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pdfQuestion ID: VFY.0010.00.1
Variable name: CURRES_A
Interview module: VFY(Adult.VFY)
Universe: (GEN.ASTAT=2 or GEN.CBSTAT_A=1)
Question Text:
Response:
Enter the line number of the person to whom you are speaking.
00.
01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Not on roster
^ALIASNAME[1]
^ALIASNAME[2]
^ALIASNAME[3]
^ALIASNAME[4]
^ALIASNAME[5]
^ALIASNAME[6]
^ALIASNAME[7]
^ALIASNAME[8]
^ALIASNAME[9]
^ALIASNAME[10]
^ALIASNAME[11]
^ALIASNAME[12]
^ALIASNAME[13]
^ALIASNAME[14]
^ALIASNAME[15]
^ALIASNAME[16]
^ALIASNAME[17]
^ALIASNAME[18]
^ALIASNAME[19]
^ALIASNAME[20]
^ALIASNAME[21]
^ALIASNAME[22]
^ALIASNAME[23]
^ALIASNAME[24]
^ALIASNAME[25]
Skip Instructions: <1-25> [goto AVAIL_A]
Page 1 of 306
Question ID: VFY.0020.00.1
Variable name: AVAIL_A
Interview module: VFY(Adult.VFY)
Universe: (GEN.ASTAT=2 or GEN.CBSTAT_A=1)
Question Text:
Response:
Fills:
The next questions must be answered by ^SANAME. Probe as necessary to
determine the availability of ^SANAME. If Sample Adult refuses to participate enter
CTRL-R. Read if necessary: The next questions are about ^SANAME.
^Awayschool ^IshesheArethey_A ^stayinghere available now? ^ONCAMPSA
1.
2.
3.
RF:
Available
Not Available or not able to answer right now
Physical or mental condition prohibits responding
Refused
^SANAME
Sample Adult's name
^Awayschool
If Roster.HHC.tblNAME.bPerson.ONOFFCAMPUS
IN (1,RF,DK), fill: "Earlier, you said ^SANAME is
living away at school or college."
^IshesheArethey_A
If SEX_A=1 fill: "Is he"
If SEX_A=2 fill: "Is she"
If SEX_A IN ('DK'. 'RF") fill: "Are they"
^stayinghere
student is away at school but staying at household
^ONCAMPSA
If
Roster.HHC.tblNAME.bPerson.ONOFFCAMPUS=1
and GEN.HHRESPSA_FLG ne 1, fill:
*If the on-campus Sample Adult is currently at the
sample unit and able to complete the interview:
Proceed with the Sample Adult interview.
*If the on-campus Sample Adult is not currently at
the sample unit and able to complete the interview:
Proceed with arranging a callback.
Page 2 of 306
Skip Instructions: <1> if CURRES_A ne PX_A [goto INTMODE_A]
elseif Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMPUS IN (1,RF,DK)
and GEN.HHRESPSA_FLG ne 1 [goto VFYONCAMP_A]
else [goto VFYALL_A]
<2> [goto bCallback.CB_POSSIBLE] then if there is a Sample child and they
have not been interviewed [goto Child.VFY.CURRES_C]
elseif GEN.OUTCOME=203 [goto BCK.THANKS_SUF]
else [goto BCK.THANKS_INSUF]
<3> [goto PROXY_A]
if there is a SC [goto Child.VFY.CURRES_C]
elseif GEN.OUTCOME=203 [goto BCK.THANKS_SUF]
else [goto BCK.THANKS_INSUF]
Question ID: VFY.0030.00.1
Variable name: PROXY_A
Interview module: VFY(Adult.VFY)
Universe: AVAIL_A=3
Question Text:
Response:
Fills:
Proxy interviews can be done for sample adults that have a mental or physical
condition that prevents them from responding for themselves. Is a family member
or caregiver that is knowledgeable about ^SANAME's health available?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^SANAME
Sample Adult's name
Skip Instructions: <1> [goto PROXYREL_A]
<2,RF,DK> [goto PROXYCALL_A]
Page 3 of 306
Question ID: VFY.0040.00.1
Variable name: PROXYREL_A
Interview module: VFY(Adult.VFY)
Universe: PROXY_A=1
Question Text:
Response:
Fills:
What is this person's relationship to ^SANAME?
1.
2.
3.
4.
DK:
RF:
Relative who lives in household
Relative who doesn't live in household
Nonrelative who lives in household
Nonrelative who does not live in household
Don't Know
Refused
^SANAME
Sample Adult's name
Skip Instructions: <1,3> if PCNT18PLUS=1 [goto ERR1_PROXYREL_A]
else [goto PROXYLNO_A]
<2,4,RF,DK> [goto INTMODE_A]
Check Name: ERR1_PROXYREL_A
Text:
{check ERR1_PROXYREL_A} This is not a valid option as there are no other adults
18+ living in the household. Please correct.
Hard / Soft Edit: Hard
Universe: PCNT18PLUS=1 and PROXYREL_A IN (1,3)
Page 4 of 306
Question ID: VFY.0050.00.1
Variable name: PROXYLNO_A
Interview module: VFY(Adult.VFY)
Universe: PROXYREL_A IN (1,3)
Question Text:
Response:
Fills:
Select the person in this household who is the proxy for ^SANAME.
01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
^ALIASNAME[1]
^ALIASNAME[2]
^ALIASNAME[3]
^ALIASNAME[4]
^ALIASNAME[5]
^ALIASNAME[6]
^ALIASNAME[7]
^ALIASNAME[8]
^ALIASNAME[9]
^ALIASNAME[10]
^ALIASNAME[11]
^ALIASNAME[12]
^ALIASNAME[13]
^ALIASNAME[14]
^ALIASNAME[15]
^ALIASNAME[16]
^ALIASNAME[17]
^ALIASNAME[18]
^ALIASNAME[19]
^ALIASNAME[20]
^ALIASNAME[21]
^ALIASNAME[22]
^ALIASNAME[23]
^ALIASNAME[24]
^ALIASNAME[25]
^SANAME
Sample Adult's name
Skip Instructions: <1-25> if PROXYLNO_A ne CURRES_A [goto INTMODE_A]
elseif
PROXYLNO_A=CURRES_A
and
Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMPUS IN (1,RF,DK) and
HHRESPSA_FLG ne 1 [goto VFYONCAMP_A]
else [goto VFYALL_A]
Page 5 of 306
Question ID: VFY.0060.00.1
Variable name: PROXYCALL_A
Interview module: VFY(Adult.VFY)
Universe: PROXY_A IN (2,RF,DK)
Question Text:
Response:
Fills:
Can a callback with someone knowledgeable about ^SANAME's health be
arranged?
1.
2.
Yes
No
^SANAME
Sample Adult's name
Skip Instructions: <1> [goto bCallback.CB_POSSIBLE], then
if there is a Sample child and they have not been interviewed [goto
Child.VFY.CURRES_C]
else [goto BCK.THANKS_CB]
<2> if there is a Sample child and they have not been interviewed [goto
Child.VFY.CURRES_C]
elseif GEN.OUTCOME=203 [goto BCK.THANKS_SUF]
else [goto BCK.THANKS_INSUF]
Question ID: VFY.0070.00.1
Variable name: INTMODE_A
Interview module: VFY(Adult.VFY)
Universe: (CURRES_A ne PX_A AND AVAIL_A = 1) OR (PROXYREL_A IN
(2,4,RF,DK)) OR (PROXYLNO_A IN (1-25) AND PROXYLNO_A ne
CURRES_A)
Question Text:
Response:
Fills:
How are you contacting ^SARESP?
1.
2.
Personal visit
Telephone
^SARESP
FillSample Adult respondent's name
Page 6 of 306
Skip Instructions: <1> if Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMPUS IN (1,RF,DK)
and GEN.HHRESPSA_FLG ne 1 [goto VFYONCAMP_A]
else[goto VFYALL_A]
<2> [goto TINTRO_A]
Question ID: VFY.0080.00.1
Variable name: TINTRO_A
Interview module: VFY(Adult.VFY)
Universe: INTMODE_A=2
Question Text:
Response:
Fills:
Hello, my name is ( say your name). I'm calling from the U.S. Census Bureau.
We are conducting the National Health Interview Survey on behalf of the
National Center for Health Statistics, part of the Centers for Disease Control
and Prevention (CDC). This is a nationwide survey about the health of both
adults and children. I have some information from ^HHRESP. Now, I would like
to ask you some questions.
Read if necessary: I believe I am calling you on a
cell phone. Before we continue, I have to ask: Are you currently driving a
vehicle?
Even if the respondent is using a hands-free device while driving, you
must enter '1'.
DK:
RF:
Don't Know
Refused
^HHRESP
Display the name of the person selected at
Roster.HHC.HHRESPAVAIL
Skip Instructions: <1,RF,DK> [goto ATTN_A]
<2> [goto LETTER_A]
Page 7 of 306
Question ID: VFY.0090.00.1
Variable name: ATTN_A
Interview module: VFY(Adult.VFY)
Universe: TINTRO_A=1
Question Text:
For your safety, we will call you back at another time.
Enter 1 to continue.
Response:
Skip Instructions: <1> [goto bCallback.CB_POSSIBLE]
Question ID: VFY.0100.00.1
Variable name: LETTER_A
Interview module: VFY(Adult.VFY)
Universe: TINTRO_A=2
Question Text:
Response:
If sample adult is a new respondent read question below, otherwise enter 1 Read
if necessary: A letter describing the National Health Interview Survey was sent to your
home recently. Do you remember seeing the letter?
DK:
RF:
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto S_INTRO_A]
Question ID: VFY.0110.00.1
Variable name: S_INTRO_A
Interview module: VFY(Adult.VFY)
Universe: TINTRO_A=2
Question Text:
?[F1] If sample adult is a new respondent read question below, otherwise enter 1
Read if necessary: There are a few things I need to cover before we continue. I'd like
you to know that taking part in this survey is voluntary. You may choose not to
answer any questions you don't wish to answer, or end the interview at any time
without penalty. We are required by Federal law to develop and follow strict
procedures to protect the confidentiality of your information and use your answers
only for statistical research. I can describe these laws if you wish. Except for the
National Center for Health Statistics and Census Bureau employees and specially
designated agents, no one can see your answers until all information that could
identify you and/or your family has been removed. Only after that will your data be
made available to researchers. For most adults, the survey will take less than
^SATIME minutes. I'd like to continue now unless you have any questions. If
respondent asks for more information about the privacy laws, press F1.
Response:
Page 8 of 306
Fills:
^SATIME
If GEN.CSTAT=1 and GEN.SAMEFAM_FLG=1, fill:
35
else, fill: 45
Skip Instructions: <1> if Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMPUS IN (1,RF,DK)
and GEN.HHRESPSA_FLG ne 1 [goto VFYONCAMP_A]
else [goto VFYALL_A]
Question ID: VFY.0120.00.1
Variable name: VFYONCAMP_A
Interview module: VFY(Adult.VFY)
Universe: Roster.HHC.tblNAME.bPerson.ONOFFCAMPUS
IN
(1,RF,DK)
(AVAIL_A=1 or PROXY_A=1) and GEN.HHRESPSA_FLG ne 1
Question Text:
Response:
and
I want to confirm some information. Do you live in on-campus housing or
off-campus housing? Read if necessary: On-campus housing includes residence
halls and dorms where students live together. It also includes buildings that are
owned, leased, or managed by the school. Fraternities and sororities are on-campus
housing.
1.
2.
DK:
RF:
On campus
Off campus
Don't Know
Refused
Skip Instructions: <1,RF,DK> [goto VFYALL_A]
<2> [goto NOMORE_A]
Question ID: VFY.0130.00.1
Variable name: VFYALL_A
Interview module: VFY(Adult.VFY)
Universe: (AVAIL_A=1 or PROXY_A=1) and VFYONCAMP_A ne 2
Question Text:
^Verifyintro I have recorded ^yoursexis, you are ^AGE_A, ^NATORG_A, and
^RACE_A. Would you like to make any changes to this ^additionalinfo_A?
^RACEVRBATvalue_A If respondent "refuses" or says "don't know", enter "2" for
"no."
Response:
Page 9 of 306
1.
2.
Fills:
Yes
No
^Verifyintro
If VFYONCAMP_A=empty "I want to confirm some
information."
else fill nothing
^yoursexis
If GEN.SEX_FINAL=1 fill "your sex is male"
If GEN.SEX_FINAL=2 fill "your sex is female"
If
GEN.SEX_FINAL=DK
and
GEN.HHRESPSA_FLG=1 fill "you do not know your
sex"
If
GEN.SEX_FINAL=RF
and
GEN.HHRESPSA_FLG=1 fill "you do not wish to
provide your sex"
If
GEN.SEX_FINAL
IN
(DK,RF)
and
GEN.HHRESPSA_FLG ne1 fill "your sex was not
provided"
^AGE_A
if GEN.AGE_FINAL ne RF, DK fill with age
elseif
GEN.AGE_FINAL
IN
(RF,DK)
andRoster.HHC.tblAGE.blkPerson[PX_A].AGE65=2
fill "65 or older"
elseif
GEN.AGE_FINAL
in
(RF,DK)
andRoster.HHC.tblAGE.blkPerson[PX_A].AGE65=1
fill "between 18 and 64"
elseif GEN.AGE_FINAL IN (RF, DK) and
Roster.HHC.tblAGE.blkPerson[PX_A].AGE65
IN
(RF,DK,empty) fill "18 and older"
^NATORG_A
If GEN.NATO_FINAL=1 fill: "you are of Hispanic or
Latino origin"
If GEN.NATO_FINAL=2 fill: "you are not of Hispanic
or Latino origin"
If
GEN.NATO_FINAL=DK
and
GEN.HHRESPSA_FLG=1 fill: "you do not know if
you are of Hispanic or Latino origin"
If
GEN.NATO_FINAL=RF
and
GEN.HHRESPSA_FLG=1 fill: "you do not wish to
provide information about your Hispanic or Latino
origin"
If
GEN.NATO_FINAL
IN
(DK,RF)
and
GEN.HHRESPSA_FLG ne 1 fill "information about
your Hispanic or Latino origin was not provided"
^RACE_A
Ifrace
or
races
GEN.RACE_FINAL[PX_A].RACE_FINAL
Page 10 of 306
fill:
IN
"you
are ^RACEFILLAND_A."
If GEN.RACE_FINAL[PX_A].RACE_FINAL=DK and
GEN.HHRESPSA_FLG=1 fill "you do not know your
race."
If GEN.RACE_FINAL[PX_A].RACE_FINAL=RF and
GEN.HHRESPSA_FLG=1 fill: "you do not wish to
provide your race."
If
GEN.RACE_FINAL[PX_A].RACE_FINAL
IN
(DK,RF) and GEN.HHRESPSA_FLG ne 1 fill "your
race was not provided."
^additionalinfo_A
See attachment for fill instructions
^RACEVRBATvalue_A
IF
GEN.HHRESPSA_FLG
ne
1
and
GEN.RACE_FINAL[PX_A].RACE_VRBAT_FINAL ne
(empty,RF,DK), fill "If respondent wants information
on which other race they are listed as,
say^RACE_VRBAT."
Skip Instructions: <1> [goto VFYDEM_A]
<2> if GEN.SEX_FINAL IN (RF,DK) [goto SEXGUESS_A]
elseif GEN.NATO_FINAL=1 [goto HISPTYPE_A]
elseif GEN.RACE_FINAL=6 [goto PITYPE_A]
elseif GEN.RACE_FINAL=7 [goto ASIANTYPE_A]
elseif
(NEWRACE_A=8
or
(NEWRACE_A=empty
and
GEN.HHRESPSA_FLG
ne
1
and
Roster.HHC.tblRACE.bpersonRACE_SP[PX_A] in (ZZ,RF,DK)))
[goto
RACEOTHER_A]
else [goto BMONTH_A]
Page 11 of 306
Question ID: VFY.0140.00.1
Variable name: VFYDEM_A
Interview module: VFY(Adult.VFY)
Universe: VFYALL_A=1
Question Text:
Response:
Read if necessary: What should I change?
commas.
1.
2.
3.
4.
DK:
RF:
Enter all that apply, separate with
Sex
Age
Hispanic or Latino Origin
Race
Don't Know
Refused
Skip Instructions: if 1 IN VFYDEM_A [goto NEWSEX_A]
elseif (2,3,4) IN VFYDEM_A and GEN.SEX_FINAL[PX_A] IN (RF,DK) [goto
SEXGUESS_A]
elseif 2 IN VFYDEM_A and GEN.SEX_FINAL[PX_A] NOT IN (RF,DK)[goto
NEWAGE_A]
elseif 3 IN VFYDEM_A and GEN.SEX_FINAL[PX_A] NOT IN (RF,DK) [goto
NEWNATORG_A]
elseif 4 IN VFYDEM_A and GEN.SEX_FINAL[PX_A] NOT IN (RF,DK) [goto
NEWRACE_A]
If GEN.SEX_FINAL[PX_A] IN (RF,DK) [goto SEXGUESS_A]
elseif GEN.NATO_FINAL=1 [goto HISPTYPE_A]
elseif GEN.RACE_FINAL=6 [goto PITYPE_A]
elseif GEN.RACE_FINAL=7 [goto ASIANTYPE_A]
elseif (NEWRACE_A=8 or (NEWRACE_A=empty and
GEN.HHRESPSA_FLG
ne
1
and
Roster.HHC.tblRACE.bpersonRACE_SP[PX_A] in (ZZ,RF,DK)))
[goto
RACEOTHER_A]
else [goto BMONTH_A]
Page 12 of 306
Question ID: VFY.0150.00.1
Variable name: NEWSEX_A
Interview module: VFY(Adult.VFY)
Universe: 1 IN VFYDEM_A
Question Text:
Response:
Are you male or female?
1.
2.
DK:
RF:
Male
Female
Don't Know
Refused
Skip Instructions: if
GEN.SEX_FINAL[PX_A]=RF,DK
and
NEWSEX_A=RF,DK
[goto
SEXGUESS_A]
elseif 2 IN VFYDEM_A [goto NEWAGE_A]
elseif 3 IN VFYDEM_A [goto NEWNATORG_A]
elseif 4 IN VFYDEM_A [goto NEWRACE_A]
elseif GEN.NATO_FINAL=1 [goto HISPTYPE_A]
elseif GEN.RACE_FINAL[PX_A].RACE_FINAL=6 [goto PITYPE_A]
elseif GEN.RACE_FINAL[PX_A].RACE_FINAL=7 [goto ASIANTYPE_A]
elseif (NEWRACE_A=8 or (NEWRACE_A=empty and GEN.HHRESPSA_FLG
ne 1 and Roster.HHC.tblRACE.bperson.RACE_SP[PX_A] in (ZZ,RF,DK)))
[goto RACEOTHER_A]
else [goto BMONTH_A]
Question ID: VFY.0160.00.1
Variable name: SEXGUESS_A
Interview module: VFY(Adult.VFY)
Universe: GEN.SEX_FINAL IN (DK,RF) and (VFYDEM_A NOT IN 1 or (VFYDEM_A=1
and NEWSEX_A IN (RF,DK)))
Question Text:
Response:
Fills:
Enter your best guess of ^SANAME's sex.
1.
2.
Male
Female
^SANAME
Sample Adult's name
Page 13 of 306
Skip Instructions: <1,2>
if 2 IN VFYDEM_A [goto NEWAGE_A]
elseif 3 IN VFYDEM_A [goto NEWNATORG_A]
elseif 4 IN VFYDEM_A [goto NEWRACE_A]
elseif GEN.NATO_FINAL=1 [goto HISPTYPE_A]
elseif GEN.RACE_FINAL=6 [goto PITYPE_A]
elseif GEN.RACE_FINAL=7 [goto ASIANTYPE_A]
elseif (NEWRACE_A=8 or (NEWRACE_A=empty and GEN.HHRESPSA_FLG
ne 1 and Roster.HHC.tblRACE.bpersonRACE_SP[PX_A] in (ZZ,RF,DK)))
[goto RACEOTHER_A]
else [goto BMONTH_A]
Question ID: VFY.0170.00.1
Variable name: NEWAGE_A
Interview module: VFY(Adult.VFY)
Universe: 2 IN VFYDEM_A
Question Text:
Response:
How old are you?
DK:
RF:
Enter age.
Don't Know
Refused
Skip Instructions: <0-120, RF, DK> if 3 IN VFYDEM_A [goto NEWNATORG_A]
elseif 4 IN VFYDEM_A [goto NEWRACE_A]
elseif GEN.NATO_FINAL=1 [goto HISPTYPE_A]
elseif GEN.RACE_FINAL[PX_A].RACE_FINAL=6 [goto PITYPE_A]
elseif GEN.RACE_FINAL[PX_A].RACE_FINAL=7 [goto ASIANTYPE_A]
elseif (NEWRACE_A=8 or (NEWRACE_A=empty and GEN.HHRESPSA_FLG
ne 1 and Roster.HHC.tblRACE.bperson.RACE_SP[PX_A] in (ZZ,RF,DK)))
[goto RACEOTHER_A]
else [goto BMONTH_A]
Page 14 of 306
Question ID: VFY.0190.00.1
Variable name: NEWNATORG_A
Interview module: VFY(Adult.VFY)
Universe: 3 IN VFYDEM_A
Question Text:
Response:
Do you consider yourself to be Hispanic or Latino?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> if 4 IN VFYDEM_A [goto NEWRACE_A]
elseif GEN.NATO_FINAL=1 [goto HISPTYPE_A]
elseif GEN.RACE_FINAL[PX_A].RACE_FINAL=6 [goto PITYPE_A]
elseif GEN.RACE_FINAL[PX_A].RACE_FINAL=7 [goto ASIANTYPE_A]
elseif
(NEWRACE_A=8
or
(NEWRACE_A=empty
and
GEN.HHRESPSA_FLG
ne
1
and
Roster.HHC.tblRACE.bpersonRACE_SP[PX_A] in (ZZ,RF,DK)))
[goto
RACEOTHER_A]
else [goto BMONTH_A]
Question ID: VFY.0200.00.1
Variable name: NEWRACE_A
Interview module: VFY(Adult.VFY)
Universe: 4 IN VFYDEM_A
Question Text:
Response:
What race or races do you consider yourself to be? Please select 1 or more of
these categories: White, Black, African American, American Indian, Alaska
Native, Native Hawaiian, Pacific Islander, Asian, or some other race? Enter all
that apply, separate with commas.
1.
2.
3.
4.
5.
White
Black/African American
American Indian
Alaska Native
Native Hawaiian
Page 15 of 306
6.
7.
8.
DK:
RF:
Pacific Islander
Asian
Some other race
Don't Know
Refused
Skip Instructions: <1-8,RF,DK> if GEN.NATO_FINAL=1 [goto HISPTYPE_A]
elseif GEN.RACE_FINAL[PX_A].RACE_FINAL=6 [goto PITYPE_A]
elseif GEN.RACE_FINAL[PX_A].RACE_FINAL=7 [goto
ASIANTYPE_A]
elseif (NEWRACE_A=8 or (NEWRACE_A=empty and
GEN.HHRESPSA_FLG
ne
1
and
Roster.HHC.tblRACE.bperson.RACE_SP[PX_A] in (ZZ,RF,DK)))
[goto
RACEOTHER_A]
else [goto BMONTH_A]
Question ID: VFY.0210.00.1
Variable name: HISPTYPE_A
Universe: GEN.NATO_FINAL[PX_A]=1
NOMORE_A ne 1
Question Text:
Response:
and
Interview module: VFY(Adult.VFY)
(AVAIL_A=1
or
PROXY_A=1)
and
What is your Hispanic or Latino ancestry or origin, such as Mexican, Mexican
American, ^CHICANOA, Central or South American, Puerto Rican, Cuban,
Dominican (Republic), or Other Hispanic, ^LATINOA, or Spanish -- and if you
have more than one, tell me all of them. Enter all that apply, separate with
commas.
1.
2.
3.
4.
5.
6.
7.
DK:
RF:
Mexican, Mexican American, or Chicano(a)
Central American
South American
Puerto Rican (Boricua)
Cuban
Dominican (Republic)
Other Hispanic, Latino(a), or Spanish (specify)
Don't Know
Refused
Page 16 of 306
Fills:
^CHICANOA
If SEX_FINAL = 1 fill: "Chicano"
if SEX_FINAL = 2,DK,RF fill "Chicano or Chicana"
^LATINOA
If SEX_FINAL= 1 fill: "Latino"
if SEX_FINAL = 2,DK,RF fill "Latino or Latina"
Skip Instructions: <7> [goto HISPOTHER_A]
<1-6,RF,DK>
if GEN.RACE_FINAL[PX_A]=6 [goto PITYPE_A]
elseif GEN.RACE_FINAL[PX_A]=7 [goto ASIANTYPE_A]
elseif (NEWRACE_A=8 or (NEWRACE_A=empty and GEN.HHRESPSA_FLG
ne 1 and Roster.HHC.tblRACE.bPerson.RACE_SP[PX_A] in (ZZ,RF,DK)))
[goto RACEOTHER_A]
else [goto BMONTH_A]
Question ID: VFY.0220.00.1
Variable name: HISPOTHER_A
Interview module: VFY(Adult.VFY)
Universe: HISPTYPE_A=7
Question Text:
Response:
?[F1] What is your Hispanic or Latino ancestry or origin? If you have more than
one, tell me all of them. Start typing and then select from list. If Hispanic or Latino
ancestry is not on the list, type "ZZ" and enter verbatim.
If any of the following are
mentioned, backup to previous screen and correct the entry. Mexican Mexican
American Chicano/Chicana Central American (REFER TO HELP SCREEN) South
American (REFER TO HELP SCREEN) Puerto Rican (Boricua) Cuban/Cuban
American Dominican (Republic) If respondent provides more than one other
Hispanic or Latino ancestry or origin, select 'ZZ' from the lookup table. At the next
question, enter ALL the other Hispanic or Latino ancestries or origins in the verbatim
field.
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto HISPVRBAT_A]
if GEN.RACE_FINAL[PX_A]=6 [goto
PITYPE_A]
elseif GEN.RACE_FINAL[PX_A]=7 [goto ASIANTYPE_A]
elseif (NEWRACE_A=8 or (NEWRACE_A=empty and GEN.HHRESPSA_FLG
ne 1 and Roster.HHC.tblRACE.bPerson.RACE_SP[PX_A] in (ZZ,RF,DK)))
[goto RACEOTHER_A]
else [goto BMONTH_A]
Page 17 of 306
Question ID: VFY.0230.00.1
Variable name: HISPVRBAT_A
Interview module: VFY(Adult.VFY)
Universe: HISPOTHER_A=ZZ
Question Text:
Response:
Read if necessary: What is your Hispanic or Latino ancestry or origin? If you have
more than one, tell me all of them.
DK:
RF:
Don't Know
Refused
Skip Instructions: if GEN.RACE_FINAL[PX_A].RACE_FINAL=6 [goto
PITYPE_A]
elseif GEN.RACE_FINAL[PX_A].RACE_FINAL=7 [goto ASIANTYPE_A]
elseif (NEWRACE_A=8 or (NEWRACE_A=empty and GEN.HHRESPSA_FLG
ne 1 and Roster.HHC.tblRACE.bPerson.RACE_SP[PX_A].RACE_FINAL in
(ZZ,RF,DK))) [goto RACEOTHER_A]
else [goto BMONTH_A]
Question ID: VFY.0240.00.1
Variable name: PITYPE_A
Interview module: VFY(Adult.VFY)
Universe: GEN.RACE_FINAL[PX_A].RACE_FINAL=6 and (AVAIL_A=1 or PROXY_A=1)
and NOMORE_A ne 1
Question Text:
Response:
I have recorded that you are Pacific Islander. What specific ethnic group or
groups are you-- such as Guamanian or Chamorro, Samoan, or other Pacific
Islander? If you are more than one, tell me all of them. Enter all that apply,
separate with commas.
1.
2.
3.
DK:
RF:
Guamanian or Chamorro
Samoan
Other Pacific Islander
Don't Know
Refused
Skip Instructions: <3> [goto PIOTHER_A]
<1,2,RF,DK>
if
GEN.RACE_FINAL[PX_A].RACE_FINAL=7
[goto
ASIANTYPE_A]
elseif (NEWRACE_A=8 or (NEWRACE_A=empty and GEN.HHRESPSA_FLG
ne 1 and Roster.HHC.tblRACE.bPerson.RACE_SP[PX_A] IN (ZZ,RF,DK)))
[goto RACEOTHER_A]
else [goto BMONTH_A]
Page 18 of 306
Question ID: VFY.0250.00.1
Variable name: PIOTHER_A
Interview module: VFY(Adult.VFY)
Universe: PITYPE_A=3
Question Text:
Response:
Read if necessary: I have recorded that you are Pacific Islander. What specific ethnic
group or groups are you? If you are more than one, tell me all of them. Start typing
and then select from list. If Pacific Islander ethnic group is not on the list, type "ZZ"
and enter verbatim. If respondent provides more than one ethnic group, select 'ZZ'
from the lookup table. At the next question, enter ALL the ethnic groups in the
verbatim field.
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto PIVRBAT_A]
if GEN.RACE_FINAL[PX_A].RACE_FINAL=7 [goto ASIANTYPE_A]
elseif (NEWRACE_A=8 or (NEWRACE_A=empty and HHRESPSA_FLG ne 1
and Roster.HHC.tblRACE.bPerson.RACE_SP[PX_A] IN (ZZ,RF,DK))) [goto
RACEOTHER_A]
else [goto BMONTH_A]
Question ID: VFY.0260.00.1
Variable name: PIVRBAT_A
Interview module: VFY(Adult.VFY)
Universe: PIOTHER_A=ZZ
Question Text:
Response:
Read if necessary: I have recorded that you are Pacific Islander. What specific ethnic
group or groups are you? If you are more than one, tell me all of them.
DK:
RF:
Don't Know
Refused
Skip Instructions:
if GEN.RACE_FINAL[PX_A].RACE_FINAL=7 [goto ASIANTYPE_A]
elseif (NEWRACE_A=8 or (NEWRACE_A=empty and GEN.HHRESPSA_FLG
ne 1 and Roster.HHC.tblRACE.bPerson.RACE_SP[PX_A] IN (ZZ,RF,DK)))
[goto RACEOTHER_A]
else [goto BMONTH_A]
Page 19 of 306
Question ID: VFY.0270.00.1
Variable name: ASIANTYPE_A
Interview module: VFY(Adult.VFY)
Universe: GEN.RACE_FINAL[PX_A].RACE_FINAL=7 and (AVAIL_A=1 or PROXY_A=1)
and NOMORE_A ne 1
Question Text:
Response:
I have recorded that you are Asian. What specific ethnic group or groups are
you-- such as Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese,
or Other Asian? If you are more than one, tell me all of them. Enter all that
apply, separate with commas.
1.
2.
3.
4.
5.
6.
7.
DK:
RF:
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Don't Know
Refused
Skip Instructions: <7> [goto ASIANOTHER_A]
<1-6,RF,DK>
elseif (NEWRACE_A=8 or (NEWRACE_A=empty and GEN.HHRESPSA_FLG
ne
1
and
Roster.HHC.tblRACE.bPerson.RACE_SP[PX_A]
in
(ZZ,RF,DK)))[goto RACEOTHER_A]
else [goto BMONTH_A]
Question ID: VFY.0280.00.1
Variable name: ASIANOTHER_A
Interview module: VFY(Adult.VFY)
Universe: ASIANTYPE_A=7
Question Text:
Response:
What is your specific Asian ethnic group or groups? If you have more than one,
tell me all of them. Start typing and then select from list. If Asian ethnic group is not
on the list, type "ZZ" and enter verbatim.
If any of the following are mentioned,
backup to previous screen and correct the entry. (Asian) Indian Chinese Filipino
Japanese Korean Vietnamese If respondent provides more than one ethnic group,
select 'ZZ' from the lookup table. At the next question, enter ALL the ethnic groups in
the verbatim field.
DK:
RF:
Don't Know
Refused
Page 20 of 306
Skip Instructions: (NEWRACE_A=8 or (NEWRACE_A=empty and
GEN.HHRESPSA_FLG
ne
1
and
Roster.HHC.tblRACE.bPerson.RACE_SP[PX_A] in (ZZ,RF,DK))) [goto
RACEOTHER_A]
else [goto BMONTH_A]
Question ID: VFY.0290.00.1
Variable name: ASIANVRBAT_A
Interview module: VFY(Adult.VFY)
Universe: ASIANOTHER_A=ZZ
Question Text:
Response:
Read if necessary: What is your specific Asian ethnic group or groups? If you have
more than one, tell me all of them.
DK:
RF:
Don't Know
Refused
Skip Instructions:
if (NEWRACE_A=8 or (NEWRACE_A=empty and GEN.HHRESPSA_FLG ne
1 and Roster.HHC.tblRACE.bPerson.RACE_SP[PX_A] in (ZZ,RF,DK))) [goto
RACEOTHER_A]
else [goto BMONTH_A]
Question ID: VFY.0300.00.1
Variable name: RACEOTHER_A
Interview module: VFY(Adult.VFY)
Universe: (AVAIL_A=1 or PROXY_A=1) and (NEWRACE_A=8 or (NEWRACE_A=empty
and GEN.HHRESPSA_FLG ne 1 and ROSTER.HHC.RACE_SP[PX_A] IN
(ZZ,RF,DK)))
Question Text:
Response:
What other race or races do you consider yourself to be? Start typing and then
select from list. If race is not on the list, type "ZZ" and enter verbatim.
If
respondent provides more than one other race, select 'ZZ' from the lookup table. At
the next question, enter ALL the other races in the verbatim field.
DK:
RF:
Don't Know
Refused
Page 21 of 306
Skip Instructions: [goto RACEVRBAT]
[goto BMONTH_A]
Question ID: VFY.0310.00.1
Variable name: RACEVRBAT_A
Interview module: VFY(Adult.VFY)
Universe: RACEOTHER_A=ZZ
Question Text:
Response:
Read if necessary: What other race or races do you consider yourself to be?
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto BMONTH_A]
Question ID: VFY.0340.01.1
Variable name: BMONTH_A
Interview module: VFY(Adult.VFY)
Universe: (AVAIL_A=1 or PROXY_A=1) and DOB_COUNT_A lt 2
Question Text:
Response:
1 of 3 What is your date of birth? Please give month, day, and year for the
date of birth.
