Form 0920-1061 BRFSS Field Test Questionnaire Example

Public reporting burden of this collection of information is estimated to average 25 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).

Questions by Section

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. If you have any questions about the survey, please call (give appropriate state telephone number).

Core Section 1: Health Status

1.1 Would you say that in general your health is—

READ:

1 Excellent,

2 Very good,

3 Good,

4 Fair, or

5 Poor.

DO NOT READ:

7 Don’t know / Not sure

9 Refused

Core Section 2: Healthy Days — Health-Related Quality of Life

2.1 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?

DO NOT READ:

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

2.2 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?

DO NOT READ:

_ _ Number of days

88 None [If Q2.1 and Q2.2 = 88 (None), go to next section]

77 Don’t know / Not sure

99 Refused

2.3 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?

DO NOT READ:

__ Number of days

88 None

77 Don’t know / Not sure

99 Refused

Core Section 3: Demographics

3.1 What was your sex at birth?

DO NOT READ:

1 Male

2 Female

9 Refused

3.2. Which of the following best represents how you think of yourself

INTERVIEWER NOTE: WE ASK THIS QUESTION IN ORDER TO BETTER UNDERSTAND THE HEALTH AND HEALTH CARE NEEDS OF PEOPLE WITH DIFFERENT SEXUAL ORIENTATIONS.

INTERVIEWER NOTE: PLEASE SAY THE NUMBER BEFORE THE TEXT RESPONSE. RESPONDENT CAN ANSWER WITH EITHER THE NUMBER OR THE TEXT/WORD.

READ:

1 1 - Straight

2 2 - Lesbian or gay

3 3 - Bisexual

DO NOT READ:

4 Other

7 Don’t know/Not sure

9 Refused

3.3 Do you consider yourself to be transgender?

IF YES, ASK “DO YOU CONSIDER YOURSELF TO BE 1 MALE-TO-FEMALE, 2. FEMALE-TO-MALE, OR 3. GENDER NON-CONFORMING?

INTERVIEWER NOTE: Please say the number before the “yes” text response. Respondent can answer with either the number or the text/word.

READ:

1 1. Yes, Transgender, male-to-female

2 2. Yes, Transgender, female to male

3 3. Yes, Transgender, gender nonconforming

4 4. No, not transgender.

DO NOT READ:

7 Don’t know/not sure

9 Refused

INTERVIEWER NOTE: IF ASKED ABOUT DEFINITION OF TRANSGENDER: SOME PEOPLE DESCRIBE THEMSELVES AS TRANSGENDER WHEN THEY EXPERIENCE A DIFFERENT GENDER IDENTITY FROM THEIR SEX AT BIRTH. FOR EXAMPLE, A PERSON BORN INTO A MALE BODY, BUT WHO FEELS FEMALE OR LIVES AS A WOMAN WOULD BE TRANSGENDER. SOME TRANSGENDER PEOPLE CHANGE THEIR PHYSICAL APPEARANCE SO THAT IT MATCHES THEIR INTERNAL GENDER IDENTITY. SOME TRANSGENDER PEOPLE TAKE HORMONES AND SOME HAVE SURGERY. A TRANSGENDER PERSON MAY BE OF ANY SEXUAL ORIENTATION – STRAIGHT, GAY, LESBIAN, OR BISEXUAL.

INTERVIEWER NOTE: IF ASKED ABOUT DEFINITION OF GENDER NON-CONFORMING: SOME PEOPLE THINK OF THEMSELVES AS GENDER NON-CONFORMING WHEN THEY DO NOT IDENTIFY ONLY AS A MAN OR ONLY AS A WOMAN.

3.4 What is your age?

DO NOT READ:

_ _ Code age in years

07 Don’t know / Not sure

09 Refused

3.5 Are you Hispanic, Latino/a, or Spanish origin?

If yes, ask: Are you…

INTERVIEWER NOTE: One or more categories may be selected.

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

3.6 Which one or more of the following would you say is your race?

INTERVIEWER NOTE: Select all that apply.

INTERVIEWER NOTE: 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.

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

CATI NOTE: If more than one response to Q3.5; continue. Otherwise, go to Q3.6.

3.5 Which one of these groups would you say best represents your race?

INTERVIEWER NOTE: If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategory underneath major heading.

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

3.6 Are you…?

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

3.7 What is the highest grade or year of school you completed?

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

3.8 Do you own or rent your home?

DO NOT READ:

1 Own

2 Rent

3 Other arrangement

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: “Other arrangement” may include group home, staying with friends or family without paying rent.

