			77
			7 Don’t know/Not sure 9 Refused	TERMINATE	Thank you for your time, your number may be selected for another survey in the future.
Transition to Section 1.			I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).		Do not read: Introductory text may be reread when selected respondent is reached. Do not read: The sentence “Any information you give me will not be connected to any personal information” may be replaced by “Any personal information that you provide will not be used to identify you.” If the state coordinator approves the change.

Cell Phone Introduction

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)		SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CP01.	Is this a safe time to talk with you?	SAFETIME	1 Yes		Go to CP02		78
			2 No		([set appointment if possible]) TERMINATE]	Thank you very much. We will call you back at a more convenient time.
CP02.	Is this [PHONE NUMBER]?	CTELNUM1	1 Yes		Go to CP03		79
			2 No		TERMINATE
CP03.	Is this a cell phone?	CELLFON5	1 Yes		Go to CADULT		80
			2 No		TERMINATE	If "no”: thank you very much, but we are only interviewing persons on cell telephones at this time
CP04.	Are you 18 years of age or older?	CADULT1	1 Yes				81
			2 No		TERMINATE	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
CP05.	Are you male or female?	CELLSEX	1 Male 2 Female				82
			7 Don’t Know/ Not sure 9 Refused	TERMINATE		Thank you for your time, your number may be selected for another survey in the future.
CP06.	Do you live in a private residence?	PVTRESD3	1 Yes		Go to CP08	Read if necessary: By private residence we mean someplace like a house or apartment Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.	83
			2 No		Go to CP07
CP07.	Do you live in college housing?	CCLGHOUS	1 Yes		Go to CP08	Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.	84
			2 No		TERMINATE	Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
CP08.	Do you currently live in___(state)____?	CSTATE1	1 Yes		Go to CP10		85
			2 No		Go to CP09
CP09.	In what state do you currently live?	RSPSTAT1	1 Alabama 2 Alaska 4 Arizona 5 Arkansas 6 California 8 Colorado 9 Connecticut 10 Delaware 11 District of Columbia 12 Florida 13 Georgia 15 Hawaii 16 Idaho 17 Illinois 18 Indiana 19 Iowa 20 Kansas 21 Kentucky 22 Louisiana 23 Maine 24 Maryland 25 Massachusetts 26 Michigan 27 Minnesota 28 Mississippi 29 Missouri 30 Montana 31 Nebraska 32 Nevada 33 New Hampshire 34 New Jersey 35 New Mexico 36 New York 37 North Carolina 38 North Dakota 39 Ohio 40 Oklahoma 41 Oregon 42 Pennsylvania 44 Rhode Island 45 South Carolina 46 South Dakota 47 Tennessee 48 Texas 49 Utah 50 Vermont 51 Virginia 53 Washington 54 West Virginia 55 Wisconsin 56 Wyoming 66 Guam 72 Puerto Rico 78 Virgin Islands 99 Refused				86-87
CP10.	Do you also have a landline telephone in your home that is used to make and receive calls?	LANDLINE	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused			Read if necessary: By landline telephone, we mean a regular telephone in your home that is used for making or receiving calls. Please include landline phones used for both business and personal use.	88
CP11.	How many members of your household, including yourself, are 18 years of age or older?	HHADULT	_ _ Number 77 Don’t know/ Not sure 99 Refused		If CP07 = yes then number of adults is automatically set to 1		89-90
Transition to section 1.			I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).