Enter month of birth.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
DK:
RF:
January
February
March
April
May
June
July
August
September
October
November
December
Don't Know
Refused
Page 22 of 306
Skip Instructions: <1-12,RF,DK> [goto BDAY_A]
Question ID: VFY.0340.02.1
Variable name: BDAY_A
Interview module: VFY(Adult.VFY)
Universe: (AVAIL_A=1 or PROXY_A=1) and DOB_COUNT_A lt 2
Question Text:
Response:
2 of 3
DK:
RF:
Enter day of birth.
Don't Know
Refused
Skip Instructions: <1-31,RF,DK> Only allow valid days for month entered. if days not valid [goto
ERR_BDAY_A]
else [goto BYEAR_A]
Check Name: ERR_BDAY_A
Text:
{check ERR_BDAY_A}
^BDAY_A is not a valid day for ^BMONTH_A.
Hard / Soft Edit: Hard
Fills:
^BDAY_A
Fill value from Adult.VFY.BDAY_A
^BMONTH_A
Fill value from Adult.VFY.BMONTH_A
Universe: Invalid dates for the month entered
Page 23 of 306
Question ID: VFY.0340.03.1
Variable name: BYEAR_A
Interview module: VFY(Adult.VFY)
Universe: (AVAIL_A=1 or PROXY_A=1) and DOB_COUNT_A lt 2
Question Text:
Response:
3 of 3
DK:
RF:
Enter year of birth.
If year of birth is before 1900, enter 1900.
Don't Know
Refused
Skip Instructions: <1900-current year,RF,DK>
if (BYEAR_A gt current year) or (BYEAR_A=current year and BMONTH_A gt
current month) or (BYEAR_A=current year and BMONTH_A=current month
and BDAY_A gt current day) [goto ERR_BYEAR_A]
elseif BDAY_A=29 and BMONTH_A=2 and (BYEAR=2000 or BYEAR_A/4
remainder ne 0) [goto ERR_BDAYLEAP_A]
elseif GEN.AGE_FINAL IN (RF,DK) [goto AGEGUESS_A]
elseif ((BYEAR_A not IN (RF,DK) and AGETEMP_A not IN (RF,DK) and
AGETEMP_A ne AGE_CALC_A) AND (AGETEMP_A not IN (RF,DK) and
AGETEMP_A ne AGE_CALCMINUS1_A)) and DOB_COUNT_A ne 1 [goto
VFYDOB_A]
elseif (AGETEMP_A eq (AGE_CALC_A or AGE_CALCMINUS1_A)) or
DOB_COUNT_A=1
if GEN.AGE_FINAL[PX_A] lt 18 [goto NOMORE_A]
else [goto next section]
Page 24 of 306
Check Name: ERR_BDAYLEAP_A
Text:
{check ERR_BDAYLEAP_A}
^BDAY_A is not a valid day for ^BMONTH_A.
Hard / Soft Edit: Hard
Fills:
^BDAY_A
Fill value from Adult.VFY.BDAY_A
^BMONTH_A
Fill value from Adult.VFY.BMONTH_A
Universe: Invalid dates for the month entered
Check Name: ERR_BYEAR_A
Text:
{check ERR_BYEAR_A}
Future date invalid
Hard / Soft Edit: Hard
Universe: (BYEAR_A>current
year)
or
(BYEAR_A=current
BMONTH_A>current
month)
or
(BYEAR_A=current
BMONTH_A=current month and BDAY_A>current day)
Question ID: VFY.0370.00.1
Variable name: AGEGUESS_A
year
year
and
and
Interview module: VFY(Adult.VFY)
Universe: GEN.AGE_FINAL IN (DK,RF)
Question Text:
An age has not been collected and we are unable to determine an age based upon
the date of birth. What is your best guess at ^ALIASNAME's age?
Response:
Fills:
^ALIASNAME
Fill value from Roster.HHC.ALIAS[PX]
Page 25 of 306
Skip Instructions: <18-120> [goto next section]
Question ID: VFY.0380.00.1
Variable name: VFYDOB_A
Interview module: VFY(Adult.VFY)
Universe: ((BYEAR_A not IN (DK,RF) and AGETEMP_A not IN (DK,RF) and
AGETEMP_A ne AGE_CALC_A) AND (AGETEMP_A not IN (DK,RF) and
AGETEMP_A ne AGE_CALCMINUS1_A)) and DOB_COUNT_A ne 1
Question Text:
Response:
Fills:
There is a difference between the age the computer calculated from your date
of birth of ^AGEDOB_A_fill and the age I had previously recorded of
^TEMPAGE_A. I recorded your ^dateofbirth
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^TEMPAGE_A
Fill value of AGETEMP_A
^AGEDOB_A_fill
Fill one age calculated from AGE_CALC_A as
"(age)"
Fill two ages calculated from AGE_CALC_A and
AGE_CALCMINUS1_A as "(age) or (age)"
^dateofbirth
If BDAY_A, BMONTH,A and BYEAR_A are all valid,
fill: "date of birth as ^BMONTH_A ^BDAY_A,
^BYEAR_A, is that correct?"
If only BMONTH_A and BYEAR_A are valid, fill:
"date of birth as ^BMONTH_A ^BYEAR_A, is that
correct?"
If only BDAY_A and BYEAR_A are valid, fill: "year of
birth as ^BYEAR_A, is that correct?"
If only BYEAR_A is valid, fill: "year of birth as
^BYEAR_A, is that correct?"
Page 26 of 306
Skip Instructions: <1,RF,DK> if GEN.AGE_FINAL[PX_A] lt 18 [goto NOMORE_A]
else [goto next section]
<2> if DOB_COUNT_A le 1 [goto BMONTH_A]
else if GEN.AGE_FINAL[PX_A] lt 18 [goto NOMORE_A]
else [goto next section]
Question ID: VFY.0390.00.1
Variable name: NOMORE_A
Interview module: VFY(Adult.VFY)
Universe: GEN.AGE_FINAL[PX_A] lt 18 or VFYONCAMP_A=2
Question Text:
Response:
Fills:
^SANAME is no longer the sample adult for this family. End this interview and begin
the Sample Child Interview. If there is no Sample Child or the Sample Child interview
has been completed, EXIT Not everyone in our survey is asked all questions. I
have all the information that I need about you at this time.
Enter '1' to
Continue.
1.
Enter 1 to Continue
^SANAME
Sample Adult's name
Skip Instructions: <1> if there is a Sample Child that has not been interviewed [goto
Child.VFY.CURRES_C]
else if GEN.OUTCOME IN 215 [goto BCK.THANKS_INSUF]
else [goto BCK.THANKS_SUF]
Question ID: HIS.0010.00.1
Question Text:
Response:
Variable name: PHSTAT_A
Interview module: HIS(Adult.HIS)
Would you say your health in general is excellent, very good, good, fair, or
poor?
1.
2.
Excellent
Very Good
Page 27 of 306
3.
4.
5.
DK:
RF:
Good
Fair
Poor
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto next section]
Question ID: LS1.0010.00.3
Question Text:
Response:
Variable name: LSATIS11_A
Interview module: LS1(Adult.LS1)
Using a scale of 0 to 10, where 0 means "very dissatisfied" and 10 means "very
satisfied", how do you feel about your life as a whole these days?
DK:
RF:
Don't Know
Refused
Skip Instructions: <0-10,RF,DK> [goto next section]
Question ID: HYP.0010.00.1
Question Text:
Response:
Variable name: HYPINTRO_A
Interview module: HYP(Adult.HYP)
Now I am going to ask you about certain medical conditions.
continue.
1.
Enter '1' to
Enter 1 to Continue
Skip Instructions: <1> [goto HYPEV_A]
Question ID: HYP.0020.00.1
Question Text:
Variable name: HYPEV_A
Interview module: HYP(Adult.HYP)
Have you EVER been told by a doctor or other health professional that you had
...Hypertension, also called high blood pressure? Enter ‘1' if respondent is
taking medication to control his/her high blood pressure.
Response:
Page 28 of 306
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto HYPDIF_A]
<2,RF,DK> [goto next section]
Question ID: HYP.0030.00.1
Variable name: HYPDIF_A
Interview module: HYP(Adult.HYP)
Universe: HYPEV_A=1
Question Text:
Response:
Were you told on two or more DIFFERENT visits that you had hypertension or
high blood pressure? Enter '1' if respondent is taking medication to control
his/her high blood pressure.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto HYP12M_A]
<2,RF,DK> [goto HYPMED_A]
Question ID: HYP.0040.00.1
Variable name: HYP12M_A
Interview module: HYP(Adult.HYP)
Universe: HYPDIF_A=1
Question Text:
Response:
During the past 12 months, have you had hypertension or high blood pressure?
Enter '1' if respondent is taking medication to control his/her high blood pressure.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 29 of 306
Skip Instructions: <1,2,RF,DK> [goto HYPMED_A]
Question ID: HYP.0050.00.1
Variable name: HYPMED_A
Interview module: HYP(Adult.HYP)
Universe: HYPEV_A=1
Question Text:
Response:
Are you NOW taking any medication prescribed by a doctor for your high blood
pressure?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: CHL.0010.00.1
Question Text:
Response:
Variable name: CHLEV_A
Interview module: CHL(Adult.CHL)
Have you EVER been told by a doctor or other health professional that you had
high cholesterol? Enter ‘1' if respondent is taking medication to control his/her
high cholesterol.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CHL12M_A]
<2,RF,DK> [goto next section]
Page 30 of 306
Question ID: CHL.0020.00.1
Variable name: CHL12M_A
Interview module: CHL(Adult.CHL)
Universe: CHLEV_A=1
Question Text:
Response:
During the past 12 months, have you had high cholesterol? Enter '1' if
respondent is taking medication to control his/her high cholesterol.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto CHLMED_A]
Question ID: CHL.0030.00.1
Variable name: CHLMED_A
Interview module: CHL(Adult.CHL)
Universe: CHLEV_A=1
Question Text:
Response:
Are you NOW taking any medication prescribed by a doctor to help lower your
cholesterol?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: CVC.0010.00.1
Question Text:
Response:
Variable name: CHDEV_A
Interview module: CVC(Adult.CVC)
Have you EVER been told by a doctor or other health professional that you had
...Coronary heart disease?
1.
Yes
Page 31 of 306
2.
DK:
RF:
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto ANGEV_A]
Question ID: CVC.0020.00.1
Question Text:
Response:
Variable name: ANGEV_A
Interview module: CVC(Adult.CVC)
Read if necessary: Have you EVER been told by a doctor or other health
professional that you had ...Angina, also called angina pectoris?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto MIEV_A]
Question ID: CVC.0030.00.1
Question Text:
Response:
Variable name: MIEV_A
Interview module: CVC(Adult.CVC)
Read if necessary: Have you EVER been told by a doctor or other health
professional that you had ...A heart attack, also called myocardial infarction?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto STREV_A]
Page 32 of 306
Question ID: CVC.0040.00.1
Question Text:
Response:
Variable name: STREV_A
Interview module: CVC(Adult.CVC)
Read if necessary: Have you EVER been told by a doctor or other health
professional that you had ...A stroke?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: AST.0010.00.1
Question Text:
Response:
Variable name: ASEV_A
Interview module: AST(Adult.AST)
Have you EVER been told by a doctor or other health professional that you had
asthma?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto ASTILL_A]
<2,RF,DK> [goto next section]
Question ID: AST.0020.00.1
Variable name: ASTILL_A
Universe: ASEV_A=1
Question Text:
Response:
Do you still have asthma?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 33 of 306
Interview module: AST(Adult.AST)
Skip Instructions: <1,2,RF,DK> [goto ASAT12M_A]
Question ID: AST.0030.00.1
Variable name: ASAT12M_A
Interview module: AST(Adult.AST)
Universe: ASEV_A=1
Question Text:
Response:
During the past 12 months, have you had an episode of asthma or an asthma
attack?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto ASER12M_A]
Question ID: AST.0040.00.1
Variable name: ASER12M_A
Interview module: AST(Adult.AST)
Universe: ASEV_A=1
Question Text:
Response:
During the past 12 months, have you had to visit an emergency room or urgent
care center because of asthma?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Page 34 of 306
Question ID: CAN.0010.00.1
Question Text:
Response:
Variable name: CANEV_A
Interview module: CAN(Adult.CAN)
Have you EVER been told by a doctor or other health professional that you had
...Cancer or a malignancy of any kind?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CANKIND1_A]
<2,RF,DK> [goto next section]
Question ID: CAN.0020.00.1
Variable name: CANKIND1_A
Interview module: CAN(Adult.CAN)
Universe: CANEV_A=1
Question Text:
Response:
What kind of cancer was it?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Enter code for the first kind of cancer.
Bladder
Blood
Bone
Brain
Breast
Cervix/Cervical
Colon
Esophagus/Esophageal
Gallbladder
Kidney
Larynx-trachea
Leukemia
Liver
Lung
Lymphoma
Melanoma
Page 35 of 306
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
DK:
RF:
Mouth/tongue/lip
Ovary/Ovarian
Pancreas/Pancreatic
Prostate
Rectum/Rectal
Skin (melanoma)
Skin (non-melanoma)
Skin (don't know kind)
Stomach
Testis/Testicular
Throat - pharynx
Thyroid
Uterus/Uterine
Other
Don't Know
Refused
Skip Instructions: If GEN.SEX_FINAL[PX_A]=1 and CANKIND1_A IN (6,18,29)
ERR1_CANKIND_A]
elseif GEN.SEX_FINAL[PX_A]=2 and CANKIND1_A IN (20,26)
ERR2_CANKIND_A]
<1-30,RF,DK> [goto CANAGE1_A]
[goto
[goto
Check Name: ERR1_CANKIND_A
Text:
{signal ERR1_CANKIND_A}
Verify. Code 6 or 18 or 29 is unavailable for males.
Hard / Soft Edit: Soft
Universe: GEN.SEX_FINAL=1 and (CANKIND1_A IN (6,18,29) or CANKIND2_A IN
(6,18,29) or CANKIND3_A IN (6,18,29))
Page 36 of 306
Check Name: ERR2_CANKIND_A
Text:
{signal ERR2_CANKIND_A}
Verify.Code 20 or 26 is unavailable for females.
Hard / Soft Edit: Soft
Universe: GEN.SEX_FINAL=2 and (CANKIND1_A IN (20,26) or CANKIND2_A IN
(20,26) or CANKIND3_A IN (20,26))
Question ID: CAN.0030.00.1
Variable name: CANAGE1_A
Interview module: CAN(Adult.CAN)
Universe: CANEV_A=1
Question Text:
Response:
Fills:
How old were you when a doctor or other health professional first told you that
you had ^CANKIND1? Enter 1 if reported age is 1 or younger.
DK:
RF:
Don't Know
Refused
^CANKIND1
If CANKIND1_A = RF,DK fill "this cancer";
else fill "bladder cancer" if CANKIND1_A = 1;
else fill "blood cancer" if CANKIND1_A = 2;
else fill "bone cancer" if CANKIND1_A = 3;
else fill "brain cancer" if CANKIND1_A = 4;
else fill "breast cancer" if CANKIND1_A = 5;
else fill "cervical cancer" if CANKIND1_A = 6;
else fill "colon cancer" if CANKIND1_A = 7;
else fill "esophageal cancer" if CANKIND1_A = 8;
else fill "gallbladder cancer" if CANKIND1_A = 9;
else fill "kidney cancer" if CANKIND1_A = 10;
else fill "larynx-trachea cancer" if CANKIND1_A = 11;
else fill "leukemia" if CANKIND1_A = 12;
else fill "liver cancer" if CANKIND1_A = 13;
else fill "lung cancer" if CANKIND1_A = 14;
else fill "lymphoma" if CANKIND1_A = 15;
else fill "melanoma" if CANKIND1_A = 16;
else fill "mouth/tongue/lip cancer" if CANKIND1_A =
17;
else fill "ovarian cancer" if CANKIND1_A = 18;
else fill "pancreatic cancer" if CANKIND1_A = 19;
else fill "prostate cancer" if CANKIND1_A = 20;
else fill "rectal cancer" if CANKIND1_A = 21;
else fill "skin (melanoma) cancer" if CANKIND1_A =
22;
else fill "skin (non-melanoma) cancer" if
CANKIND1_A = 23;
Page 37 of 306
else fill "skin (don't know kind) cancer" if
CANKIND1_A = 24;
else fill "stomach cancer" if CANKIND1_A = 25;
else fill "testicular cancer" if CANKIND1_A = 26;
else fill "throat/pharynx cancer" if CANKIND1_A =
27;
else fill "thyroid cancer" if CANKIND1_A = 28;
else fill "uterine cancer" if CANKIND1_A = 29;
else fill "other cancer" if CANKIND1_A = 30
Skip Instructions: <1-120,DK> [goto CANKIND2_A]
if CANKIND1_A=RF [goto next section] else [goto CANKIND2_A]
If
number
in
CANAGE1_A
gt
GEN.AGE_FINAL[PX_A]
ERR_CANAGE1_A]
[goto
Check Name: ERR_CANAGE1_A
Text:
{check ERR_CANAGE1_A}
Please correct.
^CANAGE1_A years old is older than age ^SA_AGE.
Hard / Soft Edit: Hard
Fills:
^CANAGE1_A
Fill value from Adult.CAN.CANAGE1_A
^SA_AGE
Fill GEN.AGE_FINAL[PX_A] value for sample adult
Universe: If GEN.AGE_FINAL=valid and value in CANAGE1_A gt GEN.AGE_FINAL
Page 38 of 306
Question ID: CAN.0040.00.1
Variable name: CANKIND2_A
Interview module: CAN(Adult.CAN)
Universe: CANEV_A=1 and (CANKIND1_A IN (1-30,DK) or CANAGE1_A IN (1-120,DK))
Question Text:
Response:
Have you EVER had any other kinds of cancer?
If yes, ask respondent for
second kind of cancer, enter code. If no, enter '96' for no more.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
Bladder
Blood
Bone
Brain
Breast
Cervix/Cervical
Colon
Esophagus/Esophageal
Gallbladder
Kidney
Larynx-trachea
Leukemia
Liver
Lung
Lymphoma
Melanoma
Mouth/tongue/lip
Ovary/Ovarian
Pancreas/Pancreatic
Prostate
Rectum/Rectal
Skin (melanoma)
Skin (non-melanoma)
Skin (don't know kind)
Stomach
Testis/Testicular
Throat - pharynx
Thyroid
Uterus/Uterine
Page 39 of 306
30.
96.
DK:
RF:
Other
No more
Don't Know
Refused
Skip Instructions: If GEN.SEX_FINAL[PX_A]=1 and CANKIND2_A IN (6,18,29)
ERR1_CANKIND_A]
elseif GEN.SEX_FINAL[PX_A]=2 and CANKIND2_A IN (20,26)
ERR2_CANKIND_A]
<1-30,RF,DK> [goto CANAGE2_A]
<96> [goto next section]
Question ID: CAN.0050.00.1
Variable name: CANAGE2_A
[goto
[goto
Interview module: CAN(Adult.CAN)
Universe: CANKIND2_A IN (1-30,DK,RF)
Question Text:
Response:
Fills:
How old were you when a doctor or other health professional first told you that
you had ^CANKIND2? Enter 1 if reported age is 1 or younger.
DK:
RF:
Don't Know
Refused
^CANKIND2
If CANKIND2_A = R,D fill "this cancer";
else fill "bladder cancer" if CANKIND2_A = 1;
else fill "blood cancer" if CANKIND2_A = 2;
else fill "bone cancer" if CANKIND2_A = 3;
else fill "brain cancer" if CANKIND2_A = 4;
else fill "breast cancer" if CANKIND2_A = 5;
else fill "cervical cancer" if CANKIND2_A = 6;
else fill "colon cancer" if CANKIND2_A = 7;
else fill "esophageal cancer" if CANKIND2_A = 8;
else fill "gallbladder cancer" if CANKIND2_A = 9;
else fill "kidney cancer" if CANKIND2_A = 10;
else fill "larynx-trachea cancer" if CANKIND2_A = 11;
else fill "leukemia" if CANKIND2_A = 12;
else fill "liver cancer" if CANKIND2_A = 13;
else fill "lung cancer" if CANKIND2_A = 14;
else fill "lymphoma" if CANKIND2_A = 15;
else fill "melanoma" if CANKIND2_A = 16;
else fill "mouth/tongue/lip cancer" if CANKIND2_A =
17;
else fill "ovarian cancer" if CANKIND2_A = 18;
else fill "pancreatic cancer" if CANKIND2_A = 19;
else fill "prostate cancer" if CANKIND2_A = 20;
else fill "rectal cancer" if CANKIND2_A = 21;
else fill "skin (melanoma) cancer" if CANKIND2_A =
22;
Page 40 of 306
else fill "skin (non-melanoma) cancer" if
CANKIND2_A = 23;
else fill "skin (don't know kind) cancer" if
CANKIND2_A = 24;
else fill "stomach cancer" if CANKIND2_A = 25;
else fill "testicular cancer" if CANKIND2_A = 26;
else fill "throat/pharynx cancer" if CANKIND2_A =
27;
else fill "thyroid cancer" if CANKIND2_A = 28;
else fill "uterine cancer" if CANKIND2_A = 29;
else fill "other cancer" if CANKIND2_A = 30
Skip Instructions: <1-120,DK> [goto CANKIND3_A]
if CANKIND2_A=RF [goto next section] else [goto CANKIND3_A]
If CANAGE2_A gt GEN.AGE_FINAL[PX_A] [goto ERR_CANAGE2_A]
Check Name: ERR_CANAGE2_A
Text:
{check ERR_CANAGE2_A} ^CANAGE2_A years old is older than age ^SA_AGE.
Please correct.
Hard / Soft Edit: Hard
Fills:
^CANAGE2_A
Fill value from Adult.CAN.CANAGE2_A
^SA_AGE
Fill GEN.AGE_FINAL[PX_A] value for sample adult
Universe: If GEN.AGE_FINAL=valid and value in CANAGE2_A gt GEN.AGE_FINAL
Page 41 of 306
Question ID: CAN.0060.00.1
Variable name: CANKIND3_A
Interview module: CAN(Adult.CAN)
Universe: CANKIND2_A IN (1-30,DK) or CANAGE2_A IN (1-120,DK)
Question Text:
Response:
Have you EVER had any other kinds of cancer? If yes, ask respondent for third
kind of cancer, enter code. If no, enter '96' for no more.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
Bladder
Blood
Bone
Brain
Breast
Cervix/Cervical
Colon
Esophagus/Esophageal
Gallbladder
Kidney
Larynx-trachea
Leukemia
Liver
Lung
Lymphoma
Melanoma
Mouth/tongue/lip
Ovary/Ovarian
Pancreas/Pancreatic
Prostate
Rectum/Rectal
Skin (melanoma)
Skin (non-melanoma)
Skin (don't know kind)
Stomach
Testis/Testicular
Throat - pharynx
Thyroid
Uterus/Uterine
Page 42 of 306
30.
96.
DK:
RF:
Other
No more
Don't Know
Refused
Skip Instructions: If
GEN.SEX_FINAL=1
and
CANKIND3_A
IN
(6,18,29)
ERR1_CANKIND_A]
elseif
GEN.SEX_FINAL=2
and
CANKIND3_A
IN
(20,26)
ERR2_CANKIND_A]
<1-30,RF,DK>[goto CANAGE3_A]
<96> [goto next section]
Question ID: CAN.0070.00.1
Variable name: CANAGE3_A
[goto
[goto
Interview module: CAN(Adult.CAN)
Universe: CANKIND3_A IN (1-30,DK,RF)
Question Text:
Response:
Fills:
How old were you when a doctor or other health professional first told you that
you had ^CANKIND3? Enter 1 if reported age is 1 or younger.
DK:
RF:
Don't Know
Refused
^CANKIND3
If CANKIND3_A = R,D fill "this cancer";
else fill "bladder cancer" if CANKIND3_A = 1;
else fill "blood cancer" if CANKIND3_A = 2;
else fill "bone cancer" if CANKIND3_A = 3;
else fill "brain cancer" if CANKIND3_A = 4;
else fill "breast cancer" if CANKIND3_A = 5;
else fill "cervical cancer" if CANKIND3_A = 6;
else fill "colon cancer" if CANKIND3_A = 7;
else fill "esophageal cancer" if CANKIND3_A = 8;
else fill "gallbladder cancer" if CANKIND3_A = 9;
else fill "kidney cancer" if CANKIND3_A = 10;
else fill "larynx-trachea cancer" if CANKIND3_A = 11;
else fill "leukemia" if CANKIND3_A = 12;
else fill "liver cancer" if CANKIND3_A = 13;
else fill "lung cancer" if CANKIND3_A = 14;
else fill "lymphoma" if CANKIND3_A = 15;
else fill "melanoma" if CANKIND3_A = 16;
else fill "mouth/tongue/lip cancer" if CANKIND3_A =
17;
else fill "ovarian cancer" if CANKIND3_A = 18;
else fill "pancreatic cancer" if CANKIND3_A = 19;
else fill "prostate cancer" if CANKIND3_A = 20;
else fill "rectal cancer" if CANKIND3_A = 21;
else fill "skin (melanoma) cancer" if CANKIND3_A =
22;
Page 43 of 306
else fill "skin (non-melanoma) cancer" if
CANKIND3_A = 23;
else fill "skin (don't know kind) cancer" if
CANKIND3_A = 24;
else fill "stomach cancer" if CANKIND3_A = 25;
else fill "testicular cancer" if CANKIND3_A = 26;
else fill "throat/pharynx cancer" if CANKIND3_A =
27;
else fill "thyroid cancer" if CANKIND3_A = 28;
else fill "uterine cancer" if CANKIND3_A = 29;
else fill "other cancer" if CANKIND3_A = 30
Skip Instructions: <1-120,DK> [goto CANMORE_A]
if CANKIND3_A=RF [goto next section] else [goto CANMORE_A]
if CANAGE3_A gt GEN.AGE_FINAL[PX_A] [goto ERR_CANAGE3_A]
Check Name: ERR_CANAGE3_A
Text:
{check ERR_CANAGE3_A}
Please correct.
^CANAGE3_A years old is older than age ^SA_AGE.
Hard / Soft Edit: Hard
Fills:
^CANAGE3_A
Fill value from Adult.CAN.CANAGE3_A
^SA_AGE
Fill GEN.AGE_FINAL[PX_A] value for sample adult
Universe: If GEN.AGE_FINAL=valid and value in CANAGE3_A gt GEN.AGE_FINAL
Page 44 of 306
Question ID: CAN.0080.00.1
Variable name: CANMORE_A
Interview module: CAN(Adult.CAN)
Universe: CANKIND3_A IN (1-30,DK) or CANAGE3_A IN (1-120,DK)
Question Text:
Response:
Did you have any other kinds of cancer?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: DIB.0010.00.1
Question Text:
Response:
Variable name: PREDIB_A
Interview module: DIB(Adult.DIB)
Has a doctor or other health professional EVER told you that you had
prediabetes or borderline diabetes?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> If GEN.SEX_FINAL[PX_A]=2 [goto GESDIB_A]
elseif GEN.SEX_FINAL[PX_A]=1,RF,DK [goto DIBEV_A]
Question ID: DIB.0020.00.1
Variable name: GESDIB_A
Interview module: DIB(Adult.DIB)
Universe: SEX_FINAL[PX_A]=2
Question Text:
Has a doctor or other health professional EVER told you that you had
gestational diabetes, a type of diabetes that occurs ONLY during pregnancy?
Read if necessary: Gestational diabetes is diabetes that you did not have prior to
being pregnant and goes away after you are pregnant. Pregnant women are usually
screened for gestational diabetes during the 24th to 28th week of pregnancy.
Response:
Page 45 of 306
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto DIBEV_A]
Question ID: DIB.0030.00.1
Question Text:
Response:
Fills:
Variable name: DIBEV_A
Interview module: DIB(Adult.DIB)
^NOTPREGDM a doctor or other health professional EVER told you that you
had diabetes?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^NOTPREGDM
If GESDIB_A ne 1 AND PREDIB_A ne 1: "Has"
If GESDIB_A=1 AND PREDIB_A ne 1: "Not including
gestational diabetes, has"
If PREDIB_A=1 AND GESDIB_A ne 1: "Not including
prediabetes, has"
If GESDIB_A=1 AND PREDIB_A=1: "Not including
prediabetes orgestational diabetes, has"
Skip Instructions: <1> [goto DIBAGE_A]
<2,RF,DK> if PREDIB_A=1 [goto DIBPILL_A]
else if PREDIB_A=2,RF,DK [goto next section]
Page 46 of 306
Question ID: DIB.0040.00.1
Variable name: DIBAGE_A
Interview module: DIB(Adult.DIB)
Universe: DIBEV_A=1
Question Text:
Response:
Fills:
How old were you when a doctor or other health professional FIRST told you
that you had diabetes^NOTPREGDM2? Enter '1' if reported age is 1 or younger.
DK:
RF:
Don't Know
Refused
^NOTPREGDM2
If GESDIB_A ne 1 AND PREDIB_A ne 1: NO FILL
If GESDIB_A=1 AND PREDIB_A ne 1: ",not
including gestational diabetes"
If PREDIB_A=1 AND GESDIB_A ne 1: ",not
including prediabetes"
If GESDIB_A=1 AND PREDIB_A=1: ",not including
prediabetes orgestational diabetes"
Skip Instructions: <1-120> if DIBAGE_A gt GEN.AGE_FINAL [goto ERR1_DIBAGE_A]
else [goto DIBPILL_A]
Check Name: ERR_ DIBAGE_A
Text:
{check ERR_DIBAGE_A}
Please correct.
^DIBAGE_A years old is older than your age ^SA_AGE.
Hard / Soft Edit: Hard
Fills:
^SA_AGE
Fill GEN.AGE_FINAL[PX_A] value for sample adult
^DIBAGE_A
Fill value from Adult.DIB.DIBAGE_A
Universe: If AGE_FINAL=valid and value in DIBAGE_A gt AGE_FINAL
Page 47 of 306
Question ID: DIB.0050.00.1
Variable name: DIBPILL_A
Interview module: DIB(Adult.DIB)
Universe: PREDIB_A=1 or DIBEV_A=1
Question Text:
Response:
Are you NOW taking diabetic pills to lower your blood sugar? These are
sometimes called oral agents or oral hypoglycemic agents.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1-2,RF,DK> [goto DIBINS_A]
Question ID: DIB.0060.00.1
Variable name: DIBINS_A
Interview module: DIB(Adult.DIB)
Universe: PREDIB_A=1 or DIBEV_A=1
Question Text:
Response:
Insulin can be taken by shot or pump. Are you NOW taking insulin?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> if DIBEV_A=1 [goto DIBINSTIME_A]
else [goto INSKIP12M_A]
<2,RF,DK> if DIBEV_A=1 [goto DIBTYPE_A]
else [goto next section]
Page 48 of 306
Question ID: DIB.0070.00.3
Variable name: DIBINSTIME_A
Interview module: DIB(Adult.DIB)
Universe: DIBEV_A=1 and DIBINS_A=1
Question Text:
Response:
Thinking back to when you were first diagnosed with diabetes, how long was it
before you started taking insulin?
1.
2.
3.
4.
DK:
RF:
Less than 1 month
1 month to less than 6 months
6 months to less than 1 year
1 year or more
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto DIBINSSTOP_A]
Question ID: DIB.0080.00.3
Variable name: DIBINSSTOP_A
Interview module: DIB(Adult.DIB)
Universe: DIBEV_A=1 and DIBINS_A=1
Question Text:
Response:
Since you started taking insulin, have you ever stopped taking it for more than
6 months?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> if DIBINSTIME_A IN (1,2,3) [goto DIBINSSTYR_A]
else [goto INSSKIP12M_A]
<2,RF,DK> [goto INSSKIP12M_A]
Page 49 of 306
Question ID: DIB.0090.00.3
Variable name: DIBINSSTYR_A
Interview module: DIB(Adult.DIB)
Universe: DIBINSTIME_A in (1,2,3) and DIBINSSTOP_A=1
Question Text:
Response:
Was this only during the first year after you were diagnosed with diabetes?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto INSSKIP12M_A]
Question ID: DIB.0100.00.3
Variable name: INSSKIP12M_A
Interview module: DIB(Adult.DIB)
Universe: DIBINS_A='1'
Question Text:
Response:
During the past 12 months, were any of the following true for you? ...You
skipped insulin doses to save money.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,DK,RF> [goto INSLESS12M_A]
Question ID: DIB.0110.00.3
Variable name: INSLESS12M_A
Interview module: DIB(Adult.DIB)
Universe: DIBINS_A='1'
Question Text:
Read if necessary: During the past 12 months, were any of the following true for
you? ...You took less insulin than needed to save money.
Response:
Page 50 of 306
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto INSDLY12M_A]
Question ID: DIB.0120.00.3
Variable name: INSDLY12M_A
Interview module: DIB(Adult.DIB)
Universe: DIBINS='1'
Question Text:
Response:
Read if necessary: During the past 12 months, were any of the following true for
you? ...You DELAYED buying insulin to save money.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> if DIBEV_A=1 [goto DIBTYPE_A]
else [goto next section]
Question ID: DIB.0130.00.1
Variable name: DIBTYPE_A
Interview module: DIB(Adult.DIB)
Universe: DIBEV_A=1
Question Text:
Response:
According to your doctor or other health professional, what type of diabetes do
you have? Is it type 1, type 2, or some other type? If you don't remember or
weren't told, that's OK.
1.
2.
3.
DK:
RF:
Type 1
Type 2
Other type of diabetes
Don't Know
Refused
Page 51 of 306
Skip Instructions: <1-3,RF,DK> [goto DIBSTRESS_A]
Question ID: DIB.0140.00.3
Variable name: DIBSTRESS_A
Interview module: DIB(Adult.DIB)
Universe: DIBEV_A=1
Question Text:
Response:
During the past month, how often have you felt overwhelmed by the demands
of living with diabetes?
1.
2.
3.
4.
5.
DK:
RF:
Always
Usually
Sometimes
Rarely
Never
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto DIBCSTRESS_A]
Question ID: DIB.0150.00.3
Variable name: DCIBSTRESS_A
Interview module: DIB(Adult.DIB)
Universe: DIBEV_A=1
Question Text:
Response:
Compared with the time before the coronavirus pandemic, would you say that
you now feel more overwhelmed by the demands of living with diabetes, less
overwhelmed, or about the same as before the pandemic?
1.
2.
3.