NOTE: Home is defined as the place where you live most of the time/the majority of the year.

INTERVIEWER NOTE: We ask this question in order to compare health indicators among people with different housing situations.

3.9 Are you currently…?

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

8 Unable to work

DO NOT READ:

9 Refused

3.10 In the past 12 months, have you received food stamps, also called SNAP, the Supplemental Nutrition Assistance Program on an EBT card?

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused

INTERVIEWER NOTE: Food Stamps or SNAP (Supplemental Nutrition Assistance Program) is a government program that provides plastic cards, also known as EBT (Electronic Benefit Transfer) cards, that can be used to buy food. In the past, SNAP was called the Food Stamp Program and gave people benefits in paper coupons or food stamps.

3.11 How many children less than 18 years of age live in your household?

_ _ Number of children

88 None

99 Refused

3.12 Is your annual household income from all sources—

If respondent refuses at ANY income level, code ‘99’ (Refused)

READ ONLY 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

3.13 About how much do you weigh without shoes?

INTERVIEWER NOTE: If respondent answers in metrics, put “9” in column XXX. Round fractions up

_ _ _ _ Weight (pounds/kilograms)

7777 Don’t know / Not sure

9999 Refused

3.14 About how tall are you without shoes?

INTERVIEWER NOTE: If respondent answers in metrics, put “9” in column XXX. Round fractions down

_ _ / _ _ Height

(f t / inches/meters/centimeters)

7 7/ 7 7 Don’t know / Not sure

9 9/ 9 9 Refused

Core Section 4: Cardio Vascular Disease

Has a doctor, nurse, or other health professional ever told you that you had any of the following?

6.1 (Ever told) you that you had a heart attack also called a myocardial infarction?

DO NOT READ:

1 Yes, one

2 Yes, more than one

3 No

7 Don’t know / Not sure

9 Refused

6.2 (Ever told) you had a stroke?

DO NOT READ:

1 Yes, one

2 Yes, more than one

3 No

7 Don’t know / Not sure

9 Refused

6.3 (Ever told) you have heart failure? (a condition when the heart cannot pump enough blood to the body)

DO NOT READ:

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Module 5: Cholesterol Awareness

5.1 Blood cholesterol is a fatty substance found in the blood. About how long has it been since you last had your blood cholesterol checked?

INTERVIEWER NOTE:

DO NOT READ:

1 Never [GO TO 5.3]

2 Within the past year (anytime less than 12 months ago)

3 1 to 3 years ago

4 4 to 6 years ago

5 More than 6 years ago

7 Don’t know / Not sure

9 Refused [GO TO 5.3]

5.2 Have you EVER been told by a doctor, nurse or other health professional that your blood cholesterol is high?

DO NOT READ:

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

5.3 Are you currently taking medicine prescribed by a doctor or other health professional for your blood cholesterol? Would you say you….

READ:

1 Usually take it as directed (by your doctor or other health care professional)

2 Sometimes take it as directed

3 Was prescribed it but never started or stopped taking it, or

4 Was never prescribed it

DO NOT READ:

7 Don’t know / Not sure

9 Refused

Module 6: Sodium

Most of the sodium or salt we eat comes from processed foods and foods prepared in restaurants. Salt also can be added in cooking or at the table.

Are you currently watching or reducing your sodium or salt intake?

DO NOT READ:

1. Yes

2. No

7. Don’t know/not sure

9. Refused

Has a doctor or other health professional ever advised you to reduce sodium or salt intake?

DO NOT READ:

1. Yes

2. No

7. Don’t know/not sure

9. Refused

Module 7: Rehabilitation

CATI NOTE: If response to 6.1 =1 or 6.1=2 ask questions 3-5 among those answering; Otherwise go to CATI NOTE at 7.6].

7.1 Following your heart attack, did you go to any kind of outpatient rehabilitation? This is sometimes called "rehab" or “cardiac rehab”.

DO NOT READ:

Yes [Go to Question 7.2]
No [Go to Question 7.3]

7. Don’t know / Not sure

9. Refused

7.2 About how many sessions of outpatient rehabilitation did you attend? Was it….

READ:

Less than 12
12 to 24
25 or more

DO NOT READ:

7 Don’t know / Not sure

9 Refused

7.3 What was the main reason you didn’t go to outpatient rehabilitation?

DO NOT READ:

Not recommended by my doctor or other healthcare provider

Didn’t know about it

Hard to travel to the rehab facility (includes being too far away from a facility)

Work conflict

Unable to afford (because no health insurance coverage or high copayments)

Did not think that it would help me

Don’t know / Not sure

Refused

[CATI NOTE; If q 6.2 = 1 or 2 ask question 6-6].