Core Section 1: Health Status

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C01.01	Would you say that in general your health is—	GENHLTH	Read: 1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor Do not read: 7 Don’t know/Not sure 9 Refused			101

Core Section 2: Healthy Days

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C02.01	Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?	PHYSHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused			102-103
C02.02	Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?	MENTHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused			104-105
C02.03	During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?	POORHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused	Skip if C02.01, PHYSHLTH, is 88 and C02.02, MENTHLTH, is 88		106-107

Core Section 3: Healthcare Access

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C03.01	Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Service?	HLTHPLN1	1 Yes	If using Healthcare Access (HCA) Module go to HCA.01, else continue		108
			2 No 7 Don’t know/Not Sure 9 Refused
C03.02	Do you have one person you think of as your personal doctor or health care provider?	PERSDOC2	1 Yes, only one 2 More than one 3 No 7 Don’t know / Not sure 9 Refused		If No, read: Is there more than one, or is there no person who you think of as your personal doctor or health care provider?	109
C03.03	Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?	MEDCOST	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			110
C03.04	About how long has it been since you last visited a doctor for a routine checkup?	CHECKUP1	Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 5 years (2 years but less than 5 years ago) 4 5 or more years ago Do not read: 7 Don’t know / Not sure 8 Never 9 Refused		Read if necessary: A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.	111

Core Section 4: Exercise

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C04.01	During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?	EXERANY2	1 Yes		If respondent does not have a regular job or is retired, they may count the physical activity or exercise they spend the most time doing in a regular month.	223
			2 No 7 Don’t know/Not Sure 9 Refused	Go to C 11.08

Core Section 5: Inadequate Sleep

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C05.01	On average, how many hours of sleep do you get in a 24-hour period?	CHOLCHK2	_ _ Number of hours [01-24] 77 Don’t know / Not sure 99 Refused

Core Section 6: Chronic Health Conditions

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C06.01	Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You’re Not Sure. (Ever told) you that you had a heart attack also called a myocardial infarction?	CVDINFR4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			117
C06.02	(Ever told) (you had) angina or coronary heart disease?	CVDCRHD4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			118
C06.03	(Ever told) (you had) a stroke?	CVDSTRK3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			119
C06.04	(Ever told) (you had) asthma?	ASTHMA3	1 Yes			120
			2 No 7 Don’t know / Not sure 9 Refused	Go to C06.06
C06.05	Do you still have asthma?	ASTHNOW	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			121
C06.06	(Ever told) (you had) skin cancer?	CHCSCNCR	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			122
C06.07	(Ever told) (you had) any other types of cancer?	CHCOCNCR	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			123
C06.08	(Ever told) (you had) chronic obstructive pulmonary disease, C.O.P.D., emphysema or chronic bronchitis?	CHCCOPD1	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			124
C06.09	(Ever told) (you had) a depressive disorder (including depression, major depression, dysthymia, or minor depression)?	ADDEPEV2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			125
C06.10	Not including kidney stones, bladder infection or incontinence, were you ever told you have kidney disease?	CHCKDNY2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: Incontinence is not being able to control urine flow.	126
C06.11	(Ever told) (you had) diabetes?	DIABETE3	1 Yes		If yes and respondent is female, ask: was this only when you were pregnant? If respondent says pre-diabetes or borderline diabetes, use response code 4.	127
			2 Yes, but female told only during pregnancy 3 No 4 No, pre-diabetes or borderline diabetes 7 Don’t know / Not sure 9 Refused	Go to Pre-Diabetes Optional Module (if used). Otherwise, go to next section.
C06.12	How old were you when you were told you have diabetes?	DIABAGE2	_ _ Code age in years [97 = 97 and older] 98 Don‘t know / Not sure 99 Refused	Go to Diabetes Module if used, otherwise go to next section.		128-129

Core Section 7: Oral Health

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C07.01	Including all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists as well as dental hygienists, how long has it been since you last visited a dentist or a dental clinic for any reason?		1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 5 years (2 years but less than 5 years ago) 4 5 or more years ago Do not read: 7 Don’t know / Not sure 8 Never
C07.02	Not including teeth lost for injury or orthodontics, how many of your permanent teeth have been removed because of tooth decay or gum disease?		1 1 to 5 2 6 or more but not all 3 All 8 None DO NOT READ 7 Don’t know / Not sure 9 Refused

