ACBS Child consent and questionnaire

BRFSS/ASTHMA CALL BACK SURVEY

CHILD QUESTIONNAIRE - 2021

CATI SPECIFICATIONS

Form Approved

OMB Control No. 0920-1204

Exp. Date 11/30/2020

_______________________________________________________________________________

Section Subject Page

Section 1 Introduction……....................................................... 02

Section 2 Informed Consent.......................................................... 03

Section 3 Recent History.............….................................……. 04

Section 4 History of Asthma (Symptoms & Episodes)............… 06

Section 5 Health Care Utilization.................................................. 09

Section 6 Knowledge of Asthma/Management Plan..................... 14

Section 7 Modifications to Environment....................................... 16

Section 8 Medications........................... ........................................… 20

Section 9 Cost of Care...................................................................… 31

Section 10 School Related Asthma ………………………………… 33

Section 11 Additional Child Demographics …………………...…… 40

CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (No. 0920-1204, Exp. Date 11/30/2020).

Appendix A: Language for Identifying Most Knowledgeable Person…

during the BRFSS interview……….…………………….. 42

Appendix B: Coding Notes and Pronunciation Guide. ….……....... 57

______________________________________________________________________________

Section 1: Introduction

Introduction to the Asthma Call Back Survey for adult parent/guardian of child with asthma Hello, my name is ________________. I’m calling on behalf of the {STATE NAME} health department and the Centers for Disease Control and Prevention about an asthma study we are doing in your state. ALTERNATE (no reference to asthma): Hello, my name is ________________. I’m calling on behalf of the {STATE NAME} health department and the Centers for Disease Control and Prevention about a health study we are doing in your state.
Question Number	Question text	Responses	SKIP INFO/ CATI Note	Interviewer Note (s)
Q1.1	Are you {MKPNAME}?	1. Yes	[GO TO 1.5]
		2. No
Q1.2	May I speak with {MKPNAME}?	1. Yes	[GO TO 1.4 when person comes to phone]
		2. Person not available
Q1.3	When would be a good time to call back and speak with {MKPNAME}. For example, evenings, days, weekends?	CBTIME: Enter day/time: _________________	[CATI: Start over at introduction at next call.]	READ: Thank you we will call again later to speak with {MKPNAME}.

Question number	Read Text	Alternative text (no reference to asthma):
Q1.4	Hello, my name is ________________. I’m calling on behalf of the [STATE NAME} state health department and the Centers for Disease Control and Prevention about an asthma study we are doing in your state. During a recent phone interview [“you” if MKPNAME=ADULTNAME; OR “adultname” if MKPNAME=ALTNAME, MKP is pointed by BRFSS respondents] gave us permission to call again to ask some questions about {child’s name}’s asthma and said that you knew the most about that child’s asthma.	Hello, my name is ________________. I’m calling on behalf of the [STATE NAME} state health department and the Centers for Disease Control and Prevention about a health study we are doing in your state. During a recent phone [“you” if MKPNAME=ADULTNAME; OR “adultname” if MKPNAME=ALTNAME, MKP is pointed by BRFSS respondents] gave us permission to call again to ask some questions about {child’s name}’s health and said that you knew the most about that child’s health.	GO TO SECTION 2

Q1.5

During a recent phone interview [“you” if MKPNAME=ADULTNAME; OR “adultname” if MKPNAME=ALTNAME, MKP is pointed by BRFSS respondents] gave us permission to call again to ask some questions about {child’s name}’s asthma and said that you knew the most about that child’s asthma.

During a recent phone interview [“you” if MKPNAME=ADULTNAME; OR “adultname” if MKPNAME=ALTNAME, MKP is pointed by BRFSS respondents] gave us permission to call again to ask some questions about {child’s name}’s health and said that you knew the most about that child’s health.

GO TO SECTION 2

Section 2: Informed Consent

Before we continue, I’d like you to know that this survey is authorized by the U.S. Public Health Service Act. You may choose not to answer any question you don’t want to answer or stop at any time. In order to evaluate my performance, my supervisor may listen as I ask the questions. I’d like to continue now unless you have any questions. {child’s name} was selected to participate in this study about asthma because of responses to questions about his or her asthma in a prior survey.
If responses for sample child in BRFSS survey answers are: CASTHDX2= 1 (Yes) and CASTHNO2 = 2 (No), READ: The answers to asthma questions during the earlier survey indicated that a doctor or other health professional said that {child’s name} had asthma sometime in {his/her} life but does not have it now. Is that correct? If YES, READ: Since {child’s name} no longer has asthma, your interview will be very brief (about 5 minutes). [Go to RELATION (2.3)]. IF NO, [Go to REPEAT (2.0)]
If responses for sample child in BRFSS survey answers are: CASTHDX2= 1 (Yes) and CASTHNO2 = 1 (Yes) READ: Answers to the asthma questions in the earlier survey indicated that a doctor or other health professional said that {child’s name} had asthma sometime in {his/her} life, and that {child’s name} still has asthma. Is that correct? IF YES, [Go to RELATION (2.3)] IF NO, [Go to REPEAT (2.0)]
Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Q2.0	I would like to repeat the questions from the previous survey now to make sure {child’s name} qualifies for this study.	REPEAT	(1) YES	[Go to EVER_ASTH (2.1)]
			(2) NO	[Skip to TERMINATE]
Q2.1	Have you ever been told by a doctor or other health professional that sure {child’s name} had asthma?	EVER_ASTH	(1) YES
			(2) NO	[Skip Go to TERMINATE]
			(7) DON’T KNOW	[Skip Go to TERMINATE]
			(9) REFUSED	[Skip Go to TERMINATE]
Q2.2	Does {he/she} still have asthma?	CUR_ASTH	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q2.3	What is your relationship to {child’s name}?	RELATION	READ: (1) MOTHER (BIRTH/ADOPTIVE/STEP) (2) FATHER (BIRTH/ADOPTIVE/STEP) (3) BROTHER/SISTER (STEP/FOSTER/HALF/ADOPTIVE) (4) GRANDPARENT (FATHER/MOTHER) (5) OTHER RELATIVE (6) UNRELATED (7) DON’T KNOW (9) REFUSED
Q2.4	Are you the legal guardian for {child’s name}?	GUARDIAN	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
READ: {child’s name} does qualify for this study, I’d like to continue unless you have any questions. [If CUR_ASTH (2.2) = 1 (Yes)] READ: Since {child’s name} does have asthma now, your interview will last about 15 minutes. [Go to section 3] [If CUR_ASTH (2.2) = 2 (No)] READ: Since {child’s name} does not have asthma now, your interview will last about 5 minutes. [Go to section 3] [If CUR_ASTH (2.2) = 7, 9 (Don’t know or refused)] READ: Since you are not sure if {child’s name} has asthma now, your interview will probably last about 10 minutes. [Go to section 3]
TERMINATE: Upon survey termination, READ: I’m sorry {child’s name} does not qualify for this study. I’d like to thank you on behalf of the {STATE} Health Department and the Centers for Disease Control and Prevention for answering these questions. If you have any questions about this survey, you may call my supervisor toll-free at [1–800-xxx-xxxx}. If you have questions about your rights as a survey participant, you may call the chairman of the Institutional Review Board at [1 800 xxx-xxxx}. Thanks again. Goodbye.