7.4 Following your stroke, did you go to any kind of rehabilitation to strengthen muscles and regain skills in walking, swallowing, or speaking? This is sometimes called "rehab."

DO NOT READ:

Yes [Go to Question 7.5]
No [Go to Question 7.6]

Don’t know / Not sure [Go to Q9]

Refused [Go to Q9)

7.5 What type of rehab did you go to after your stroke? Was it at the

READ:

Facility you were staying at (inpatient rehab or a nursing home)
A facility you had to travel to or in your home
Both types

DO NOT READ:

7. Don’t know / Not sure

9. Refused

7.6 What was the main reason you didn’t go to rehab (rehabilitation)?

DO NOT READ:

Not recommended by doctor or other healthcare provider
Didn’t know about it
Hard to travel to the rehab facility (includes being too far away from a facility)
Work conflict
Unable to afford (because no health insurance coverage or high copayments)
Did not think that it would help
Don’t know / Not sure

Refused

7.7 Do you regularly check your blood pressure outside of your healthcare provider’s office?

DO NOT READ:

Yes, mostly at home
Yes, mostly on a free machine at my pharmacy, grocery or similar location
No, but would like to
No, not interested

7. Don’t know / Not sure

9. Refused

7.8 Would you say that you regularly share blood pressure information with your healthcare provider…

READ:

Mostly by telephone
Mostly electronically (email, internet portal, fax)
Mostly in person
Do not share information

DO NOT READ:

7. Don’t know / Not sure

9. Refused

7.9 When, if ever, did you receive CPR training? Was it…

READ:

Within in the past 2 years
2 or more years ago (any time beyond and including 2 years)
Never, but would like to be trained
Never and have no interest in training

DO NOT READ:

7 Don’t know / Not sure

9 Refused

7.10 How often are you currently taking an aspirin to prevent or control heart disease, heart attacks or stroke?

READ:

Daily
Some days
Used to take but, had to stop taking due to side effects
No, never taken

DO NOT READ:

7. Don’t know / Not sure

9. Refused

7.11 Before today, have you ever heard of the term FAST (Face, Arms, Speech, Time to call 911) as a way to remember and identify the most common symptoms of a stroke?

DO NOT READ:

7 Don’t know / Not sure

9 Refused

Module 8: Hypertension Awareness

8.1 When was the last time you had your blood pressure checked by a doctor, nurse, or other health professional?

INTERVIEWER NOTE: By “other health professional” we mean a nurse practitioner, a physician’s assistant, or some other licensed health professional.

DO NOT READ:

1 Within the past year (anytime less than 12 months)

2 1 to 5 years ago

3 More than 5 years ago

4 Never

7 Don’t know / Not sure

9 Refused

8.2 Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?

INTERVIEWER NOTE: By “other health professional” we mean a nurse practitioner, a physician’s assistant, or some other licensed health professional.

If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”

DO NOT READ:

1 Yes

2 Yes, but female told only during pregnancy [GO TO NEXT SECTION]

3 No [GO TO NEXT SECTION]

4 Told borderline high or pre-hypertensive [GO TO NEXT SECTION]

7 Don’t know / Not sure [GO TO NEXT SECTION]

9 Refused [GO TO NEXT SECTION]

8.3 Would you say you take medicine for your high blood pressure..

READ:

1 Yes, usually as directed (by your doctor or other health care professional)

2 Yes, sometimes as directed

3 No, medication was prescribed but never started or stopped taking it

4 No, medication was never prescribed

DO NOT READ:

7 Don’t know / Not sure

9 Refused

Module Section 9: Depression/ Anxiety (2 Options/ Randomized)

Option 1

9.1 Over the last 2 weeks, how often have you been bothered by having little interest or pleasure in doing things. Would you say this happens...