DK:
RF:
Less overwhelmed
More overwhelmed
About the same
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto next section]
Page 52 of 306
Question ID: CON.0010.00.1
Question Text:
Response:
Variable name: COPDEV_A
Interview module: CON(Adult.CON)
Have you EVER been told by a doctor or other health professional that you had
...Chronic Obstructive Pulmonary Disease, C.O.P.D., emphysema, or chronic
bronchitis?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto ARTHEV_A]
Question ID: CON.0020.00.1
Question Text:
Response:
Variable name: ARTHEV_A
Interview module: CON(Adult.CON)
Read if necessary: Have you EVER been told by a doctor or other health
professional that you had ...Some form of arthritis, rheumatoid arthritis, gout,
lupus, or fibromyalgia (fy-bro-my-AL-jee-uh)?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto DEMENEV_A]
Question ID: CON.0030.00.1
Question Text:
Response:
Variable name: DEMENEV_A
Interview module: CON(Adult.CON)
Read if necessary: Have you EVER been told by a doctor or other health
professional that you had ...Dementia, including Alzheimer's disease?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 53 of 306
Skip Instructions: <1,2,RF,DK> [goto ANXEV_A]
Question ID: CON.0040.00.1
Question Text:
Response:
Variable name: ANXEV_A
Interview module: CON(Adult.CON)
Read if necessary: Have you EVER been told by a doctor or other health
professional that you had ...Any type of anxiety disorder? Read if necessary:
Some common types of anxiety disorders include generalized anxiety disorder, social
anxiety disorder, panic disorder, post-traumatic stress disorder,
obsessive-compulsive disorder, and phobias.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto DEPEV_A]
Question ID: CON.0050.00.1
Question Text:
Response:
Variable name: DEPEV_A
Interview module: CON(Adult.CON)
Read if necessary: Have you EVER been told by a doctor or other health
professional that you had ...Any type of depression? Read if necessary: Some
common types of depression include major depression (or major depressive
disorder), bipolar depression, dysthymia, post-partum depression, and seasonal
affective disorder.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Page 54 of 306
Question ID: RCN.0010.00.4
Question Text:
Response:
Variable name: KIDWEAKEV_A
Interview module: RCN(Adult.RCN)
Read if necessary: Have you EVER been told by a doctor or other health
professional that you had ...Weak or failing kidneys?
Read if necessary: Do not
include kidney stones, bladder infections, or incontinence.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto HEPEV_A]
Question ID: RCN.0020.00.4
Question Text:
Response:
Variable name: HEPEV_A
Interview module: RCN(Adult.RCN)
Read if necessary: Have you EVER been told by a doctor or other health
professional that you had ...Hepatitis?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto LIVEREV_A]
Question ID: RCN.0030.00.4
Question Text:
Response:
Variable name: LIVEREV_A
Interview module: RCN(Adult.RCN)
Read if necessary: Have you EVER been told by a doctor or other health
professional that you had ...Cirrhosis (suh-ROE-siss) or any other kind of
long-term liver condition?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 55 of 306
Skip Instructions: <1,2,RF,DK> [goto CFSEV_A]
Question ID: RCN.0040.00.3
Question Text:
Response:
Variable name: CFSEV_A
Interview module: RCN(Adult.RCN)
Read if necessary: Have you EVER been told by a doctor or other health
professional that you had ...Chronic Fatigue Syndrome (CFS) or Myalgic
Encephalomyelitis (My-AL-jick In-seff-ah-low-my-uh-LIE-tiss) (ME)?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CFSNOW_A]
<2,RF,DK> [goto COLDFLU12M_A]
Question ID: RCN.0050.00.3
Variable name: CFSNOW_A
Interview module: RCN(Adult.RCN)
Universe: CFSEV_A=1
Question Text:
Response:
Do you still have Chronic Fatigue Syndrome (CFS) or ME?
ME is also known as Myalgic Encephalomyelitis (My-AL-jick
In-seff-ah-low-my-uh-LIE-tiss).
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto COLDFLU12M_A]
Page 56 of 306
Read if necessary:
Question ID: RCN.0060.00.3
Question Text:
Response:
Variable name: COLDFLU12M_A
Interview module: RCN(Adult.RCN)
During the past 12 months, have you had a head cold or flu for longer than a
month?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto DRYMOUTH_A]
Question ID: RCN.0070.00.3
Question Text:
Response:
Variable name: DRYMOUTH12M_A
Interview module: RCN(Adult.RCN)
During the past 12 months, have you had persistent dry mouth?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: ISN.0010.00.4
Question Text:
Response:
Variable name: MEDRXTRT_A
Interview module: ISN(Adult.ISN)
In the past 12 months, have you taken prescription medication or had any
medical treatments that a doctor or other health professional told you would
weaken your immune system? Read if necessary: Examples include steroid or
corticosteroid (Core-tih-coe-STAIR-oid) pills, such as prednisone (PRED-nuh-sown),
or other oral or injected medications for treating many types of autoimmune
conditions or certain cancers.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 57 of 306
Skip Instructions: <1,2,RF,DK> [goto HLTHCOND_A]
Question ID: ISN.0020.00.4
Question Text:
Response:
Fills:
Variable name: HLTHCOND_A
Interview module: ISN(Adult.ISN)
Do you currently have a health condition that a doctor or other health
professional told you weakens the immune system^MEDTRT? Read if
necessary: Examples include certain kinds of leukemia, lymphoma, or HIV infection.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^MEDTRT
If MEDRXTRT_A=1, fill: ", even without related
medications or treatments"
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: EPI.0010.00.3
Question Text:
Response:
Variable name: EPIEV_A
Interview module: EPI(Adult.EPI)
Have you ever been told by a doctor or other health professional that you have
a seizure disorder or epilepsy?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto EPIMED_A]
<2,RF,DK> [goto next section]
Page 58 of 306
Question ID: EPI.0020.00.3
Variable name: EPIMED_A
Interview module: EPI(Adult.EPI)
Universe: EPIEV_A=1
Question Text:
Response:
Are you currently taking any medicine to control your seizure disorder or
epilepsy?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto EPINUMSEIZ_A]
Question ID: EPI.0030.00.3
Variable name: EPINUMSEIZ_A
Interview module: EPI(Adult.EPI)
Universe: EPIEV_A=1
Question Text:
Response:
Fills:
Today is ^CURRENTDATE. Think back to the last year about the same time.
About how many seizures of any type have you had during the past 12 months?
Read if necessary: Some people may call it "convulsion," "fit," "falling out spell,"
"episode," "attack," "drop attack," "staring spell," or "out-of-touch." If the respondent
mentions and counts "auras" as seizures accept the response.
If the respondent
indicates that he/she has had nothing more than an aura and is unsure about
counting the aura(s), do NOT count auras as seizures.
0.
1.
2.
3.
4.
DK:
RF:
0
1
2 or 3
Between 4 and 10
More than 10
Don't Know
Refused
^CURRENTDATE
display current date
Page 59 of 306
Skip Instructions: <0-4,RF,DK> [goto EPIDR_A]
Question ID: EPI.0040.00.3
Variable name: EPIDR_A
Interview module: EPI(Adult.EPI)
Universe: EPIEV_A=1
Question Text:
Response:
During the past 12 months, have you seen a neurologist or epilepsy specialist
for your seizure disorder or epilepsy?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: ALG.0010.00.2
Question Text:
Response:
Variable name: ALGINTRO_A
Interview module: ALG(Adult.ALG)
The next set of questions are about different types of allergies.
1.
Enter 1 to Continue
Skip Instructions: <1> [goto CURRESP_A]
Question ID: ALG.0020.00.2
Question Text:
Response:
Variable name: CURRESP_A
Interview module: ALG(Adult.ALG)
Do you get symptoms such as sneezing, runny nose, or itchy or watery eyes
due to hay fever, seasonal or year-round allergies? Read if necessary: Hay
fever, seasonal or year-round allergies may also be known as environmental
allergies, allergic rhinitis or allergic conjunctivitis.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 60 of 306
Skip Instructions: <1> [goto DXRESP_A]
<2,RF,DK> [goto CURFOOD_A]
Question ID: ALG.0030.00.2
Variable name: DXRESP_A
Interview module: ALG(Adult.ALG)
Universe: CURRESP_A=1
Question Text:
Response:
Have you ever been told by a doctor or other health professional that you had
hay fever, seasonal or year-round allergies? Read if necessary: Hay fever,
seasonal or year-round allergies may also be known as environmental allergies,
allergic rhinitis or allergic conjunctivitis.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto CURFOOD_A]
Question ID: ALG.0040.00.2
Question Text:
Response:
Variable name: CURFOOD_A
Interview module: ALG(Adult.ALG)
The next question is about food allergies. People with food allergies have
reactions such as hives, vomiting, trouble breathing, or throat tightening that
occur within two hours of eating a specific food. Do you have an allergy to one
or more foods? Read if necessary: Food allergies are different from food
intolerances, such as lactose and gluten intolerance, and other digestive disorders,
including irritable bowel syndrome.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto DXFOOD_A]
<2,RF,DK> [goto CURSKIN_A]
Page 61 of 306
Question ID: ALG.0050.00.2
Variable name: DXFOOD_A
Interview module: ALG(Adult.ALG)
Universe: CURFOOD_A=1
Question Text:
Response:
Have you ever been told by a doctor or other health professional that you had
an allergy to one or more foods?
Read if necessary: Food allergies are different
from food intolerances, such as lactose and gluten intolerance, and other digestive
disorders, including irritable bowel syndrome.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto CURSKIN_A]
Question ID: ALG.0060.00.2
Question Text:
Response:
Variable name: CURSKIN_A
Interview module: ALG(Adult.ALG)
The next question is about an allergic skin condition. Do you get an itchy rash
due to eczema or atopic dermatitis? Read if necessary: The rash can be dry,
scaly, bumpy, or crusty and lasts for several days or longer without treatment.
Eczema is different from hives which come and go in a few hours.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto DXSKIN_A]
<2,RF,DK> [goto next section]
Page 62 of 306
Question ID: ALG.0070.00.2
Variable name: DXSKIN_A
Interview module: ALG(Adult.ALG)
Universe: CURSKIN_A=1
Question Text:
Response:
Have you ever been told by a doctor or other health professional that you had
eczema or atopic dermatitis?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: BMI.0010.00.1
Variable name: PREGNOW_A
Interview module: BMI(Adult.BMI)
Universe: GEN.SEX_FINAL[PX_A]=2 and ((GEN.AGE_FINAL[PX_A] ge 18
GEN.AGE_FINAL[PX_A] le 49) or GEN.AGE_FINAL[PX_A] IN (DK,RF))
Question Text:
Response:
and
Are you currently pregnant?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto HEIGHTFT_A]
Question ID: BMI.0020.01.1
Question Text:
Response:
Variable name: HEIGHTFT_A
Interview module: BMI(Adult.BMI)
How tall are you without shoes? Enter M to record metric measurements. If
^SANAME's height is less than 2 feet, enter 2. If ^SANAME's height is greater than 7
feet, enter 7.
DK:
RF:
Don't Know
Refused
Page 63 of 306
Fills:
^SANAME
Sample Adult's name
Skip Instructions: If HEIGHTFT_A NE <2-7,RF,DK,M> [goto ERR1_HEIGHTFT_A]
If HEIGHTFT_A = <2,3> [goto ERR2_HEIGHTFT_A]
<2-7> [goto HEIGHTIN_A]
[goto WEIGHTLB_A]
[goto HEIGHTM_A]
Check Name: ERR1_HEIGHTFT_A
Text:
{check ERR1_HEIGHTFT_A}
field. Please correct.
Only 2-7, Don't Know/Refused or M allowed in this
Hard / Soft Edit: Hard
Universe: HEIGHTFT_A NE (2-7,RF,DK,M)
Check Name: ERR2_HEIGHTFT_A
Text:
{signal ERR2_HEIGHTFT_A}
Please verify.
Respondent's height in feet is ^HEIGHTFT?
Hard / Soft Edit: Soft
Fills:
^HEIGHTFT
Fill value from Adult.BMI.HEIGHTFT_A
Universe: HEIGHTFT_A IN (2,3)
Page 64 of 306
Question ID: BMI.0020.02.1
Variable name: HEIGHTIN_A
Interview module: BMI(Adult.BMI)
Universe: HEIGHTFT_A=2-7
Question Text:
Response:
Fills:
Enter inches.
DK:
RF:
Enter '0' if exactly ^HEIGHTFT feet tall.
Don't Know
Refused
^HEIGHTFT
Fill value from Adult.BMI.HEIGHTFT_A
Skip Instructions: <0-11,RF,DK> [goto WEIGHTLB_A]
Check Name: ERR2_HEIGHTIN_A
Text:
{signal ERR2_HEIGHTIN_A}
Probe only if necessary.
Please verify that the height was entered correctly.
Hard / Soft Edit: Soft
Universe: ((GEN.SEX_FINAL[PX_A]=1 and (AHTINCH_A lt 61 or AHTINCH_A gt 75)) or
(GEN.SEX_FINAL[PX_A]=2 and (AHTINCH_A lt 56 or AHTINCH_A gt 69)) or
(GEN.SEX_FINAL[PX_A] IN (DK,RF) and (AHTINCH_A lt 56 or AHTINCH_A
gt 75)))
Question ID: BMI.0020.04.1
Variable name: HEIGHTM_A
Interview module: BMI(Adult.BMI)
Universe: HEIGHTFT_A=M
Question Text:
Response:
How tall are you without shoes? Enter height in metric. If the height is given in
centimeters, press '0' at meters and enter the measure in centimeters (241
centimeters maximum).
DK:
RF:
Don't Know
Refused
Page 65 of 306
Skip Instructions: <0-2> [goto HEIGHTCM_A]
[goto WEIGHTLB_A]
Question ID: BMI.0020.05.1
Variable name: HEIGHTCM_A
Interview module: BMI(Adult.BMI)
Universe: HEIGHTM_A=0-2
Question Text:
Response:
Fills:
Enter centimeters. Enter height in metric.
241 centimeters, enter 241.
DK:
RF:
If ^SANAME's height is greater than
Don't Know
Refused
^SANAME
Sample Adult's name
Skip Instructions: <0-241,RF,DK> [goto WEIGHTLB_A]
Check Name: ERR1_HEIGHTCM_A
Text:
{check ERR1_HEIGHTCM_A}
correct.
Total height exceeds maximum allowed.
Please
Hard / Soft Edit: Hard
Universe: ((HEIGHTM_A=2 and HEIGHTCM_A gt 41) or (HEIGHTM_A=1 and
HEIGHTCM_A gt 141) or (HEIGHTCM_A gt 241))
Page 66 of 306
Check Name: ERR2_HEIGHTCM_A
Text:
{signal ERR2_HEIGHTCM_A}
Probe only if necessary.
Please verify that the height was entered correctly.
Hard / Soft Edit: Soft
Universe: ((GEN.SEX_FINAL[PX_A]=1 and (AHTCM_A lt 156 or AHTCM_A gt 192)) or
(GEN.SEX_FINAL[PX_A]=2 and (AHTCM_A lt 143 or AHTCM_A gt 176)) or
(GEN.SEX_FINAL[PX_A] IN (DK,RF) and (AHTCM_A lt 143 or AHTCM_A gt
192)))
Question ID: BMI.0030.01.1
Question Text:
Response:
Fills:
Variable name: WEIGHTLB_A
Interview module: BMI(Adult.BMI)
^PREGWEIGH Enter M to record metric measurements. If ^SANAME's weight is
less than 50 pounds, enter 50. If ^SANAME's weight is greater than 500 pounds,
enter 500.
DK:
RF:
Don't Know
Refused
^PREGWEIGH
If GEN.SEX_FINAL=2ANDPREGNOW_A=1: "How
much did you weighbefore your pregnancy?"
else: "How much do you weigh?"
^SANAME
Sample Adult's name
Skip Instructions: If WEIGHTLB_A lt 50 or WEIGHTLB_A gt 500 [goto ERR1_WEIGHTLB_A]
elseif ((GEN.SEX_FINAL[PX_A]=1 and (WEIGHTLB_A lt 113 or
WEIGHTLB_A gt 316)) or (GEN.SEX_FINAL[PX_A]=2 and (WEIGHTLB_A lt
96 or WEIGHTLB_A gt 293)) or (GEN.SEX_FINAL[PX_A] IN (RF,DK) and
(WEIGHTLB_A lt 96 or WEIGHTLB_A gt 316))) [goto ERR2_WEIGHTLB_A]
<50-500,RF,DK> [goto next section]
[goto WEIGHTKG_A]
Page 67 of 306
Check Name: ERR1_WEIGHTLB_A
Text:
{check ERR1_WEIGHTLB_A} Weight is out of range. Only "50-500" or "M" or
"Don't know/Refused" allowed in this field.
Hard / Soft Edit: Hard
Universe: (WEIGHTLB_A lt 50 or WEIGHTLB_A gt 500) or WEIGHTLB_A not IN (M,
DK, RF)
Check Name: ERR2_WEIGHTLB_A
Text:
{signal ERR2_WEIGHTLB_A}
Probe only if necessary.
Please verify that the weight was entered correctly.
Hard / Soft Edit: Soft
Universe: ((GEN.SEX_FINAL[PX_A]=1 and (WEIGHTLB_A lt 113 or WEIGHTLB_A gt
316)) or
(GEN.SEX_FINAL[PX_A]=2 and (WEIGHTLB_A lt 96 or WEIGHTLB_A gt
293)) or (GEN.SEX_FINAL[PX_A] IN (DK,RF) and (WEIGHTLB_A lt 96 or
WEIGHTLB_A gt 316)))
Question ID: BMI.0030.02.1
Variable name: WEIGHTKG_A
Interview module: BMI(Adult.BMI)
Universe: WEIGHTLB_A=M
Question Text:
Response:
^PREGWEIGH Enter weight in kilograms. If ^SANAME's weight is less than 23
kilograms, enter 23. If ^SANAME's weight is greater than 226 kilograms, enter 226.
DK:
RF:
Don't Know
Refused
Page 68 of 306
Fills:
^PREGWEIGH
If GEN.SEX_FINAL=2ANDPREGNOW_A=1: "How
much did you weighbefore your pregnancy?"
else: "How much do you weigh?"
^SANAME
Sample Adult's name
Skip Instructions: If WEIGHTKG_A lt 23 or WEIGHTKG_A gt 226 [goto ERR1_WEIGHTKG_A]
elseif ((GEN.SEX_FINAL[PX]=1 and (WEIGHTKG_A lt 51 or WEIGHTKG_A gt
143)) or (GEN.SEX_FINAL[PX]=2 and (WEIGHTKG_A lt 43 or WEIGHTKG_A
gt 133)) or (GEN.SEX_FINAL[PX] IN (RF,DK) and (WEIGHTKG_A lt 43 or
WEIGHTKG_A gt 143)))[goto ERR2_WEIGHTKG_A]
<23-226,RF,DK> [goto next section]
Check Name: ERR1_WEIGHTKG_A
Text:
{check ERR1_WEIGHTKG_A}
Weight is out of range (23-226).
Please correct.
Hard / Soft Edit: Hard
Universe: (WEIGHTKG_A lt 23 or WEIGHTKG_A gt 226)
Check Name: ERR2_WEIGHTKG_A
Text:
{signal ERR2_WEIGHTKG_A}
Probe only if necessary.
Please verify that the weight was entered correctly.
Hard / Soft Edit: Soft
Universe: ((GEN.SEX_FINAL[PX]=1 and (WEIGHTKG_A lt 51 or WEIGHTKG_A gt 143))
or (GEN.SEX_FINAL[PX]=2 and (WEIGHTKG_A lt 43 or WEIGHTKG_A gt
133)) or (GEN.SEX_FINAL[PX] IN (RF,DK) and (WEIGHTKG_A lt 43 or
WEIGHTKG_A gt 143)))
Page 69 of 306
Question ID: VIS.0010.00.1
Question Text:
Response:
Variable name: VISINTRO_A
Interview module: VIS(Adult.VIS)
The next questions ask about difficulties you may have doing certain activities
because of a health problem. Enter '1' to continue.
1.
Enter 1 to Continue
Skip Instructions: <1> [goto WEARGLSS_A]
Question ID: VIS.0020.00.1
Question Text:
Response:
Variable name: WEARGLSS_A
Interview module: VIS(Adult.VIS)
Do you wear glasses or contact lenses? Read if necessary: Persons who wear
glasses to read or to do other occasional tasks should answer yes to this question.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto VISIONDF_A]
Question ID: VIS.0030.00.1
Question Text:
Response:
Fills:
Variable name: VISIONDF_A
Interview module: VIS(Adult.VIS)
Do you have difficulty ^AGLASSCNTS? Would you say no difficulty, some
difficulty, a lot of difficulty, or you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
^AGLASSCNTS
fill if wear glasses/contacts
Page 70 of 306
Skip Instructions: <1-4,RF,DK> [goto next section]
Question ID: HEA.0010.00.1
Question Text:
Response:
Variable name: HEARAID_A
Interview module: HEA(Adult.HEA)
Do you use a hearing aid?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [HEARAIDFR_A]
<2,RF,DK> [HEARINGDF_A]
Question ID: HEA.0020.00.1
Variable name: HEARAIDFR_A
Interview module: HEA(Adult.HEA)
Universe: HEARAID_A=1
Question Text:
Response:
How often do you use your hearing aid(s)? Would you say all of the time, some
of the time, rarely, or never?
1.
2.
3.
4.
DK:
RF:
All of the time
Some of the time
Rarely
Never
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [HEARINGDF_A]
Page 71 of 306
Question ID: HEA.0030.00.1
Question Text:
Response:
Fills:
Variable name: HEARINGDF_A
Interview module: HEA(Adult.HEA)
Do you have difficulty hearing^HEARAID? Would you say no difficulty, some
difficulty, a lot of difficulty, or you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
^HEARAID
IfHEARAID_A=1, fill: ", even when using your
hearing aid(s)"
else NO FILL
Skip Instructions: <1-3,RF,DK> [goto HEARQTRM_A]
<4> [goto next section]
Question ID: HEA.0040.00.2
Variable name: HEARQTRM_A
Interview module: HEA(Adult.HEA)
Universe: HEARINGDF_A IN (1,2,3,RF,DK)
Question Text:
Response:
Do you have difficulty hearing what is said in a conversation with one other
person in a quiet room^HEARAID? Would you say no difficulty, some difficulty,
a lot of difficulty, or you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Page 72 of 306
Fills:
^HEARAID
IfHEARAID_A=1, fill: ", even when using your
hearing aid(s)"
else NO FILL
Skip Instructions: <1-3,RF,DK> [goto HEARNYRM_A]
<4> [goto next section]
Question ID: HEA.0050.00.2
Variable name: HEARNYRM_A
Interview module: HEA(Adult.HEA)
Universe: HEARQTRM_A IN (1,2,3,RF,DK)
Question Text:
Response:
Fills:
Do you have difficulty hearing what is said in a conversation with one other
person in a noisier room^HEARAID? Read if necessary: Would you say no
difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
^HEARAID
IfHEARAID_A=1, fill: ", even when using your
hearing aid(s)"
else NO FILL
Skip Instructions: <1-4,RF,DK>[goto next section]
Page 73 of 306
Question ID: MOB.0010.00.1
Question Text:
Response:
Variable name: DIFF_A
Interview module: MOB(Adult.MOB)
Do you have difficulty walking or climbing steps? Would you say no difficulty,
some difficulty, a lot of difficulty, or you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto EQUIP_A]
Question ID: MOB.0020.00.1
Question Text:
Response:
Variable name: EQUIP_A
Interview module: MOB(Adult.MOB)
Do you use any equipment or receive help for getting around?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CANEWLKR_A]
<2,RF,DK> [goto WLK100_A]
Question ID: MOB.0030.00.1
Variable name: WLK100_A
Interview module: MOB(Adult.MOB)
Universe: EQUIP_A IN (2,RF,DK)
Question Text:
Do you have difficulty walking 100 yards on level ground, that would be about
the length of one football field or one city block? Would you say no difficulty,
some difficulty, a lot of difficulty, or you cannot do this at all?
Response:
Page 74 of 306
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto WLK13M_A]
<4> [goto STEPS_A]
Question ID: MOB.0040.00.1
Variable name: WLK13M_A
Interview module: MOB(Adult.MOB)
Universe: WLK100_A IN (1,2,3,RF,DK)
Question Text:
Response:
Do you have difficulty walking a third of a mile on level ground, that would be
the length of five football fields or five city blocks?
Read if necessary: Would
you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto STEPS_A]
Question ID: MOB.0050.00.1
Variable name: STEPS_A
Interview module: MOB(Adult.MOB)
Universe: EQUIP_A IN (2,RF,DK)
Question Text:
Do you have difficulty walking up or down 12 steps? Read if necessary:
Would you say no difficulty, some difficulty, a lot of difficulty, you cannot do this at all?
Response:
Page 75 of 306
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto next section]
Question ID: MOB.0060.00.1
Variable name: CANEWLKR_A
Interview module: MOB(Adult.MOB)
Universe: EQUIP_A=1
Question Text:
Response:
Do you use any of the following... ...Cane or walker?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto WCHAIR_A]
Question ID: MOB.0070.00.1
Variable name: WCHAIR_A
Interview module: MOB(Adult.MOB)
Universe: EQUIP_A=1
Question Text:
Response:
Read if necessary: Do you use any of the following? ...Wheelchair or scooter?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto PERASST_A]
Page 76 of 306
Question ID: MOB.0080.00.1
Variable name: PERASST_A
Interview module: MOB(Adult.MOB)
Universe: EQUIP_A=1
Question Text:
Response:
Read if necessary: Do you use any of the following? ...Someone's assistance?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto NOEQWLK100_A]
Question ID: MOB.0090.00.1
Variable name: NOEQWLK100_A
Interview module: MOB(Adult.MOB)
Universe: EQUIP_A=1
Question Text:
Response:
WITHOUT THE USE OF YOUR AID, do you have difficulty walking 100 yards on
level ground, that would be about the length of one football field or one city
block? Would you say no difficulty, some difficulty, a lot of difficulty, or you
cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto NOEQWLK13M_A]
<4> [goto NOEQSTEPS_A]
Page 77 of 306
Question ID: MOB.0100.00.1
Variable name: NOEQWLK13M_A
Interview module: MOB(Adult.MOB)
Universe: NOEQWLK100_A IN (1,2,3,RF,DK)
Question Text:
Response:
WITHOUT THE USE OF YOUR AID, do you have difficulty walking a third of a
mile on level ground, that would be the length of five football fields or five city
blocks? Read if necessary: Would you say no difficulty, some difficulty, a lot of
difficulty, or you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto NOEQSTEPS_A]
Question ID: MOB.0110.00.1
Variable name: NOEQSTEPS_A
Interview module: MOB(Adult.MOB)
Universe: EQUIP_A=1
Question Text:
Response:
WITHOUT THE USE OF YOUR AID, do you have difficulty walking up or down 12
steps? Read if necessary: Would you say no difficulty, some difficulty, a lot of
difficulty, or you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> if WCHAIR_A ne 1 [goto EQWLK100_A]
else [goto next section]
Page 78 of 306
Question ID: MOB.0120.00.1
Variable name: EQWLK100_A
Interview module: MOB(Adult.MOB)
Universe: EQUIP_A=1 and WCHAIR_A IN (2,RF,DK)
Question Text:
Response:
WHEN USING YOUR AID, do you have difficulty walking 100 yards on level
ground, that would be about the length of one football field or one city block?
Read if necessary: Would you say no difficulty, some difficulty, a lot of difficulty, or
you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto EQWLK13M_A]
<4> [goto EQSTEPS_A]
Question ID: MOB.0130.00.1
Variable name: EQWLK13M_A
Interview module: MOB(Adult.MOB)
Universe: EQWLK100_A IN (1,2,3,RF,DK)
Question Text:
Response:
WHEN USING YOUR AID, do you have difficulty walking a third of a mile on
level ground, that would be the length of five football fields or five city blocks?
Read if necessary: Would you say no difficulty, some difficulty, a lot of difficulty, or
you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Page 79 of 306
Skip Instructions: <1-4,RF,DK> [goto EQSTEPS_A]
Question ID: MOB.0140.00.1
Variable name: EQSTEPS_A
Interview module: MOB(Adult.MOB)
Universe: EQUIP_A=1 and WCHAIR_A ne 1
Question Text:
Response:
WHEN USING YOUR AID, do you have difficulty walking up or down 12 steps?
Read if necessary: Would you say no difficulty, some difficulty, a lot of difficulty, or
you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto next section]
Question ID: COM.0010.00.1
Question Text:
Response:
Variable name: COMDIFF_A
Interview module: COM(Adult.COM)
Using your usual language, do you have difficulty communicating, for example,
understanding or being understood?
Read if necessary: Would you say no
difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto COMUSESL_A]
Page 80 of 306
Question ID: COM.0020.00.2
Question Text:
Response:
Variable name: COMUSESL_A
Interview module: COM(Adult.COM)
Do you use sign language?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: COG.0010.00.1
Question Text:
Response:
Variable name: COGMEMDFF_A
Interview module: COG(Adult.COG)
Do you have difficulty remembering or concentrating? Read if necessary:
Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at
all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1,RF,DK> [goto next section]
<2-4> [goto COGTYPEDFF_A]
Question ID: COG.0020.00.1
Variable name: COGTYPEDFF_A
Interview module: COG(Adult.COG)
Universe: COGMEMDFF_A IN (2,3,4)
Question Text:
Response:
Is that a difficulty with remembering, concentrating, or both?
1.
Difficulty remembering only
Page 81 of 306
2.
3.
DK:
RF:
Difficulty concentrating only
Difficulty with both remembering and concentrating
Don't Know
Refused
Skip Instructions: <1,3> [goto COGFRQDFF_A]
<2,RF,DK> [goto next section]
Question ID: COG.0030.00.1
Variable name: COGFRQDFF_A
Interview module: COG(Adult.COG)
Universe: COGTYPEDFF_A IN (1,3)
Question Text:
Response:
How often do you have difficulty remembering? Would you say sometimes,
often or all of the time?
1.
2.
3.
DK:
RF:
Sometimes
Often
All of the time
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto COGAMTDFF_A]
Question ID: COG.0040.00.1
Variable name: COGAMTDFF_A
Interview module: COG(Adult.COG)
Universe: COGTYPEDFF_A IN (1,3)
Question Text:
Response:
Do you have difficulty remembering a few things, a lot of things, or almost
everything?
1.
2.
3.
DK:
RF:
A few things
A lot of things
Almost everything
Don't Know
Refused
Page 82 of 306
Skip Instructions: <1-3,RF,DK> [goto next section]
Question ID: UPP.0010.00.1
Question Text:
Response:
Variable name: UPPSLFCR_A
Interview module: UPP(Adult.UPP)
Do you have difficulty with self care, such as washing all over or dressing?
Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do
this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto UPPRAISE_A]
Question ID: UPP.0020.00.1
Question Text:
Response:
Variable name: UPPRAISE_A
Interview module: UPP(Adult.UPP)
Do you have difficulty raising a 2 liter bottle of water or soda from waist to eye
level?
Read if necessary: Would you say no difficulty, some difficulty, a lot of
difficulty, or you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto UPPOBJCT_A]
Page 83 of 306
Question ID: UPP.0030.00.1
Question Text:
Response:
Variable name: UPPOBJCT_A
Interview module: UPP(Adult.UPP)
Do you have difficulty using your hands and fingers, such as picking up small
objects, for example, a button or pencil, or opening or closing containers or
bottles? Read if necessary: Would you say no difficulty, some difficulty, a lot of
difficulty, or you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto next section]
Question ID: SOC.0010.00.1
Question Text:
Response:
Variable name: SOCERRNDS_A
Interview module: SOC(Adult.SOC)
Because of a physical, mental, or emotional condition, do you have difficulty
doing errands alone such as visiting a doctor's office or shopping? Read if
necessary: Would you say no difficulty, some difficulty, a lot of difficulty, or you
cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto SOCSCLPAR_A]
Page 84 of 306
Question ID: SOC.0020.00.1
Question Text:
Response:
Variable name: SOCSCLPAR_A
Interview module: SOC(Adult.SOC)
Because of a physical, mental, or emotional condition, do you have difficulty
participating in social activities such as visiting friends, attending clubs and
meetings, or going to parties? Read if necessary: Would you say no difficulty,
some difficulty, a lot of difficulty, or you cannot do this at all?
1.
2.
3.
4.
DK:
RF:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto SOCWRKLIM_A]
Question ID: SOC.0030.00.1
Question Text:
Response:
Variable name: SOCWRKLIM_A
Interview module: SOC(Adult.SOC)
Are you limited in the kind OR amount of work you can do because of a
physical, mental or emotional problem? Read if necessary: Work includes paid
work, volunteer work, school work, and homework.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Page 85 of 306
Question ID: ADO.0010.00.3
Question Text:
Response:
Fills:
Variable name: DEVDONSET_A
Interview module: ADO(Adult.ADO)
You said that you have difficulty with ^DIFF. Did ^THISDIFF begin before age
22?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^DIFF
if (MOB.WLK100_A IN (3,4) or MOB.WLK13M_A IN
(3,4) or MOB.NOEQWLK100_A IN (3,4) or
MOB.NOEQWLK13M_A IN (3,4)), then fill "walking"
if (MOB.STEPS_AIN (3,4) or MOB.NOEQSTEPS_A
IN (3,4)), then fill "climbing steps"
if none of MOB.WLK100_A, MOB.WLK13M_A,
MOB.NOEQWLK100_A,
MOB.NOEQWLK13M_A,
MOB.STEPS_A, or MOB.NOEQSTEPS_A = 3 or 4,
but MOB.DIFF_A = 3 or 4, then fill "walking or
climbing steps"
If
COM.COMDIFF_A
"communicating"
IN
(3,4),
then
fill
If COG.COGMEMDFF_A IN (3,4),
If COG.COGTYPEDFF_A IN (1,3), then fill
"remembering"
If COG.COGTYPEDFF_A IN (2,3), then fill
"concentrating"
If COG.COGTYPEDFF_A IN (DK,RF), then fill
"remembering or concentrating"
If UPP.UPPSLFCR_A = 3 or 4, then fill "self-care"
If SOC.SOCERRNDS_A = 3 or 4, then fill "doing
errands alone"
If more than two of the above are true, then separate
the fills with commas and place an "and" before the
last item.