Section 3: Recent History

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Section 3 (Recent History) Q3.1	How old was {child’s name} when a doctor or other health professional first said {he/she} had asthma	AGEDX	__ __ __ (ENTER AGE IN YEARS) (777) DON’T KNOW (888) Under 1 year old (999) REFUSED	[RANGE CHECK: IS 001-018, 777, 888, 999] [CATI CHECK: IF RESPONSE = 77, 99, 88 VERIFY THAT 777, 888, 999 WERE NOT THE INTENT]	[INTERVIEWER: ENTER 888 IF LESS THAN ONE YEARS OLD
Q3.2	How long ago was that? Was it...	INCIDNT	(1) Within the past 12 months (2) 1-5 years ago (3) more than 5 years ago (7) DON’T KNOW (9) REFUSED
Q3.3	How long has it been since you last talked to a doctor or other health professional about {child’s name} asthma? This could have been in a doctor’s office, the hospital, an emergency room or urgent care center.	LAST_MD	(88) Never (04) Within the past year (05) 1 YEAR to less than 3 years ago (06) 3 YEARS to 5 years ago (07) More than 5 years ago (77) DON’T KNOW (99) REFUSED		[INTERVIEWER: READRESPONSE OPTIONS IF NECESSARY]
Q3.4	How long has it been since {he/she} last took asthma medication?	LAST_MED	(88) NEVER (01) LESS THAN ONE DAY AGO (02) 1-6 DAYS AGO (03) 1 WEEK TO LESS THAN 3 MONTHS AGO (04) 3 MONTHS TO LESS THAN 1 YEAR AGO (05) 1 YEAR TO LESS THAN 3 YEARS AGO (06) 3 YEARS TO 5 YEARS AGO (07) MORE THAN 5 YEARS AGO (77) DON’T KNOW (99) REFUSED		[INTERVIEWER: READ RESPONSE OPTIONS IF NECESSARY]
Q3.5	How long has it been since {he/she} last had any symptoms of asthma?	LASTSYMP	(88) NEVER (01) LESS THAN ONE DAY AGO (02) 1-6 DAYS AGO (03) 1 WEEK TO LESS THAN 3 MONTHS AGO (04) 3 MONTHS TO LESS THAN 1 YEAR AGO (05) 1 YEAR TO LESS THAN 3 YEARS AGO (06) 3 YEARS TO 5 YEARS AGO (07) MORE THAN 5 YEARS AGO (77) DON’T KNOW (99) REFUSED		[INTERVIEWER: READ RESPONSE OPTIONS IF NECESSARY] R EAD: Symptoms of asthma include coughing, wheezing, shortness of breath, chest tightness or phlegm production when {child’s name} did not have a cold or respiratory infection.

Section 4: History of Asthma (Symptoms & Episodes in past year)

Section 4. History of Asthma (Symptoms & Episodes in the past year			IF LASTSYMP (3.5) = 1, 2, 3 then continue IF LASTSYMP (3.5) = 4 SKIP TO EPIS_INT (between 4.4 and 4.5) IF LASTSYMP (3.5) = 88, 5, 6, 7 SKIP TO INS1 (Section 5) IF LASTSYMP (3.5) = 77, 99 then continue
Question Number	Question text		Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Q4.1	During the past 30 days, on how many days did {child’s name} have any symptoms of asthma?		SYMP_30D	__ __DAYS		[RANGE CHECK: (01-30, 77, 88, 99)] CLARIFICATION: [1-29, 77, 99]
				(88) NO SYMPTOMS IN THE PAST 30 DAYS	[SKIP TO EPIS_INT]
				(30) EVERY DAY	[CONTINUE]
				(77) DON’T KNOW	[SKIP TO ASLEEP30 (4.3)]
				(99) REFUSED	[SKIP TO ASLEEP30 (4.3)]
Q4.2	Does { he/she } have symptoms all the time? "All the time” means symptoms that continue throughout the day. It does not mean symptoms for a little while each day.		DUR_30D	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q4.3	During the past 30 days, on how many days did symptoms of asthma make it difficult for { him/her } to stay asleep?		ASLEEP30	__ __ DAYS/NIGHTS (88) NONE (30) Every day (77) DON’T KNOW (99) REFUSED		[RANGE CHECK: (01-30, 77, 88, 99)]
Q4.4	During the past two weeks, on how many days was {child’s name} completely symptom-free, that is no coughing, wheezing, or other symptoms of asthma?		SYMPFREE	__ __ Number of days (88) NONE (77) DON’T KNOW (99) REFUSED		[RANGE CHECK: (01-14, 77, 88, 99)]
EPIS_INT	If LASTSYMP (3.5) = 4 (last symptoms was 3 months to 1 year ago), pick up here; IF LASTSYMP (3.5) = 1, 2, 3, 77, 99 (symptoms within the past 3 months, DON’T KNOW / refused), CONTINUE
Interview notes	Asthma attacks, sometimes called episodes, refer to periods of worsening asthma symptoms that make you limit your activity more than you usually do, or make you seek medical care.
Q4.5	During the past 12 months, has {child’s name} had an episode of asthma or an asthma attack?		EPIS_12M	(1) YES
				(2) NO	[SKIP TO Section 5]
				(7) DON’T KNOW	[SKIP TO Section 5]
				(9) REFUSED	[SKIP TO Section 5]
Q4.6	During the past three months, how many asthma episodes or attacks has {he/she} had?		EPIS_TP	__ __ Number of episodes/attacks (888) NONE (777) DON’T KNOW (999) REFUSED	[CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888 AND 999 WERE NOT THE INTENT]	[RANGE CHECK: (001-100, 777, 888, 999)]
Q4.7	How long did {his/her} MOST RECENT asthma episode or attack last?		DUR_ASTH	1_ _ Minutes 2_ _ Hours 3_ _ Days 4_ _ Weeks 5 5 5 Never 7 7 7 Don’t know / Not sure 9 9 9 Refused		Interviewer note: If answer is #.5 to #.99 round up If answer is #.01 to #.49 ignore fractional part ex. 1.5 should be recorded as 2 1.25 should be recorded as 1