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

9.2 Over the last 2 weeks, how often have you been bothered by feeling down, depressed or hopeless? Would you say this happens…

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

9.3 Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge? Would you say this happens…

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

9.4 Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying? Would you say this happens…

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

Option 2:

9.1 Over the last 2 weeks, how many days have you been bothered by having little interest or pleasure in doing things.

DO NOT READ:

__ __ Number of days (0-14)

DO NOT READ:

77 Don’t know/ Not sure

09 Refused

9.2 Over the last 2 weeks, how many days have you been bothered by feeling down, depressed or hopeless?

__ __ Number of days (0-14)

DO NOT READ:

77 Don’t know/ Not sure

09 Refused

9.3 Over the last 2 weeks, how many days have you been bothered by feeling nervous, anxious or on edge?

DO NOT READ:

__ __ Number of days (0-14)

DO NOT READ:

77 Don’t know/ Not sure

Refused

9.4 Over the last 2 weeks, how many days have you been bothered by not being able to stop or control worrying?

DO NOT READ:

__ __ Number of days (0-14)

77 Don’t know/ Not sure

09 Refused

Module Section 10: Indoor Tanning and Excess Sun Exposure

10.1 Not including spray-on tans, during the past 12 months, how many times have you used an indoor tanning device such as a sunlamp, tanning bed, or booth even one time?

DO NOT READ:

Enter number (0-365) __ __ __

777 Don’t know/ Not sure

999 Refused

10.2 During the past 12 months, how many times have you had a sunburn?

DO NOT READ:

Enter number (0-365) __ __ __

777 Don’t know/ Not sure

999 Refused

10.3 When you go outside on a warm sunny day for more than one hour, how often do you protect yourself from the sun (for example, using sunscreen, wearing a wide-brimmed hat, or wearing a long-sleeved shirt)? Is that….

READ:

1 Always

2 Most of the time

3 Sometimes

4 Rarely

5 Never

DO NOT READ:

5 Don’t stay outside for more than one hour on warm sunny days

6 Don’t go outside at all on warm sunny days

7 Don’t know/ Not sure

9 Refused

10.4 In the summer, on average, how long are you outside per day between 10am and 4pm on weekdays?

DO NOT READ:

1 Less than half an hour

2 (more than half an hour) up to 1 hour

3 (more than 1 hour) up to 2 hours

4 (more than 2 hours) up to 3 hours

5 (more than 3 hours) up to 4 hours

6 (more than 4 hours) up to 5 hours

7 Up to 6 hours

77 Don’t know/ Not sure

99 Refused

10.5 In the summer, on average, how long are you outside each day between 10am and 4pm on weekends?

DO NOT READ:

1 Less than half an hour

2 (more than half an hour) up to 1 hour

3 (more than 1 hour) up to 2 hours

4 (more than 2 hours) up to 3 hours

5 (more than 3 hours) up to 4 hours

6 (more than 4 hours) up to 5 hours

7 Up to 6 hours

77 Don’t know/ Not sure

99 Refused

Module Section 11: Colorectal Cancer Screening (2 Options/ Randomized)

Option 1

11.1.1 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?

DO NOT READ:

1 Yes

2 No [Go to Q3]

7 Don't know / Not sure [Go to Q3]

9 Refused [Go to Q3]

11.1.2 How long has it been since you had your last blood stool test using a home kit?

DO NOT READ:

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

11.1.3. A sigmoidoscopy uses a flexible tube that is inserted in the rectum to look for problems. Have you ever had a sigmoidoscopy?

DO NOT READ:

1 Yes

2 No [Go to Q5]

7 Don’t know / Not sure [Go to Q5]

9 Refused [Go to Q5]

11.1.4 How long has it been since you had your last sigmoidoscopy?

DO NOT READ:

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 (5 years but less than 10 years ago)

6 10 or more years ago

7 Don't know / Not sure

9 Refused

11.1.5 A colonoscopy uses a flexible tube that is longer than a sigmoidoscopy. For this test, 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. Have you ever had a colonoscopy?

DO NOT READ:

1 Yes

2 No [Go to Q7]

7 Don’t know / Not sure [Go to Q7]

9 Refused [Go to Q7]

11.1.6 How long has it been since you had your last colonoscopy?

DO NOT READ:

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 (5 years but less than 10 years ago)

6 10 or more years ago

7 Don't know / Not sure

9 Refused

11.1.7 There are several new colorectal cancer screening tests. One is the multi-targeted stool DNA test. It is similar to the blood stool test and looks for blood in the stool. It also looks at changes in DNA, which may be a sign of cancer. Have you ever had a multi-targeted stool DNA test?

DO NOT READ:

1 Yes

2 No [Go to Q9]

7 Don’t know / Not sure [Go to Q9]

9 Refused [Go to Q9]

11.1.8. How long has it been since you had your last multi-targeted stool DNA test?

DO NOT READ:

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 (5 years but less than 10 years ago)

6 10 or more years ago

7 Don't know / Not sure

9 Refused

11.1.9. The other new test is a CT colonography and uses a series of X-rays to take pictures of the inside of the colon. Have you ever had a CT colonography?