If two of the above are true, separate them with
"and"
^THISDIFF
if ADO.countDIFF=1, fill "this difficulty"
elseif ADO.countDIFF gt 1, fill "any of these
difficulties"
Page 86 of 306
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: INS.0010.00.1
Question Text:
Response:
Variable name: HICOV_A
Interview module: INS(Adult.INS)
?[F1] The next questions are about health insurance. Include health insurance
obtained through employment or purchased directly as well as government
programs like Medicare, Medicaid, and the Children's Health Insurance
Program that provide medical care or help pay medical bills. Are you covered
by any kind of health insurance or some other kind of health care plan?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,RF,DK> [goto HIKIND_A]
<2>
if
(GEN.AGE_FINAL[PX_A]
ge
65
Roster.HHC.tblAGE.blkPerson[PX_A].AGE65=2) [goto MCAREPRB_A]
else [goto MCAIDPRB_A]
Question ID: INS.0020.00.1
Variable name: HIKIND_A
or
Interview module: INS(Adult.INS)
Universe: HICOV_A IN (1,RF,DK)
Question Text:
Response:
?[F1] What kinds of health insurance or health care coverage do you have? Is
it...Private health insurance, Medicare, Medicare supplement, Medicaid,
Children's Health Insurance Program or CHIP, military related health care
including TRICARE, CHAMPUS, VA health care and CHAMP-VA, Indian Health
Service, a state-sponsored health plan, or an other government program?
Enter all that apply, separate with commas.
1.
2.
3.
Private health insurance
Medicare (including Medicare Advantage)
Medicare supplement (Medigap)
Page 87 of 306
4.
5.
6.
7.
8.
9.
10.
DK:
RF:
Medicaid
Children's Health Insurance Program (CHIP)
Military related health care: TRICARE (CHAMPUS) / VA health care /
CHAMP-VA
Indian Health Service
State-sponsored health plan
Other government program
No coverage of any type
Don't Know
Refused
Skip Instructions: if more than 1 answer selected and (10 IN HIKIND_A) [goto ERR1_HIKIND_A]
elseif (GEN.AGE_FINAL[PX_A] ge 65 or (GEN.AGE_FINAL[PX_A] IN (RF,DK)
and Roster.HHC.tblAGE.blkPerson[PX_A]=2) and 2 NOT IN HIKIND_A [goto
MCAREPRB_A]
elseif (GEN.AGE_FINAL[PX_A] lt 65 or (GEN.AGE_FINAL[PX_A] IN (RF,DK)
and Roster.HHC.tblAGE.blkPerson[PX_A].AGE65 IN (1,RF,DK,empty)) and
HIKIND_A IN (10,RF,DK) [goto MCAIDPRB_A]
else [goto SINCOVDE_A]
Check Name: ERR1_HIKIND_A
Text:
{check ERR1_HIKIND_A}
type. Please correct.
Cannot mark "no coverage of any kind" and another
Hard / Soft Edit: Hard
Universe: if more than 1 answer selected at HIKIND_A and (<10> in HIKIND_A)
Page 88 of 306
Question ID: INS.0030.00.1
Variable name: MCAREPRB_A
Interview module: INS(Adult.INS)
Universe: (GEN.AGE_FINAL[PX_A] ge 65 or (GEN.AGE_FINAL[PX_A] IN (DK,RF) and
Roster.HHC.tblAGE.blkPerson[PX_A].AGE65=2)) and 2 NOT IN HIKIND_A
Question Text:
Response:
?[F1] Are you covered by Medicare?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto SINCOVDE_A]
Question ID: INS.0040.00.1
Variable name: MCAIDPRB_A
Interview module: INS(Adult.INS)
Universe: (GEN.AGE_FINAL[PX_A] lt 65 or (GEN.AGE_FINAL IN (RF,DK) and
Roster.HHC.tblAGE.bPerson[PX_A].AGE65
IN
(1,RF,DK,empty))
and
HIKIND_A IN (10,RF,DK)
Question Text:
Response:
Fills:
?[F1] There is a program called Medicaid that pays for health care for persons
in need. ^STATEMA Are you covered by Medicaid?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^STATEMA
if STMEDICAID ne empty, fill: "In ^STATENAME it is
alsocalled ^STMEDICAID."
else fill: blank
Skip Instructions: <1,2,RF,DK> [goto SINCOVDE_A]
Page 89 of 306
Question ID: INS.0050.00.1
Question Text:
Response:
Fills:
Variable name: SINCOVDE_A
Interview module: INS(Adult.INS)
?[F1] ^INADDITIONARE you covered by a SEPARATE plan that only pays for
dental services?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^INADDITIONARE
If
(HIKIND_A=1-9
or
MCAIDPRB_A=1),
fill
^HITYPEANOSS, are"
else fill "Are"
MCAREPRB_A=1
"In
addition
or
to
Skip Instructions: <1,2,RF,DK> [goto SINCOVVS_A]
Question ID: INS.0060.00.1
Question Text:
Response:
Variable name: SINCOVVS_A
Interview module: INS(Adult.INS)
?[F1] Are you covered by a SEPARATE plan that only pays for vision services?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto SINCOVRX_A]
Page 90 of 306
Question ID: INS.0070.00.1
Question Text:
Response:
Variable name: SINCOVRX_A
Interview module: INS(Adult.INS)
?[F1] Are you covered by a SEPARATE plan that only pays for prescriptions?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto HICHANGE_A]
Question ID: INS.0080.00.1
Question Text:
Response:
Fills:
Variable name: HICHANGE_A
Interview module: INS(Adult.INS)
?[F1] I have recorded you are ^COVEREDA. Is this correct?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^COVEREDA
if
HIKIND_A=10,R,D
and
(MCAIDPRB_A=2,R,DorMCAREPRB_A=2,R,D) and
SINCOVDE_A=2,R,Dand SINCOVVS_A=2,R,Dand
SINCOVRX_A=2,R,Dfill: "not covered by health
insurance"
else fill: "covered by ^HITYPEA"
Skip Instructions: <1,RF,DK>
if 02 in HIKIND_A or MCAREPRB_A=1[goto MCPART_A]
else if 04 in HIKIND_A or MCAIDPRB_A=1[goto MACHMN_A]
else if 01 in HIKIND_A [goto SET_INSPRI_FLAG]
else if 03 in HIKIND_A [goto SET_INSPRI_FLAG]
else if 05 in HIKIND_A [goto CHNAME_A]
else if 08 in HIKIND_A [goto OPNAME_A]
else if 09 in HIKIND_A [goto OGNAME_A]
else if 06 in HIKIND_A [goto MILSPC_A]
else if 07 in HIKIND_A [goto HINOTYR_A]
else if 10 in HIKIND_A and (MCAIDPRB_A IN (2,RF,DK) or MCAREPRB_A IN
(2,RF,DK))[goto HILAST_A]
else [goto FINISH_A]
<2> [goto ERR1_HICHANGE_A]
Page 91 of 306
Check Name: ERR1_HICHANGE_A
Text:
{signal ERR1_HICHANGE_A} Suppress this error to go back to HIKIND_A and
update coverage. Close this error to change your answer to HICHANGE_A.
Hard / Soft Edit: Soft
Universe: HICHANGE_A=2
Skip Instructions: [goto HIKIND_A]
[goto HICHANGE_A]
Question ID: INS.0090.00.1
Variable name: MCPART_A
Interview module: INS(Adult.INS)
Universe: 02 IN HIKIND_A or MCAREPRB_A=1
Question Text:
Response:
?[F1] What type of Medicare coverage do you have? Is it Part A - hospital
insurance, Part B - medical insurance, or both?
1.
2.
3.
DK:
RF:
Part A- hospital only
Part B- medical only
Both Part A and Part B
Don't Know
Refused
Skip Instructions: <1> [goto MCPARTD_A]
<2-3,RF,DK> [goto MCCHOICE_A]
Question ID: INS.0100.00.1
Variable name: MCCHOICE_A
Interview module: INS(Adult.INS)
Universe: (02 IN HIKIND_A or MCAREPRB_A=1) and MCPART_A IN (2,3,RF,DK)
Question Text:
?[F1] Are you enrolled in a Medicare Advantage plan?
Response:
Page 92 of 306
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto MCHMO_A]
Question ID: INS.0110.00.1
Variable name: MCHMO_A
Interview module: INS(Adult.INS)
Universe: (02 IN HIKIND_A or MCAREPRB_A=1) and MCPART_A IN (2,3,RF,DK)
Question Text:
Response:
?[F1] Are you under a Medicare managed care arrangement, such as an HMO,
that is, a Health Maintenance Organization?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto MCANAME_A]
<2,RF,DK> if MCCHOICE_A=1 [goto MCANAME_A]
elseif MCCHOICE_A IN (2,RF,DK) [goto MCPARTD_A]
Question ID: INS.0120.00.1
Variable name: MCANAME_A
Interview module: INS(Adult.INS)
Universe: MCCHOICE_A=1 or MCHMO_A=1
Question Text:
Response:
?[F1] What is the name of your Medicare Advantage or Medicare HMO plan?
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto MCPARTD_A]
Page 93 of 306
Question ID: INS.0130.00.1
Variable name: MCPARTD_A
Interview module: INS(Adult.INS)
Universe: 02 IN HIKIND_A or MCAREPRB_A=1
Question Text:
Response:
?[F1] Are you enrolled in Medicare Part D, also known as the Medicare
Prescription Drug Plan?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK>
if 04 in HIKIND_A or MCAIDPRB_A=1 [goto MACHMN_A]
elseif 01 in HIKIND_A [goto SET_INSPRI_FLAG]
elseif 03 in HIKIND_A [goto SET_INSPRI_FLAG]
elseif 05 in HIKIND_A [goto CHNAME_A]
elseif 08 in HIKIND_A [goto OPNAME_A]
elseif 09 in HIKIND_A [goto OGNAME_A]
elseif 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
Question ID: INS.0140.00.1
Variable name: MACHMN_A
Interview module: INS(Adult.INS)
Universe: 04 IN HIKIND_A or MCAIDPRB_A=1
Question Text:
Response:
?[F1] The next questions are about Medicaid coverage. What is the name of
your Medicaid health plan?
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto MAXCHNG_A]
Page 94 of 306
Question ID: INS.0150.00.1
Variable name: MAXCHNG_A
Interview module: INS(Adult.INS)
Universe: 04 IN HIKIND_A or MCAIDPRB_A=1
Question Text:
Response:
Fills:
?[F1] Was your Medicaid obtained through Healthcare.gov or the
^MARKETPLACE?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^MARKETPLACE
If no state specified below, fill "Health Insurance
Marketplace"
If state specified below fill:
If CA then fill "Health Insurance Marketplace, such
as Covered California"
If CO then fill "Health Insurance Marketplace, such
as Connect for Health Colorado"
If CT then fill "Health Insurance Marketplace, such
as Access Health CT"
If DC then fill "Health Insurance Marketplace, such
as DC Health Link"
If ID then fill "Health Insurance Marketplace, such as
Your Health Idaho"
If KY then fill "Health Insurance Marketplace, such
as Kentucky Health Benefit Exchange"
If MA then fill "Health Insurance Marketplace, such
as Massachusetts Health Connector"
If MD then fill "Health Insurance Marketplace, such
as Maryland Health Connection"
If MN then fill "Health Insurance Marketplace, such
as MNsure"
If NM then fill "Health Insurance Marketplace, such
as BeWellNM"
If NV then fill "Health Insurance Marketplace, such
as Nevada Health Link"
If NY then fill "Health Insurance Marketplace, such
as New York State of Health"
If RI then fill "Health Insurance Marketplace, such as
HealthSource RI"
If VT then fill "Health Insurance Marketplace, such as
Vermont Health Connect"
If WA then fill "Health Insurance Marketplace, such
as Washington Health Plan Finder"
Page 95 of 306
Skip Instructions: <1,2,RF,DK> [goto MAPREM_A]
Question ID: INS.0160.00.1
Variable name: MAPREM_A
Interview module: INS(Adult.INS)
Universe: 04 IN HIKIND_A or MCAIDPRB_A=1
Question Text:
Response:
?[F1] A health insurance premium is the amount you or a family member pay
each month for health care coverage. Do you or a family member pay a
premium for this Medicaid plan?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto MADEDUC_A]
Question ID: INS.0170.00.1
Variable name: MADEDUC_A
Interview module: INS(Adult.INS)
Universe: 04 IN HIKIND_A or MCAIDPRB_A=1
Question Text:
Response:
?[F1] A deductible is the amount you have to pay for health care before your
health insurance or health coverage plan will start paying your medical bills.
Does your Medicaid plan have an annual deductible? Read if necessary: A
deductible is different from a copay (copayment).
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto MAHDHP_A]
<2,RF,DK>
if 01 in HIKIND_A [goto SET_INSPRI_FLAG]
else if 03 in HIKIND_A [goto SET_INSPRI_FLAG]
else if 05 in HIKIND_A [goto CHNAME_A]
else if 08 in HIKIND_A [goto OPNAME_A]
else if 09 in HIKIND_A [goto OGNAME_A]
else if 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
Page 96 of 306
Question ID: INS.0180.00.1
Variable name: MAHDHP_A
Interview module: INS(Adult.INS)
Universe: MADEDUC_A=1
Question Text:
Response:
Fills:
?[F1] Is the annual deductible for medical care for this plan less than
^HDHPDED or ^HDHPDED or more? If there is a separate deductible for
prescription drugs, hospitalization, or out-of-network care, do not include those
deductible amounts here.
1.
2.
DK:
RF:
Less than ^HDHPDED
^HDHPDED or more
Don't Know
Refused
^HDHPDED
Fill: $1,400
Skip Instructions: <1,2,RF,DK>
if 01 in HIKIND_A [goto SET_INSPRI_FLAG]
elseif 03 in HIKIND_A [goto SET_INSPRI_FLAG]
elseif 05 in HIKIND_A [goto CHNAME_A]
elseif 08 in HIKIND_A [goto OPNAME_A]
elseif 09 in HIKIND_A [goto OGNAME_A]
elseif 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
Question ID: INS.0270.00.1
Variable name: PLANNAME1_A
Interview module: INS(Adult.INS)
Universe: INSPRI1_FLG1_A=1 and INSPRI1_FLG2_A=1 and INSPRI1_FLG3_A=1 and
GEN.INSPRI_FLG=1
and
GEN.SAMEFAM_FLG=1
and
Child.INS.PLANNAME1_C=empty
Question Text:
Earlier I recorded that ^SCNAME was covered by ^HIPNAM1_C. Are you
covered by this same plan as ^SCNAME?
Response:
Page 97 of 306
1.
2.
DK:
RF:
Fills:
Yes
No
Don't Know
Refused
^SCNAME
Fill ALIAS of HHSTAT_C=1
^HIPNAM1_C
Fill value from Child.INS.HIPNAM1_C
Skip Instructions: <1> if Child.INS.bPlan[1].POLHLD_C ne 1 [goto POLHLDA1_A]
elseif Child.INS.bPlan[1].POLHLD_C=1 [goto PRPOLHP1_A]
<2,RF,DK> if INSPRI2_FLG2_A=1 and INSPRI2_FLG3_A=1 and
INSPRI2_FLG4_A=1 and INSPRI2_FLG5_A=1 and INSPRI_FLG=1 and
SAMEFAM_FLG=1
and
CHILD.INS.PLANNAME2_C=empty
[goto
PLANNAME2_A] else [goto HIPNAM1_A]
Question ID: INS.0280.00.1
Variable name: POLHLDA1_A
Interview module: INS(Adult.INS)
Universe: PLANNAME1_A=1 and Child.INS.bPlan[1].POLHLD_C IN (2,RF,DK)
Question Text:
Response:
Fills:
?[F1] Health insurance plans are usually obtained in one person's name even if
other family members are covered by that plan. That person is called the
policyholder. Are you the policyholder for ^HIPNAM1_C?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^HIPNAM1_C
Fill value from Child.INS.HIPNAM1_C
Skip Instructions: <1>
if
INSPRI2_FLG2_A=1
and
INSPRI2_FLG3_A=1
INSPRI2_FLG4_A=1 and INSPRI2_FLG5_A=1 [goto PLANNAME2_A]
else [goto MORPLAN_A]
<2,RF,DK> [goto PRPOLHP1_A]
Page 98 of 306
and
Question ID: INS.0290.00.1
Variable name: PRPOLHP1_A
Interview module: INS(Adult.INS)
Universe: PLANNAME1_A=1 and (Child.INS.bPlan[1].POLHLD_C=1 or POLHLDA1_A
IN (2,RF,DK))
Question Text:
Response:
Fills:
?[F1] How are you related to the policyholder for ^HIPNAM1_C? Are you the
policyholder's child, spouse, former spouse, or are you related in some other
way?
1.
2.
3.
4.
DK:
RF:
Child
Spouse
Former spouse
Some other relationship
Don't Know
Refused
^HIPNAM1_C
Fill value from Child.INS.HIPNAM1_C
Skip Instructions: <1-4,RF,DK> if INSPRI2_FLG2_A=1 and INSPRI2_FLG3_A=1
INSPRI2_FLG4_A=1 and INSPRI2_FLG5_A=1 [goto PLANNAME2_A]
else [goto MORPLAN_A]
Question ID: INS.0300.00.1
Variable name: PLANNAME2_A
and
Interview module: INS(Adult.INS)
Universe: INSPRI2_FLG2_A=1 and INSPRI2_FLG3_A=1 and INSPRI2_FLG4_A=1 and
INSPRI2_FLG5_A=1 and GEN.INSPRI_FLG=1 and GEN.SAMEFAM_FLG=1
and Child.INS.PLANNAME2_C=empty
Question Text:
Response:
Earlier I recorded that ^SCNAME was covered by a second plan: ^HIPNAM2_C.
Are you covered by this same plan as ^SCNAME?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 99 of 306
Fills:
^SCNAME
Fill ALIAS of HHSTAT_C=1
^HIPNAM2_C
Fill value from Child.INS.HIPNAM2_C
Skip Instructions: <1> if Child.INS.bPlan[2].POLHLD_C ne 1 [goto POLHLDA2_A],
if Child.INS.bPlan[2].POLHLD_C=1 [goto PRPOLHP2_A]
<2,RF,DK> if PLANNAME1_A IN(2,RF,DK,empty) [goto HIPNAM1_A]
else [goto MORPLAN_A]
Question ID: INS.0310.00.1
Variable name: POLHLDA2_A
Interview module: INS(Adult.INS)
Universe: PLANNAME2_A=1 and Child.INS.bPlan[2].POLHLD_C IN (2,RF,DK)
Question Text:
Response:
Fills:
?[F1] Read if necessary: Health insurance plans are usually obtained in one
person's name even if other family members are covered by that plan. That person is
called the policyholder. Are you the policyholder for ^HIPNAM2_C?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^HIPNAM2_C
Fill value from Child.INS.HIPNAM2_C
Skip Instructions: <1> if PLANNAME1_A IN (2,RF,DK,empty) [goto MORPLAN_A]
elseif 05 in HIKIND_A [goto CHNAME_A]
elseif 08 in HIKIND_A [goto OPNAME_A]
elseif 09 in HIKIND_A [goto OGNAME_A]
elseif 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
<2,RF,DK>[goto PRPOLHP2_A]
Page 100 of 306
Question ID: INS.0320.00.1
Variable name: PRPOLHP2_A
Interview module: INS(Adult.INS)
Universe: PLANNAME2_A=1 and (Child.INS.bPlan[2].POLHLD_C=1 or POLHLDA2_A
IN (2,RF,DK))
Question Text:
Response:
Fills:
?[F1] How are you related to the policyholder for ^HIPNAM2_C? Are you the
policyholder's child, spouse, former spouse, or are you related in some other
way?
1.
2.
3.
4.
DK:
RF:
Child
Spouse
Former spouse
Some other relationship
Don't Know
Refused
^HIPNAM2_C
Fill value from Child.INS.HIPNAM2_C
Skip Instructions: <1-4,RF,DK> if PLANNAME1_A IN (2,RF,DK,empty) [goto MORPLAN_A]
elseif 05 in HIKIND_A [goto CHNAME_A]
elseif 08 in HIKIND_A [goto OPNAME_A]
elseif 09 in HIKIND_A [goto OGNAME_A]
elseif 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
Question ID: INS.0330.00.1
Variable name: HIPNAM1_A
Interview module: INS(Adult.INS)
Universe: 03 IN HIKIND_A or (01 IN HIKIND_A and PLANNAME1_A
(2,RF,DK,empty) and PLANNAME2_A IN (2,RF,DK,empty))
Question Text:
Response:
IN
?[F1] It is important that we record the complete and accurate name of each
private health insurance plan. What is the COMPLETE name of your plan? Do
NOT include plans that only provide extra cash while in the hospital or plans
that pay for only one type of service such as long term care, accidents, or
dental care. Read if necessary: Do you have a health plan card or something with
the plan name on it?
DK:
RF:
Don't Know
Refused
Page 101 of 306
Skip Instructions: [goto MORPLAN_A]
Question ID: INS.0340.00.1
Variable name: MORPLAN_A
Interview module: INS(Adult.INS)
Universe: HIPNAM1_A
ne
empty
or
((PLANNAME1_A=1
and
PLANNAME2_A=2,RF,DK,empty) or (PLANNAME1_A=2,RF,DK,empty and
PLANNAME2_A=1))
Question Text:
Response:
?[F1] Are you covered by any other private health insurance plans?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto HIPNAM2_A]
<2,RF,DK>
if (PLANNAME1_A=1 or PLANNAME2_A=1) then
if 05 in HIKIND_A [goto CHNAME_A]
elseif 08 in HIKIND_A [goto OPNAME_A]
elseif 09 in HIKIND_A [goto OGNAME_A]
elseif 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
else [goto bPlan[1].POLHLD_A]
Question ID: INS.0350.00.1
Variable name: HIPNAM2_A
Interview module: INS(Adult.INS)
Universe: MORPLAN_A=1
Question Text:
Response:
?[F1] What is the name of that private health insurance plan?
Read if
necessary: Do you have a health plan card or something with the plan name on it?
DK:
RF:
Don't Know
Refused
Page 102 of 306
Skip Instructions: [goto bPlan[1].POLHLD_A]
Question ID: INS.0370.00.1
Question Text:
Response:
Fills:
Variable name: POLHLD_A
Interview module: INS(Adult.INS.bPlan)
?[F1] I am going to ask you some questions about ^FIRSTPLANA. Health
insurance plans are usually obtained in one person's name even if other family
members are covered by that plan. That person is called the policyholder. Are
you the policyholder for ^THISPLANA?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^THISPLANA
if PlanNum=1 then
if HIPNAM1_A IN (RF,DK) fill: "this plan"
else fill: "^HIPNAM1_A"
if PlanNum=2 then
if HIPNAM2_A IN (RF,DK) fill: "this plan"
Else fill: "^HIPNAM2_A"
^FIRSTPLANA
if PlanNum=1 then
if HIPNAM1_A IN (RF,DK) and HIPNAM2_A=
empty fill: "this plan"
elseif HIPNAM1_A IN (RF,DK) fill: "this first plan"
else fill: "this ^HIPNAM1_A plan"
if PlanNum=2 then
if HIPNAM2_A IN (RF,DK) fill: "this second plan"
else fill: "this ^HIPNAM2_A plan"
Skip Instructions: <1,RF,DK> [goto PRPLCOV_A]
<2> [goto PRPOLH_A]
Page 103 of 306
Question ID: INS.0380.00.1
Variable name: PRPLCOV_A
Interview module: INS(Adult.INS.bPlan)
Universe: POLHLD_A=1,RF,DK
Question Text:
Response:
Does this plan cover someone other than yourself?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto PLNWRK_A]
Question ID: INS.0390.00.1
Variable name: PRPOLH_A
Interview module: INS(Adult.INS.bPlan)
Universe: POLHLD_A=2
Question Text:
Response:
?[F1] How are you related to the policyholder? Are you the policyholder's child,
spouse, former spouse, or are you related in some other way?
1.
2.
3.
4.
DK:
RF:
Child
Spouse
Former spouse
Some other relationship
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto PLNWRK_A]
Page 104 of 306
Question ID: INS.0400.00.1
Question Text:
Response:
Variable name: PLNWRK_A
Interview module: INS(Adult.INS.bPlan)
?[F1] Which one of these categories best describes how this plan was
obtained? Was it obtained through an employer or union, purchased directly,
obtained through Healthcare.gov or the Affordable Care Act, also known as
Obamacare, obtained through a state or local government or community
program or obtained in some other way?
1.
2.
3.
4.
5.
DK:
RF:
Through an employer, union, or professional association
Purchased directly
Through Healthcare.gov or the Affordable Care Act, also known as
Obamacare
Through a state or local government or community program
Other
Don't Know
Refused
Skip Instructions: <1,3> [goto PLNPAY_A]
<2,4,RF,DK> [goto PLNEXCHG_A]
<5> [goto PLNWKSP_A]
Question ID: INS.0410.00.1
Variable name: PLNWKSP_A
Interview module: INS(Adult.INS.bPlan)
Universe: PLNWRK_A=5
Question Text:
Response:
Read if necessary: How was this plan obtained?
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto PLNEXCHG_A]
Page 105 of 306
Question ID: INS.0420.00.1
Variable name: PLNEXCHG_A
Interview module: INS(Adult.INS.bPlan)
Universe: PLNWRK_A IN (2,4,5,RF,DK)
Question Text:
Response:
Fills:
?[F1] Was the plan obtained through Healthcare.gov or the ^MARKETPLACE?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^MARKETPLACE
If no state specified below, fill "Health Insurance
Marketplace"
If state specified below fill:
If CA then fill "Health Insurance Marketplace, such
as Covered California"
If CO then fill "Health Insurance Marketplace, such
as Connect for Health Colorado"
If CT then fill "Health Insurance Marketplace, such
as Access Health CT"
If DC then fill "Health Insurance Marketplace, such
as DC Health Link"
If ID then fill "Health Insurance Marketplace, such as
Your Health Idaho"
If KY then fill "Health Insurance Marketplace, such
as Kentucky Health Benefit Exchange"
If MA then fill "Health Insurance Marketplace, such
as Massachusetts Health Connector"
If MD then fill "Health Insurance Marketplace, such
as Maryland Health Connection"
If MN then fill "Health Insurance Marketplace, such
as MNsure"
If NM then fill "Health Insurance Marketplace, such
as BeWellNM"
If NV then fill "Health Insurance Marketplace, such
as Nevada Health Link"
If NY then fill "Health Insurance Marketplace, such
as New York State of Health"
If RI then fill "Health Insurance Marketplace, such as
HealthSource RI"
If VT then fill "Health Insurance Marketplace, such as
Vermont Health Connect"
If WA then fill "Health Insurance Marketplace, such
as Washington Health Plan Finder"
Page 106 of 306
Skip Instructions: <1,2,RF,DK> [goto PLNPAY_A]
Question ID: INS.0430.00.1
Question Text:
Response:
Variable name: PLNPAY_A
Who pays for this health insurance plan?
commas.
1.
2.
3.
4.
5.
6.
DK:
RF:
Interview module: INS(Adult.INS.bPlan)
Enter all that apply, separate with
Self or family (living in the household)
Employer or union
Someone outside the household
Medicare
Medicaid
Other government program
Don't Know
Refused
Skip Instructions: if <1> IN PLNPAY_A [goto HICOSTN_A]
else if <2-6> IN PLNPAY_A or PLNPAY_A IN (RF,DK)[goto PRDEDUC_A]
Question ID: INS.0440.01.1
Variable name: HICOSTN_A
Interview module: INS(Adult.INS.bPlan)
Universe: 1 IN PLNPAY_A
Question Text:
Response:
Fills:
?[F1] How much ^DOYOUFAM currently spend for health insurance premiums
for ^FIRSTPLANA? Please include payroll deductions for premiums.
DK:
RF:
Don't Know
Refused
^DOYOUFAM
if PCNT_A=1 fill "do you",
else fill "does your family"
^FIRSTPLANA
if PlanNum=1 then
if HIPNAM1_A IN (RF,DK) and HIPNAM2_A=
empty fill: "this plan"
elseif HIPNAM1_A IN (RF,DK) fill: "this first plan"
else fill: "this ^HIPNAM1_A plan"
if PlanNum=2 then
if HIPNAM2_A IN (RF,DK) fill: "this second plan"
else fill: "this ^HIPNAM2_A plan"
Page 107 of 306
Skip Instructions: <20000-99995> [goto ERR1_HICOSTN_A]
<1-19999> [goto HICOSTT_A]
[goto PRDEDUC_A]
Check Name: ERR1_HICOSTN_A
Text:
{signal ERR1_HICOSTN_A}
corrections if necessary.
[^HICOSTN_A] is unusually high. Please verify. Make
Hard / Soft Edit: Soft
Fills:
^HICOSTN_A
Fill value from Adult.INS.HICOSTN_A
Universe: if HICOSTN_A ge 20000
Question ID: INS.0440.02.1
Variable name: HICOSTT_A
Interview module: INS(Adult.INS.bPlan)
Universe: HICOSTN_A IN (1-99995)
Question Text:
?[F1]
Response:
1.
2.
3.
4.
5.
6.
7.
8.
DK:
RF:
Enter time period for premium payments.
Once a week
Once every 2 weeks
Once a month
Twice a month
Every two months
Quarterly (every 3 months)
Once a year
Twice a year
Don't Know
Refused
Skip Instructions: <1-8,RF,DK> [goto PRDEDUC_A]
Page 108 of 306
Question ID: INS.0450.00.1
Question Text:
Response:
Variable name: PRDEDUC_A
Interview module: INS(Adult.INS.bPlan)
?[F1] A deductible is the amount you have to pay for health care before your
health insurance or health coverage plan will start paying your medical bills.
Does this health plan have an annual deductible? Read if necessary: A
deductible is different from a copay (copayment).
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto PRHDHP_A]
<2,RF,DK> [goto INTROCOV_A]
Question ID: INS.0460.00.1
Variable name: PRHDHP_A
Interview module: INS(Adult.INS.bPlan)
Universe: PRDEDUC_A=1
Question Text:
Response:
Fills:
?[F1] Is the ^FAM_A annual deductible for medical care for this plan less than
^HDHPAMT_A, or ^HDHPAMT_A or more? If there is a separate deductible for
prescription drugs, hospitalization, or out-of-network care, do not include those
deductible amounts here.
1.
2.
DK:
RF:
Less than ^HDHPAMT_A
^HDHPAMT_A or more
Don't Know
Refused
^FAM_A
if POLHLD_A=2 or PRPLCOV_A=1, fill 'family'.
Else no fill.
^HDHPAMT_A
if
POLHLD_A=2
"^HDHPDED_family"
Else fill "^HDHPDED"
Page 109 of 306
or
PRPLCOV_A=1,
fill
Skip Instructions: <1> [goto INTROCOV_A]
<2,RF,DK> [goto HSAHRA_A]
Question ID: INS.0470.00.1
Variable name: HSAHRA_A
Interview module: INS(Adult.INS.bPlan)
Universe: PRHDHP_A=2,RF,DK
Question Text:
Response:
There are special accounts or funds that can be used to pay for medical
expenses, sometimes referred to as Health Savings Accounts or HSAs, Health
Reimbursement Accounts or HRAs, Personal Care accounts, Personal Medical
funds, or Choice funds. These are DIFFERENT from Flexible Spending
Accounts or FSAs. Is there one of these accounts or funds with this plan?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto INTROCOV_A]
Question ID: INS.0475.00.1
Question Text:
Response:
Fills:
Variable name: INTROCOV_A
Interview module: INS(Adult.INS.bPlan)
The next three questions are about services ^FIRSTPLANA may cover.
'1' to continue.
1.
Enter
Enter 1 to Continue
^FIRSTPLANA
if PlanNum=1 then
if HIPNAM1_A IN (RF,DK) and HIPNAM2_A=
empty fill: "this plan"
elseif HIPNAM1_A IN (RF,DK) fill: "this first plan"
else fill: "this ^HIPNAM1_A plan"
if PlanNum=2 then
if HIPNAM2_A IN (RF,DK) fill: "this second plan"
else fill: "this ^HIPNAM2_A plan"
Page 110 of 306
Skip Instructions: <1> [goto PRRXCOV_A]
Question ID: INS.0480.00.1
Question Text:
Response:
Fills:
Variable name: PRRXCOV_A
Interview module: INS(Adult.INS.bPlan)
Does ^FIRSTPLANA pay for any of the costs for medications prescribed by a
doctor? Read if necessary: Even if you have not used this benefit, please answer
if this plan would cover at least some of the costs if you were prescribed medications.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^FIRSTPLANA
if PlanNum=1 then
if HIPNAM1_A IN (RF,DK) and HIPNAM2_A=
empty fill: "this plan"
elseif HIPNAM1_A IN (RF,DK) fill: "this first plan"
else fill: "this ^HIPNAM1_A plan"
if PlanNum=2 then
if HIPNAM2_A IN (RF,DK) fill: "this second plan"
else fill: "this ^HIPNAM2_A plan"
Skip Instructions: <1,2,RF,DK> [goto PRDNCOV_A]
Question ID: INS.0490.00.1
Question Text:
Response:
Variable name: PRDNCOV_A
Interview module: INS(Adult.INS.bPlan)
Does ^FIRSTPLANA pay for any of the costs for dental care? Read if
necessary: Even if you have not used this benefit, please answer if this plan would
cover at least some of the costs if you did have dental care.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 111 of 306
Fills:
^FIRSTPLANA
if PlanNum=1 then
if HIPNAM1_A IN (RF,DK) and HIPNAM2_A=
empty fill: "this plan"
elseif HIPNAM1_A IN (RF,DK) fill: "this first plan"
else fill: "this ^HIPNAM1_A plan"
if PlanNum=2 then
if HIPNAM2_A IN (RF,DK) fill: "this second plan"
else fill: "this ^HIPNAM2_A plan"
Skip Instructions: <1,2,RF,DK> [goto PRVSCOV_A]
Question ID: INS.0500.00.1
Question Text:
Response:
Fills:
Variable name: PRVSCOV_A
Interview module: INS(Adult.INS.bPlan)
Does ^FIRSTPLANA pay for any of the costs for routine vision care, such as
glasses and contact lenses? Read if necessary: Even if you have not used this
benefit, please answer if this plan would cover at least some of the costs if you did
have vision care.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^FIRSTPLANA
if PlanNum=1 then
if HIPNAM1_A IN (RF,DK) and HIPNAM2_A=
empty fill: "this plan"
elseif HIPNAM1_A IN (RF,DK) fill: "this first plan"
else fill: "this ^HIPNAM1_A plan"
if PlanNum=2 then
if HIPNAM2_A IN (RF,DK) fill: "this second plan"
else fill: "this ^HIPNAM2_A plan"
Skip Instructions: <1,2,RF,DK> If there is another plan [goto bPlan for next plan]
elseif 05 in HIKIND_A [goto CHNAME_A]
elseif 08 in HIKIND_A [goto OPNAME_A]
elseif 09 in HIKIND_A [goto OGNAME_A]
elseif 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
Page 112 of 306
Question ID: INS.0510.00.1
Variable name: CHNAME_A
Interview module: INS(Adult.INS)
Universe: 05 IN HIKIND_A
Question Text:
Response:
?[F1] Earlier I recorded that you are covered by the Children's Health Insurance
Program or CHIP. What is the name of the plan?