S ection 5. Health Care Utilization

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Section 5 (Health Care Utilization) Q5.1	Does {child’s name} have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare or Medicaid?	INS1	(1) YES
			(2) NO	[SKIP TO FLU_SHOT (5.4)]
			(7) DON’T KNOW	[SKIP TO FLU_SHOT (5.4)]
			(9) REFUSED	[SKIP TO FLU_SHOT (5.4)]
Q5.2	What kind of health care coverage does {he/she} have? Is it paid for through the parent’s employer, or is it Medicaid, Medicare, Children's Health Insurance Program (CHIP), or some other type of insurance?	INS_TYP	(1) parent’s employer (2) medicaid/medicare (3) CHIP {replace with state specific name} (4) Other (7) DON’T KNOW (9) REFUSED		[READ RESPONSE OPTIONS IF NECESSARY]
Q5.3	During the past 12 months was there any time that {he/she} did not have any health insurance or coverage?	INS2	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q5.4	A flu shot is an influenza vaccine injected in your arm. During the past 12 months, did {CHILD’S NAME} have a flu shot?	FLU_SHOT	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q5.5	A flu vaccine that is sprayed in the nose is called FluMistTM. During the past 12 months, did {he/she} have a flu vaccine that was sprayed in {his/her} nose?	FLU_SPRAY	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
CATI notes:	How to define the value “of “Does the child still have asthma?”: The best-known value for whether or not the child “still has asthma” is used in the skip below. It can be the previously answered BRFSS childhood prevalence module value (CASTHNO2) or the answer to CUR_ASTH (2.2) if this question is asked in this call back survey. If the respondent confirms in the “Informed Consent” question that the previously answered BRFSS module value is correct, then the value from the BRFSS (CASTHNO2) is used. If the respondent does not agree with the previous BRFSS (CASTNO2) in “Informed Consent” of Section 2 and REPEAT (2.0) = 1 (Yes), then the value of CUR_ASTH (2.2) is used. SKIP INSTRUCTION: If “Does the child still have asthma?” = 1 (Yes), {using BRFSS CASTHNO2 or (CUR_ASTH (2.2) if REPEAT (2.0) =1)}, continue to Section 5. If “Does the child still have asthma?” = 2 (No), 7 (DK), or 9 (Refused) {using BRFSS CASTHNO2 or (CUR_ASTH (2.2) if REPEAT (2.0) =1)} AND [(LAST_MD = 4) OR (LAST_MED = 1, 2, 3 or 4) OR (LASTSYMP = 1, 2, 3 or 4)] THEN CONTINUE WITH SECTION 5 If “Does the child still have asthma?” = 2 (No), 7 (DK), or 9 (Refused), {using BRFSS CASTHNO2 or (CUR_ASTH (2.2) if REPEAT (2.0) =1)} AND (LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LASTSYMP (3.5) = 88 (Never) or 05, 06, 07, 77 or 99) THEN SKIP TO Section 6.
Q5.6	During just the past 30 days, would you say {child’s name} limited {his/her} usual activities due to asthma not at all, a little, a moderate amount, or a lot?	ACT_DAYS30	(1) NOT AT ALL (2) A LITTLE (3) A MODERATE AMOUNT (4) A LOT (7) DON’T KNOW (9) REFUSED
Q5.7	During the past 12 months how many times did {he/she} see a doctor or other health professional for a routine checkup for {his/her} asthma?	NER_TIME	__ __ __ ENTER NUMBER (888) NONE (777) DON’T KNOW (999) REFUSED	{IF LAST_MD= 88, 05, 06, 07 (have not seen a doctor in the past 12 months); SKIP to COORDIN (5.14)} {RANGE CHECK: (001-365, 777, 888, 999)] {Verify any value >50] {CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888, AND 999 WERE NOT THE INTENT]	{RANGE CHECK: (001-365, 777, 888, 999)] {Verify any value >50]
Q5.8	An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment. During the past 12 months, has {child’s name} had to visit an emergency room or urgent care center because of {his/her} asthma?	ER_VISIT	(1) YES
			(2) NO	[SKIP TO URG_TIME (5.10)]
			(7) DON’T KNOW	[SKIP TO URG_TIME (5.10)]
			(9) REFUSED	[SKIP TO URG_TIME (5.10)]
Q5.9	During the past 12 months, how many times did {he/she} visit an emergency room or urgent care center because of [his/her} asthma?	ER_TIMES	__ __ __ ENTER NUMBER (888) ZERO [LOOPING BACK TO CORRECT ER_VISIT (5.8) TO “NO”] (777) DON’T KNOW (999) REFUSED	[RANGE CHECK: (001-365, 777, 999)] [Verify any entry >50] [CATI CHECK: IF RESPONSE = 77, 99 VERIFY THAT 777 AND 999 WERE NOT THE INTENT] [CATI CHECK: IF ER_VISIT (5.8) =1 (YES) AND RESPONDENT SAYS “NONE” OR “ZERO” TO ER_TIMES (5.9) ALLOW LOOPING BACK TO CORRECT ER_VISIT (5.8) TO “2, NO”]	[RANGE CHECK: (001-365, 777, 999)] [Verify any entry >50] [HELP SCREEN: An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment.]
Q5.10	(If ER_VISIT (5.8) = 1 (Yes), INSERT “Besides those emergency room or urgent care center visits,” During the past 12 months, how many times did {child’s name}? see a doctor or other health professional for urgent treatment of worsening asthma symptoms or an asthma episode or attack?	URG_TIME	__ __ __ ENTER (888) NONE (777) DON’T KNOW (999) REFUSED	[RANGE CHECK: (001-365, 777, 888, 999)] [Verify any entry >50] [CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888 AND 999 WERE NOT THE INTENT] [HELP SCREEN: An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment.]	[RANGE CHECK: (001-365, 777, 888, 999)] [Verify any entry >50] [HELP SCREEN: An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment.]
SKIP INSTRUCTION	[IF LASTSYMP > 5 AND < 7, (one year ago and longer), SKIP TO COORDIN (5.14) IF LASTSYMP=88 (NEVER), SKIP TO COORDIN (5.14)]
Q5.11	During the past 12 months, that is since [1 YEAR AGO TODAY], has {child’s name} had to stay overnight in a hospital because of {his/her} asthma? Do not include an overnight stay in the emergency room.	HOSP_VST	(1) YES
			(2) NO	[SKIP TO COORDIN (5.14)]
			(7) DON’T KNOW	[SKIP TO COORDIN (5.14)]
			(9) REFUSED	[SKIP TO COORDIN (5.14)]
Q5.12	During the past 12 months, how many different times did {he/she} stay in any hospital overnight or longer because of {his/her} asthma?	HOSPTIME	__ __ __ TIMES (777) DON’T KNOW (999) REFUSED	[RANGE CHECK: (001-365, 777, 999)] [Verify any entry >50] [CATI CHECK: IF RESPONSE = 77, 99 VERIFY THAT 777 AND 999 WERE NOT THE INTENT] [CATI CHECK: IF RESPONSE TO 5.11 IS “YES” AND RESPONDENT SAYS NONE OR ZERO TO 5.12, ALLOW LOOPING BACK TO CORRECT 5.11 TO “NO”]	[RANGE CHECK: (001-365, 777, 999)] [Verify any entry >50]
Q5.13	The last time {he/she} left the hospital, did a health professional TALK with you or {child’s name} about how to prevent serious attacks in the future?	HOSPPLAN	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED	[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators. This should not be coded yes if the respondent only received a pamphlet or instructions to view a website or video since the question clearly states “talk with you”].	[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators. This should not be coded yes if the respondent only received a pamphlet or instructions to view a website or video since the question clearly states “talk with you”].
Q5.14	Does anyone help you arrange or coordinate {child’s name}’s asthma care among the different doctors or services that [he/she] uses?	COORDIN	(1) YES (2) NO (7) DON'T KNOW (9) REFUSED		READ IF NECESSARY: By “arrange or coordinate,” I mean: Is there anyone who helps you make sure that {child’s name} gets all the health care and services [he/she] needs, that health care providers share information, and that these services fit together and are paid for in a way that works for you?

Section 6. Knowledge of Asthma/Management Plan

Section 6. Knowledge of Asthma/Management Plan		CATI: [HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators] Interview notes: [HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]
Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Q6.1	Has a doctor or other health professional ever taught you or {child’s name}: How to recognize early signs or symptoms of an asthma episode?	TCH_SIGN	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q6.2	Has a doctor or other health professional ever taught you or {child’s name}: What to do during an asthma episode or attack?	TCH_RESP	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q6.3	A peak flow meter is a hand-held device that measures how quickly you can blow air out of your lungs. Has a doctor or other health professional ever taught you or {child’s name}: How to use a peak flow meter to adjust his/her daily medication?	TCH_MON	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q6.4	An asthma action plan, or asthma management plan, is a form with instructions about when to change the amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room. Has a doctor or other health professional EVER given you or {child’s name}: an asthma action plan?	MGT_PLAN	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q6.5	Have you or {child’s name} ever taken a course or class on how to manage [his/her] asthma?	MGT_CLAS	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

Section 7. Modifications to Environment

Section 7. Modifications to Environment	CATI: The following questions are about {child’s name} household and living environment. I will be asking about various things that may be related to experiencing symptoms of asthma. Interview Notes: The following questions are about {child’s name} household and living environment. I will be asking about various things that may be related to experiencing symptoms of asthma.
Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Q7.1	An air cleaner or air purifier can filter out pollutants like dust, pollen, mold and chemicals. It can be attached to the furnace or free standing. It is not, however, the same as a normal furnace filter. Is an air cleaner or purifier regularly used inside {child’s name}? home?	AIRCLEANER	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q7.2	A dehumidifier is a small, portable appliance which removes moisture from the air. Is a dehumidifier regularly used to reduce moisture inside [his/her} home?	DEHUMID	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q7.3	Is an exhaust fan that vents to the outside used regularly when cooking in the kitchen in {his/her} home?	KITC_FAN	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q7.4	Is gas used for cooking in [his/her} home?	COOK_GAS	(1) Yes (2) NO (7) DON’T KNOW (9) REFUSED
Q7.5	In the past 30 days, has anyone seen or smelled mold or a musty odor inside in [his/her} home? Do not include mold on food.	ENV_MOLD	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q7.6	Does {child’s name} home have pets such as dogs, cats, hamsters, birds or other feathered or furry pets that spend time indoors?	ENV_PETS	(1) YES
			(2) NO	[SKIP TO C_ROACH (7.8)]
			(7) DON’T KNOW	[SKIP TO C_ROACH (7.8)]
			(9) REFUSED	[SKIP TO C_ROACH (7.8)]
Q7.7	Is the pet allowed in [his/her} bedroom?	PETBEDRM	(1) YES (2) NO (3) SOME ARE/SOME AREN’T (7) DON’T KNOW (9) REFUSED	[SKIP THIS QUESTION IF ENV_PETS = 2, 7, 9]
Q7.8	In the past 30 days, has anyone seen cockroaches inside {child’s name}? home?	C_ROACH	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[HELP SCREEN: Studies have shown that cockroaches may be a cause of asthma. Cockroach droppings and carcasses can also cause symptoms of asthma.]
Q7.9	In the past 30 days, has anyone seen mice or rats inside [his/her} home? Do not include mice or rats kept as pets.	C_RODENT	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[HELP SCREEN: Studies have shown that rodents may be a cause of asthma.]
Q7.10	Is a wood burning fireplace or wood burning stove used in {child’s name}? home?	WOOD_STOVE	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[HELP SCREEN: OCCASIONAL USE SHOULD BE CODED AS “YES”.]
Q7.11	Are unvented gas logs, unvented gas fireplaces, or unvented gas stoves used in [his/her} home?	GAS_STOVE	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[HELP SCREEN: “Unvented” means no chimney or the chimney flue is kept closed during operation.]
Q7.12	In the past week, has anyone smoked inside [his/her} home?	S_INSIDE	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		HELP SCREEN: “The intent of this question is to measure smoke resulting from tobacco products (cigarettes, cigars, pipes) or illicit drugs (cannabis, marijuana) delivered by smoking (inhaling intentionally). Do not include things like smoke from incense, candles, or fireplaces, etc.”
Q7.13	Has a health professional ever advised you to change things in [his/her} home, school, or work to improve his/her asthma?	MOD_ENV	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		INTERVIEWER READ: Now, back to questions specifically about {child’s name} [HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]
Q7.14	Does {he/she} use a mattress cover that is made especially for controlling dust mites?	MATTRESS	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[INTERVIEWER read if necessary: This does not include normal mattress covers used for padding or sanitation (wetting). These covers are for the purpose of controlling allergens (like dust mites) from inhabiting the mattress. They are made of special fabric, entirely enclose the mattress, and have zippers.]
Q7.15	Does {he/she} use a pillow cover that is made especially for controlling dust mites?	E_PILLOW	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[INTERVIEWER read if necessary: This does not include normal pillow covers used for fabric protection. These covers are for the purpose of controlling allergens (like dust mites) from inhabiting the pillow. They are made of special fabric, entirely enclose the pillow, and have zippers.]
Q7.16	Does {child’s name} have carpeting or rugs in [his/her} bedroom? This does not include throw rugs small enough to be laundered.	CARPET	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q7.17	Are [his/her} sheets and pillowcases washed in cold, warm, or hot water?	HOTWATER	(1) COLD (2) WARM (3) HOT (4) VARIES (7) DON’T KNOW (9) REFUSED
Q7.18	In {child’s name} bathroom, does {he/she} regularly use an exhaust fan that vents to the outside?	BATH_FAN	(1) YES (2) NO OR “NO FAN” (7) DON’T KNOW (9) REFUSED		[HELP SCREEN: IF RESPONDENT INDICATES THEY HAVE MORE THAN ONE BATHROOM, THIS QUESTION REFERS TO THE BATHROOM THE CHILD USES MOST FREQUENTLY FOR SHOWERING AND BATHING.]