Core Section 8: Demographics

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
Prologue					Read if necessary: I will ask you some questions about yourself in the next section. We include these questions so that we can compare health indicators by groups.
C08.01	What is your age?	AGE	_ _ Code age in years 07 Don’t know / Not sure 09 Refused			137-138
C08.02	Are you Hispanic, Latino/a, or Spanish origin?	HISPANC3	If yes, read: Are you… 1 Mexican, Mexican American, Chicano/a 2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino/a, or Spanish origin Do not read: 5 No 7 Don’t know / Not sure 9 Refused		One or more categories may be selected.	139-142
C08.03	Which one or more of the following would you say is your race?	MRACE1	Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 88 No additional choices 77 Don’t know / Not sure 99 Refused	If more than one response to C08.04; continue. Otherwise, go to C08.06.	If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. One or more categories may be selected.	143-170
C08.04	Which one of these groups would you say best represents your race?	ORACE3	Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 77 Don’t know / Not sure 99 Refused		If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. If respondent has selected multiple races in previous and refuses to select a single race, code refused	171-172
C08.05	Are you…	MARITAL	Please read: 1 Married 2 Divorced 3 Widowed 4 Separated 5 Never married Or 6 A member of an unmarried couple Do not read: 9 Refused			173
C08.06	What is the highest grade or year of school you completed?	EDUCA	Read if necessary: 1 Never attended school or only attended kindergarten 2 Grades 1 through 8 (Elementary) 3 Grades 9 through 11 (Some high school) 4 Grade 12 or GED (High school graduate) 5 College 1 year to 3 years (Some college or technical school) 6 College 4 years or more (College graduate) Do not read: 9 Refused			174
C08.07	Do you own or rent your home?	RENTHOM1	1 Own 2 Rent 3 Other arrangement 7 Don’t know / Not sure 9 Refused		Other arrangement may include group home, staying with friends or family without paying rent. Home is defined as the place where you live most of the time/the majority of the year. Read if necessary: We ask this question in order to compare health indicators among people with different housing situations.	175
C08.08	In what county do you currently live?	CTYCODE2	_ _ _ANSI County Code 777 Don’t know / Not sure 999 Refused			176-178
C08.09	What is the ZIP Code where you currently live?	ZIPCODE1	_ _ _ _ _ 77777 Do not know 99999 Refused			179-183
C08.10	Not including cell phones or numbers used for computers, fax machines or security systems, do you have more than one telephone number in your household?	NUMHHOL3	1 Yes	If cellular telephone interview skip to 8.13 (Veteran3)		184
			2 No 7 Don’t know / Not sure 9 Refused	Go to C08.13
C08.11	How many of these telephone numbers are residential numbers?	NUMPHON3	__ Enter number (1-5) 6 Six or more 7 Don’t know / Not sure 8 None 9 Refused			185
C08.12	How many cell phones do you have for personal use?	CPDEMO1B	__ Enter number (1-5) 6 Six or more 7 Don’t know / Not sure 8 None 9 Refused	Last question needed for partial complete.	Read if necessary: Include cell phones used for both business and personal use.	186
C08.13	Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?	VETERAN3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.	187
C08.14	Are you currently…?	EMPLOY1	Read: 1 Employed for wages 2 Self-employed 3 Out of work for 1 year or more 4 Out of work for less than 1 year 5 A Homemaker 6 A Student 7 Retired Or 8 Unable to work Do not read: 9 Refused		If more than one, say “select the category which best describes you”.	188
C08.15	How many children less than 18 years of age live in your household?	CHILDREN	_ _ Number of children 88 None 99 Refused			189-190
C08.16	Is your annual household income from all sources—	INCOME2	Read if necessary: 04 Less than $25,000 If no, ask 05; if yes, ask 03 ($20,000 to less than $25,000) 03 Less than $20,000 If no, code 04; if yes, ask 02 ($15,000 to less than $20,000) 02 Less than $15,000 If no, code 03; if yes, ask 01 ($10,000 to less than $15,000) 01 Less than $10,000 If no, code 02 05 Less than $35,000 If no, ask 06 ($25,000 to less than $35,000) 06 Less than $50,000 If no, ask 07 ($35,000 to less than $50,000) 07 Less than $75,000 If no, code 08 ($50,000 to less than $75,000) 08 $75,000 or more Do not read: 77 Don’t know / Not sure 99 Refused		If respondent refuses at ANY income level, code ‘99’ (Refused)	191-192
C08.17	About how much do you weigh without shoes?	WEIGHT2	_ _ _ _ Weight (pounds/kilograms) 7777 Don’t know / Not sure 9999 Refused		If respondent answers in metrics, put 9 in first column. Round fractions up	193-196
C08.18	About how tall are you without shoes?	HEIGHT3	_ _ / _ _ Height (ft / inches/meters/centimeters) 77/ 77 Don’t know / Not sure 99/ 99 Refused		If respondent answers in metrics, put 9 in first column. Round fractions down	197-200
C08.19	To your knowledge, are you now pregnant?	PREGNANT	1 Yes 2 No 7 Don’t know / Not sure 9 Refused	Skip if M28.01, BIRTHSEX, is coded 1; or CP05=1 or LL12=1; or LL09 = 1 or LL07 =1 or C08.01, AGE, is greater than 49		201
C08.20	Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone. Are you deaf or do you have serious difficulty hearing?	DEAF	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			202
C08.21	Are you blind or do you have serious difficulty seeing, even when wearing glasses?	BLIND	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			203
C08.22	Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?	DECIDE	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			204
C08.23	Do you have serious difficulty walking or climbing stairs?	DIFFWALK	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			205
C08.24	Do you have difficulty dressing or bathing?	DIFFDRES	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			206
C08.25	Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?	DIFFALON	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			207