DO NOT READ:

1 Yes

2 No [End module]

7 Don’t know / Not sure [End module]

9 Refused [End module]

11.1.10 How long has it been since you had your last CT colonography?

DO NOT READ:

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 (5 years but less than 10 years ago)

6 10 or more years ago

7 Don't know / Not sure

9 Refused

Option 2:

11.2.1. There are several kinds of tests for colorectal cancer including a stool test, a flexible sigmoidoscopy, a colonoscopy, and a virtual colonoscopy. Stool tests include using a special kit at home to determine whether the stool contains blood. A flexible sigmoidoscopy and colonoscopy view the inside of the rectum and colon for signs of cancer or other health problems. The colonoscopy includes getting medication through a needle in your arm to make you sleepy and you were told to have someone else drive you home after the test. The virtual colonoscopy uses x-rays so that a doctor can see images of the colon on a computer screen. Have you ever had a test for colorectal cancer?

DO NOT READ:

1 Yes

2 No [Go to next module]

7 Don't know / Not sure [Go to next module]

9 Refused [Go to next module]

11.2.2. How long has it been since you had your last test for colorectal cancer?

DO NOT READ:

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 [Go to next module]

9 Refused [Go to next module]

11.2.3. Was that test for colorectal cancer a:

READ:

1 Blood stool test (FIT, gFOBT) [go to Q4]

2 Blood stool test that tested for DNA (multi-targeted stool DNA test; FIT-DNA test) [go to next module]

3 Flexible sigmoidoscopy [go to Q6]

4 Colonoscopy [Go to next module]

5 Virtual colonoscopy [Go to next module]

DO NOT READ:

7 Don't know / Not sure [Go to next module]

9 Refused [Go to next module]

11.2.4. A sigmoidoscopy uses a flexible tube that is inserted in the rectum to look for problems. Did you also have a flexible sigmoidoscopy with the blood stool test?

DO NOT READ:

1 Yes

2 No [Go to next module]

7 Don't know / Not sure [Go to next module]

9 Refused [Go to next module]

11.2.5. How long has it been since you had your last sigmoidoscopy?

DO NOT READ:

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 [Go to next module]

9 Refused [Go to next module]

11.2.6. Did you also have a blood stool test with the flexible sigmoidoscopy? A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood.

DO NOT READ:

1 Yes

2 No [Go to next module]

7 Don't know / Not sure [Go to next module]

9 Refused [Go to next module]

11.2.7. How long has it been since you had your last blood stool test?

DO NOT READ:

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 [Go to next module]

9 Refused [Go to next module]

Module Section 12: Immunization

12.1 Have you received a tetanus shot in the past 10 years?

INTERVIEWER NOTE: IF YES, ASK: WAS THIS TDAP, THE TETANUS SHOT THAT ALSO HAS PERTUSSIS OR WHOOPING COUGH VACCINE?

DO NOT READ:

1 Yes, received TDAP

2 Yes, received tetanus shot, but not TDAP

3 Yes, received tetanus shot but not sure what type

4 No, did not receive any tetanus shot in the past 10 years

7 Don’t know/Not sure

9 Refused

12.2 Shingles involves a rash or blisters on the skin and is often painful. A vaccine for shingles has been available since 2006. Have you ever had a vaccine for shingles?

DO NOT READ:

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

12.3 A vaccine to prevent the human papillomavirus or HPV infection is available and is called the cervical cancer or genital warts vaccine, HPV shot, [Fill: if female “GARDASIL or CERVARIX”; if male “ or GARDASIL”]. Have you EVER had an HPV vaccination?

CATI NOTE: To be asked of respondents between the ages of 18 and 49 years; otherwise, go to next module.

INTERVIEWER NOTE: Human Papillomavirus (Human Pap·uh·loh·muh virus); Gardasil (Gar·duh· seel); Cervarix Sir·var· icks

DO NOT READ:

2 No [Go to closing statements]

3 Doctor refused when asked [Go to closing statements]

7 Don’t know / Not sure [Go to closing statements]

9 Refused [Go to closing statements]

12.4 How many HPV shots did you receive?

DO NOT READ:

_ _ Number of shots

77 Don’t know / Not sure

99 Refused

Closing statement

Thank you for your participation. You answers will be combined with others to determine the best way to understand health risk behaviors and preventive practices.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	CDC
File Modified	0000-00-00
File Created	2021-01-15