Section 8. Medications

Section 8. Medications	[IF LAST_MED = 88 (NEVER), SKIP TO SECTION 9. ELSE, CONTINUE.] READ: The next set of questions is about medications for asthma. The first few questions are very general, but later questions are very specific to {child’s name}? medication use.
Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note		Interviewer Note (s)
Q8.1	Over-the-counter medication can be bought without a doctor’s order. Has {child’s name} ever used over-the-counter medication for {his/her} asthma?	OTC	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q8.2	Has [he/she} ever used a prescription inhaler?	INHALERE	(1) YES
			(2) NO	[SKIP TO SCR_MED1 (8.5)]
			(7) DON’T KNOW	[SKIP TO SCR_MED1 (8.5)]
			(9) REFUSED	[SKIP TO SCR_MED1 (8.5)]
Q8.3	Did a health professional show {him/her} how to use the inhaler?	INHALERH	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED			[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]
Q8.4	Did a doctor or other health professional watch {him/her} use the inhaler?	INHALERW	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
[IF LAST_MED = 4, 5, 6, 7, 77, or 99, SKIP TO SECTION 9]
Q8.5	Now I am going to ask questions about specific prescription medications {child’s name} may have taken for asthma in the past 3 months. I will be asking for the names, amount, and how often [he/she} takes each medicine. I will ask separately about medication taken in various forms: pill or syrup, inhaler, and Nebulizer. It will help to get {child’s name} medicines so you can read the labels. Can you please go get the asthma medicines while I wait on the phone?	SCR_MED1	(1) YES
			(2) NO	[SKIP TO INH_SCR (8.8)]
			(3) RESPONDENT KNOWS THE MEDS	[SKIP TO INH_SCR (8.8)]
			(7) DON’T KNOW	[SKIP TO INH_SCR (8.8)]
			(9) REFUSED	[SKIP TO INH_SCR (8.8)]
Q8.7	[when Respondent returns to phone:] Do you have all the medications?	SCR_MED3	(1) YES I HAVE ALL THE MEDICATIONS (2) YES I HAVE SOME OF THE MEDICATIONS BUT NOT ALL (3) NO (7) DON’T KNOW (9) REFUSED		[INTERVIEWER: Read if necessary]
Q8.8	In the past 3 months has {child’s name}? taken prescription asthma medicine using an inhaler?	INH_SCR	(1) YES
			(2) NO	[SKIP TO PILLS (8.20)]
			(7) DON’T KNOW	[SKIP TO PILLS (8.20)]
			(9) REFUSED	[SKIP TO PILLS (8.20)]
Inhalers	For the following inhalers the respondent can choose up to eight medications; however, each medication can only be used once. When 66 (Other) is selected as a response, questions ILP03 (8.13) to ILP10 (8.19) are not asked for that response. [INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION.] CATI Note: Please use the table of INHALER series name. The top ten items (in bold below) should be highlighted in the CATI system if possible so they can be found more easily
Q8.9	In the past 3 months, what prescription asthma medications did {he/she} take by inhaler? [MARK ALL THAT APPLY. PROBE: Any other prescription asthma inhaler medications?]	INH_MEDS	_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _		[IF RESPONDENT SELECTS ANY ANSWER <66, SKIP TO ILP03]
			(66) Other [Please Specify, 100 character limit]	[SKIP TO OTH_I1]
			(88) NO PRESCRIPTION INHALERS	[SKIP TO PILLS (8.20)]
			(77) DON’T KNOW	[SKIP TO PILLS (8.20)]
			(99) REFUSED	[SKIP TO PILLS (8.20)]
CATI NOTES	CATI programmers note that the text for 66 (other) should be checked to make sure one of the medication names above was not entered. If the medication entered is on the list above, then an error message should be shown.
Interview Notes	[Loop back to ILP03 as necessary to administer questions ILP03 (8.13) thru ILP10 (8.19) for each medicine 01-51 reported in INH_MEDS, but not for 66 (other)].
Q8.10	ENTER OTHER MEDICATION FROM INH_MEDS(8.9) IN TEXT FIELD. IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE. 100 alphanumeric character limit	OTH_I1	_______________

Inhaler table

	Medication	Pronunciation
1	Advair (+ A. Diskus)	ăd-vâr (or add-vair)
2	Aerobid	â-rō'bĭd (or air-row-bid)
3	Albuterol ( + A. sulfate or salbutamol)	ăl'-bu'ter-ōl (or al-BYOO-ter-ole) săl-byū'tə-môl'
4	Alupent	al-u-pent
43	Alvesco (+ Ciclesonide)	al-ves-co
49	Anoro Ellipta (Umeclidinium and vilanterol)	a-nor' oh e-LIP-ta
40	Asmanex (twisthaler)	as-muh-neks twist-hey-ler
5	Atrovent	At-ro-vent
6	Azmacort	az-ma-cort
7	Beclomethasone dipropionate	bek"lo-meth'ah-son dī' pro’pe-o-nāt (or be-kloe-meth-a-sone)
8	Beclovent	be' klo-vent" (or be-klo-vent)
9	Bitolterol	bi-tōl'ter-ōl (or bye-tole-ter-ole)
45	Breo Ellipta (Fluticasone and vilanterol)	BRE-oh e-LIP-ta
11	Budesonide	byoo-des-oh-nide
12	Combivent	com-bi-vent
13	Cromolyn	kro'mŏ-lin (or KROE-moe-lin)
44	Dulera	do-lair-a
14	Flovent	flow-vent
15	Flovent Rotadisk	flow-vent row-ta-disk
16	Flunisolide	floo-nis'o-līd (or floo-NISS-oh-lide)
17	Fluticasone	flue-TICK-uh-zone
34	Foradil	FOUR-a-dil
35	Formoterol	for moh' te rol
48	Incruse Ellipta (Umeclidium inhaler powder)	IN-cruise e-LIP-ta
19	Ipratropium Bromide	ĭp-rah-tro'pe-um bro'mīd (or ip-ra-TROE-pee-um)
37	Levalbuterol tartrate	lev-al-BYOU-ter-ohl
20	Maxair	măk-sâr
21	Metaproteronol	met"ah-pro-ter'ĕ-nōl (or met-a-proe-TER-e-nole)
39	Mometasone furoate	moe-MET-a-sone
22	Nedocromil	ne-DOK-roe-mil
23	Pirbuterol	pēr-bu'ter-ōl (or peer-BYOO-ter-ole)
41	Pro-Air HFA	proh-air HFA
24	Proventil	pro"ven-til' (or pro-vent-il)
25	Pulmicort Flexhaler	pul-ma-cort flex-hail-er
36	QVAR	q -vâr (or q-vair)
3	Salbutamol (or Albuterol)	săl-byū'tə-môl'
26	Salmeterol	sal-ME-te-role
27	Serevent	Sair-a-vent
46	Spiriva HandiHaler or Respimat (Tiotropium bromide)	speh REE vah - RES peh mat
51	Stiolto Respimat (tiotropium bromide & olodaterol)	sti-OL-to– RES peh mat
42	Symbicort	sim-buh-kohrt
28	Terbutaline (+ T. sulfate)	ter-bu'tah-lēn (or ter-BYOO-ta-leen)
30	Tornalate	tor-na-late
50	Trelegy Ellipta ((fluticasone furoate, umeclidinium & vilanterol)	TREL-e-gee e-LIP-ta
31	Triamcinolone acetonide	tri"am-sin'o-lōn as"ĕ-tō-nīd' (or trye-am-SIN-oh-lone)
47	Tudorza Pressair	TU-door-za PRESS-air
32	Vanceril	van-sir-il
33	Ventolin	vent-o-lin
38	Xopenex HFA	ZOH-pen-ecks
66	Other, Please Specify	[SKIP TO OTH_I1], 100 alphanumeric character limit