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto CHXCHNG_A]
Question ID: INS.0520.00.1
Variable name: CHXCHNG_A
Interview module: INS(Adult.INS)
Universe: 05 IN HIKIND_A
Question Text:
Response:
Fills:
?[F1] Was your CHIP plan obtained through Healthcare.gov or the
^MARKETPLACE?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^MARKETPLACE
If no state specified below, fill "Health Insurance
Marketplace"
If state specified below fill:
If CA then fill "Health Insurance Marketplace, such
as Covered California"
If CO then fill "Health Insurance Marketplace, such
as Connect for Health Colorado"
If CT then fill "Health Insurance Marketplace, such
as Access Health CT"
If DC then fill "Health Insurance Marketplace, such
as DC Health Link"
If ID then fill "Health Insurance Marketplace, such as
Your Health Idaho"
If KY then fill "Health Insurance Marketplace, such
as Kentucky Health Benefit Exchange"
If MA then fill "Health Insurance Marketplace, such
as Massachusetts Health Connector"
If MD then fill "Health Insurance Marketplace, such
as Maryland Health Connection"
If MN then fill "Health Insurance Marketplace, such
as MNsure"
Page 113 of 306
If NM then fill "Health Insurance Marketplace, such
as BeWellNM"
If NV then fill "Health Insurance Marketplace, such
as Nevada Health Link"
If NY then fill "Health Insurance Marketplace, such
as New York State of Health"
If RI then fill "Health Insurance Marketplace, such as
HealthSource RI"
If VT then fill "Health Insurance Marketplace, such as
Vermont Health Connect"
If WA then fill "Health Insurance Marketplace, such
as Washington Health Plan Finder"
Skip Instructions: <1,2,RF,DK> [goto CHPREM_A]
Question ID: INS.0530.00.1
Variable name: CHPREM_A
Interview module: INS(Adult.INS)
Universe: 05 IN HIKIND_A
Question Text:
Response:
?[F1] A health insurance premium is the amount you or a family member pays
each month for health care coverage. Do you or a family member pay a
premium for this CHIP plan?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto CHDEDUC_A]
Page 114 of 306
Question ID: INS.0540.00.1
Variable name: CHDEDUC_A
Interview module: INS(Adult.INS)
Universe: 05 IN HIKIND_A
Question Text:
Response:
?[F1] A deductible is the amount you have to pay for health care before your
health insurance or health coverage plan will start paying your medical bills.
Does your CHIP plan have an annual deductible? Read if necessary: A
deductible is different from a copay (copayment).
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CHHDHP_A]
<2,RF,DK> if 08 in HIKIND_A [goto OPNAME_A]
elseif 09 in HIKIND_A [goto OGNAME_A]
elseif 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
Question ID: INS.0550.00.1
Variable name: CHHDHP_A
Interview module: INS(Adult.INS)
Universe: CHDEDUC_A=1
Question Text:
Response:
Fills:
?[F1] Is the annual deductible for medical care for this plan less than
^HDHPDED or ^HDHPDED or more? If there is a separate deductible for
prescription drugs, hospitalization, or out-of-network care, do not include those
deductible amounts here.
1.
2.
DK:
RF:
Less than ^HDHPDED
^HDHPDED or more
Don't Know
Refused
^HDHPDED
Fill: $1,400
Page 115 of 306
Skip Instructions: <1,2,RF,DK> if 08 in HIKIND_A [goto OPNAME_A]
elseif 09 in HIKIND_A [goto OGNAME_A]
elseif 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
Question ID: INS.0560.00.1
Variable name: OPNAME_A
Interview module: INS(Adult.INS)
Universe: 08 IN HIKIND_A
Question Text:
Response:
?[F1] Earlier I recorded that you are covered by a state-sponsored plan. What is
the name of the plan?
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto OPXCHNG_A]
Question ID: INS.0570.00.1
Variable name: OPXCHNG_A
Interview module: INS(Adult.INS)
Universe: 08 IN HIKIND_A
Question Text:
Response:
Fills:
?[F1] Was your state-sponsored plan obtained through Healthcare.gov or the
^MARKETPLACE?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^MARKETPLACE
If no state specified below, fill "Health Insurance
Marketplace"
If state specified below fill:
If CA then fill "Health Insurance Marketplace, such
as Covered California"
If CO then fill "Health Insurance Marketplace, such
as Connect for Health Colorado"
If CT then fill "Health Insurance Marketplace, such
as Access Health CT"
If DC then fill "Health Insurance Marketplace, such
as DC Health Link"
If ID then fill "Health Insurance Marketplace, such as
Your Health Idaho"
If KY then fill "Health Insurance Marketplace, such
as Kentucky Health Benefit Exchange"
Page 116 of 306
If MA then fill "Health Insurance Marketplace, such
as Massachusetts Health Connector"
If MD then fill "Health Insurance Marketplace, such
as Maryland Health Connection"
If MN then fill "Health Insurance Marketplace, such
as MNsure"
If NM then fill "Health Insurance Marketplace, such
as BeWellNM"
If NV then fill "Health Insurance Marketplace, such
as Nevada Health Link"
If NY then fill "Health Insurance Marketplace, such
as New York State of Health"
If RI then fill "Health Insurance Marketplace, such as
HealthSource RI"
If VT then fill "Health Insurance Marketplace, such as
Vermont Health Connect"
If WA then fill "Health Insurance Marketplace, such
as Washington Health Plan Finder"
Skip Instructions: <1,2,RF,DK> [goto OPPREM_A]
Question ID: INS.0580.00.1
Variable name: OPPREM_A
Interview module: INS(Adult.INS)
Universe: 08 IN HIKIND_A
Question Text:
Response:
?[F1] A health insurance premium is the amount you or a family member pays
each month for health care coverage. Do you or a family member pay a
premium for this state-sponsored plan?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 117 of 306
Skip Instructions: <1,2,RF,DK> [goto OPDEDUC_A]
Question ID: INS.0590.00.1
Variable name: OPDEDUC_A
Interview module: INS(Adult.INS)
Universe: 08 IN HIKIND_A
Question Text:
Response:
?[F1] A deductible is the amount you have to pay for health care before your
health insurance or health coverage plan will start paying your medical bills.
Does your state-sponsored plan have an annual deductible? Read if
necessary: A deductible is different from a copay (copayment).
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1>[goto OPHDHP_A]
<2,RF,DK> if 09 in HIKIND_A [goto OGNAME_A]
elseif 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
Question ID: INS.0600.00.1
Variable name: OPHDHP_A
Interview module: INS(Adult.INS)
Universe: OPDEDUC_A=1
Question Text:
Response:
?[F1] Is the annual deductible for medical care for this plan less than
^HDHPDED or ^HDHPDED or more? If there is a separate deductible for
prescription drugs, hospitalization, or out-of-network care, do not include those
deductible amounts here.
1.
2.
DK:
RF:
Less than ^HDHPDED
^HDHPDED or more
Don't Know
Refused
Page 118 of 306
Fills:
^HDHPDED
Fill: $1,400
Skip Instructions: <1,2,RF,DK> if 09 in HIKIND_A [goto OGNAME_A]
elseif 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
Question ID: INS.0610.00.1
Variable name: OGNAME_A
Interview module: INS(Adult.INS)
Universe: 09 IN HIKIND_A
Question Text:
Response:
?[F1] Earlier I recorded that you are covered by an other government program.
What is the name of the plan?
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto OGXCHNG_A]
Question ID: INS.0620.00.1
Variable name: OGXCHNG_A
Interview module: INS(Adult.INS)
Universe: 09 IN HIKIND_A
Question Text:
Response:
Fills:
?[F1] Was your other government plan obtained through Healthcare.gov or the
^MARKETPLACE?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^MARKETPLACE
If no state specified below, fill "Health Insurance
Marketplace"
If state specified below fill:
If CA then fill "Health Insurance Marketplace, such
as Covered California"
If CO then fill "Health Insurance Marketplace, such
as Connect for Health Colorado"
If CT then fill "Health Insurance Marketplace, such
as Access Health CT"
If DC then fill "Health Insurance Marketplace, such
as DC Health Link"
If ID then fill "Health Insurance Marketplace, such as
Your Health Idaho"
Page 119 of 306
If KY then fill "Health Insurance Marketplace, such
as Kentucky Health Benefit Exchange"
If MA then fill "Health Insurance Marketplace, such
as Massachusetts Health Connector"
If MD then fill "Health Insurance Marketplace, such
as Maryland Health Connection"
If MN then fill "Health Insurance Marketplace, such
as MNsure"
If NM then fill "Health Insurance Marketplace, such
as BeWellNM"
If NV then fill "Health Insurance Marketplace, such
as Nevada Health Link"
If NY then fill "Health Insurance Marketplace, such
as New York State of Health"
If RI then fill "Health Insurance Marketplace, such as
HealthSource RI"
If VT then fill "Health Insurance Marketplace, such as
Vermont Health Connect"
If WA then fill "Health Insurance Marketplace, such
as Washington Health Plan Finder"
Skip Instructions: <1,2,RF,DK> [goto OGPREM_A]
Question ID: INS.0630.00.1
Variable name: OGPREM_A
Interview module: INS(Adult.INS)
Universe: 09 IN HIKIND_A
Question Text:
Response:
?[F1] A health insurance premium is the amount you or a family member pays
each month for health care coverage. Do you or a family member pay a
premium for your other government plan?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 120 of 306
Skip Instructions: <1,2,RF,DK> [goto OGDEDUC_A]
Question ID: INS.0640.00.1
Variable name: OGDEDUC_A
Interview module: INS(Adult.INS)
Universe: 09 IN HIKIND_A
Question Text:
Response:
?[F1] A deductible is the amount you have to pay for health care before your
health insurance or health coverage plan will start paying your medical bills.
Does your other government plan have an annual deductible? Read if
necessary: A deductible is different from a copay (copayment).
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto OGHDHP_A]
<2,RF,DK> if 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
Question ID: INS.0650.00.1
Variable name: OGHDHP_A
Interview module: INS(Adult.INS)
Universe: OGDEDUC_A=1
Question Text:
Response:
?[F1] Is the annual deductible for medical care for this plan less than
^HDHPDED or ^HDHPDED or more? If there is a separate deductible for
prescription drugs, hospitalization, or out-of-network care, do not include those
deductible amounts here.
1.
2.
DK:
RF:
Less than ^HDHPDED
^HDHPDED or more
Don't Know
Refused
Page 121 of 306
Fills:
^HDHPDED
Fill: $1,400
Skip Instructions: <1,2,RF,DK> if 06 in HIKIND_A [goto MILSPC_A]
else [goto HINOTYR_A]
Question ID: INS.0660.00.1
Variable name: MILSPC_A
Interview module: INS(Adult.INS)
Universe: 06 IN HIKIND_A
Question Text:
Response:
?[F1] Earlier I recorded that you are covered by military related health care.
What types of military related health care are you covered by?
Enter all that
apply, separate with commas.
1.
2.
3.
DK:
RF:
VA health care
TRICARE (CHAMPUS)
CHAMP-VA (do not include CHAMPUS)
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto HINOTYR_A]
Question ID: INS.0670.00.1
Variable name: HILAST_A
Interview module: INS(Adult.INS)
Universe: 10 IN HIKIND_A and (MCAIDPRB_A IN (2,RF,DK) or MCAREPRB_A IN
(2,RF,DK))
Question Text:
Response:
How long has it been since you last had health care coverage that paid for
doctor's visits or hospital stays?
0.
1.
2.
3.
Never
Within the past year (anytime less than 12 months ago)
Within the last 2 years (1 year but less than 2 years ago)
Within the last 3 years (2 years but less than 3 years ago)
Page 122 of 306
4.
5.
6.
DK:
RF:
Within the last 5 years (3 years but less than 5 years ago)
Within the last 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1> [goto HILASTMY_A]
<2,3> [goto HISTOPJOB_A]
<4,5,6,0,RF,DK> [goto RSNHICOST_A]
Question ID: INS.0680.00.1
Variable name: HILASTMY_A
Interview module: INS(Adult.INS)
Universe: HILAST_A=1
Question Text:
Response:
In the past 12 months, how many months were you without coverage?
than 1 month, enter '1'.
DK:
RF:
If less
Don't Know
Refused
Skip Instructions: <1-12,RF,DK> [goto HISTOPJOB_A]
Question ID: INS.0690.00.1
Variable name: HISTOPJOB_A
Interview module: INS(Adult.INS)
Universe: HILAST_A IN (1,2,3)
Question Text:
Response:
?[F1] Think about the last time that you did have health care coverage that paid
for doctor's visits or hospital stays. I am going to read a list of reasons why
someone might no longer be enrolled in coverage. Please tell me, yes or no, if
this is a reason why you are no longer enrolled in your last health care plan.
You or the policyholder retired, lost a job, or changed employers?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 123 of 306
Skip Instructions: <1,2,RF,DK> [goto HISTOPMISS_A]
Question ID: INS.0700.00.1
Variable name: HISTOPMISS_A
Interview module: INS(Adult.INS)
Universe: HILAST_A IN (1,2,3)
Question Text:
Response:
Read if necessary: Are you no longer enrolled in your last health care plan
because... You missed a deadline for signing up or paying for the coverage?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto HISTOPAGE_A]
Question ID: INS.0710.00.1
Variable name: HISTOPAGE_A
Interview module: INS(Adult.INS)
Universe: HILAST_A IN (1,2,3)
Question Text:
Response:
Read if necessary: Are you no longer enrolled in your last health care plan
because... You became ineligible because of your age or because you left
school?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto HISTOPCOST_A]
Page 124 of 306
Question ID: INS.0720.00.1
Variable name: HISTOPCOST_A
Interview module: INS(Adult.INS)
Universe: HILAST_A IN (1,2,3)
Question Text:
Response:
Read if necessary: Are you no longer enrolled in your last health care plan
because... The cost for your coverage increased?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto HISTOPELIG_A]
Question ID: INS.0730.00.1
Variable name: HISTOPELIG_A
Interview module: INS(Adult.INS)
Universe: HILAST_A IN (1,2,3)
Question Text:
Response:
?[F1] Read if necessary: Are you no longer enrolled in your last health care plan
because... You had Medicaid or other public coverage, but were no longer
eligible?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto RSNHICOST_A]
Page 125 of 306
Question ID: INS.0740.00.1
Variable name: RSNHICOST_A
Interview module: INS(Adult.INS)
Universe: 10 IN HIKIND_A and (MCAIDPRB_A IN (2,RF,DK) or MCAREPRB_A IN
(2,RF,DK))
Question Text:
Response:
Fills:
^INSREASONS Are you currently uninsured because coverage is not afforable?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^INSREASONS
If HILAST_A IN (0,4,5,6,RF,DK) fill: "There are many
reasons why people do not have health insurance
coverage."
If HILAST_A IN (1,2,3) fill: "We just discussed
reasons you lost coverage. Now I am going to ask
you some questions about why you haven't obtained
coverage."
Skip Instructions: <1,2,RF,DK> [goto RSNHIWANT_A]
Question ID: INS.0750.00.1
Variable name: RSNHIWANT_A
Interview module: INS(Adult.INS)
Universe: 10 IN HIKIND_A and (MCAIDPRB_A IN (2,RF,DK) or MCAREPRB_A IN
(2,RF,DK))
Question Text:
Response:
There are other reasons that people do not have health insurance coverage.
^PLUSCOSTA you currently uninsured because... ...you do not need or want
coverage?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 126 of 306
Fills:
^PLUSCOSTA
if RSNHICOST_A = 1 then fill "In addition to cost,
are"
Else fill "Are"
Skip Instructions: <1,2,RF,DK> [goto RSNHIELIG_A]
Question ID: INS.0760.00.1
Variable name: RSNHIELIG_A
Interview module: INS(Adult.INS)
Universe: 10 IN HIKIND_A and (MCAIDPRB_A IN (2,RF,DK) or MCAREPRB_A IN
(2,RF,DK))
Question Text:
Response:
Fills:
Read if necessary: There are other reasons that people do not have health
insurance coverage. ^PLUSCOSTA you currently uninsured because... ...you are
not eligible for coverage?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^PLUSCOSTA
if RSNHICOST_A = 1 then fill "In addition to cost,
are"
Else fill "Are"
Skip Instructions: <1,2,RF,DK> [goto RSNHICONF_A]
Question ID: INS.0770.00.1
Variable name: RSNHICONF_A
Interview module: INS(Adult.INS)
Universe: 10 IN HIKIND_A and (MCAIDPRB_A IN (2,RF,DK) or MCAREPRB_A IN
(2,RF,DK))
Question Text:
Read if necessary: There are other reasons that people do not have health
insurance coverage. ^PLUSCOSTA you currently uninsured because... ...the
process of signing up for coverage is too difficult or confusing?
Response:
Page 127 of 306
1.
2.
DK:
RF:
Fills:
Yes
No
Don't Know
Refused
^PLUSCOSTA
if RSNHICOST_A = 1 then fill "In addition to cost,
are"
Else fill "Are"
Skip Instructions: <1,2,RF,DK> [goto RSNHIMEET_A]
Question ID: INS.0780.00.1
Variable name: RSNHIMEET_A
Interview module: INS(Adult.INS)
Universe: 10 IN HIKIND_A and (MCAIDPRB_A IN (2,RF,DK) or MCAREPRB_A IN
(2,RF,DK))
Question Text:
Response:
Fills:
Read if necessary: There are other reasons that people do not have health
insurance coverage. ^PLUSCOSTA you currently uninsured because... ...you
cannot find a plan that meets your needs?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^PLUSCOSTA
if RSNHICOST_A = 1 then fill "In addition to cost,
are"
Else fill "Are"
Skip Instructions: <1,2,RF,DK> [goto RSNHIWAIT_A]
Page 128 of 306
Question ID: INS.0790.00.1
Variable name: RSNHIWAIT_A
Interview module: INS(Adult.INS)
Universe: 10 IN HIKIND_A and (MCAIDPRB_A IN (2,RF,DK) or MCAREPRB_A IN
(2,RF,DK))
Question Text:
Response:
Fills:
Read if necessary: There are other reasons that people do not have health
insurance coverage. ^PLUSCOSTA you currently uninsured because... ...you
applied for coverage but it has not started yet?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^PLUSCOSTA
if RSNHICOST_A = 1 then fill "In addition to cost,
are"
Else fill "Are"
Skip Instructions: <1,2,RF,DK> [goto RSNHIOTH_A]
Question ID: INS.0800.00.1
Variable name: RSNHIOTH_A
Interview module: INS(Adult.INS)
Universe: 10 IN HIKIND_A and (MCAIDPRB_A IN (2,RF,DK) or MCAREPRB_A IN
(2,RF,DK))
Question Text:
Response:
Is there another reason that you currently do not have health insurance
coverage?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto RSNHIOTHSP_A]
<2,RF,DK> [goto next section]
Page 129 of 306
Question ID: INS.0810.00.1
Variable name: RSNHIOTHSP_A
Interview module: INS(Adult.INS)
Universe: RSNHIOTH_A=1
Question Text:
Response:
What is your other reason for not having coverage?
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto next section]
Question ID: INS.0820.00.1
Variable name: HINOTYR_A
Interview module: INS(Adult.INS)
Universe: 01<=HIKIND_A<=09 or (MCAIDPRB_A=1 or MCAREPRB_A=1)
Question Text:
Response:
In the past 12 months, was there any time when you did NOT have ANY health
insurance or coverage?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto HINOTMYR_A]
<2,RF,DK> [goto FINISH_A]
Question ID: INS.0830.00.1
Variable name: HINOTMYR_A
Universe: 01<=HIKIND_A<=09
HINOTYR_A=1
Question Text:
Response:
or
(MCAIDPRB_A=1
Interview module: INS(Adult.INS)
or
MCAREPRB_A=1)
and
In the past 12 months, about how many months were you without coverage?
If less than 1 month, enter '1'.
DK:
RF:
Don't Know
Refused
Page 130 of 306
Skip Instructions: <1-12,RF,DK> [goto FINISH_A]
Question ID: INS.0840.00.1
Question Text:
Response:
Variable name: FINISH_A
Interview module: INS(Adult.INS)
The Sample Adult health insurance section is now complete.
continue.
1.
Enter '1' to
Enter 1 to Continue
Skip Instructions: <1> [goto next section]
Question ID: PAY.0010.00.1
Variable name: PAYINTRO_A
Interview module: PAY(Adult.PAY)
Universe: (GEN.SAMEFAM_FLG=1
and
GEN.PAY_FLG_C=empty)
(GEN.SAMEFAM_FLG=1
and
GEN.PAY_FLG_C=2
GEN.SARESPSC_FLG ne 1) or (GEN.SAMEFAM_FLG ne 1)
Question Text:
Response:
Fills:
or
and
?[F1] Now I am going to ask you about your medical bills. Include bills for
doctors, dentists, hospitals, therapists, medication, equipment, and nursing
home or home care. ^Dormfill
Enter '1' to continue.
1.
Enter 1 to Continue
^Dormfill
If
Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMP
US=1, fill "When I ask about your family, please think
about your family living at ^HNO ^HNOSUF
^STRNAME."
else leave blank
Skip Instructions: <1> [goto PAYBLL12M_A]
Page 131 of 306
Question ID: PAY.0020.00.1
Variable name: PAYBLL12M_A
Interview module: PAY(Adult.PAY)
Universe: (SAMEFAM_FLG=1 and PAY_FLG_C=blank) or (SAMEFAM_FLG=1 and
PAY_FLG_C=2 and SARESPSC_FLG ne 1) or (SAMEFAM_FLG ne 1)
Question Text:
Response:
Fills:
?[F1] In the past 12 months did ^youanyone have problems paying or were
unable to pay any medical bills?
Read if necessary: Include bills for doctors,
dentists, hospitals, therapists, medication, equipment, nursing home or home care.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^youanyone
If GEN.PCNT_A=1 fill "you";
else fill "anyone in the family"
Skip Instructions: <1,RF,DK> [goto PAYNOBLLNW_A]
<2> [goto PAYWORRY_A]
Question ID: PAY.0030.00.1
Variable name: PAYNOBLLNW_A
Interview module: PAY(Adult.PAY)
Universe: ((SAMEFAM_FLG=1 and PAY_FLG_C=blank) or (SAMEFAM_FLG=1 and
PAY_FLG_C=2 and SARESPSC_FLG ne 1) or (SAMEFAM_FLG ne 1)) and
PAYBLL12M_A IN (1,RF,DK)
Question Text:
Response:
^DoyouDoesanyoneinfam currently have any medical bills that you are unable
to pay at all?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 132 of 306
Fills:
^DoyouDoesanyoneinfamIf GEN.PCNT_A=1 fill "Do you";
else fill "Does anyone in your family"
Skip Instructions: <1,2,RF,DK> [goto PAYWORRY_A]
Question ID: PAY.0040.00.1
Question Text:
Response:
Variable name: PAYWORRY_A
Interview module: PAY(Adult.PAY)
If you get sick or have an accident, how worried are you that you will be able to
pay your medical bills? Are you very worried, somewhat worried, or not at all
worried?
1.
2.
3.
DK:
RF:
Very worried
Somewhat worried
Not at all worried
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto next section]
Question ID: CVD.0010.00.4
Question Text:
Response:
Variable name: CVDINTRO_A
Interview module: CVD(Adult.CVD)
The next set of questions are about coronavirus or COVID-19.
continue.
1.
Enter 1 to Continue
Skip Instructions: <1> [goto CVDDIAG_A]
Page 133 of 306
Enter '1' to
Question ID: CVD.0020.00.4
Question Text:
Response:
Variable name: CVDDIAG_A
Interview module: CVD(Adult.CVD)
Has a doctor or other health professional ever told you that you had or likely
had coronavirus or COVID-19?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto COVIDTEST_A]
Question ID: CVD.0030.00.4
Question Text:
Response:
Variable name: COVIDTEST_A
Interview module: CVD(Adult.CVD)
Have you ever been tested for coronavirus or COVID-19?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CVDRSLT_A]
<2,RF,DK> if CVDDIAG_A=1 [goto CVDSEV_A]
else [goto next section]
Question ID: CVD.0040.00.4
Variable name: CVDRSLT_A
Interview module: CVD(Adult.CVD)
Universe: COVIDTEST_A=1
Question Text:
Did the test find that you had coronavirus or COVID-19? If any test has shown
they have COVID-19, enter '1' for yes.
If the respondent indicates they are waiting
for their results, enter '3' for Did not receive results. If the respondent indicates the
test was inconclusive, enter 'CTRL-D' for Don't Know.
Response:
Page 134 of 306
1.
2.
3.
DK:
RF:
Yes
No
Did not receive results
Don't Know
Refused
Skip Instructions: <1> [goto CVDSEV_A]
<2-3,RF,DK> if CVDDIAG_A=1 [goto CVDSEV_A]
else [goto next section]
Question ID: CVD.0050.00.4
Variable name: CVDSEV_A
Interview module: CVD(Adult.CVD)
Universe: CVDDIAG_A=1 or CVDRSLT_A=1
Question Text:
Response:
How would you describe your coronavirus symptoms when they were at their
worst? Would you say no symptoms, mild symptoms, moderate symptoms, or
severe symptoms?
1.
2.
3.
4.
DK:
RF:
No symptoms
Mild symptoms
Moderate symptoms
Severe symptoms
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto next section]
Question ID: TSC.0010.00.3
Variable name: CVDSYMSM_A
Interview module: TSC(Adult.TSC)
Universe: CVD.CVDDIAG_A=1 or CVD.CVDRSLT_A=1
Question Text:
When you had coronavirus, did you lose some or all of your sense of smell or
smell odors that were not there?
Response:
Page 135 of 306
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CVDSMREC_A]
<2,RF,DK> [goto CVDSYMTST_A]
Question ID: TSC.0020.00.3
Variable name: CVDSMREC_A
Interview module: TSC(Adult.TSC)
Universe: CVDSYMSM_A=1
Question Text:
Response:
Has your sense of smell fully or partially recovered?
1.
2.
3.
DK:
RF:
Yes, fully
Yes, partially
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto CVDSYMTST_A]
Question ID: TSC.0030.00.3
Variable name: CVDSYMTST_A
Interview module: TSC(Adult.TSC)
Universe: CVD.CVDDIAG_A=1 or CVD.CVDRSLT_A=1
Question Text:
Response:
When you had coronavirus, did you lose some or all of your ability to taste or
have unwanted tastes or sensations in your mouth that did not go away?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CVDTSTREC_A]
<2,RF,DK> [goto next section]
Page 136 of 306
Question ID: TSC.0040.00.3
Variable name: CVDTSTREC_A
Interview module: TSC(Adult.TSC)
Universe: CVDSYMSM_A=1
Question Text:
Response:
Has your ability to taste fully or partially recovered?
1.
2.
3.
DK:
RF:
Yes, fully
Yes, partially
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: UTZ.0010.00.1
Question Text:
Response:
Variable name: UTZINTRO_A
Interview module: UTZ(Adult.UTZ)
Now that we finished talking about dental care, I would like to ask you about
other health care. Enter '1' to continue.
1.
Enter 1 to Continue
Skip Instructions: <1> [goto LASTDR_A]
Question ID: UTZ.0020.00.1
Question Text:
Response:
Variable name: LASTDR_A
Interview module: UTZ(Adult.UTZ)
About how long has it been since you last saw a doctor or other health
professional about your health? Read if necessary: Include doctors seen while a
patient in a hospital. Read if necessary: Do not include dental care.
0.
1.
2.
3.
4.
Never
Within the past year (anytime less than 12 months ago)
Within the last 2 years (1 year but less than 2 years ago)
Within the last 3 years (2 years but less than 3 years ago)
Within the last 5 years (3 years but less than 5 years ago)
Page 137 of 306
5.
6.
DK:
RF:
Within the last 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1-6> [goto WELLNESS_A]
<0,RF,DK> [goto USUALPL_A]
Question ID: UTZ.0030.00.1
Variable name: WELLNESS_A
Interview module: UTZ(Adult.UTZ)
Universe: LASTDR_A IN (1,2,3,4,5,6)
Question Text:
Response:
Was this a wellness visit, physical, or general purpose check-up? Read if
necessary: This kind of visit typically includes: blood pressure, cholesterol, and blood
sugar checks, height and weight measurements, and vaccinations. The doctor or
other health professional may also discuss topics related to your health such as
smoking, alcohol use, diet and exercise. These visits are usually scheduled in
advance and occur when you are not sick or injured. Read if necessary: If a
wellness exam was combined with a sick care visit, include this visit. Read if
necessary: An obstetrician/gynecologist (OB/GYN) may perform this visit.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto USUALPL_A]
<2,RF,DK> [goto WELLVIS_A]
Question ID: UTZ.0040.00.1
Variable name: WELLVIS_A
Interview module: UTZ(Adult.UTZ)
Universe: WELLNESS_A IN (2,RF,DK)
Question Text:
About how long has it been since you last saw a doctor or other health
professional for a wellness visit, physical, or general purpose check-up?
Read if necessary: This kind of visit typically includes: blood pressure, cholesterol,
and blood sugar checks, height and weight measurements, and vaccinations. The
doctor or other health professional may also discuss topics related to your health
such as smoking, alcohol use, diet and exercise. These visits are usually scheduled
in advance and occur when you are not sick or injured. Read if necessary: If a
wellness exam was combined with a sick care visit, include this visit. Read if
necessary: An obstetrician/gynecologist (OB/GYN) may perform this visit.
Response:
Page 138 of 306
0.
1.
2.
3.
4.
5.
6.
DK:
RF:
Never
Within the past year (anytime less than 12 months ago)
Within the last 2 years (1 year but less than 2 years ago)
Within the last 3 years (2 years but less than 3 years ago)
Within the last 5 years (3 years but less than 5 years ago)
Within the last 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <0-6,RF,DK> [goto USUALPL_A]
Question ID: UTZ.0050.00.1
Question Text:
Response:
Variable name: USUALPL_A
Interview module: UTZ(Adult.UTZ)
Is there a place that you USUALLY go to if you are sick and need health care?
1.
2.
3.
DK:
RF:
Yes
There is NO place
There is MORE THAN ONE place
Don't Know
Refused
Skip Instructions: <1,3,RF,DK> [goto USPLKIND_A]
<2> [goto URGENT12M_A]
Question ID: UTZ.0060.00.1
Variable name: USPLKIND_A
Interview module: UTZ(Adult.UTZ)
Universe: USUALPL_A IN (1,3,RF,DK)
Question Text:
What kind of place ^ISITGOMSTOFT - a doctor's office or health center; an
urgent care center, a clinic in a drug store or grocery store; a hospital
emergency room; a VA Medical Center or VA outpatient clinic; or some other
place? Read if necessary: A doctor's office or health center is a place where you
see the same doctor or the same group of doctors every visit, where you usually need
to make an appointment ahead of time, and where your medical records are on file.
Read if necessary: Urgent care centers and clinics in a drug store or grocery store
are places where you do not need to make an appointment ahead of time, and do not
usually see the same health care provider at each visit.
Response:
Page 139 of 306
1.
2.
3.
4.
5.
6.
DK:
RF:
Fills:
A doctor's office or health center
Urgent care center or clinic in a drug store or grocery store
Hospital emergency room
A VA Medical Center or VA outpatient clinic
Some other place
Does not go to one place most often
Don't Know
Refused
^ISITGOMSTOFT
If USUALPL_A=1 fill "is it";
else fill "do you go to most often"
Skip Instructions: <1-6,RF,DK> [goto URGENT12M_A]
Question ID: UTZ.0070.00.1
Question Text:
Response:
Variable name: URGENT12M_A
Interview module: UTZ(Adult.UTZ)
During the past 12 months, how many times have you gone to an urgent care
center or a clinic in a drug store or grocery store about your health? Enter 96
if number is 96 or greater. Read if necessary: Urgent care centers and clinics in
drug stores or grocery stores are places where you do not need to make an
appointment ahead of time, and do not usually see the same health care provider at
each visit. Read if necessary: This is different from a hospital emergency room.
DK:
RF:
Don't Know
Refused
Skip Instructions: <0-39,RF,DK> [goto EMERGE12M_A]
<40-96> [goto ERR1_URGENT12M_A]
Page 140 of 306
Check Name: ERR1_URGENT12M_A
Text:
{signal ERR1_URGENT12M_A} ^URGENT12M_A is an unusually large number.
Did you visit an urgent care center or clinic in a drug store or grocery
storeabout your health ^URGENT12M_A times in the past 12 months? Please
verify.
Hard / Soft Edit: Soft
Fills:
^URGENT12M_A
fill value from URGENT12M_A
Universe: URGENT12M_A=40-96
Question ID: UTZ.0080.00.1
Question Text:
Response:
Variable name: EMERGE12M_A
Interview module: UTZ(Adult.UTZ)
During the past 12 months, how many times have you gone to a hospital
emergency room about your health? Read if necessary: This includes
emergency room visits that resulted in a hospital admission. Enter 96 if number of
times is 96 or more.
DK:
RF:
Don't Know
Refused
Skip Instructions: <0-39,RF,DK> [goto HOSPONGT_A]
<40-96> [goto ERR1_EMERGE12M_A]
Check Name: ERR1_EMERGE12M_A
Text:
{signal ERR1_EMERGE12M_A} ^EMERGE12M_A is an unusually large number.
Did you visit a hospital emergency room about your health ^EMERGE12M_A
times in the past 12 months? Please verify.
Hard / Soft Edit: Soft
Fills:
^EMERGE12M_A
Fill value from Adult.UTZ.EMERGE12M_A
Universe: EMERGE12M=40-96
Page 141 of 306
Question ID: UTZ.0090.00.1
Question Text:
Response:
Fills:
Variable name: HOSPONGT_A
Interview module: UTZ(Adult.UTZ)
During the past 12 months, have you been hospitalized overnight?
^PAST12MER_A
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^PAST12MER_A
If ((EMERGE12M_A ge 01 and EMERGE12M_A le
96) or EMERGE12M_A IN (RF,DK): Fill: "Do not
include an overnight stay in the emergency room."