Core Section 9: Tobacco Use

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C09.01	Have you smoked at least 100 cigarettes in your entire life?	SMOKE100	1 Yes		Do not include: electronic cigarettes (e-cigarettes, njoy, bluetip), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs) or marijuana. 5 packs = 100 cigarettes	208
			2 No 7 Don’t know/Not Sure 9 Refused	Go to C09.05
C09.02	Do you now smoke cigarettes every day, some days, or not at all?	SMOKDAY2	1 Every day 2 Some days			209
			3 Not at all	Go to C09.04
			7 Don’t know / Not sure 9 Refused	Go to C09.05
C09.03	During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?	STOPSMK2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused	Go to C09.05		210
C09.04	How long has it been since you last smoked a cigarette, even one or two puffs?	LASTSMK2	Read if necessary: 01 Within the past month (less than 1 month ago) 02 Within the past 3 months (1 month but less than 3 months ago) 03 Within the past 6 months (3 months but less than 6 months ago) 04 Within the past year (6 months but less than 1 year ago) 05 Within the past 5 years (1 year but less than 5 years ago) 06 Within the past 10 years (5 years but less than 10 years ago) 07 10 years or more 08 Never smoked regularly 77 Don’t know / Not sure 99 Refused			211-212
C09.05	Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?	USENOW3	1 Every day 2 Some days 3 Not at all 7 Don’t know / Not sure 9 Refused		Read if necessary: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.	213

Core Section 10: Alcohol Consumption

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C10.01	During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?	ALCDAY5	1 _ _ Days per week 2 _ _ Days in past 30 days		INTERVIEWER NOTE: One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor.	214-216
			888 No drinks in past 30 days 777 Don’t know / Not sure 999 Refused	Go to next section
C10.02	One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?	AVEDRNK2	_ _ Number of drinks 88 None 77 Don’t know / Not sure 99 Refused		Read if necessary: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.	217-218
C10.03	Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion?	DRNK3GE5	_ _ Number of times 88 None 77 Don’t know / Not sure 99 Refused	CATI X = 5 for men, X = 4 for women		219-220
C10.04	During the past 30 days, what is the largest number of drinks you had on any occasion?	MAXDRNKS	_ _ Number of drinks 77 Don’t know / Not sure 99 Refused			221-222