CATI NOTE:	[For medicines from [MEDICINE FROM INH_MEDS SERIES], ask questions ILP03 (8.13) through ILP10 (8.19)] SKIP to ILP04 (8.14) if [MEDICINE FROM INH_MEDS SERIES] is (1, 15, 20, 25, 27, 34, 39, 40, 42) ADVAIR (01) or FLOVENT ROTADISK (15) or MAXAIR (20) or PULMICORT (25) or SEREVENT (27) or FORADIL (34) or MOMETASONE FUROATE (39) or ASMANEX (40) or SYMBICORT (42) SKIP TO ILP04 (8.14) [HELP SCREEN: A spacer is a device that attaches to a metered dose inhaler. It holds the medicine in its chamber long enough for you to inhale it in one or two slow, deep breaths. The spacer makes it easy to take the medicines the right way.] [HELP SCREEN: The response category 3 (disk or dry powder) and 4 (built-in spacer) are primarily intended for medications Beclomethosone (7), Beclovent (08) or QVAR (36), which are known to come in disk or breath-activated inhalers (which do not use a spacer). However, new medications may come on the market that might fit with either category. So 3 or 4 can be used for other medications as well.]
Q8.13	A spacer is a small attachment for an inhaler that makes it easier to use. Does {he/she} use a spacer with [MEDICINE FROM INH_MEDS SERIES]?	ILP03	(1) YES (2) NO (3) Medication is a dry powder inhaler or disk inhaler, not a canister inhaler (4) Medication has a built-in spacer/does not need a spacer (7) DON’T KNOW (9) REFUSED
Q8.14	In the past 3 months, did {child’s name} take [MEDICINE FROM INH_MEDS (8.9) SERIES] when {he/she} had an asthma episode or attack?	ILP04	(1) YES (2) NO (3) NO ATTACK IN PAST 3 MONTHS (7) DON’T KNOW (9) REFUSED
Q8.15	In the past 3 months, did {he/she} take [MEDICINE FROM INH_MEDS SERIES] before exercising?	ILP05	(1) YES (2) NO (3) DIDN’T EXERCISE IN PAST 3 MONTHS (7) DON’T KNOW (9) REFUSED
Q8.16	In the past 3 months, did [he/she} take [MEDICINE FROM INH_MEDS (8.9) SERIES] on a regular schedule everyday?	ILP06	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q8.18	How many times per day or per week did [he/she} use [MEDICINE FROM INH_MEDS SERIES]?	ILP08	3 _ _ Times per DAY	[RANGE CHECK: (>10)]
			4 _ _ Times per WEEK	[RANGE CHECK: (>75)]
			5 5 5 Never	[RANGE CHECK: 301-399, 401-499, 555, 666, 777, 999]
			6 6 6 LESS OFTEN THAN ONCE A WEEK
			7 7 7 Don’t know / Not sure
			9 9 9 Refused
CATI NOTES	[ASK ILP10 ONLY IF INH_MEDS = 3, 4, 9, 10, 20, 21, 23, 24, 28, 30, 33, 37, 38, 41 OTHERWISE SKIP TO PILLS (8.20)]
Q8.19	How many canisters of [MEDICINE FROM INH_MEDS (8.9) SERIES] has {child’s name} used in the past 3 months?	ILP10	___ CANISTERS (77) DON’T KNOW (88) NONE (99) REFUSED	[RANGE CHECK: (01-76, 77, 88, 99)] [HELP SCREEN: IF RESPONDENT INDICATES THAT <CHILD> HAS MULTIPLE CANISTERS, (I.E., ONE IN THE CAR, ONE AT SCHOOL, ETC.) ASK THE RESPONDENT TO ESTIMATE HOW MANY FULL CANISTERS HE/SHE USED. THE INTENT IS TO ESTIMATE HOW MUCH MEDICATION WAS CONSUMEDIS USED, NOT HOW MANY DIFFERNT INHALERS WAS USED.]	[INTERVIEWER: IF RESPONDENT USED LESS THAN ONE FULL CANISTER IN THE PAST THREE MONTHS, CODE IT AS ‘88’]
Q8.20	In the past 3 months, have you taken any PRESCRIPTION medicine in pill form for your asthma?	PILLS	(1) YES
			(2) NO	[SKIP TO SYRUP (8.23)]
			(7) DON’T KNOW	[SKIP TO SYRUP (8.23)]
			(9) REFUSED	[SKIP TO SYRUP (8.23)]
Pill	For the following pills the respondent can chose up to five medications; however, each medication can only be used once (in the past, errors such as 232723 were submitted in the data file). [INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION.] [IF RESPONDENT SELECTS ANY ANSWER FROM 01-49, SKIP TO PILL01] Note: The top 10 items (in bold below) should be highlighted in the CATI system if possible so they can be found more easily.
Q8.21	What PRESCRIPTION asthma medications does {child’s name} take in pill form? [MARK ALL THAT APPLY. PROBE: Any other PRESCRIPTION asthma pills?]	PILLS_MD	_ _ _ _ _ _ _ _ _ _
			(66) Other [Please Specify, 100 character limit]	[SKIP TO OTH_P1]
			(88) NO PILLS	[SKIP TO SYRUP (8.24)]
			(77) DON’T KNOW	[SKIP TO SYRUP (8.24)]
			(99) REFUSED	[SKIP TO SYRUP (8.24)]
CATI NOTES	CATI programmers note that the text for 66 (other) should be checked to make sure one of the medication names above was not entered. If the medication entered is on the list above, then an error message should be shown.
Interview notes	[REPEAT QUESTION PILL01 AS NECESSARY FOR EACH PILL 01-49 REPORTED IN PILLS_MD, BUT NOT FOR 66 (OTHER).]
Q8.21a	ENTER OTHER MEDICATION IN TEXT FIELD. IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE. 100 ALPHANUMERIC CHARACTER LIMIT FOR 66	OTH_P1

PILL table

	Medication	Pronunciation
1	Accolate	ac-o-late
2	Aerolate	air-o-late
3	Albuterol	ăl'-bu'ter-ōl (or al-BYOO-ter-all)
4	Alupent	al-u-pent
49	Brethine	breth-een
5	Choledyl (oxtriphylline)	ko-led-il
7	Deltasone	del-ta-sone
8	Elixophyllin	e-licks-o-fil-in
11	Medrol	Med-rol
12	Metaprel	Met-a-prell
13	Metaproteronol	met"ah-pro-ter'ĕ-nōl (or met-a-proe-TER-e-nole)
14	Methylpredinisolone	meth-ill-pred-niss-oh-lone (or meth-il-pred-NIS-oh-lone)
15	Montelukast	mont-e-lu-cast
17	Pediapred	Pee-dee-a-pred
18	Prednisolone	pred-NISS-oh-lone
19	Prednisone	PRED-ni-sone
21	Proventil	pro-ven-til
23	Respid	res-pid
24	Singulair	sing-u-lair
26	Slo-bid	slow-bid
25	Slo-phyllin	slow- fil-in
48	Terbutaline (+ T. sulfate)	ter byoo' ta leen
28	Theo-24	thee-o-24
30	Theochron	thee -o-kron
31	Theoclear	thee-o-clear
32	Theodur	thee-o-dur
33	Theo-Dur	thee-o-dur
35	Theophylline	thee-OFF-i-lin
37	Theospan	thee-o-span
40	T-Phyl	t-fil
42	Uniphyl	u-ni-fil
43	Ventolin	vent-o-lin
44	Volmax	vole-max
45	Zafirlukast	za-FIR-loo-kast
46	Zileuton	zye-loo-ton
47	Zyflo Filmtab	zye-flow film tab