Skip Instructions: <1,2,RF,DK> [goto MEDDL12M_A]
Question ID: UTZ.0100.00.1
Question Text:
Response:
Variable name: MEDDL12M_A
Interview module: UTZ(Adult.UTZ)
During the past 12 months, have you DELAYED getting medical care because
of the cost?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto MEDNG12M_A]
Page 142 of 306
Question ID: UTZ.0110.00.1
Question Text:
Response:
Variable name: MEDNG12M_A
Interview module: UTZ(Adult.UTZ)
During the past 12 months, was there any time when you needed medical care,
but DID NOT GET IT because of the cost?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: ACC.0010.00.4
Question Text:
Response:
Variable name: DLYCARE_A
Interview module: ACC(Adult.ACC)
Was there any time when you DELAYED getting medical care because of the
coronavirus pandemic?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto DNGCARE_A]
Question ID: ACC.0020.00.4
Question Text:
Response:
Variable name: DNGCARE_A
Interview module: ACC(Adult.ACC)
Was there any time when you needed medical care for something other than
coronavirus, but DID NOT GET IT because of the coronavirus pandemic?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 143 of 306
Skip Instructions: <1,2,RF,DK> [goto VIRAPP12M_A]
Question ID: ACC.0030.00.4
Question Text:
Response:
Variable name: VIRAPP12M_A
Interview module: ACC(Adult.ACC)
In the past 12 months, have you had an appointment with a doctor, nurse, or
other health professional by video or by phone?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto VIRAPPCVD_A]
<2,RF,DK> [goto next section]
Question ID: ACC.0040.00.4
Variable name: VIRAPPCVD_A
Interview module: ACC(Adult.ACC)
Universe: VIRAPP12M_A=1
Question Text:
Response:
Were any of your appointments done by video or by phone because of reasons
related to the coronavirus pandemic?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Page 144 of 306
Question ID: CNV.0010.00.4
Question Text:
Response:
Variable name: CANCOVTREA_A
Interview module: CNV(Adult.CNV)
The next question refers to treatments for cancer such as surgery, radiation
therapy, chemotherapy, bone marrow transplants, stem cell transplants, or
hormone therapy. At any time since the start of the coronavirus pandemic,
were you in treatment or supposed to receive treatment for your cancer?
Read if necessary: Hormone therapy includes Tamoxifen, Fulvestrant
(full-VESS-trant) or Aromatase (uh-ROH-muh-tayz) inhibitors for breast cancer and
androgen therapy, such as Eligard or Zoladex for prostate cancer.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CANCOVCHG_A]
<2,RF,DK> [goto CANCOVOTH_A]
Question ID: CNV.0020.00.4
Variable name: CANCOVCHG_A
Interview module: CNV(Adult.CNV)
Universe: CANCOVTREA_A=1
Question Text:
Response:
Were any of your treatments for cancer changed, delayed, or cancelled
because of the coronavirus pandemic?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto CANCOVOTH_A]
Page 145 of 306
Question ID: CNV.0030.00.4
Question Text:
Response:
Variable name: CANCOVOTH_A
Interview module: CNV(Adult.CNV)
As a cancer patient or cancer survivor, you may need OTHER medical care
related to your cancer such as lab visits, imaging, monitoring visits,
rehabilitation, physical therapy, care for side-effects, or visits with medical
specialists. At any time since the start of the coronavirus pandemic, did you
need any of this OTHER medical care related to your cancer?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CANCOVCARE_A]
<2,RF,DK> [goto next section]
Question ID: CNV.0040.00.4
Variable name: CANCOVCARE_A
Interview module: CNV(Adult.CNV)
Universe: CANCOVOTH_A=1
Question Text:
Response:
Was any of this OTHER medical care related to your cancer changed, delayed,
or cancelled because of the coronavirus pandemic?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Page 146 of 306
Question ID: PMD.0010.00.1
Question Text:
Response:
Variable name: RX12M_A
Interview module: PMD(Adult.PMD)
At any time in the past 12 months, did you take prescription medication?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto RXSK12M_A]
<2,RF,DK> [goto RXDG12M_A]
Question ID: PMD.0020.00.1
Variable name: RXSK12M_A
Interview module: PMD(Adult.PMD)
Universe: RX12M_A=1
Question Text:
Response:
During the past 12 months, were any of the following true for you? ...You
skipped medication doses to save money.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto RXLS12M_A]
Question ID: PMD.0030.00.1
Variable name: RXLS12M_A
Interview module: PMD(Adult.PMD)
Universe: RX12M_A=1
Question Text:
Response:
Read if necessary: During the past 12 months, were any of the following true for
you? ...You took less medication to save money.
1.
Yes
Page 147 of 306
2.
DK:
RF:
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto RXDL12M_A]
Question ID: PMD.0040.00.1
Variable name: RXDL12M_A
Interview module: PMD(Adult.PMD)
Universe: RX12M_A=1
Question Text:
Response:
Read if necessary: During the past 12 months, were any of the following true for
you? ...You DELAYED filling a prescription to save money.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto RXDG12M_A]
Question ID: PMD.0050.00.1
Question Text:
Response:
Variable name: RXDG12M_A
Interview module: PMD(Adult.PMD)
During the past 12 months, was there any time when you needed prescription
medication, but DID NOT GET IT because of the cost?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Page 148 of 306
Question ID: PRV.0010.00.2
Question Text:
Response:
Variable name: BPLAST_A
Interview module: PRV(Adult.PRV)
When was the last time you had your blood pressure checked by a doctor,
nurse, or other health professional?
0.
1.
2.
3.
4.
5.
6.
DK:
RF:
Never
Within the past year (anytime less than 12 months ago)
Within the last 2 years (1 year but less than 2 years ago)
Within the last 3 years (2 years but less than 3 years ago)
Within the last 5 years (3 years but less than 5 years ago)
Within the last 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <0-6,RF,DK> [goto CHOLLAST_A]
Question ID: PRV.0020.00.2
Question Text:
Response:
Variable name: CHOLLAST_A
Interview module: PRV(Adult.PRV)
When was the last time you had your cholesterol checked by a doctor, nurse,
or other health professional?
0.
1.
2.
3.
4.
5.
6.
DK:
RF:
Never
Within the past year (anytime less than 12 months ago)
Within the last 2 years (1 year but less than 2 years ago)
Within the last 3 years (2 years but less than 3 years ago)
Within the last 5 years (3 years but less than 5 years ago)
Within the last 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <0-6,RF,DK> if DIBEV_A in (2,RF,DK) [goto DIBLAST1_A]
else if DIBEV_A=1 [goto DIBA1CLAST_A]
Page 149 of 306
Question ID: PRV.0030.00.2
Variable name: DIBLAST1_A
Interview module: PRV(Adult.PRV)
Universe: DIBEV_A ne 1
Question Text:
Response:
When was the last time you had a blood test for high blood sugar or diabetes
by a doctor, nurse, or other health professional?
0.
1.
2.
3.
4.
5.
6.
DK:
RF:
Never
Within the past year (anytime less than 12 months ago)
Within the last 2 years (1 year but less than 2 years ago)
Within the last 3 years (2 years but less than 3 years ago)
Within the last 5 years (3 years but less than 5 years ago)
Within the last 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <0-6,RF,DK> if GEN.AGE_FINAL[PX_A] ge 40 [goto COLORECTEV_A]
elseif (GEN.SEX_FINAL[PX_A]=1 and (GEN.AGE_FINAL[PX_A] lt 40 or
GEN.AGE_FINAL[PX_A] IN (DK,RF)) or GEN.SEX_FINAL[PX_A] IN (DK,RF)
[goto next section]
elseif (GEN.SEX_FINAL[PX_A]=2 and (GEN.AGE_FINAL[PX_A] lt 40 or
GEN.AGE_FINAL[PX_A] IN (DK,RF)) [goto CERVICEV1_A]
Question ID: PRV.0033.00.3
Variable name: DIBA1CLAST_A
Interview module: PRV(Adult.PRV)
Universe: DIBEV_A=1
Question Text:
An A-one-C test is used to measure the average level of blood sugar over the
past three months. When was the last time you had your A1C checked by a
doctor, nurse, or other health professional? Read if necessary: A1C values
typically range between 5 and 13.9. For many people with diabetes the goal is to
have an A1C of 7 or less, but your goal may be different depending on what you and
your doctor determine is best for you.
Response:
Page 150 of 306
0.
1.
2.
3.
4.
5.
6.
DK:
RF:
Never
Within the past year (anytime less than 12 months ago)
Within the last 2 years (1 year but less than 2 years ago)
Within the last 3 years (2 years but less than 3 years ago)
Within the last 5 years (3 years but less than 5 years ago)
Within the last 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1> [goto DIBA1CNUM_A]
<0,2-6,RF,DK> if GEN.AGE_FINAL[PX_A] ge 40 [goto COLORECTEV_A]
elseif (GEN.SEX_FINAL[PX_A]=1 and (GEN.AGE_FINAL[PX_A] lt 40 or
GEN.AGE_FINAL[PX_A] IN (DK,RF)) or GEN.SEX_FINAL[PX_A] IN (DK,RF)
[goto next section]
elseif (GEN.SEX_FINAL[PX_A]=2 and (GEN.AGE_FINAL[PX_A] lt 40 or
GEN.AGE_FINAL[PX_A] IN (DK,RF)) [goto CERVICEV1_A]
Question ID: PRV.0037.00.3
Variable name: DIBA1CNUM_A
Interview module: PRV(Adult.PRV)
Universe: DIBEV_A=1 & DIBA1CLAST_A=1
Question Text:
Response:
Fills:
About how many times in the past 12 months has a doctor, nurse, or other
health professional checked your A-one-C? Read if necessary: A1C values
typically range between 5 and 13.9. For many people with diabetes the goal is to
have an A1C of 7 or less, but your goal may be different depending on what you and
your doctor determine is best for you. If ^SANAME reports more than 96 A1C tests,
enter 96.
DK:
RF:
Don't Know
Refused
^SANAME
Sample Adult's name
Skip Instructions: <1-96,RF,DK> if GEN.AGE_FINAL[PX_A] ge 40 [goto COLORECTEV_A]
elseif (GEN.SEX_FINAL[PX_A]=1 and (GEN.AGE_FINAL[PX_A] lt 40 or
GEN.AGE_FINAL[PX_A] IN (DK,RF)) or GEN.SEX_FINAL[PX_A] IN (DK,RF)
[goto next section]
elseif (GEN.SEX_FINAL[PX_A]=2 and (GEN.AGE_FINAL[PX_A] lt 40 or
GEN.AGE_FINAL[PX_A] IN (DK,RF)) [goto CERVICEV1_A]
Page 151 of 306
Question ID: PRV.0040.00.2
Variable name: COLORECTEV_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40
Question Text:
Response:
These next questions are about colorectal cancer screening. Colonoscopy and
sigmoidoscopy are exams to check for colon cancer. Have you ever had either
of these exams?
Read if necessary: Colonoscopy (colon-OS-copy) and
sigmoidoscopy (sigmoid-OS-copy) are exams in which a doctor inserts a tube into the
rectum to look for polyps or cancer.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto COLORECTYP_A]
<2,RF,DK> [goto CTCOLEV1_A]
Question ID: PRV.0050.00.2
Variable name: COLORECTYP_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40 and COLORECTEV_A=1
Question Text:
Response:
Have you had a colonoscopy, a sigmoidoscopy, or both? Read if necessary:
For a colonoscopy, the doctor checks the entire colon, and you are given medication
through a needle in your arm to make you sleepy, and told to have someone take you
home. For a sigmoidoscopy, the doctor checks only part of the colon and you are fully
awake. Enter 'DK' if respondent has had a colonoscopy or sigmoidoscopy, but
doesn't know which.
1.
2.
3.
DK:
RF:
Colonoscopy
Sigmoidoscopy
Both
Don't Know
Refused
Page 152 of 306
Skip Instructions: <1,3> [goto COLWHEN_A]
<2> [goto SIGWHEN_A]
[goto COLSIGWHEN_A]
[goto CTCOLEV1_A]
Question ID: PRV.0060.00.2
Variable name: COLWHEN_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40 and COLORECTYP_A IN (1,3)
Question Text:
Response:
About how long has it been since your MOST RECENT colonoscopy?
1.
2.
3.
4.
5.
6.
DK:
RF:
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1-6,RF,DK> [goto COLREASON_A]
Question ID: PRV.0070.00.3
Variable name: COLREASON_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40 and COLORECTYP_A IN (1,3)
Question Text:
Response:
What was the MAIN reason you had this colonoscopy - was it part of a routine
exam, because of a problem, as a follow-up test of an earlier test or screening
exam, or some other reason?
1.
2.
3.
4.
DK:
RF:
Part of a routine exam
Because of a problem
Follow-up test of an earlier test or screening exam
Other reason
Don't Know
Refused
Page 153 of 306
Skip Instructions: <1-4,RF,DK> [goto COLPAY_A]
Question ID: PRV.0080.00.3
Variable name: COLPAY_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40 and COLORECTYP_A IN (1,3)
Question Text:
Response:
Did you pay none, part, or all of the cost for your most recent colonoscopy?
1.
2.
3.
DK:
RF:
None of the cost
Part of the cost
All of the cost
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> if COLORECTYP_A=3 [goto SIGWHEN_A]
else [goto CTCOLEV1_A]
Question ID: PRV.0090.00.2
Variable name: COLSIGWHEN_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL ge 40 and COLORECTYP_A=DK
Question Text:
Response:
When was your MOST RECENT colonoscopy or sigmoidoscopy?
1.
2.
3.
4.
5.
6.
DK:
RF:
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1-6,RF,DK> [goto CTCOLEV1_A]
Page 154 of 306
Question ID: PRV.0100.00.2
Variable name: SIGWHEN_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40 and COLORECTYP_A IN (2,3)
Question Text:
Response:
When was your MOST RECENT sigmoidoscopy?
1.
2.
3.
4.
5.
6.
DK:
RF:
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1-6,RF,DK> [goto CTCOLEV1_A]
Question ID: PRV.0120.00.2
Variable name: CTCOLEV1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40
Question Text:
Response:
CT colonography, sometimes called virtual colonoscopy, is a test that looks for
cancer in the colon. Unlike regular colonoscopies, you do not need medication
to make you sleepy during the test. In this test, your colon is filled with air and
you are moved through a donut-shaped X-ray machine as you lie on your back
and then your stomach. Have you ever had a CT colonography or virtual
colonoscopy?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CTCOLWHEN1_A]
<2,RF,DK> [goto FITHEV1_A]
Page 155 of 306
Question ID: PRV.0130.00.2
Variable name: CTCOLWHEN1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40 and CTCOLEV1_A=1
Question Text:
Response:
When was your most recent CT colonography or virtual colonoscopy?
1.
2.
3.
4.
5.
6.
DK:
RF:
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1-6,RF,DK> [goto FITHEV1_A]
Question ID: PRV.0140.00.2
Variable name: FITHEV1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40
Question Text:
Response:
The following questions are about the blood stool or fecal occult blood test,
fecal immunochemical or FIT test. These are tests to determine whether you
have blood in your stool or bowel movement and can be done at home using a
kit. You use a stick or brush to obtain a small amount of stool at home and
send it back to the doctor or lab. Have you ever had a blood stool or FIT test,
using a HOME test kit?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto FITHWHEN1_A]
<2,RF,DK> [goto COLOGUARD1_A]
Page 156 of 306
Question ID: PRV.0150.00.2
Variable name: FITHWHEN1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40 and FITHEV1_A=1
Question Text:
Response:
When was your most recent blood stool or FIT test, using a home test kit?
1.
2.
3.
4.
5.
6.
DK:
RF:
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1-6,DK,RF> [goto COLOGUARD1_A]
Question ID: PRV.0160.00.3
Variable name: COLOGUARD1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40
Question Text:
Response:
Cologuard or FIT-DNA is a new type of stool test for colon cancer. Unlike other
stool tests, Cologuard looks for changes in DNA in addition to checking for
blood in your stool. The Cologuard test is shipped to your home in a box that
includes a container for your stool sample. Have you ever had a Cologuard
test?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> if FITHEV1_A=1 [goto FITCOLG1_A]
elseif FITHEV1_A IN (2,RF,DK) [goto CGUARDWHE1_A]
<2,RF,DK> if ((COLWHEN_A IN (1-5) or SIGWHEN_A IN (1-4) or
CTCOLWHEN1_A
IN
(1-4)
or
COLSIGWHEN_A
IN
(1-4)
or
FITHWHEN1_A=1) and GEN.SEX_FINAL[PX_A]=1) [goto PSATEST_A]
elseif ((COLWHEN_A IN (1-5) or SIGWHEN_A IN (1-4) or CTCOLWHEN1_A
IN (1-4) or COLSIGWHEN_A IN (1-4) or FITHWHEN1_A=1) and
GEN.SEX_FINAL[PX_A]=2) [goto CERVICEV1_A]
elseif ((COLWHEN1_A IN (1-5) or SIGWHEN_A IN (1-4) or CTCOLWHEN1_A
IN (1-4) or COLSIGWHEN_A IN (1-4) or FITHWHEN1_A=1) and
GEN.SEX_FINAL[PX_A] in (RF,DK)) [goto next section]
Page 157 of 306
else [goto COLPROB1_A]
Question ID: PRV.0170.00.3
Variable name: FITCOLG1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40 and FITHEV1_A=1 & COLOGUARD1_A=1
Question Text:
Response:
Was the blood stool or FIT test you reported earlier conducted as part of a
Cologuard test?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> if ((COLWHEN_A IN (1-5) or SIGWHEN_A IN (1-4) or CTCOLWHEN1_A
IN (1-4) or COLSIGWHEN_A IN (1-4) or FITHWHEN1_A=1) and
GEN.SEX_FINAL[PX_A]=1 [goto PSATEST_A]
elseif ((COLWHEN_A IN (1-5) or SIGWHEN_A IN (1-4) or CTCOLWHEN1_A
IN (1-4) or COLSIGWHEN_A IN (1-4) or FITHWHEN1_A=1) and
GEN.SEX_FINAL[PX_A]=2) [goto CERVICEV1_A]
elseif ((COLWHEN_A in (1-5) or SIGWHEN_A IN (1-4) or CTCOLWHEN1_A
IN (1-4) or or COLSIGWHEN_A IN (1-4) or FITHWHEN1_A=1) and
GEN.SEX_FINAL[PX_A] IN (RF,DK) [goto next section]
else [goto COLPROB1_A]
<2,RF,DK> [goto CGUARDWHE1_A]
Page 158 of 306
Question ID: PRV.0180.00.3
Variable name: CGUARDWHE1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40 and COLOGUARD1_A=1 and FITCOLG1_A
ne 1
Question Text:
Response:
When did you have your most recent Cologuard test?
1.
2.
3.
4.
5.
6.
DK:
RF:
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1-3> if GEN.SEX_FINAL[PX_A]=1) [goto PSATEST_A]
elseif GEN.SEX_FINAL[PX_A]=2) [goto CERVICEV1_A]
elseif GEN.SEX_FINAL[PX_A] IN (RF,DK)) [goto next section]
<4-6,RF,DK> if ((COLWHEN_A IN (1-5) or SIGWHEN_A IN (1-4) or
CTCOLWHEN1_A
IN
(1-4)
or
COLSIGWHEN_A
IN
(1-4)
or
FITHWHEN1_A=1) and GEN.SEX_FINAL[PX_A]=1) [goto PSATEST_A]
elseif ((COLWHEN_A IN (1-5) or SIGWHEN_A IN (1-4) or CTCOLWHEN1_A
IN (1-4) or COLSIGWHEN_A IN (1-4) or FITHWHEN1_A=1) and
GEN.SEX_FINAL[PX_A]=2) [goto CERVICEV1_A]
elseif ((COLWHEN_A IN (1-5) or SIGWHEN_A IN (1-4) or CTCOLWHEN1_A
IN (1-4) or COLSIGWHEN_A IN (1-4) or FITHWHEN1_A=1) and
GEN.SEX_FINAL[PX_A] IN (RF,DK)) [goto next section]
else [goto COLPROB1_A]
Page 159 of 306
Question ID: PRV.0190.00.3
Variable name: COLPROB1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40
and (COLORECTEV_A IN (empty,2,RF,DK) or (COLORECTEV_A=1 and
(COLWHEN_A IN (empty,6,RF,DK) and SIGWHEN_A IN (empty,5,6,RF,DK)
and COLSIGWHEN_A IN (empty,5,6,RF,DK)))
and CTCOLWHEN1_A IN (empty,5,6,RF,DK)
and ((FITHWHEN1_A IN (empty,2,3,4,5,6,RF,DK) and (COLOGUARD1_A IN
(empty,2,RF,DK) or FITCOL_A in (empty,2,RF,DK))) or (FITHWHEN1_A in
(empty,4,5,6) and FITCOL_A=1))
and CGUARDWHE1_A IN (empty,4,5,6,RF,DK)
Question Text:
Response:
In the past 12 MONTHS, did a doctor or other health professional RECOMMEND
that you be tested to look for problems in your colon or rectum?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto COLTEST_A]
<2,RF,DK> if GEN.SEX_FINAL[PX_A]=1 [goto PSATEST_A]
elseif GEN.SEX_FINAL[PX_A]=2 [goto CERVICEV1_A]
elseif GEN.SEX_FINAL[PX_A] IN (RF,DK) [goto next section]
Question ID: PRV.0200.00.3
Variable name: COLTEST_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 40 and COLPROB1_A=1
Question Text:
Which tests to check for colon cancer did the doctor or other health
professional recommend to you? Possible tests include stool blood or fecal
occult blood or FIT test; Cologuard or FIT DNA test; sigmoidoscopy;
colonoscopy; CT colonography or virtual colonoscopy; or other. Enter all that
apply, separate with commas.
Response:
Page 160 of 306
1.
2.
3.
4.
5.
6.
DK:
RF:
Stool blood test/fecal occult blood/FIT test
Cologuard or FIT DNA test
Sigmoidoscopy
Colonoscopy
CT colonography/virtual colonoscopy
Other
Don't Know
Refused
Skip Instructions: <1-6,RF,DK> if GEN.SEX_FINAL[PX_A]=1 [goto PSATEST_A]
elseif GEN.SEX_FINAL[PX_A]=2 [goto CERVICEV1_A]
elseif GEN.SEX_FINAL[PX_A] IN (RF,DK) [goto next section]
Question ID: PRV.0210.00.3
Variable name: PSATEST_A
Interview module: PRV(Adult.PRV)
Universe: GEN.SEX_FINAL[PX_A]=1 and GEN.AGE_FINAL[PX_A] ge 40
Question Text:
Response:
A PSA test is a blood test to detect prostate cancer. It is also called a
prostate-specific antigen test. Have you EVER had a PSA test?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto PSAWHEN_A]
<2,RF,DK> [goto next section]
Question ID: PRV.0220.00.3
Variable name: PSAWHEN_A
Universe: GEN.SEX_FINAL[PX_A]=1
PSATEST_A=1
Question Text:
and
Interview module: PRV(Adult.PRV)
GEN.AGE_FINAL[PX_A]
ge
40
About how long has it been since your MOST RECENT PSA test?
Response:
Page 161 of 306
and
1.
2.
3.
4.
5.
6.
DK:
RF:
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1-6,RF,DK> [goto PSAREASON_A]
Question ID: PRV.0230.00.3
Variable name: PSAREASON_A
Universe: GEN.SEX_FINAL[PX_A]=1
PSATEST_A=1
Question Text:
Response:
and
Interview module: PRV(Adult.PRV)
GEN.AGE_FINAL[PX_A]
ge
40
and
What was the MAIN reason you had this PSA test - was it part of a routine
exam, because of a problem, or some other reason?
1.
2.
3.
DK:
RF:
Part of a routine exam
Because of a problem
Other reason
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto PSASUGGEST_A]
Question ID: PRV.0250.00.3
Variable name: PSASUGGEST_A
Universe: GEN.SEX_FINAL[PX_A]=1
PSATEST_A=1
Question Text:
and
Interview module: PRV(Adult.PRV)
GEN.AGE_FINAL[PX_A]
ge
40
and
Who first suggested your MOST RECENT PSA test: you, your doctor, or
someone else?
Response:
Page 162 of 306
1.
2.
3.
DK:
RF:
Self
Doctor
Someone else
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto next section]
Question ID: PRV.0280.00.2
Variable name: CERVICEV1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.SEX_FINAL[PX_A]=2
Question Text:
Response:
There are two different kinds of tests to check for cervical cancer. One is a Pap
smear or Pap test and the other is the HPV or Human Papillomavirus test.
Have you EVER HAD a test or tests to check for cervical cancer? Read if
necessary: These are routine tests for women in which a doctor or other health
professional takes a sample from the cervix with a swab or brush and sends it to the
lab.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CERVICWHEN_A]
<2> [goto CERVICNOT1_A]
[goto HYSTEV1_A]
Question ID: PRV.0290.00.2
Variable name: CERVICWHEN_A
Interview module: PRV(Adult.PRV)
Universe: GEN.SEX_FINAL[PX_A]=2 and CERVICEV1_A=1
Question Text:
When did you have your MOST RECENT test to check for cervical cancer?
Response:
Page 163 of 306
1.
2.
3.
4.
5.
6.
DK:
RF:
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1-6,RF,DK> [goto CERREASON1_A]
Question ID: PRV.0300.00.3
Variable name: CERREASON1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.SEX_FINAL[PX_A]=2 and CERVICEV1_A=1
Question Text:
Response:
What was the main reason you had this cervical cancer test - was it part of a
routine exam, because of a problem, or as a follow-up test of an earlier test or
screening exam, or some other reason?
1.
2.
3.
4.
DK:
RF:
Part of a routine exam
Because of a problem
Follow-up test of an earlier test or screening exam
Other reason
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto PAPTEST_A]
Question ID: PRV.0310.00.3
Variable name: PAPTEST_A
Interview module: PRV(Adult.PRV)
Universe: GEN.SEX_FINAL[PX_A]=2 and CERVICEV1_A=1
Question Text:
At your MOST RECENT cervical cancer screening, did you have a Pap test?
Response:
Page 164 of 306
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto HPVTEST_A]
Question ID: PRV.0320.00.3
Variable name: HPVTEST_A
Interview module: PRV(Adult.PRV)
Universe: GEN.SEX_FINAL[PX_A]=2 and CERVICEV1_A=1
Question Text:
Response:
At your MOST RECENT cervical cancer screening, did you have an HPV test?
Read if necessary: HPV stands for Human Papillomavirus.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> goto TELLCERVIC_A]
Question ID: PRV.0325.00.3
Variable name: TELLCERVIC_A
Interview module: PRV(Adult.PRV)
Universe: GEN.SEX_FINAL[PX_A]=2 and CERVICEV1_A=1
Question Text:
Response:
At your MOST RECENT cervical test, did a doctor or other health professional
tell you which type of test or tests you recieved?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> if CERVICWHEN_A IN (1,2,3,4) [goto CERVICRES_A]
if CERVICWHEN_A IN (5,6) [goto CERVICNOT1_A]
if CERVICWHEN_A IN (RF,DK) [goto HYSTEV1_A]
Page 165 of 306
Question ID: PRV.0330.00.3
Variable name: CERVICRES_A
Interview module: PRV(Adult.PRV)
Universe: GEN.SEX_FINAL[PX_A]=2 and CERVICWHEN_A IN (1,2,3,4)
Question Text:
Response:
In the PAST 5 years, did any of your cervical cancer screening tests require
follow-up to check for cancer or precancerous cells?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto HYSTEV1_A]
Question ID: PRV.0340.00.3
Variable name: CERVICNOT1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.SEX_FINAL[PX_A]=2 and (CERVICEV1_A=2 or CERVICWHEN IN
(5,6))
Question Text:
Response:
What is the MAIN REASON that you have ^never5yearsPAPHPV?
choices, select answer category based on respondent's answer.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
DK:
RF:
No reason/never thought about it
Didn't need it/didn't know I needed this type of test
Doctor didn't order it/didn't say I needed it
Haven't had any problems
Put it off/didn't get around to it
Too expensive/no insurance/cost
Too painful, unpleasant, or embarrassing
Had hysterectomy
Don't have a doctor
Had HPV vaccine
I am too old
I am too young
Other
Don't Know
Refused
Page 166 of 306
Do not read
Fills:
^never5yearsPAPHPV
If CERVICEV_A=2 fill "NEVER had a test to check
for cervical cancer"
If CERVICEV_A=1 and CERVICWHEN_A IN (5,6)
fill: "NOT had a test to check for cervical cancer in
the last 5 years"
Skip Instructions: <1-7,9-13,RF,DK> [goto HYSTEV1_A]
<8> if GEN.AGE_FINAL ge 30 [goto MAMEV_A]
elseif GEN.AGE_FINAL lt 30 or GEN.AGE_FINAL IN (RF,DK) [goto next
section]
Question ID: PRV.0350.00.2
Variable name: HYSTEV1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.SEX_FINAL[PX_A]=2 and CERVICNOT1_A ne 8
Question Text:
Response:
A hysterectomy is when the uterus or womb is removed, this is different from
having your tubes tied. Have you had a hysterectomy?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> if GEN.AGE_FINAL ge 30 [goto MAMEV_A]
elseif GEN.AGE_FINAL lt 30 or GEN.AGE_FINAL IN (RF,DK) [goto next
section]
Question ID: PRV.0360.00.2
Variable name: MAMEV_A
Interview module: PRV(Adult.PRV)
Universe: GEN.AGE_FINAL[PX_A] ge 30 and GEN.SEX_FINAL[PX_A]=2
Question Text:
Have you EVER HAD a mammogram? Read if necessary: A mammogram is an
x-ray taken only of the breast by a machine that presses against the breast.
Response:
Page 167 of 306
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto MAMWHEN_A]
<2> [goto MAMNOT1_A]
[goto next section]
Question ID: PRV.0370.00.2
Variable name: MAMWHEN_A
Universe: GEN.AGE_FINAL[PX_A]
MAMEV_A=1
Question Text:
Response:
ge
30
Interview module: PRV(Adult.PRV)
and
GEN.SEX_FINAL[PX_A]=2
and
About how long has it been since your MOST RECENT mammogram?
1.
2.
3.
4.
5.
6.
DK:
RF:
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1-6,RF,DK> [goto MAMREASON_A]
Question ID: PRV.0380.00.3
Variable name: MAMPAY_A
Universe: GEN.SEX_FINAL[PX_A]=2
MAMEV_A=1
Question Text:
and
Interview module: PRV(Adult.PRV)
GEN.AGE_FINAL[PX_A]
ge
30
and
Did you pay none, part, or all of the cost for your most recent mammogram?
Response:
Page 168 of 306
1.
2.
3.
DK:
RF:
None of the cost
Part of the cost
All of the cost
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto MAMREASON_A]
Question ID: PRV.0390.00.3
Variable name: MAMREASON_A
Universe: GEN.SEX_FINAL[PX_A]=2
MAMEV_A=1
Question Text:
Response:
and
Interview module: PRV(Adult.PRV)
GEN.AGE_FINAL[PX_A]
ge
30
and
What was the MAIN reason you had this mammogram -- was it part of a routine
exam, because of a problem, or some other reason?
1.
2.
3.
DK:
RF:
Part of a routine exam
Because of a problem
Other reason
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto MAMAGE1ST1_A]
Question ID: PRV.0400.00.3
Variable name: MAMAGE1ST1_A
Universe: GEN.SEX_FINAL[PX_A]=2
MAMEV_A=1
Question Text:
Response:
and
Interview module: PRV(Adult.PRV)
GEN.AGE_FINAL[PX_A]
ge
About how old were you when you had your first mammogram?
1.
2.
3.
Under 30 years
30-39
40-49
Page 169 of 306
30
and
4.
5.
6.
DK:
RF:
50-59
60-74
75 years or older
Don't Know
Refused
Skip Instructions: if((GEN.AGE_FINAL[PX_A] lt 75 and MAMAGE1ST1_A=6)
if((GEN.AGE_FINAL[PX_A]
lt
60
and
MAMAGE1ST1_A=5,6)
or
(GEN.AGE_FINAL[PX_A] lt 50 and MAMAGE1ST1_A IN (4,5,6)) or
(GEN.AGE_FINAL[PX_A] lt 40 and MAMAGE1ST1_A IN (3,4,5,6)))[goto
ERR_MAMAGE1ST11_A]
<1-3> [goto next section]
<4-6,RF,DK> if MAMWHEN_A IN (3-6) [goto MAMNOT1_A]
else [goto next section]
Check Name: ERR_MAMAGE1ST1_A
Text:
{check ERR_MAMAGE1ST1_A}
correct.
That selection is not valid at this time.
Please
Hard / Soft Edit: Hard
Universe: ((GEN.AGE_FINAL LT 75 and MAMAGE1ST_A=6) or (GEN.AGE_FINAL LT
60 and MAMAGE1ST_A IN (5,6)) or (GEN.AGE_FINAL LT 50 and
MAMAGE1ST_A IN (4,5,6)) or (GEN.AGE_FINAL LT 40 and MAMAGE1ST_A
IN (3,4,5,6)))
Question ID: PRV.0410.00.3
Variable name: MAMNOT1_A
Interview module: PRV(Adult.PRV)
Universe: GEN.SEX_FINAL[PX_A]=2 and GEN.AGE_FINAL[PX_A]
(MAMEV_A=2 or MAMWHEN_A IN [3-6,RF,DK])
Question Text:
ge
30
and
What is the most important reason why you have ^MAMNEVER2YEARS_A?
Put response into correct category below.