Core Section 11: Immunization

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)		SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C13.01	During the past 12 months, have you had either a flu vaccine that was sprayed in your nose or a flu shot injected into your arm?	FLUSHOT7	1 Yes			A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.	261
			2 No 7 Don’t know / Not sure 9 Refused	Go to C13.03
C13.02	During what month and year did you receive your most recent flu vaccine that was sprayed in your nose or flu shot injected into your arm?	FLSHTMY3	_ _ / _ _ _ _ Month/ Year 777777 Don’t know/ Not sure 999999 Refused		Module on Place of Flu Shot Vaccination may be inserted after this question.		262-267
C13.03	At what kind of place did you get your last flu shot or vaccine?		01 A doctor’s office or health maintenance organization (HMO) 02 A health department 03 Another type of clinic or health center (a community health center) 04 A senior, recreation, or community center 05 A store (supermarket, drug store) 06 A hospital (inpatient) 07 An emergency room 08 Workplace 09 Some other kind of place 11 A school Do not read: 10 Received vaccination in Canada/Mexico 77 Don’t know / Not sure (Probe: How would you describe the place where you went to get your most recent flu vaccine?) 99 Refused
C13.04	Have you ever had a pneumonia shot also known as a pneumococcal vaccine?	PNEUVAC4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			Read if necessary: There are two types of pneumonia shots: polysaccharide, also known as Pneumovax, and conjugate, also known as Prevnar.	269

Core Section 12: Falls

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C12.01	In the past 12 months, how many times have you fallen?		_ _ Number of times [76 = 76 or more] 88 None [Go to next section] 77 Don’t know / Not sure [Go to next section] 99 Refused[Go to next section]		INTERVIEWER NOTE: By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.	270
			88 None 77 Don’t know / Not sure 99 Refused	Go to NEXT SECTION
C12.02	How many of these falls caused an injury that limited your regular activities for at least a day?		_ _ Number of falls [76 = 76 or more] 88 None 77 Don’t know / Not sure 99 Refused	[Fill in Did this fall (from Q12.1) cause an injury?]. If only one fall from Q12.1 and response is Yes (caused an injury); code 01. If response is No, code 88.	INTERVIEWER NOTE: By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.	271-276

Core Section 13: Seat Belt Use and Drinking and Driving

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C13.01	How often do you use seat belts when you drive or ride in a car? Would you say—		Read: 1 Always 2 Nearly always 3 Sometimes 4 Seldom 5 Never Do not read: 7 Don’t know / Not sure 9 Refused			270
			8 Never drive or ride in a car	Go to NEXT SECTION
C13.02	During the past 30 days, how many times have you driven when you’ve had perhaps too much to drink?		_ _ Number of times 88 None 77 Don’t know / Not sure 99 Refused

Core Section 14: Breast and Cervical Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C14.01	Have you ever had a mammogram?		1 Yes	If male go to the next section.		270
			2 No 7 Don’t know/ Not sure 9 Refused	Go to 14.3
C14.02	How long has it been since you had your last mammogram?		READ IF NECESSARY: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago 7 Don’t know / Not sure 9 Refused
C14.03	Have you ever had a Pap test?		1 Yes		INTERVIEWER NOTE: A Pap test is a test for cancer of the cervix.
			2 No 7 Don’t know/ Not sure 9 Refused	Go to 14.5
C14.04	How long has it been since you had your last Pap test?		READ IF NECESSARY: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago 7 Don’t know / Not sure 9 Refused
C14.05	An H.P.V. test is sometimes given with the Pap test for cervical cancer screening. Have you ever had an H.P.V. test?		1 Yes		INTERVIEWER NOTE: HUMAN PAPILLOMAVIRUS (PAP-UH-LOH-MUH VIRUS)
			2 No 7 Don’t know/ Not sure 9 Refused	Go to 14.7
C14.06	How long has it been since your last H.P.V. test?		READ IF NECESSARY: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago 7 Don’t know / Not sure 9 Refused
C14.07	Have you had a hysterectomy?		1 Yes 2 No 7 Don’t know / Not sure 9 Refused		INTERVIEWER NOTE: A hysterectomy is an operation to remove the uterus (womb).