CATI notes	For medicines from [MEDICATION LISTED IN PILLS_MD], ask QUESTION PILL01]
Q8.22	In the past 3 months, did {child’s name}? take [MEDICATION LISTED IN PILLS_MD] on a regular schedule every day?	PILL01	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q8.23	In the past 3 months, has [he/she} taken prescription medicine in syrup form?	SYRUP	(1) YES
			(2) NO	[SKIP TO NEB_SCR (8.25)]
			(7) DON’T KNOW	[SKIP TO NEB_SCR (8.25)]
			(9) REFUSED	[SKIP TO NEB_SCR (8.25)]
Syrup	For the following syrups the respondent can choose up to four medications; however, each medication can only be used once (in the past, errors such as 020202 were submitted in the data file). [INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION.] [IF RESPONDENT SELECTS ANY ANSWER FROM 01-10, SKIP TO NEB_SCR]
Q8.24	What PRESCRIPTION asthma medications has {child’s name} taken as a syrup? [MARK ALL THAT APPLY. PROBE: Any other PRESCRIPTION syrup medications for asthma?]	SYRUP_ID	_ _ _ _ _ _ _ _
			(66) Other [Please Specify, 100 character limit]	[SKIP TO OTH_S1]
			(88) NO SYRUPS	[SKIP TO NEB_SCR (8.25)]
			(77) DON’T KNOW	[SKIP TO NEB_SCR (8.25)]
			(99) REFUSED	[SKIP TO NEB_SCR (8.25)]
CATI Notes	CATI programmers note that the text for 66 (other) should be checked to make sure one of the medication names above was not entered. If the medication entered is on the list above, then an error message should be shown.
Q8.24a	ENTER OTHER MEDICATION. IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE. [100 ALPHANUMERIC CHARACTER LIMIT FOR 66]	OTH_S1	______________

Syrup table

	Medication	Pronunciation
1	Aerolate	air-o-late
2	Albuterol	ăl'-bu'ter-ōl (or al-BYOO-ter-ole)
3	Alupent	al-u-pent
4	Metaproteronol	met"ah-pro-ter'ĕ-nōl (or met-a-proe-TER-e-nole)
5	Prednisolone	pred-NISS-oh-lone
6	Prelone	pre-loan
7	Proventil	Pro-ven-til
8	Slo-Phyllin	slow-fil-in
9	Theophyllin	thee-OFF-i-lin
10	Ventolin	vent-o-lin
66	Other, Please Specify:	[SKIP TO OTH_S1]

Q8.25	A nebulizer is a small machine with a tube and facemask or mouthpiece that you breathe through continuously. In the past 3 months, were any of {child’s name}’s PRESCRIPTION asthma medicines used with a nebulizer?	NEB_SCR	(1) YES
			(2) NO		[SKIP TO Section 9]
			(7) DON’T KNOW		[SKIP TO Section 9]
			(9) REFUSED		[SKIP TO Section 9]
Q8.26	I am going to read a list of places where your child might have used a nebulizer. Please answer yes if your child has used a nebulizer in the place I mention, otherwise answer no. In the past 3 months did {child’s name}? use a nebulizer …	NEB_PLC	RESPONSES
			(8.26a) AT HOME (1) YES (2) NO (7) DK (9) REF
			(8.26b) AT A DOCTOR’S OFFICE (1) YES (2) NO (7) DK (9) REF
			(8.26c) IN AN EMERGENCY ROOM (1) YES (2) NO (7) DK (9) REF
			(8.26d) AT WORK OR AT SCHOOL (1) YES (2) NO (7) DK (9) REF
			(8.26e) AT ANY OTHER PLACE (1) YES (2) NO (7) DK (9) REF
Nebulizer	For the following nebulizers, the respondent can choose up to five medications; however, each medication can only be used once (in the past, errors such as 0101 were submitted in the data file). [INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION.]
Q8.27	In the past 3 months, what prescription ASTHMA medications has {he/she} taken using a nebulizer? [MARK ALL THAT APPLY. PROBE: Has your child taken any other prescription ASTHMA medications with a nebulizer in the past 3 months?]	NEB_ID	_ _ _ _ _ _ _ _ _ _
			(66) Other [Please Specify, 100 character limit]	[SKIP TO OTH_N1]
			(88) NONE	[SKIP TO Section 9]
			(77) DON’T KNOW	[SKIP TO Section 9]
			(99) REFUSED	[SKIP TO Section 9]
CATI Notes	CATI programmers note that the text for 66 (other) should be checked to make sure one of the medication names above was not entered. If the medication entered is on the list above, then an error message should be shown.
Interview Notes	[LOOP BACK TO NEB01 AS NECESSARY TO ADMINISTER QUESTIONS NEB01 THROUGH NEB03 FOR EACH MEDICINE 01 THROUGH 19 (NEB_01 to NEB_19) REPORTED IN NEB_ID, BUT NOT FOR 66 (OTHER)].
Q8.27a	ENTER OTHER MEDICATION. IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE. [100 ALPHANUMERIC CHARACTER LIMIT FOR 66]	OTH_N1	_______________

Nebulizer table

	Medication	Pronunciation
1	Albuterol	ăl'-bu'ter-ōl (or al-BYOO-ter-ole)
2	Alupent	al-u-pent
3	Atrovent	At-ro-vent
4	Bitolterol	bi-tōl'ter-ōl (or bye-tole-ter-ole)
19	Brovana	brō vă nah
5	Budesonide	byoo-des-oh-nide
17	Combivent Inhalation solution	com-bi-vent
6	Cromolyn	kro'mŏ-lin (or KROE-moe-lin)
7	DuoNeb	DUE-ow-neb
8	Intal	in-tel
9	Ipratroprium bromide	ĭp-rah-tro'pe-um bro'mīd (or ip-ra-TROE-pee-um)
10	Levalbuterol	lev al byoo' ter ol
11	Metaproteronol	met"ah-pro-ter'ĕ-nōl (or met-a-proe-TER-e-nole)
18	Perforomist (Formoterol)	per-form-ist
12	Proventil	Pro-ven-til
13	Pulmicort	pul-ma-cort
14	Tornalate	tor-na-late
15	Ventolin	vent-o-lin
16	Xopenex	ZOH-pen-ecks
66	Other, Please Specify:	[SKIP TO OTH_N1]

CATI notes	[For medicines from [MEDICATION LISTED IN NEB_ID], ask questions NEB01 to NEB03]
Q8.28	In the past 3 months, did {child’s name} take [MEDICINE FROM NEB_ID SERIES] when {he/she} had an asthma episode or attack?	NEB01	(1) YES (2) NO (3) NO ATTACK IN PAST 3 MONTHS (7) DON’T KNOW (9) REFUSED
Q8.29	In the past 3 months, did he/she take [MEDICINE FROM NEB_ID SERIES] on a regular schedule every day?	NEB02	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q8.30	How many times per day or per week does he/she use [MEDICINE FROM NEB_ID SERIES]?	NEB03	3__ __ DAYS 4__ __ WEEKS (555) NEVER (666) LESS OFTEN THAN ONCE A WEEK (777) DON’T KNOW / NOT SURE (999) REFUSED