Response:
Page 170 of 306
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
DK:
RF:
Fills:
No reason/never thought about it
Didn't need it/didn't know I needed this type of test
Doctor didn't order it/didn't say I needed it
Haven't had any problems
Put it off/didn't get around to it
Too expensive/no insurance/cost
Too painful, unpleasant, or embarrassing
Don't have a doctor
I am too old
I am too young
Other
Don't Know
Refused
^MAMNEVER2YEARS_Anever or more than 2 years mammogram
Skip Instructions: <1-11,RF,DK> [goto next section]
Question ID: IMS.0010.00.3
Variable name: PREGFLUYR_A
Interview module: IMS(Adult.IMS)
Universe: GEN.SEX_FINAL[PX_A]=2
and
((GEN.AGE_FINAL[PX_A]=18-49
or
GEN.AGE_FINAL[PX_A] IN (DK,RF)) and (Adult.BMI.PREGNOW_A IN (2,DK)
OR (Adult.BMI.PREGNOW_A=1 and GEN.INTERVIEW_MONTH IN (4,5,6,7)))
Question Text:
Response:
Fills:
Were you pregnant any time ^AUGUSTYEAR?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^AUGUSTYEAR
If INTERVIEW_MONTH=1-3 "since August 1st,
^LASTYEAR"
If
INTERVIEW_MONTH=4-7
"from
August
^LASTYEAR through March ^YEAR"
If INTERVIEW_MONTH=8-12 "since August 1st,
^YEAR"
Page 171 of 306
Skip Instructions: <1,2,DK> [goto LIVEBIRTH_A]
[goto SHTFLU12M_A]
Question ID: IMS.0020.00.3
Variable name: LIVEBIRTH_A
Interview module: IMS(Adult.IMS)
Universe: GEN.SEX_FINAL=2
and
(GEN.AGE_FINAL[PX_A]=18-49
or
GEN.AGE_FINAL[PX_A] IN (DK,RF)) and Adult.BMI.PREGNOW_A ne RF
and PREGFLUYR_A ne RF
Question Text:
Response:
During the past 12 months, did you have a pregnancy that ended in a live birth?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto SHTFLU12M_A]
Question ID: IMS.0030.00.1
Question Text:
Response:
Variable name: SHTFLU12M_A
Interview module: IMS(Adult.IMS)
There are two types of flu vaccinations. One is a shot and the other is a spray,
mist, or drop in the nose. During the past 12 months, have you had a flu
vaccination? Read if necessary: A flu vaccination is usually given in the fall and
protects against influenza for the flu season.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto SHTFLUM_A]
<2,RF,DK> [goto SHTPNUEV_A]
Page 172 of 306
Question ID: IMS.0040.01.1
Variable name: SHTFLUM_A
Interview module: IMS(Adult.IMS)
Universe: SHTFLU12M_A=1
Question Text:
Response:
1 of 2 During what month and year did you receive your most recent flu
vaccine?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
DK:
RF:
January
February
March
April
May
June
July
August
September
October
November
December
Don't Know
Refused
Skip Instructions: <1-12,DK> [goto SHTFLUY_A]
if Adult.BMI.PREGNOW_A=1 and GEN.INTERVIEW_MONTH IN
(1,2,3,8,9,10,11,12) [goto FLUPREG_A]
elseif PREGFLUYR_A=1 [goto FLUPREG2_A]
else [goto SHTPNUEV_A]
Question ID: IMS.0040.02.1
Variable name: SHTFLUY_A
Interview module: IMS(Adult.IMS)
Universe: SHTFLUM_A IN (1-12,DK)
Question Text:
Response:
2 of 2
DK:
RF:
Enter year of most recent flu vaccine.
Don't Know
Refused
Page 173 of 306
Skip Instructions:
if SHTFLUM_A and SHTFLUY_A = a future date [goto ERR1_SHTFLUY_A]
elseif SHTFLUM_A and SHTFLUY_A = a date before 12 months ago [goto
ERR2_SHTFLUY_A]
elseif
PREGNOW_A=1
and
GEN.INTERVIEW_MONTH
IN
(1,2,3,8,9,10,11,12) [goto FLUPREG_A]
elseif PREGFLUYR_A=1 [goto FLUPREG2_A]
else [goto SHTPNUEV_A]
Check Name: ERR1_SHTFLUY_A
Text:
{check ERR1_SHTFLUY_A}
Future date invalid.
Please correct.
Hard / Soft Edit: Hard
Universe: SHTFLUM_A + SHTFLUY_A= future date
Check Name: ERR2_SHTFLUY_A
Text:
{check ERR2_SHTFLUY_A}
Date more than 12 months ago.
Please correct.
Hard / Soft Edit: Hard
Universe: SHTFLUM_A + SHTFLUY_A= a date before 12 months ago
Question ID: IMS.0050.00.3
Variable name: FLUPREG_A
Interview module: IMS(Adult.IMS)
Universe: GEN.SEX_FINAL[PX_A]=2
and
(GEN.AGE_FINAL[PX_A]=18-49
or
GEN.AGE_FINAL[PX_A] IN (DK,RF)) and Adult.BMI.PREGNOW_A=1 and
SHTFLU12M_A=1 and GEN.INTERVIEW_MONTH IN (1,2,3,8,9,10,11,12)
Question Text:
Did you get a flu vaccination before or during your current pregnancy?
Response:
Page 174 of 306
1.
2.
DK:
RF:
Before pregnancy
During pregnancy
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto SHTPNUEV_A]
Question ID: IMS.0060.00.3
Variable name: FLUPREG2_A
Interview module: IMS(Adult.IMS)
Universe: GEN.SEX_FINAL[PX_A]=2
and
(GEN.AGE_FINAL[PX_A]=18-49
GEN.AGE_FINAL[PX_A] IN (DK,RF)) and PREGFLUYR_A=1
SHTFLU12M_A=1
Question Text:
Response:
Fills:
or
and
Earlier you said you were pregnant sometime ^AUGUSTYEAR. Did you get a
flu vaccination before, during, or after your pregnancy?
1.
2.
3.
DK:
RF:
Before pregnancy
During pregnancy
After pregnancy
Don't Know
Refused
^AUGUSTYEAR
If INTERVIEW_MONTH=1-3 "since August 1st,
^LASTYEAR"
If
INTERVIEW_MONTH=4-7
"from
August
^LASTYEAR through March ^YEAR"
If INTERVIEW_MONTH=8-12 "since August 1st,
^YEAR"
Skip Instructions: <1-3,RF,DK> [goto SHTPNUEV_A]
Page 175 of 306
Question ID: IMS.0070.00.1
Question Text:
Response:
Variable name: SHTPNUEV_A
Interview module: IMS(Adult.IMS)
A pneumonia shot is also known as a pneumococcal vaccine. Have you EVER
had a pneumonia shot? Read if necessary: There are two types of pneumonia
shots: polysaccharide, also known as Pneumovax®, and conjugate, also known as
Prevnar®.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto SHTPNEUNB_A]
<2,RF,DK> if GEN.AGE_FINAL[PX_A] ge 50 [goto SHTSHINGLE_A]
else if (GEN.AGE_FINAL[PX_A] le 49 or GEN.AGE_FINAL[PX_A] IN (DK,RF))
and LIVEBIRTH_A=1 [goto TDAPPREG_A]
else [goto SHTHEPB_A]
Question ID: IMS.0080.00.1
Variable name: SHTPNEUNB_A
Interview module: IMS(Adult.IMS)
Universe: SHTPNUEV_A=1
Question Text:
Response:
How many pneumonia shots have you ever had?
1.
2.
3.
DK:
RF:
One pneumonia shot
Two pneumonia shots
More than two pneumonia shots
Don't Know
Refused
Skip Instructions: <1,2,3,RF,DK> if GEN.AGE_FINAL[PX_A] ge 50 [goto SHTSHINGLE_A]
elseif LIVEBIRTH_A=1 [goto TDAPPREG_A]
else [goto SHTHEPB_A]
Page 176 of 306
Question ID: IMS.0090.00.3
Variable name: SHTSHINGLE_A
Interview module: IMS(Adult.IMS)
Universe: GEN.AGE_FINAL[PX_A] ge 50
Question Text:
Response:
Have you had a vaccine for shingles? Read if necessary: Shingles is an illness
that results in a rash or blisters on the skin, and is usually painful. There are two
vaccines that have been used for for shingles. The first was Zostavax®, which
required one shot and was made available in 2006. The other is Shingrix®, a new
vaccine which requires two shots and has been available since 2017.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto ZOSTAVAX1_A]
<2,RF,DK> [goto SHTHEPB_A]
Question ID: IMS.0100.00.3
Variable name: ZOSTAVAX1_A
Interview module: IMS(Adult.IMS)
Universe: AGE_FINAL[PX_A] ge 50 and SHTSHINGLE_A=1
Question Text:
Response:
There are two vaccines that have been used for shingles. The first was
Zostavax®, which required one shot and was made available in 2006. The other
is Shingrix®, a new vaccine which requires 2 shots and has been available
since 2017. Have you EVER had Zostavax®, the shingles vaccine that required
one shot?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto ZOSTAVAXYR_A]
<2,RF,DK> [goto SHINGRIX1_A]
Page 177 of 306
Question ID: IMS.0110.00.3
Variable name: ZOSTAVAXYR_A
Interview module: IMS(Adult.IMS)
Universe: AGE_FINAL[PX_A] ge 50 and ZOSTAVAX1_A=1
Question Text:
Response:
What year did you get your most recent Zostavax® shot?
DK:
RF:
Don't Know
Refused
Skip Instructions: <1900-2030> if future date [goto ERR1_ZOSTAVAXYR_A]
elseif date before birth [goto ERR2_ZOSTAVAXYR_A]
else [goto SHINGRIX1_A]
[goto ZOSTAWHEN_A]
Check Name: ERR1_ZOSTAVAXYR_A
Text:
{check ERR1_ZOSTAVAXYR_A}
Future date invalid.
Please correct.
Hard / Soft Edit: Hard
Universe: ZOSTAVAXYR_A= future date
Check Name: ERR2_ZOSTAVAXYR_A
Text:
{check ERR2_ZOSTAVAXYR_A} Date of most recent Zostavax® shot is prior to
Sample Adult's birth. Please correct.
Hard / Soft Edit: Hard
Universe: ZOSTAVAXYR_A= a date before Sample Adult's birth
Page 178 of 306
Question ID: IMS.0120.00.3
Variable name: ZOSTAWHEN_A
Interview module: IMS(Adult.IMS)
Universe: GEN.AGE_FINAL[PX_A] ge 50 and ZOSTAVAXYR_A IN (DK,RF)
Question Text:
Response:
Was it before 2018?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto SHINGRIX1_A]
Question ID: IMS.0130.00.3
Variable name: SHINGRIX1_A (update Spanish
Interview
text)
module: IMS(Adult.IMS)
Universe: GEN.AGE_FINAL[PX_A] ge 50 and SHTSHINGLE_A=1
Question Text:
Response:
Have you EVER had Shingrix®, the new shingles vaccine which requires 2
shots and has been available since 2017?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto SHINGRIXNB_A]
<2,RF,DK> else [goto SHTHEPB_A]
Question ID: IMS.0140.00.3
Variable name: SHINGRIXNB_A
Interview module: IMS(Adult.IMS)
Universe: GEN.AGE_FINAL[PX_A] GE 50 and SHINGRIX1_A=1
Question Text:
How many Shingrix® shots have you ever had?
Response:
Page 179 of 306
1.
2.
DK:
RF:
One Shingrix shot
Two Shingrix shots
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto SHINGRIXYR_A]
Question ID: IMS.0150.00.3
Variable name: SHINGRIXYR_A
Interview module: IMS(Adult.IMS)
Universe: GEN.AGE_FINAL[PX_A] ge 50 and SHINGRIX1_A=1
Question Text:
Response:
What year did you get your most recent Shingrix® shot?
DK:
RF:
Don't Know
Refused
Skip Instructions: <1900-2030> if future date [goto ERR1_SHINGRIXYR_A]
elseif date prior to birth [goto ERR2_SHINGRIXYR_A]
else [goto SHTHEPB_A]
[goto SHINGWHEN_A]
Check Name: ERR1_SHINGRIXYR_A
Text:
{check ERR1_SHINGRIXYR_A}
Future date invalid.
Hard / Soft Edit: Hard
Universe: SHINGRIXYR_A= future date
Page 180 of 306
Please correct.
Check Name: ERR2_SHINGRIXYR_A
Text:
{check ERR2_SHINGRIXYR_A} Date of most recent Shingrix® shot is prior to
Sample Adult's birth. Please correct.
Hard / Soft Edit: Hard
Universe: SHINGRIXYR_A= a date before Sample Adult's birth
Question ID: IMS.0160.00.3
Variable name: SHINGWHEN_A
Interview module: IMS(Adult.IMS)
Universe: GEN.AGE_FINAL[PX_A] ge 50 and SHINGRIXYR_A IN (DK,RF)
Question Text:
Response:
Was it before 2018?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto SHTHEPB_A]
Question ID: IMS.0170.00.03
Variable name: TDAPPREG_A
Interview module: IMS(Adult.IMS)
Universe: GEN.SEX_FINAL[PX_A]=2 and (GEN.AGE_FINAL[PX_A]
GEN.AGE_FINAL[PX_A] IN (DK,RF)) and LIVEBIRTH_A=1
Question Text:
Response:
le
49
or
A Tdap vaccination is a tetanus booster shot that also includes pertussis
(per-TUH-sis) or whooping cough vaccine. Earlier you said that you had a
pregnancy that ended in a live birth during the past 12 months. Did you receive
a Tdap vaccine during this pregnancy?
1.
Yes
Page 181 of 306
2.
DK:
RF:
No
Don't Know
Refused
Skip Instructions: <1,2,DK,RF> [goto SHTHEPB_A]
Question ID: IMS.0180.00.3
Question Text:
Response:
Variable name: SHTHEPB_A
Interview module: IMS(Adult.IMS)
The hepatitis B vaccine is given in three separate doses. Although it can be
given as a combination vaccination with hepatitis A, it is is different from the
hepatitis A vaccine. Have you EVER received the hepatitis B vaccine? Read
if necessary: The hepatitis B vaccine has been available since 1991. It is
recommended for newborn infants, adolescents, and people such as health care
workers, who may be exposed to the hepatitis B virus.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,DK,RF> [goto SHTHEPA_A]
Question ID: IMS.0190.00.3
Question Text:
Response:
Variable name: SHTHEPA_A
Interview module: IMS(Adult.IMS)
The hepatitis A vaccine is given as a two dose series routinely to some children
starting at 1 year of age, and to some adults and people who travel outside the
United States. Although it can be given as a combination vaccine with hepatitis
B, it is different from the hepatitis B shot, and has only been available since
1995. Have you EVER received the hepatitis A vaccine?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 182 of 306
Skip Instructions: <1,2,DK,RF> if HEPEV_A=1 [goto WORKHEALTH_A]
else if HEPEV_A ne 1 [goto LIVEHEP_A]
Question ID: IMS.0200.00.3
Variable name: LIVEHEP_A (needs Spanish
Interview
translation)
module: IMS(Adult.IMS)
Universe: RCN.HEPEV_A ne 1
Question Text:
Response:
Have you ever lived with someone who had hepatitis?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto WORKHEALTH_A]
Question ID: IMS.0220.00.3
Question Text:
Response:
Variable name: WORKHEALTH_A
Interview module: IMS(Adult.IMS)
In your work or volunteer activities, do you provide direct medical care to
patients, such as being a doctor, nurse, dentist, therapist, home health care
worker, or emergency responder?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto TRAVEL_A]
<2,RF,DK> [goto WRKHLTHFC_A]
Page 183 of 306
Question ID: IMS.0230.00.3
Variable name: WRKHLTHFC_A
Interview module: IMS(Adult.IMS)
Universe: WORKHEALTH_A IN (2,DK,RF)
Question Text:
Response:
Even if you do not provide direct medical care to patients, do you do any kind
of work or volunteer activities in a health care facility, such as in a hospital,
doctor's office, dentist's office, clinic, nursing home, or residential care home?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto TRAVEL_A]
Question ID: IMS.0240.00.3
Question Text:
Response:
Variable name: TRAVEL_A
Interview module: IMS(Adult.IMS)
Since 1995, have you traveled to any countries OTHER than Japan, Australia,
New Zealand, Canada, and those in Europe?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: CGR.0010.00.1
Question Text:
Response:
Variable name: HOMEHC12M_A
Interview module: CGR(Adult.CGR)
During the past 12 months, did you receive care at home from a nurse or other
health professional?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 184 of 306
Skip Instructions: <1,2,RF,DK> [goto HOMECAREDG_A]
Question ID: CGR.0020.00.4
Question Text:
Response:
Variable name: HOMECAREDG_A
Interview module: CGR(Adult.CGR)
Was there any time when you needed care at home from a nurse or other health
professional but DID NOT GET IT because of the coronavirus pandemic?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto FAMCARE12M_A]
Question ID: CGR.0030.00.4
Question Text:
Response:
Variable name: FAMCARE12M_A
Interview module: CGR(Adult.CGR)
During the past 12 months, did you receive care at home from a friend or family
member? If the respondent asks what is meant by the term "care," say: "A wide
range of activities that a person may need help with can be considered care. For
example, care at home can include personal tasks such as giving medications or
helping with eating, dressing, or bathing or household tasks such as cleaning,
managing money, or preparing meals."
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto FAMCAREDNG_A]
Page 185 of 306
Question ID: CGR.0040.00.4
Question Text:
Response:
Variable name: FAMCAREDNG_A
Interview module: CGR(Adult.CGR)
Was there any time when you needed care at home from a friend or family
member but DID NOT GET IT because of the coronavirus pandemic?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> if HOMECAREDG_A=1
FAMCARECVD_A]
else [goto next section]
Question ID: CGR.0050.00.4
Variable name: FAMCARECVD_A
and
FAMCARE12M_A=1[goto
Interview module: CGR(Adult.CGR)
Universe: HOMECAREDG_A=1 and FAMCARE12M_A=1
Question Text:
Response:
Did a friend or family member provide some or all of the care that a nurse or
other health professional did not provide due to the coronavirus pandemic?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: ANX.0010.00.1
Question Text:
Variable name: ANXFREQ_A
Interview module: ANX(Adult.ANX)
How often do you feel worried, nervous or anxious? Would you say daily,
weekly, monthly, a few times a year, or never? If respondent asks whether they
are to answer about their emotional states after taking mood-regulating medications,
say: "Please answer based on your usual use of medication."
Response:
Page 186 of 306
1.
2.
3.
4.
5.
DK:
RF:
Daily
Weekly
Monthly
A few times a year
Never
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto ANXMED_A]
Question ID: ANX.0020.00.1
Question Text:
Response:
Variable name: ANXMED_A
Interview module: ANX(Adult.ANX)
Do you take prescription medication for these feelings?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,RF,DK> [goto ANXLEVEL_A]
<2> if ANXFREQ_A=5 [goto next section]
else [goto ANXLEVEL_A]
Question ID: ANX.0030.00.1
Variable name: ANXLEVEL_A
Interview module: ANX(Adult.ANX)
Universe: ANXFREQ_A IN (1,2,3,4,RF,DK) or ANXMED_A IN (1,RF,DK)
Question Text:
Response:
Thinking about the last time you felt worried, nervous or anxious, how would
you describe the level of these feelings? Would you say a little, a lot, or
somewhere in between?
1.
2.
3.
DK:
RF:
A little
A lot
Somewhere in between a little and a lot
Don't Know
Refused
Page 187 of 306
Skip Instructions: <1-3,RF,DK> [goto next section]
Question ID: DEP.0010.00.1
Question Text:
Response:
Variable name: DEPFREQ_A
Interview module: DEP(Adult.DEP)
How often do you feel depressed? Would you say daily, weekly, monthly, a few
times a year, or never? If respondent asks whether they are to answer about their
emotional states after taking mood-regulating medications, say: "Please answer
based on your usual use of medication."
1.
2.
3.
4.
5.
DK:
RF:
Daily
Weekly
Monthly
A few times a year
Never
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto DEPMED_A]
Question ID: DEP.0020.00.1
Question Text:
Response:
Variable name: DEPMED_A
Interview module: DEP(Adult.DEP)
Do you take prescription medication for depression?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,RF,DK> [goto DEPLEVEL_A]
<2> if DEPFREQ_A=5 [goto next section]
else [goto DEPLEVEL_A]
Page 188 of 306
Question ID: DEP.0030.00.1
Variable name: DEPLEVEL_A
Interview module: DEP(Adult.DEP)
Universe: (DEPFREQ_A IN (1,2,3,4,RF,DK)) or (DEPMED_A IN (1,RF,DK))
Question Text:
Response:
Thinking about the last time you felt depressed, how depressed did you feel?
Would you say a little, a lot, or somewhere in between?
1.
2.
3.
DK:
RF:
A little
A lot
Somewhere in between a little and a lot
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto next section]
Question ID: MHC.0010.00.2
Variable name: MHRX_A
Interview module: MHC(Adult.MHC)
Universe: ANX.ANXMED_A IN (2,RF,DK) and DEP.DEPMED_A IN (2,RF,DK)
Question Text:
Response:
During the past 12 months, did you take prescription medication to help you
with any other emotions or with your concentration, behavior or mental health?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto MHTHRPY_A]
Page 189 of 306
Question ID: MHC.0020.00.2
Question Text:
Response:
Variable name: MHTHRPY_A
Interview module: MHC(Adult.MHC)
During the past 12 months, did you receive counseling or therapy from a
mental health professional such as a psychiatrist, psychologist, psychiatric
nurse, or clinical social worker?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,RF,DK> [goto MHTPYNOW_A]
<2> [goto MHTHDLY_A]
Question ID: MHC.0030.00.2
Variable name: MHTPYNOW_A
Interview module: MHC(Adult.MHC)
Universe: MHTHRPY_A IN (1,RF,DK)
Question Text:
Response:
Are you currently receiving counseling or therapy from a mental health
professional?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto MHTHDLY_A]
Question ID: MHC.0040.00.2
Question Text:
Response:
Variable name: MHTHDLY_A
Interview module: MHC(Adult.MHC)
During the past 12 months, have you DELAYED getting counseling or therapy
from a mental health professional because of the cost?
1.
Yes
Page 190 of 306
2.
DK:
RF:
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto MHTHND_A]
Question ID: MHC.0050.00.2
Question Text:
Response:
Variable name: MHTHND_A
Interview module: MHC(Adult.MHC)
During the past 12 months, was there any time when you needed counseling or
therapy from a mental health professional, but DID NOT GET IT because of the
cost?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: SPD.0010.00.2
Question Text:
Response:
Variable name: SPDINTRO_A
Interview module: SPD(Adult.SPD)
Now I am going to ask you some questions about feelings you may have
experienced over the past 30 days. Enter '1' to continue.
1.
Enter 1 to Continue
Skip Instructions: <1> [goto SAD_A]
Page 191 of 306
Question ID: SPD.0020.00.2
Question Text:
Response:
Variable name: SAD_A
Interview module: SPD(Adult.SPD)
During the past 30 days, how often did you feel ...So sad that nothing could
cheer you up? Would you say all of the time, most of the time, some of the
time, a little of the time, or none of the time?
1.
2.
3.
4.
5.
DK:
RF:
all of the time
most of the time
some of the time
a little of the time
none of the time
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto NERVOUS_A]
Question ID: SPD.0030.00.2
Question Text:
Response:
Variable name: NERVOUS_A
Interview module: SPD(Adult.SPD)
During the past 30 days, how often did you feel ...Nervous? Would you say all
of the time, most of the time, some of the time, a little of the time, or none of the
time?
1.
2.
3.
4.
5.
DK:
RF:
all of the time
most of the time
some of the time
a little of the time
none of the time
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto RESTLESS_A]
Page 192 of 306
Question ID: SPD.0040.00.2
Question Text:
Response:
Variable name: RESTLESS_A
Interview module: SPD(Adult.SPD)
Read if necessary: During the past 30 days, how often did you feel ...Restless or
fidgety? Read if necesary: Would you say all of the time, most of the time, some of
the time, a little of the time, or none of the time?
1.
2.
3.
4.
5.
DK:
RF:
all of the time
most of the time
some of the time
a little of the time
none of the time
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto HOPELESS_A]
Question ID: SPD.0050.00.2
Question Text:
Response:
Variable name: HOPELESS_A
Interview module: SPD(Adult.SPD)
Read if necessary: During the past 30 days, how often did you feel ...Hopeless?
Read if necesary: Would you say all of the time, most of the time, some of the time, a
little of the time, or none of the time?
1.
2.
3.
4.
5.
DK:
RF:
all of the time
most of the time
some of the time
a little of the time
none of the time
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto EFFORT_A]
Page 193 of 306
Question ID: SPD.0060.00.2
Question Text:
Response:
Variable name: EFFORT_A
Interview module: SPD(Adult.SPD)
Read if necessary: During the past 30 days, how often did you feel ...That
everything was an effort? Read if necesary: Would you say all of the time, most of
the time, some of the time, a little of the time, or none of the time?
1.
2.
3.
4.
5.
DK:
RF:
all of the time
most of the time
some of the time
a little of the time
none of the time
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto WORTHLESS_A]
Question ID: SPD.0070.00.2
Question Text:
Response:
Variable name: WORTHLESS_A
Interview module: SPD(Adult.SPD)
Read if necessary: During the past 30 days, how often did you feel ...Worthless?
Read if necesary: Would you say all of the time, most of the time, some of the time, a
little of the time, or none of the time?
1.
2.
3.
4.
5.
DK:
RF:
all of the time
most of the time
some of the time
a little of the time
none of the time
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto next section]
Page 194 of 306
Question ID: PAI.0010.00.2
Question Text:
Response:
Variable name: PAIINTRO_A
Interview module: PAI(Adult.PAI)
The next question is about pain you may have had in the past three months.
Enter '1' to continue.
1.
Enter 1 to Continue
Skip Instructions: <1> [goto PAIFRQ3M_A]
Question ID: PAI.0020.00.2
Question Text:
Response:
Variable name: PAIFRQ3M_A
Interview module: PAI(Adult.PAI)
In the past three months, how often did you have pain? Would you say never,
some days, most days, or every day? If respondent asks whether they are to
answer about their pain when taking their medications, say: "Please answer based on
your usual use of medication."
1.
2.
3.
4.
DK:
RF:
Never
Some days
Most days
Every day
Don't Know
Refused
Skip Instructions: <1,RF,DK> [goto next section]
<2,3,4> [goto PAIAMNT_A]
Question ID: PAI.0030.00.2
Variable name: PAIAMNT_A
Interview module: PAI(Adult.PAI)
Universe: PAIFRQ3M_A IN (2,3,4)
Question Text:
Response:
Thinking about the last time you had pain, how much pain did you have? Would
you say a little, a lot, or somewhere in between?
1.
A little
Page 195 of 306
2.
3.
DK:
RF:
A lot
Somewhere in between a little and a lot
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto PAIWKLM3M_A]
Question ID: PAI.0040.00.2
Variable name: PAIWKLM3M_A
Interview module: PAI(Adult.PAI)
Universe: PAIFRQ3M_A IN (2,3,4)
Question Text:
Response:
Over the past three months, how often did your pain limit your life or work
activities? Would you say never, some days, most days, or every day?
1.
2.
3.
4.
DK:
RF:
Never
Some days
Most days
Every day
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto PAIAFFM3M_A]
Question ID: PAI.0050.00.2
Variable name: PAIAFFM3M_A
Interview module: PAI(Adult.PAI)
Universe: PAIFRQ3M_A IN (2,3,4)
Question Text:
Response:
Over the past three months, how often did YOUR pain affect your family and
significant others? Would you say never, some days, most days, or every day?
1.
2.
3.
4.
DK:
RF:
Never
Some days
Most days
Every day
Don't Know
Refused
Page 196 of 306
Skip Instructions: <1-4,RF,DK> [goto PAIBACK3M_A]
Question ID: PAI.0060.00.2
Variable name: PAIBACK3M_A
Interview module: PAI(Adult.PAI)
Universe: PAIFRQ3M_A IN (2,3,4)
Question Text:
Response:
The next set of questions are about the amount of pain you experience in
different locations. Over the past three months, how much have you been
bothered by ...Back pain? Would you say not at all, a little, a lot, or somewhere
in between?
1.
2.
3.
4.
DK:
RF:
Not at all
A little
A lot
Somewhere in between a little and a lot
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto PAIULMB3M_A]
Question ID: PAI.0070.00.2
Variable name: PAIULMB3M_A
Interview module: PAI(Adult.PAI)
Universe: PAIFRQ3M_A IN (2,3,4)
Question Text:
Response:
Read if necessary: Over the past three months, how much have you been bothered
by ...Pain in your hands, arms, or shoulders? Read if necessary: Would you
say not at all, a little, a lot, or somewhere in between?
1.
2.
3.
4.
DK:
RF:
Not at all
A little
A lot
Somewhere in between a little and a lot
Don't Know
Refused
Page 197 of 306
Skip Instructions: <1-4,RF,DK> [goto PAILLMB3M_A]
Question ID: PAI.0080.00.2
Variable name: PAILLMB3M_A
Interview module: PAI(Adult.PAI)
Universe: PAIFRQ3M_A IN (2,3,4)
Question Text:
Response:
Read if necessary: Over the past three months, how much have you been bothered
by ...Pain in your hips, knees, or feet? Read if necessary: Would you say not at
all, a little, a lot, or somewhere in between?
1.
2.
3.
4.
DK:
RF:
Not at all
A little
A lot
Somewhere in between a little and a lot
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto PAIHDFC3M_A]
Question ID: PAI.0090.00.2
Variable name: PAIHDFC3M_A
Interview module: PAI(Adult.PAI)
Universe: PAIFRQ3M_A IN (2,3,4)
Question Text:
Response:
Read if necessary: Over the past three months, how much have you been bothered
by ...Headache or migraine? Read if necessary: Would you say not at all, a little,
a lot, or somewhere in between?
1.
2.
3.
4.
DK:
RF:
Not at all
A little
A lot
Somewhere in between a little and a lot
Don't Know
Refused
Page 198 of 306
Skip Instructions: <1-4,RF,DK> [goto PAIAPG3M_A]
Question ID: PAI.0100.00.2
Variable name: PAIAPG3M_A
Interview module: PAI(Adult.PAI)
Universe: PAIFRQ3M_A IN (2,3,4)
Question Text:
Response:
Read if necessary: Over the past three months, how much have you been bothered
by ...Abdominal, pelvic, or genital pain? Read if necessary: Would you say not
at all, a little, a lot, or somewhere in between?
1.
2.
3.
4.
DK:
RF:
Not at all
A little
A lot
Somewhere in between a little and a lot
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto PAITOOTH_A]
Question ID: PAI.0110.00.2
Variable name: PAITOOTH3M_A
Interview module: PAI(Adult.PAI)
Universe: PAIFRQ3M_A IN (2,3,4)
Question Text:
Response:
Read if necessary: Over the past three months, how much have you been bothered
by ...Toothache or jaw pain? Read if necessary: Would you say not at all, a little,
a lot, or somewhere in between?
1.
2.
3.
4.
DK:
RF:
Not at all
A little
A lot
Somewhere in between a little and a lot
Don't Know
Refused
Page 199 of 306
Skip Instructions: <1-4,RF,DK> [goto next section]
Question ID: REP.0010.00.2
Question Text:
Response:
Variable name: REPSTRAIN_A
Interview module: REP(Adult.REP)
The next set of questions asks about injuries. The first question is about
repetitive strain injuries. By this, we mean injuries caused by repeating the
same movement over an extended period. Examples include carpal tunnel
syndrome, tennis elbow, or tendonitis. During the past 3 months, did you have
any injuries due to repetitive strain?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto REPLIMIT_A]
<2,RF,DK> [goto next section]
Question ID: REP.0020.00.2
Variable name: REPLIMIT_A
Interview module: REP(Adult.REP)
Universe: REPSTRAIN_A=1
Question Text:
Response:
Were any repetitive strain injuries serious enough to limit your usual activities
for at least 24 hours?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto REPSAWDOC_A]
<2,RF,DK> [goto next section]
Page 200 of 306
Question ID: REP.0030.00.2
Variable name: REPSAWDOC_A
Interview module: REP(Adult.REP)
Universe: REPLIMIT_A=1
Question Text:
Response:
For the next questions, please think only about the repetitive strain injuries that
limited your usual activities for at least 24 hours after the injury occurred.
During the past 3 months, did you talk to or see a doctor or other health
professional about your repetitive strain injuries?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto REPWRKDAYS_A]
Question ID: REP.0040.00.2
Variable name: REPWRKDAYS_A
Interview module: REP(Adult.REP)
Universe: REPLIMIT_A=1
Question Text:
Response:
During the past 3 months, how many days of work did you miss because of
your repetitive strain injuries? If respondent says none, no, or 0 days, ask: Did
you work at all the past 3 months? Enter '90' if respondent says they missed every
day of work in the past 3 months. Enter '91' if respondent says they did not work in
the past 3 months.
DK:
RF:
Don't Know
Refused
Skip Instructions: <1-90,DK> [goto REPFUTWORK_A]
<0,RF> [goto REPSTOPCHG_A]
<91> [goto REPWRKCAUS_A]
Page 201 of 306
Question ID: REP.0050.00.2
Variable name: REPFUTWRK_A
Interview module: REP(Adult.REP)
Universe: REPWRKDAYS_A IN (1-90,DK)
Question Text:
Response:
Do you expect to miss any more days of work because of your repetitive strain
injuries?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto REPSTOPCHG_A]
Question ID: REP.0060.00.2
Variable name: REPSTOPCHG_A
Interview module: REP(Adult.REP)
Universe: REPWRKDAYS_A IN (0-90,RF,DK)
Question Text:
Response:
During the past 3 months, did you stop working or change jobs because of
your repetitive strain injuries? Enter 'no' if respondent says they did not work in
the past 3 months.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto REPREDUCE_A]
Page 202 of 306
Question ID: REP.0070.00.2
Variable name: REPREDUCE_A
Interview module: REP(Adult.REP)
Universe: REPWRKDAYS_A IN (0-90,RF,DK)
Question Text:
Response:
During the past 3 months, did you make a major change in your work activities,
such as taking on fewer hours or lighter duties, because of your repetitive
strain injuries? Enter 'no' if respondent says they did not work in the past 3
months.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto REPWRKCAUS_A]
Question ID: REP.0080.00.2
Variable name: REPWRKCAUS_A
Interview module: REP(Adult.REP)
Universe: REPLIMIT_A=1
Question Text:
Response:
Have you ever been told by a doctor or other health professional that any of
your repetitive strain injuries were likely to be work-related?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Page 203 of 306
Question ID: INJ.0010.00.2
Question Text:
Response:
Variable name: INJINTRO_A
Interview module: INJ(Adult.INJ)
The next set of questions asks about SUDDEN injuries. People can be injured
accidentally or on purpose. They may hurt themselves or others may cause
them to be hurt. Enter '1' to continue.
1.
Enter 1 to Continue
Skip Instructions: <1> [goto ANYINJURY_A]
Question ID: INJ.0020.00.2
Question Text:
Response:
Fills:
Variable name: ANYINJURY_A
Interview module: INJ(Adult.INJ)
^NOTREPS the past 3 months, did you have an accident or an injury where any
part of your body was hurt?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^NOTREPS
prefix any injury
Skip Instructions: <1> [goto INJLIMIT_A]
<2,RF,DK> [goto next section]
Question ID: INJ.0030.00.2
Variable name: INJLIMIT_A
Interview module: INJ(Adult.INJ)
Universe: ANYINJURY_A=1
Question Text:
Response:
Did any of these injuries limit your usual activities for at least 24 hours after the
injury occurred?
1.
Yes
Page 204 of 306
2.
DK:
RF:
No
Don't Know
Refused
Skip Instructions: <1> [goto NUMINJ_A]
<2,RF,DK> [goto next section]
Question ID: INJ.0040.00.2
Variable name: NUMINJ_A
Interview module: INJ(Adult.INJ)
Universe: INJLIMIT_A=1
Question Text:
Response:
Fills:
For the next questions, please think only about the significant injuries that
occurred during the past 3 months. By significant, I mean those injuries that
limited your usual activities for at least 24 hours after the injury occurred.