Core Section 15: Prostate Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C15.01	Has a doctor, nurse, or other health professional ever talked with you about the advantages of the Prostate-Specific Antigen or P.S.A. test?		1 Yes 2 No 7 Don’t know/ Not sure 9 Refused	If respondent is <39 years of age, or is female, go to next section.	A prostate-specific antigen test, also called a P.S.A. test, is a blood test used to check men for prostate cancer.	270
C15.02	Has a doctor, nurse, or other health professional ever talked with you about the disadvantages of the P.S.A. test?		1 Yes 2 No 7 Don’t know/ Not sure 9 Refused
C15.03	Has a doctor, nurse, or other health professional ever recommended that you have a P.S.A. test?		1 Yes
			2 No 7 Don’t know/ Not sure 9 Refused	Go to Next Section
C15.04	Have you ever had a P.S.A. test?		1 Yes 2 No 7 Don’t know/ Not sure 9 Refused
C15.05	How long has it been since you had your last P.S.A. test?		READ IF NECESSARY: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago 7 Don’t know / Not sure 9 Refused
C15.06	What was the main reason you had this P.S.A. test – was it …?		Read: 1 Part of a routine exam 2 Because of a prostate problem 3 Because of a family history of prostate cancer 4 Because you were told you had prostate cancer 5 Some other reason Do not read: 7 Don’t know / Not sure 9Refused

Core Section 16: Colorectal Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)		SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C16.01	A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?		1 Yes	9 Refused If respondent is < 49 years of age, go to next section.
			2 No 7 Don’t know/ Not sure 9 Refused	Go to 16.3
C16.02	How long has it been since you had your last blood stool test using a home kit?		READ IF NECESSARY: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago 7 Don’t know / Not sure 9 Refused
C15.03	For a sigmoidoscopy, a flexible tube is inserted into the rectum to look for problems. A colonoscopy is similar, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. Was your most recent exam a sigmoidoscopy or a colonoscopy?		1 Sigmoidoscopy 2 Colonoscopy
			7 Don’t know/ Not sure 9 Refused		Go to Next Section
C16.04	How long has it been since you had your last sigmoidoscopy or colonoscopy?		READ IF NECESSARY: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 Within the past 10 years 6 10 or more years ago 7 Don’t know / Not sure 9 Refused

Core Section 17: H.I.V./AIDS

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C17.01	The next few questions are about the national health problem of H.I.V., the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don’t have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had. Including fluid testing from your mouth, but not including tests you may have had for blood donation, have you ever been tested for H.I.V?	HIVTST7	1 Yes
			2 No 7 Don’t know/ not sure 9 Refused	Go to C17.03
C17.02	Not including blood donations, in what month and year was your last H.I.V. test?	HIVTSTD3	_ _ /_ _ _ _ Code month and year 77/ 7777 Don’t know / Not sure 99/ 9999 Refused	If response is before January 1985, code "777777".	INTERVIEWER NOTE: If the respondent remembers the year but cannot remember the month, code the first two digits 77 and the last four digits for the year.	271-276
C17.03	I am going to read you a list. When I am done, please tell me if any of the situations apply to you. You do not need to tell me which one. You have injected any drug other than those prescribed for you in the past year.  You have been treated for a sexually transmitted disease or STD in the past year. You have given or received money or drugs in exchange for sex in the past year. You had anal sex without a condom in the past year. You had four or more sex partners in the past year.  Do any of these situations apply to you? Do any of these situations apply to you?	HIVRISK5	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			277

Closing Statement/ Transition to Modules

Read if necessary	Read	CATI instructions (not read)
That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.		Read if no optional modules follow, otherwise continue to optional modules.

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2 March 2021