Section 9. Cost of Care

Section 9. Cost of Care	CATI: The best-known value for whether or not the child “still has asthma” is used in the skip below. It can be the previously answered BRFSS childhood prevalence module value (CASTHNO2) or the answer to CUR_ASTH (2.2) if this question is asked in this call back survey. 1. If the respondent confirms in the “Informed Consent” question that the previously answered BRFSS module value is correct, then the value from the BRFSS (CASTHNO2) is used. 2. If the respondent does not agree with the previous BRFSS (CASTHNO2) in “Informed Consent”, then the question REPEAT (2.0) was asked (REPEAT = 1), then the value for CUR_ASTH (2.2) “Do you still have asthma?” is used. CATI: SKIP INSTRUCTION If “Does the child still have asthma?” = 2 (No), 7 (DK), or 9 (Refused). {using BRFSS CASTHNO2 or (CUR_ASTH if repeat-=1)} AND {(LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LASTSYMP (3.5) = 88 (Never) or 05, 06, 07, 77 or 99)}, then skip to section 10; If “Does the child still have asthma?” = 1 (Yes). {using BRFSS CASTHNO2 or (CUR_ASTH if repeat-=1)} continue to Section 9. Other, continue with section 9
Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Q9.1	Was there a time in the past 12 months when {child’s name} needed to see his/her primary care doctor for asthma but could not because of the cost?	ASMDCOST	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q9.2	Was there a time in the past 12 months when you were referred to a specialist for {his/her} asthma care but could not go because of the cost?	ASSPCOST	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q9.3	Was there a time in the past 12 months when {he/she} needed medication for {his/her} asthma but you could not buy it because of the cost?	ASRXCOST	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

Section 10. School Related Asthma

Question Number

Question text

Variable names

Responses (DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Section 10. School Related Asthma Q10.1

Next, we are interested in things that might affect {child’s name} asthma when {he/she} is not at home. Does {child’s name} currently go to school or pre-school outside the home?

SCH_STAT

(1) YES

[SKIP TO SCHGRADE (10.4)]

(2) NO

(7) DON’T KNOW

(9) REFUSED

Q10.2

What is the main reason {he/she} is not now in school? READ RESPONSE CATEGORIES

NO_SCHL

(1) NOT OLD ENOUGH

[SKIP TO DAYCARE (10.10)]

(2) HOME SCHOOLED

[SKIP TO SCHGRADE (10.4)]

(3) UNABLE TO ATTEND FOR HEALTH REASONS

(4) ON VACATION OR BREAK

(5) OTHER

(7) DON'T KNOW

(9) REFUSED

Q10.3

Has {child’s name} gone to school in the past 12 months?

SCHL_12

(1) YES

(2) NO

[SKIP TO DAYCARE (10.10)]

(7) DON’T KNOW

[SKIP TO DAYCARE (10.10)]

(9) REFUSED

[SKIP TO DAYCARE (10.10)]

Q10.4

What grade was {he/she} in the last time {he/she} was in school?

SCHGRADE

(88) PRE SCHOOL (66) KINDERGARDEN __ __ ENTER GRADE 1 TO 12 (77) DON’T KNOW (99) REFUSED

Ask if [IF SCHL_12 = 1]

What grade is {he/she} in?

Ask if [IF SCH_STAT = 1 or NO_SCHL = 2]

CATI Info:

“Does the child still have asthma?”: the best-known value for whether or not the child “still has asthma” is used in the skip below. It can be the previously answered BRFSS childhood prevalence module value (CASTHNO2) or the answer to CUR_ASTH (2.2) if this question is asked in this call back survey. 1. If the respondent confirms in the “Informed Consent” question that the previously answered BRFSS module value is correct, then the value from the BRFSS (CASTHNO2) is used. 2. If the respondent does not agree with the previous BRFSS (CASTHNO2) in “Informed Consent” then the question REPEAT (2.0) was asked (REPEAT = 1) then the value for CUR_ASTH (2.2) “Do you still have asthma?” is used. SKIP INSTRUCTION: If “Does the child still have asthma?” = 2 (No), 7 (DK), or 9 (Refused). {using BRFSS CASTHNO2 or (CUR_ASTH if repeat-=1)} AND {(LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LASTSYMP (3.5) = 88 (Never) or 05, 06, 07, 77 or 99);} THEN SKIP TO SCH_ANML (10.8); If “Does the child still have asthma?” = 1 (Yes). {using BRFSS CASTHNO2 or (CUR_ASTH if repeat-=1)}, then continue with MISS_SCHL (10.5); Other continue with 10.5

Q10.5

During the past 12 months, about how many days of school did {he/she} miss because of {his/her} asthma?

MISS_SCHL

__ __ __ENTER NUMBER DAYS (888) ZERO (777) DON’T KNOW (999) REFUSED

[3 NUMERIC-CHARACTER-FIELD, RANGE CHECK: (001-365, 777, 888, 999)] [Verify any entry >50] [DISPLAY THE THREE POSSIBILITIES TO THE LEFT ON THE CATI SCREEN FOR THS QUESTION TO ASSIST THE INTERVIEWER] [CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888 AND 999 WERE NOT THE INTENT]

SKIP INSTRUCTIONS

[IF NO_SCHL (10.2) = 2 (HOME SCHOOLED), SKIP TO SECTION 11] [IF SCHL_12 (10.3) = 1, READ ‘PLEASE ANSWER THESE NEXT FEW QUESTIONS ABOUT THE SCHOOL {CHILD’S NAME} WENT TO LAST]

Q10.6

Earlier I explained that an asthma action plan contains instructions about how to care for the child’s asthma. Does {child’s name} have a written asthma action plan or asthma management plan on file at school?

SCH_APL

(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

Q10.7

Does the school {he/she} goes to allow children with asthma to carry their medication with them while at school?

SCH_MED

(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

Q10.8

Are there any pets such as dogs, cats, hamsters, birds or other feathered or furry pets in {his/her} CLASSROOM?

SCH_ANML

(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

Q10.9

Are you aware of any mold problems in {child’s name} school?

SCH_MOLD

(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

[IF CHILD AGE > 10 YEARS OR 131 MONTHS, SKIP TO SECTION 11]

Q10.10

Does {child’s name} go to day care outside his/her home?

DAYCARE

(1) YES

[SKIP TO MISS_DCAR (10.12)]

(2) NO

(7) DON’T KNOW

[SKIP TO SECTION 11]

(9) REFUSED

[SKIP TO SECTION 11]

Q10.11

Has {he/she} gone to daycare in the past 12 months?

DAYCARE1

(1) YES

(2) NO

[SKIP TO SECTION 11]

(7) DON’T KNOW

[SKIP TO SECTION 11]

(9) REFUSED

[SKIP TO SECTION 11]

SKIP INSTRUCTION

If “Does the child still have asthma?” = 2 (No), 7 (DK), or 9 (Refused). {using BRFSS CASTHNO2 or (CUR_ASTH (2.2) if REPEAT = 1)} AND (LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LASTSYMP (3.5) = 88 (Never) or 05, 06, 07, 77 or 99) THEN SKIP TO DCARE_ANML(10.14); otherwise continue with MISS_DCAR (10.12) If “Does the child still have asthma?” = 1 (Yes). {using BRFSS CASTHNO2 or (CUR_ASTH if REPEAT-=1)}, then continue with MISS_DCAR (10.12)

Q10.12

During the past 12 months, about how many days of daycare did {he/she} miss because of {his/her} asthma?

MISS_DCAR

__ __ __ENTER NUMBER DAYS (888) ZERO (777) DON’T KNOW (999) REFUSED

[3 NUMERIC-CHARACTER-FIELD, RANGE CHECK: (001-365, 777, 888, 999)] [Verify any entry >50] [DISPLAY THE THREE POSSIBILITIES TO THE LEFT ON THE CATI SCREEN FOR THIS QUESTION TO ASSIST THE INTERVIEWER] [CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888 AND 999 WERE NOT THE INTENT]

Q10.13

Does {child’s name} have a written asthma action plan or asthma management plan on file at daycare?

DCARE_APL

(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

Q10.14

Are there any pets such as dogs, cats, hamsters, birds or other feathered or furry pets in {his/her} room at daycare?

DCARE_ANML

(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

Q10.15

Are you aware of any mold problems in {his/her} daycare?

DCARE_MLD

(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

Q10.16

Is smoking allowed at {his/her} daycare?

DCARE_SMK

(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

Section 11. Additional Child Demographics

Section 11. Additional Child Demographics	READ “I have just a few more questions about {child’s name}.” HELP SCREEN: WE ARE INTERESTED IN LOOKING AT HOW HEIGHT AND WEIGHT MAY BE RELATED TO ASTHMA.
Question Number	Question text		Variable names			Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note		Interviewer Note (s)
HELP SCREEN for Q11.1:	Examples: 24 inches = 200 (2 feet) 30 inches = 206 (2 feet 6 inches), 36 inches = 300 (3 feet) 40 inches = 304 (3 feet 4 inches), 48 inches = 400 (4 feet) 50 inches = 402 (4 feet 2 inches), 60 inches = 500 (5 feet) 65 inches = 505 (5 feet 5 inches), 6 feet = 600 (6 feet, zero inches) 5'3" = 503 (5 feet, 3 inches)
Q11.1	How tall is {child’s name}?		HEIGHT1			_ _ _ _ = Height (ft/inches) 7 7 7 7 = Don’t know/Not sure 9 9 9 9 = Refused	CATI Note: In the first space for the height (highlighted in yellow), if the respondent answers in feet/inches enter “0.” If respondent answers in metric, put “9” in the first space. VALUES OF GREATER THAN 8 FEET 11 INCHES OR 250 CENTIMETERS SHOULD NOT BE ALLOWED, VALUE RANGE FOR INCHES 00-11.		[INTERVIEWER: if needed: Ask the respondent to give their best guess.]
Q11.2	How much does [he/she} weigh?		WEIGHT1			_ _ _ _ Weight (pounds/kilograms) 7 7 7 7 Don’t know / Not sure 9 9 9 9 Refused	CATI Note: In the first space for the weight (highlighted in yellow), if the respondent answers in pounds, enter “0.” If respondent answers in kilograms, put “9” in the first space. [VALUES OF GREATER THAN 500 POUNDS OR 230 KILOGRAMS SHOULD NOT BE ALLOWED]		[INTERVIEWER: if needed: Ask the respondent to give their best guess.]
CATI NOTE for Q11.3:	If the respondent gives pounds and ounces: from left to right, positions one and two will hold “0 0”; positions three and four will hold the value of pounds from 0 to 30; and the last two positions will hold 00 to 15 ounces. If the respondent gives kilograms and grams: from left to right, position one will hold “9”; positions two and three will hold the value of kilograms 1-30; and the last three positions will hold the number of grams. [VALUES OF GREATER THAN 30 POUNDS OR 13.6 KILOGRAMS SHOULD NOT BE ALLOWED]
Q11.3	How much did {he/she} weigh at birth (in pounds)?			BIRTHW1		_ _ _ _ _ _ Weight (pounds/kilograms) 7 7 7 7 7 7 Don’t know / Not sure 9 9 9 9 9 9 Refused
[IF BIRTH WEIGHT (11.3) IS DON’T KNOW OR REFUSED, ASK BIRTHRF; ELSE SKIP TO CWEND.]
Q11.4		At birth, did {child’s name} weigh less than 5 ½ pounds?			BIRTHRF	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED			[INTERVIEWER NOTE: 5 ½ pounds = 2500 GRAMS]

CWEND

Those are all the questions I have. I’d like to thank you on behalf of the {STATE NAME} Health Department and the Centers for Disease Control and Prevention for the time and effort you’ve spent answering these questions. If you have any questions about this survey, you may call my supervisor toll-free at 1 – xxx-xxx-xxxx. If you have questions about your rights as a survey participant, you may call the chairman of the Institutional Review Board at 1 800 xxx-xxxx. Thanks again.

Appendix A:

Language for Identifying Most Knowledgeable Person during the BRFSS interview

Consent scripts for use during BRFSS Childhood asthma prevalence module when the most knowledgeable adult is identified during the BRFSS interview.

BRFSS Childhood asthma module:

If BRFSS respondent indicates that the randomly selected child has ever had asthma (CASTHDX2 = 1 “yes”) and the BRFSS adult never had asthma then arrange for a call-back interview. If both the BRFSS adult and the randomly selected child both have asthma the child is randomly selected for the call-back at least 75% of the time.

Only respondents who are the parent/guardian of the selected child with asthma are eligible for the child asthma call-back interview. This is required because the parent/guardian must give permission to collect information about the child even if the information is being given by someone else. [ BRFSS Random Child Selection Question: How are you related to the child? (RCSRELN2) = 1, 3]

READ: We would like to call again within the next 2 weeks to talk in more detail about your child’s experiences with asthma. The information will be used to help develop and improve the asthma programs in {state name}. The information you gave us today and any you give us in the future will be kept confidential. If you agree to this, we will keep your first name or initials and phone number on file, separate from the answers collected today. Even if you agree now, you or others may refuse to participate in the future.

Question Number

Question text

Variable names

Responses (DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Q01

Would it be all right if we call back at a later time to ask additional questions about your child’s asthma?

ADULTPERM

(1) Yes

(2) No

(GO TO BRFSS closing or next module)

(7) Don’t know/Not Sure

(GO TO BRFSS closing or next module)

(9) Refused

(GO TO BRFSS closing or next module)

Q02

Can I please have your child's first name, initials or nickname so we can ask about the right child when we call back? This is the {#} year old child which is the {FIRST CHILD, SECOND, etc.} CHILD.

CHILDNNAME

Enter child’s first name, initials or nickname: ____________

[CATI: If more than one child, show child age {#} and which child was selected (FIRST, SECOND, etc.) from child selection module]

Q03

Can I please have your first name, initials or nickname so we know who to refer to when we call back?

ADULTNAME

Enter respondent’s first name, initials or nickname: ____________

Q04

Are you the parent or guardian in the household who knows the most about {child’s name}’s asthma?

MOSTKNOW

(1) Yes

[CATI SET MKPNAME = ADULTNAME 03]

(2) No

[GO TO ALTNAME 06]

(7) Don’t know/Not Sure

[GO TO ALTNAME 06]

(9) Refused

[GO TO ALTNAME 06]

Q05

What is a good time to call you back? For example, evenings, days, weekends? Phone number: What is the best number to call you back?

CBTIME

Enter day/time: _________________

Enter phone number: _________

Interviewer Notes:

READ: The information you gave us today and will give us when we call back will be kept confidential. We will keep identifying information like your child’s name and your name and phone number on file, separate from the answers collected today. Even though you agreed today, you may refuse to participate in the future.

[If state requires active linking consent continue, if not, go to BRFSS closing or next module]

Linking consent

READ: Some of the information that you shared with us today could be useful when combined with the information we will ask for during your child’s asthma interview. If the information from the two interviews is combined, identifying information such as your phone number, your name, and your child’s name will not be included. PERMISS: May we combine your answers from today with your answers from the interview about your child’s asthma that will be done in the next two weeks? (1) Yes [GO TO BRFSS closing or next module] (2) No [GO TO BRFSS closing or next module] (7) Don’t Know [GO TO BRFSS closing or next module] (9) Refused [GO TO BRFSS closing or next module] If MOSTKNOW (04) = 2 (NO), 7 (Don’t know/Not Sure), 9 Refused, ask ALTNAME 06.

Q06

READ: If you are not the person in the household who knows the most about {child’s name}’s asthma, could you identify the person who knows the most about {child’s name}’s asthma and provide permission to speak with that person and for that person to speak on behalf of the child? May I please have the first name, initials or nickname of the person who knows the most about {child’s name}’s asthma so we will know who to ask for when we call back?

ALTNAME

Alternate’s __________;

[CATI SET MKPNAME = ALTNAME]

Q07

Is there a different phone number we should use to contact {ALTNAME}?

ALTPHONE

Alternate’s Phone number: ________;

Q08

When would be a good time to call back and speak with {ALTNAME}? For example, evenings, days, weekends?

ALTCBTIME

Enter day/time: ___________

Interview Notes

READ: The information you gave us today and that {ALTNAME} will give us when we call back will be kept confidential. We will keep their name and phone number, and your child’s name on file, separate from the answers collected today. Even though you agreed today, {ALTNAME} may refuse to participate in the future.

[If state requires linking consent, continue; if not, go to BRFSS closing or next module]

Linking Consent

READ: Some of the information that you shared with us today could be useful when combined with the information we will ask for during your child’s asthma interview. If the information from the two interviews is combined, identifying information such as your phone number, your name, and your child’s name will not be included. PERMISS: May we combine your answers from today with the answers {ALTNAME} gives us during the interview about your child’s asthma? (1) Yes [GO TO BRFSS closing or next module] (2) No [GO TO BRFSS closing or next module] (7) Don’t Know [GO TO BRFSS closing or next module] (9) Refused [GO TO BRFSS closing or next module]