^NOTREPS the past 3 months, how many times did these accidents or injury
events occur? Enter '96' if number is 96 or greater.
DK:
RF:
Don't Know
Refused
^NOTREPS
prefix any injury
Skip Instructions: <1-9,RF,DK> [goto INJHOME_A]
<10-96> [goto ERR1_NUMINJ_A], then [goto INJHOME_A]
Check Name: ERR1_NUMINJ_A
Text:
{signal ERR1_NUMINJ_A}
verify.
^NUMINJ_A is an unusually large number. Please
Hard / Soft Edit: Soft
Fills:
^NUMINJ_A
number of injuries
Universe: NUMINJ_A=10-96
Page 205 of 306
Question ID: INJ.0050.00.2
Variable name: INJHOME_A
Interview module: INJ(Adult.INJ)
Universe: INJLIMIT_A=1
Question Text:
Response:
Fills:
During the past 3 months, did ^siginj_A occur while you were at your home?
Read if necessary: Include the yards, garage, basement, and other places on the
home property.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^siginj_A
this injury or any injury fill
Skip Instructions: <1> if NUMINJ_A=1 [goto INJSPORTS_A]
elseif NUMINJ_A=2-96,RF,DK [goto INJWORK_A]
<2,RF,DK> [goto INJWORK_A]
Question ID: INJ.0060.00.2
Variable name: INJWORK_A
Interview module: INJ(Adult.INJ)
Universe: (NUMINJ_A IN (2-96,RF,DK) or (NUMINJ_A=1 and INJHOME_A IN
(2,RF,DK)))
Question Text:
Response:
Fills:
During the past 3 months, did ^siginj_A occur while you were working at a job
or business? Enter 'no' if respondent says they did not work in the past 3 months.
1.
2.
DK:
RF:
^siginj_A
Yes
No
Don't Know
Refused
this injury or any injury fill
Page 206 of 306
Skip Instructions: <1,2,RF,DK> [goto INJSPORTS_A]
Question ID: INJ.0070.00.2
Variable name: INJSPORTS_A
Interview module: INJ(Adult.INJ)
Universe: INJLIMIT_A=1
Question Text:
Response:
Fills:
During the past 3 months, did ^siginj_A occur while you were playing sports or
exercising, including walking, biking, or running, playing baseball, basketball,
football or doing any other physical activity? Read if necessary: Include
recreational sports such as skating, skiing, tennis, golf, bowling, or fishing.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^siginj_A
this injury or any injury fill
Skip Instructions: <1,2,RF,DK> [goto INJFALL_A]
Question ID: INJ.0080.00.2
Variable name: INJFALL_A
Interview module: INJ(Adult.INJ)
Universe: INJLIMIT_A=1
Question Text:
Response:
Fills:
During the past 3 months, did ^siginj_A occur as a result of a fall or falling?
1.
2.
DK:
RF:
^siginj_A
Yes
No
Don't Know
Refused
this injury or any injury fill
Page 207 of 306
Skip Instructions: <1> if NUMINJ_A=1 [goto INJMOTOR_A]
elseif NUMINJ_A IN (2-96,RF,DK) and INJHOME_A=1 [goto INJFALLHOM_A]
elseif NUMINJ_A IN (2-96,RF,DK) and INJWORK_A=1 [goto INJFALLWRK_A]
else [goto INJMOTOR_A]
<2,RF,DK> [goto INJMOTOR_A]
Question ID: INJ.0090.00.2
Variable name: INJFALLHOM_A
Interview module: INJ(Adult.INJ)
Universe: NUMINJ_A IN (2-96,RF,DK) and INJFALL_A=1 and INJHOME_A=1
Question Text:
Response:
Did any fall occur while you were at your home?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> if INJWORK_A=1 [goto INJFALLWRK_A]
else [goto INJMOTOR_A]
Question ID: INJ.0100.00.2
Variable name: INJFALLWRK_A
Interview module: INJ(Adult.INJ)
Universe: NUMINJ_A IN (2-96,RF,DK) and INJFALL_A=1 and INJWORK_A=1
Question Text:
Response:
Did any fall occur while you were working at a job or business?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto INJMOTOR_A]
Page 208 of 306
Question ID: INJ.0110.00.2
Variable name: INJMOTOR_A
Interview module: INJ(Adult.INJ)
Universe: INJLIMIT_A=1
Question Text:
Response:
Fills:
During the past 3 months, did ^siginj_A occur as a result of being in a motor
vehicle crash or being hit by a motor vehicle while walking or biking? Read if
necessary: Motor vehicles include cars, trucks, vans, buses, motorcycles, motorized
scooters, motorized wheelchairs, motorized carts, tractors, ATVs, snowmobiles, dune
buggies, and other motorized vehicles.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^siginj_A
this injury or any injury fill
Skip Instructions: <1> [goto INJMVTYPE_A]
<2,RF,DK> [goto INJCHORES_A]
Question ID: INJ.0120.00.2
Variable name: INJMVTYPE_A
Interview module: INJ(Adult.INJ)
Universe: INJMOTOR_A=1
Question Text:
Response:
Were you a driver, passenger, bicyclist, pedestrian, or doing something else
when this occurred?
Enter all that apply, separate with commas.
1.
2.
3.
4.
5.
DK:
RF:
Driver
Passenger
Bicyclist
Pedestrian
Something else
Don't Know
Refused
Page 209 of 306
Skip Instructions: <1-5,RF,DK> [goto INJCHORES_A]
Question ID: INJ.0130.00.2
Variable name: INJCHORES_A
Interview module: INJ(Adult.INJ)
Universe: INJLIMIT_A=1
Question Text:
Response:
Fills:
During the past 3 months, did ^siginj_A occur while you were doing household
activities, such as housework, cooking, home maintenance, or yardwork?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^siginj_A
this injury or any injury fill
Skip Instructions: <1,2,RF,DK> [goto INJSAWDOC_A]
Question ID: INJ.0140.00.2
Variable name: INJSAWDOC_A
Interview module: INJ(Adult.INJ)
Universe: INJLIMIT_A=1
Question Text:
Response:
Fills:
During the past 3 months, did you see or talk to a doctor or other health
professional about ^siginj_A?
1.
2.
DK:
RF:
^siginj_A
Yes
No
Don't Know
Refused
this injury or any injury fill
Page 210 of 306
Skip Instructions: <1> if UTZ.EMERGE12M_A IN (1-96,RF,DK) [goto INJER_A]
elseif UTZ.HOSPONGT_A IN (1,RF,DK) [goto INJHOSP_A]
else [goto INJBONES_A]
<2,RF,DK> [goto INJWRKDAYS_A]
Question ID: INJ.0150.00.2
Variable name: INJER_A
Interview module: INJ(Adult.INJ)
Universe: INJSAWDOC_A=1 and UTZ.EMERGE12M_A IN (1-96,RF,DK)
Question Text:
Response:
Fills:
During the past 3 months, did you go to an emergency room because of
^siginj_A?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^siginj_A
this injury or any injury fill
Skip Instructions: <1,2,RF,DK> if UTZ.HOSPONGT_A IN (1,RF,DK) [goto INJHOSP_A]
else [goto INJBONES_A]
Question ID: INJ.0160.00.2
Variable name: INJHOSP_A
Interview module: INJ(Adult.INJ)
Universe: INJSAWDOC_A=1 and UTZ.HOSPONGT_A IN (1,RF,DK)
Question Text:
Response:
During the past 3 months, were you hospitalized overnight because of
^siginj_A?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 211 of 306
Fills:
^siginj_A
this injury or any injury fill
Skip Instructions: <1,2,RF,DK> [goto INJBONES_A]
Question ID: INJ.0170.00.2
Variable name: INJBONES_A
Interview module: INJ(Adult.INJ)
Universe: INJSAWDOC_A=1
Question Text:
Response:
Fills:
During the past 3 months, did you have any broken bones as a result of
^siginj_A?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^siginj_A
this injury or any injury fill
Skip Instructions: <1,2,RF,DK> [goto INJSTITCH_A]
Question ID: INJ.0180.00.2
Variable name: INJSTITCH_A
Interview module: INJ(Adult.INJ)
Universe: INJSAWDOC_A=1
Question Text:
Response:
During the past 3 months, did you get any stitches or staples because of
^siginj_A?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 212 of 306
Fills:
^siginj_A
this injury or any injury fill
Skip Instructions: <1,2,RF,DK> [goto INJWRKDAYS_A]
Question ID: INJ.0190.00.2
Variable name: INJWRKDAYS_A
Interview module: INJ(Adult.INJ)
Universe: INJLIMIT_A=1
Question Text:
Response:
Fills:
During the past 3 months, how many days of work did you miss because of
^siginj_A? If respondent says none, no, or 0 days, ask: Did you work at all the
past 3 months? Enter '90' if respondent says they missed every day of work in the
past 3 months. Enter '91' if respondent says they did not work in the past 3 months.
DK:
RF:
Don't Know
Refused
^siginj_A
this injury or any injury fill
Skip Instructions: <1-90,DK> [goto INJFUTWRK_A]
<0,RF> [goto INJSTOPCHG_A]
<91> [goto next section]
Question ID: INJ.0200.00.2
Variable name: INJFUTWRK_A
Interview module: INJ(Adult.INJ)
Universe: INJWRKDAYS_A IN (1-90,DK)
Question Text:
Response:
Do you expect to miss any more days of work because of ^siginj_A that
occurred during the past 3 months?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 213 of 306
Fills:
^siginj_A
this injury or any injury fill
Skip Instructions: <1,2,RF,DK> [goto INJSTOPCHG_A]
Question ID: INJ.0210.00.2
Variable name: INJSTOPCHG_A
Interview module: INJ(Adult.INJ)
Universe: INJWRKDAYS_A IN (0-90,RF,DK)
Question Text:
Response:
Fills:
During the past 3 months, did you stop working or change jobs because of
^siginj_A? Enter 'no' if respondent says they did not work in the past 3 months.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^siginj_A
this injury or any injury fill
Skip Instructions: <1,2,RF,DK> [goto INJREDUCE_A]
Question ID: INJ.0220.00.2
Variable name: INJREDUCE_A
Interview module: INJ(Adult.INJ)
Universe: INJWRKDAYS_A IN (0-90,RF,DK)
Question Text:
Response:
During the past 3 months, did you make a major change in your work activities,
such as taking on fewer hours or lighter duties, because of ^siginj_A? Enter
'no' if respondent says they did not work in the past 3 months.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 214 of 306
Fills:
^siginj_A
this injury or any injury fill
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: TSM.0010.00.3
Question Text:
Response:
Variable name: SMELLDF_A
Interview module: TSM(Adult.TSM)
During the past 12 months, have you had difficulty with your sense of smell or
ability to detect odors? Would you say no difficulty, a little difficulty, moderate
difficulty, a lot of difficulty, or you cannot smell at all?
1.
2.
3.
4.
5.
DK:
RF:
No difficulty
A little difficulty
Moderate difficulty
A lot of difficulty
Cannot smell at all
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto SMELLCOMP_A]
Question ID: TSM.0020.00.3
Question Text:
Response:
Fills:
Variable name: SMELLCOMP_A
Interview module: TSM(Adult.TSM)
How would you rate your ability to smell now as compared to when you were
^25year5yearsyounger? Is it better, worse, or is there no change?
1.
2.
3.
DK:
RF:
Better
Worse
No Change
Don't Know
Refused
^25year5yearsyounger
fill "25 years old " if age 30+
age 18-29
Page 215 of 306
fill "5 years younger" if
Skip Instructions: <1-3,RF,DK> [goto SMELLPHT_A]
Question ID: TSM.0030.00.3
Question Text:
Response:
Variable name: SMELLPHT_A
Interview module: TSM(Adult.TSM)
During the past 12 months, did you sometimes smell an unpleasant, bad,
metallic, or burning odor when nothing was there?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto TASTEDF_A]
Question ID: TSM.0040.00.3
Question Text:
Response:
Variable name: TASTEDF_A
Interview module: TSM(Adult.TSM)
During the past 12 months, have you had difficulty with your ability to taste
sweet, sour, salty, or bitter foods and drinks? Would you say no difficulty, a
little difficulty, moderate difficulty, a lot of difficulty, or you cannot taste at all?
1.
2.
3.
4.
5.
DK:
RF:
No difficulty
A little difficulty
Moderate difficulty
A lot of difficulty
Cannot taste at all
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto TASTECOMP_A]
Page 216 of 306
Question ID: TSM.0050.00.3
Question Text:
Response:
Fills:
Variable name: TASTECOMP_A
Interview module: TSM(Adult.TSM)
Compared to when you were ^25year5yearsyounger, how would you rate your
ability to taste sweet, sour, salty, or bitter foods and drinks? Is it better, worse,
or is there no change?
1.
2.
3.
DK:
RF:
Better
Worse
No Change
Don't Know
Refused
^25year5yearsyounger
fill "25 years old " if age 30+
age 18-29
fill "5 years younger" if
Skip Instructions: <1-3,RF,DK> [goto TASTEFLAV_A]
Question ID: TSM.0060.00.3
Question Text:
Response:
Fills:
Variable name: TASTEFLAV_A
Interview module: TSM(Adult.TSM)
Compared to when you were ^25year5yearsyounger, how would you rate your
ability to taste flavors such as chocolate, vanilla, or strawberry? Is it better,
worse, or is there no change?
1.
2.
3.
DK:
RF:
Weekdays
Weekends
Both weekdays and weekends
Don't Know
Refused
^25year5yearsyounger
fill "25 years old " if age 30+
age 18-29
Skip Instructions: <1-3,RF,DK> [goto TASTEUNW_A]
Page 217 of 306
fill "5 years younger" if
Question ID: TSM.0070.00.3
Question Text:
Response:
Variable name: TASTEUNW_A
Interview module: TSM(Adult.TSM)
During the past 12 months, have you had an unwanted taste or other sensation
in your mouth that does not go away? Read if necessary: This could include
bad, metallic, or bitter tastes or burning or tingling sensations.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto TSTSMHP_A]
<2,RF,DK> if SMELLDF_A in [3,4,5] or SMELLCOMP_A=2 or
SMELLPHT_A=1 or TASTEDF_A in [3,4,5] or TASTECOMP_A=2 or
TASTEFLAV_A=2 or TASTEUNW_A=1 [goto TSTSMHP_A]
else [goto next section]
Question ID: TSM.0080.00.3
Variable name: TSTSMHP_A
Interview module: TSM(Adult.TSM)
Universe: SMELLDF_A in [3,4,5] or SMELLCOMP_A=2 or SMELLPHT_A=1 or
TASTEDF_A in [3,4,5] or TASTECOMP_A=2 or TASTEFLAV_A=2 or
TASTEUNW_A=1
Question Text:
Response:
Have you ever discussed any problem with, or a change in your ability to taste
or smell, with a doctor or other health professional?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto TSTSLAST_A]
<2,RF,DK> [goto next section]
Page 218 of 306
Question ID: TSM.0090.00.3
Variable name: TSTSMLAST_A
Interview module: TSM(Adult.TSM)
Universe: TSTSMHP_A=1
Question Text:
Response:
When was the last time you talked to a doctor or other health professional
about any problem with your ability to taste or smell?
1.
2.
3.
4.
5.
6.
DK:
RF:
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 years ago)
10 years ago or more
Don't Know
Refused
Skip Instructions: <1-6,RF,DK> [goto next section]
Question ID: CIG.0010.00.1
Question Text:
Response:
Variable name: CIGINTRO_A
Interview module: CIG(Adult.CIG)
These next questions are about cigarette smoking.
1.
Enter '1' to continue.
Enter 1 to Continue
Skip Instructions: <1> [goto SMKEV_A]
Question ID: CIG.0020.00.1
Question Text:
Response:
Variable name: SMKEV_A
Interview module: CIG(Adult.CIG)
Have you smoked at least 100 cigarettes in your ENTIRE LIFE?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 219 of 306
Skip Instructions: <1> [goto SMKNOW_A]
<2,RF,DK> [goto ECIGEV_A]
Question ID: CIG.0030.00.1
Variable name: SMKNOW_A
Interview module: CIG(Adult.CIG)
Universe: SMKEV_A='1'
Question Text:
Response:
Do you NOW smoke cigarettes every day, some days or not at all?
1.
2.
3.
DK:
RF:
Every day
Some days
Not at all
Don't Know
Refused
Skip Instructions: <1> [goto CIGNOW_A]
<2> [goto SMK30D_A]
<3,RF,DK> [goto ECIGEV_A]
Question ID: CIG.0040.00.1
Variable name: CIGNOW_A
Interview module: CIG(Adult.CIG)
Universe: SMKNOW_A='1'
Question Text:
Response:
On average, about how many cigarettes do you NOW smoke a day?
less than 1 cigarette. Enter '95' if 95 or more cigarettes.
DK:
RF:
Don't Know
Refused
Skip Instructions: <1-95,RF,DK> [goto ECIGEV_A]
Page 220 of 306
Enter '1' if
Question ID: CIG.0050.00.1
Variable name: SMK30D_A
Interview module: CIG(Adult.CIG)
Universe: SMKNOW_A='2'
Question Text:
Response:
On how many of the past 30 days did you smoke a cigarette?
None.
DK:
RF:
Enter '0' for
Don't Know
Refused
Skip Instructions: <0> [goto ECIGEV_A]
<1-30,RF,DK> [goto CIG30D_A]
Question ID: CIG.0060.00.1
Variable name: CIG30D_A
Interview module: CIG(Adult.CIG)
Universe: SMK30D_A=1-30,DK,RF
Question Text:
Response:
On average, when you smoked during the past 30 days, about how many
cigarettes did you smoke a day? Enter '1' if less than 1. Enter '95' if 95 or
more cigarettes.
DK:
RF:
Don't Know
Refused
Skip Instructions: <1-95,DK,RF> [goto ECIGEV_A]
Question ID: CIG.0070.00.1
Question Text:
Variable name: ECIGEV_A
Interview module: CIG(Adult.CIG)
Have you ever used an e-cigarette or other electronic vaping product, even just
one time, in your entire life? Read if necessary: Electronic cigarettes (e-cigarettes)
and other electronic vaping products include JUULs, vape pens, e-cigars, and others.
These products are battery-powered and usually contain nicotine and flavors such as
fruit, mint, or candy. These questions concern electronic vaping products for nicotine
use. Do not include marijuana use.
Response:
Page 221 of 306
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto ECIGNOW_A]
<2,RF,DK> [goto next section]
Question ID: CIG.0080.00.1
Variable name: ECIGNOW_A
Interview module: CIG(Adult.CIG)
Universe: ECIGEV_A=1
Question Text:
Response:
Do you NOW use e-cigarettes or other electronic vaping products every day,
some days, or not at all? These questions concern electronic vaping products for
nicotine use. Do not include marijuana use.
1.
2.
3.
DK:
RF:
Every day
Some days
Not at all
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto next section]
Question ID: OTB.0010.00.3
Question Text:
Variable name: CIGAREV_A
Interview module: OTB(Adult.OTB)
Have you ever smoked a regular cigar, cigarillo, or a little filtered cigar EVEN
ONE TIME? Read if necessary: "Cigarillos" are medium cigars that sometimes are
sold with plastic or wooden tips. Some common brands are Black and Mild, Swisher
Sweets, Dutch Masters and Phillies Blunts. Cigarillos are usually sold individually or
in packs of 5 or fewer. Little filtered cigars look like cigarettes and are usually brown
in color. Like cigarettes, little filtered cigars have a spongy filter and are sold in packs
of 20. Some common brands are Prime Time and Winchester. Read if necessary:
Do not include electronic cigars or e-cigars.
Response:
Page 222 of 306
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto CIGARCUR_A]
<2,RF,DK> [goto PIPEEV_A]
Question ID: OTB.0020.00.3
Variable name: CIGARCUR_A
Interview module: OTB(Adult.OTB)
Universe: CIGAREV_A=1
Question Text:
Response:
Do you NOW smoke regular cigars, cigarillos, or little filtered cigars every day,
some days, or not at all?
1.
2.
3.
DK:
RF:
Every day
Some days
Not at all
Don't Know
Refused
Skip Instructions: <1,RF,DK> [goto PIPEEV_A]
<2,3> [goto CIGAR30D_A]
Question ID: OTB.0030.00.3
Variable name: CIGAR30D_A
Interview module: OTB(Adult.OTB)
Universe: CIGARCUR_A IN (2,3)
Question Text:
Response:
On how many of the past 30 days have you smoked a regular cigar, cigarillo, or
little filtered cigar?
DK:
RF:
Don't Know
Refused
Skip Instructions: <0-30,RF,DK> [goto PIPEEV_A]
Page 223 of 306
Question ID: OTB.0040.00.3
Question Text:
Response:
Variable name: PIPEEV_A
Interview module: OTB(Adult.OTB)
Have you EVER smoked a pipe filled with tobacco - either a regular pipe, water
pipe, or hookah EVEN ONE TIME? Read if necessary: A hookah is a type of
water pipe. It is sometimes called a "narghile" (NAR-ge-lee) pipe. Do not include
electronic hookah or e-hookahs. Read if necessary: Do not include electronic pipes
or e-pipes. Read if necessary: Do not include pipes filled with substances other than
tobacco.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto PIPECUR_A]
<2,RF,DK> [goto SMOKELSEV_A]
Question ID: OTB.0050.00.3
Variable name: PIPECUR_A
Interview module: OTB(Adult.OTB)
Universe: PIPEEV_A=1
Question Text:
Response:
Do you NOW smoke pipes filled with tobacco - either regular pipes, water pipes,
or hookahs, every day, some days, or not at all? Read if necessary: Do not
include pipes filled with substances other than tobacco.
1.
2.
3.
DK:
RF:
Every day
Some days
Not at all
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto SMOKELSEV_A]
Page 224 of 306
Question ID: OTB.0060.00.3
Question Text:
Response:
Variable name: SMOKELSEV_A
Interview module: OTB(Adult.OTB)
Smokeless tobacco products are placed in the mouth or nose and can include
chewing tobacco, snuff, dip, snus (SNOOSE), or dissolvable tobacco. Have you
ever used smokeless tobacco products EVEN ONE TIME? Read if necessary:
Do not include nicotine replacement therapy products such as patch, gum, lozenge,
or spray, which are considered smoking cessation treatments.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto SMOKELSCUR_A]
<2,RF,DK> [goto next section]
Question ID: OTB.0070.00.3
Variable name: SMOKELSCUR_A
Interview module: OTB(Adult.OTB)
Universe: SMOKELSEV_A=1
Question Text:
Response:
Do you NOW use smokeless tobacco products every day, some days, or not at
all?
1.
2.
3.
DK:
RF:
Every day
Some days
Not at all
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto next section]
Page 225 of 306
Question ID: SOS.0010.00.4
Question Text:
Response:
Variable name: SUPPORT_A
Interview module: SOS(Adult.SOS)
How often do you get the social and emotional support you need? Would you
say always, usually, sometimes, rarely, or never?
1.
2.
3.
4.
5.
DK:
RF:
Always
Usually
Sometimes
Rarely
Never
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto CMPSUPPORT_A]
Question ID: SOS.0020.00.4
Question Text:
Response:
Variable name: CMPSUPPORT_A
Interview module: SOS(Adult.SOS)
Compared with 12 months ago, would you say that you now receive more
social and emotional support, less social and emotional support, or about the
same?
1.
2.
3.
DK:
RF:
More social and emotional support
Less social and emotional support
About the same
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto next section]
Page 226 of 306
Question ID: LS2.0010.00.3
Question Text:
Response:
Variable name: LSATIS4_A
Interview module: LS2(Adult.LS2)
In general, how satisfied are you with your life? Would you say very satisfied,
satisfied, dissatisfied, or very dissatisfied?
1.
2.
3.
4.
DK:
RF:
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto next section]
Question ID: ORN.0010.00.1
Question Text:
Response:
Variable name: ORNINTRO_A
Interview module: ORN(Adult.ORN)
Next we have some questions about your demographic characteristics,
including sexual orientation, income, employment, and veteran status. Like all
your answers, these will be used to understand the health of different groups in
the population and will be kept confidential. Enter '1' to continue.
1.
Enter 1 to Continue
Skip Instructions: <1> [goto ORIENT_A]
Question ID: ORN.0020.00.1
Question Text:
Response:
Variable name: ORIENT_A
Interview module: ORN(Adult.ORN)
Do you think of yourself as ^gaylesbian; straight, that is, not ^gaylesbian;
bisexual; something else; or you don't know the answer?
1.
2.
3.
4.
^GayLesbian
Straight, that is, not ^gaylesbian
Bisexual
Something else
Page 227 of 306
5.
RF:
Fills:
I don't know the answer
Refused
^gaylesbian
If GEN.SEX_FINAL=1 fill "gay";
else if GEN.SEX_FINAL='2',RF,DK fill "lesbian or
gay"
Skip Instructions: <1-5,RF> [goto next section]
Question ID: MAR.0010.00.1
Question Text:
Response:
Variable name: MARITAL_A
Interview module: MAR(Adult.MAR)
The next questions are about marriage and cohabitation. Are you now married,
living with a partner together as an unmarried couple, or neither? If
respondent answers both married and living with a different partner together as an
unmarried couple, enter living with partner.
1.
2.
3.
DK:
RF:
Married
Living with a partner together as an unmarried couple
Neither
Don't Know
Refused
Skip Instructions: <1> [goto SPOUSLIV_A]
<2> if GEN.PCNT16PLUS=1 [got
PARTNERWHO_A]
<3,RF,DK> [goto EVRMARRIED_A]
ERR1_MARITAL_A]
else
[goto
Check Name: ERR1_MARITAL_A
Text:
{signal ERR1_MARITAL_A} Respondent is the only person 16 or older on the
household roster. There is no one else eligible to select.
Hard / Soft Edit: Soft
Universe: MARITAL_A=2 and GEN.PCNT16PLUS=1
Skip Instructions: Correct: [goto MARITAL_A]
Suppress: [goto EVRMARRIED_A]
Page 228 of 306
Question ID: MAR.0020.00.1
Variable name: SPOUSLIV_A
Interview module: MAR(Adult.MAR)
Universe: MARITAL_A=1
Question Text:
Response:
Does your spouse live here?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> if GEN.PCNT16PLUS=1
SPOUSWHO_A]
<2> [goto SPOUSEP_A]
[goto next section]
[goto
ERR1_SPOUSLIV_C]
else
[goto
Check Name: ERR1_SPOUSLIV_A
Text:
{signal ERR1_SPOUSLIV_A} Respondent is the only person 16 or older on the
household roster. There is no one else eligible to select.
Hard / Soft Edit: Soft
Universe: MARITAL_A=1 and SPOUSLIV_A=1 and GEN.PCNT16PLUS=1
Skip Instructions: Correct: [goto SPOUSLIV_A]
Suppress: [goto next section]
Question ID: MAR.0030.00.1
Variable name: SPOUSWHO_A
Interview module: MAR(Adult.MAR)
Universe: SPOUSLIV_A=1 and GEN.PCNT16PLUS gt 1
Question Text:
Which person is your spouse? Enter line number of spouse. Deleted persons
cannot be selected. Enter '0' if respondent wishes to select a deleted person.
Response:
Page 229 of 306
00.
01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
DK:
RF:
Not on roster
^ALIASNAME[1]
^ALIASNAME[2]
^ALIASNAME[3]
^ALIASNAME[4]
^ALIASNAME[5]
^ALIASNAME[6]
^ALIASNAME[7]
^ALIASNAME[8]
^ALIASNAME[9]
^ALIASNAME[10]
^ALIASNAME[11]
^ALIASNAME[12]
^ALIASNAME[13]
^ALIASNAME[14]
^ALIASNAME[15]
^ALIASNAME[16]
^ALIASNAME[17]
^ALIASNAME[18]
^ALIASNAME[19]
^ALIASNAME[20]
^ALIASNAME[21]
^ALIASNAME[22]
^ALIASNAME[23]
^ALIASNAME[24]
^ALIASNAME[25]
Don't Know
Refused
Skip Instructions: <0-25> [goto SPOUSSEX_A]
[goto next section]
Page 230 of 306
Question ID: MAR.0040.00.1
Variable name: SPOUSSEX_A
Interview module: MAR(Adult.MAR)
Universe: SPOUSWHO_A=1-25
Question Text:
Response:
Fills:
I previously recorded ^SPOUSENAME's ^spousesex. Is this correct?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^spousesex
if
GEN.SEX_FINAL[person
selected
at
SPOUSWHO_A]=1, fill "sex is male"
if
GEN.SEX_FINAL[person
selected
at
SPOUSWHO_A]=2, fill "sex is female"
if
GEN.SEX_FINAL[person
selected
at
SPOUSWHO_A] IN (DK,RF), fill "sex was not
provided"
^SPOUSENAME
Name of spouse
Skip Instructions: <1,RF,DK> [goto next section]
<2> [goto SPOUNEWSEX_A]
Question ID: MAR.0050.00.1
Variable name: SPOUNEWSEX_A
Universe: SPOUSSEX_A=2
Question Text:
Response:
Is ^SPOUSENAME male or female?
1.
2.
DK:
RF:
Male
Female
Don't Know
Refused
Page 231 of 306
Interview module: MAR(Adult.MAR)
Fills:
^SPOUSENAME
Name of spouse
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: MAR.0060.00.1
Variable name: SPOUSEP_A
Interview module: MAR(Adult.MAR)
Universe: SPOUSLIV_A=2
Question Text:
Response:
Does your spouse not live here because you and your spouse are legally
separated?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: MAR.0070.00.1
Variable name: PARTNERWHO_A
Interview module: MAR(Adult.MAR)
Universe: MARITAL_A=2 and GEN.PCNT16PLUS gt 1
Question Text:
Response:
Which person is your partner? Enter line number of partner. Deleted persons
cannot be selected. Enter '0' if respondent wishes to select a deleted person.
00.
01.
02.
03.
04.
05.
06.
07.
Not on roster
^ALIASNAME[1]
^ALIASNAME[2]
^ALIASNAME[3]
^ALIASNAME[4]
^ALIASNAME[5]
^ALIASNAME[6]
^ALIASNAME[7]
Page 232 of 306
08.
09.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
DK:
RF:
^ALIASNAME[8]
^ALIASNAME[9]
^ALIASNAME[10]
^ALIASNAME[11]
^ALIASNAME[12]
^ALIASNAME[13]
^ALIASNAME[14]
^ALIASNAME[15]
^ALIASNAME[16]
^ALIASNAME[17]
^ALIASNAME[18]
^ALIASNAME[19]
^ALIASNAME[20]
^ALIASNAME[21]
^ALIASNAME[22]
^ALIASNAME[23]
^ALIASNAME[24]
^ALIASNAME[25]
Don't Know
Refused
Skip Instructions: <0-25> [goto PARTNERSEX_A]
[goto EVRMARRIED_A]
Question ID: MAR.0080.00.1
Variable name: PARTNERSEX_A
Interview module: MAR(Adult.MAR)
Universe: PARTNERWHO_A=1-25
Question Text:
Response:
Fills:
I previously recorded ^PARTNERNAME's ^partnersex. Is this correct?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^partnersex
if
GEN.SEX_FINAL[person
selected
at
PARTNERWHO_A]=1, fill "sex is male"
if
GEN.SEX_FINAL[person
selected
at
PARTNERWHO_A]=2, fill "sex is female"
if
GEN.SEX_FINAL[person
selected
at
PARTNERWHO_A] IN (DK,RF), fill "sex was not
provided"
^PARTNERNAME
Name of partner
Page 233 of 306
Skip Instructions: <1,RF,DK> [goto EVRMARRIED_A]
<2> [goto PARTNEWSEX_A]
Question ID: MAR.0090.00.1
Variable name: PARTNEWSEX_A
Interview module: MAR(Adult.MAR)
Universe: PARTNERSEX_A=2
Question Text:
Response:
Fills:
Is ^PARTNERNAME male or female?
1.
2.
DK:
RF:
Male
Female
Don't Know
Refused
^PARTNERNAME
Name of partner
Skip Instructions: <1,2,RF,DK> [goto EVRMARRIED_A]
Question ID: MAR.0100.00.1
Variable name: EVRMARRIED_A
Universe: MARITAL_A IN (2,3,RF,DK)
Question Text:
Response:
Have you ever been married?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> if MARITAL_A=2 [goto LEGALSTAT_A]
elseif MARITAL_A=3 [goto WIDIVSEP_A]
else [goto next section]
<2,RF,DK> [goto next section]
Page 234 of 306
Interview module: MAR(Adult.MAR)
Question ID: MAR.0110.00.1
Variable name: LEGALSTAT_A
Interview module: MAR(Adult.MAR)
Universe: EVRMARRIED_A=1 and MARITAL_A=2
Question Text:
Response:
What is your current legal marital status? Are you married, widowed, divorced,
or separated?
1.
2.
3.
4.
DK:
RF:
Married
Widowed
Divorced
Separated
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto next section]
Question ID: MAR.0120.00.1
Variable name: WIDIVSEP_A
Universe: EVRMARRIED_A=1 and MARITAL_A=3
Question Text:
Response:
Are you widowed, divorced, or separated?
1.
2.
3.
DK:
RF:
Widowed
Divorced
Separated
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto FINISH_MAR_A]
Page 235 of 306
Interview module: MAR(Adult.MAR)
Question ID: MAR.0130.00.1
Question Text:
Response:
Variable name: FINISH_MAR_A
Interview module: MAR(Adult.MAR)
The Sample Adult MAR section is now complete.
1.
Enter '1' to continue.
Enter 1 to Continue
Skip Instructions: <1> [goto next section]
Question ID: VET.0010.00.1
Question Text:
Response:
Variable name: AFVET_A
Interview module: VET(Adult.VET)
Did you ever serve on active duty in the U.S. Armed Forces, military Reserves,
or National Guard?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto AFVETTRN_A]
<2,RF,DK> [goto next section]
Question ID: VET.0020.00.1
Variable name: AFVETTRN_A
Interview module: VET(Adult.VET)
Universe: AFVET_A=1
Question Text:
Response:
Were you on active duty ONLY for training in the Reserves or National Guard?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto VADISB_A]
<2,RF,DK> [goto COMBAT_A]
Page 236 of 306
Question ID: VET.0030.001
Variable name: COMBAT_A
Interview module: VET(Adult.VET)
Universe: AFVET_A=1 and AFVETTRN_A IN (2,RF,DK)
Question Text:
Response:
Did you ever serve in a foreign country during a time of armed conflict or on a
humanitarian or peace-keeping mission?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto VADISB_A]
Question ID: VET.0040.00.1
Variable name: VADISB_A
Interview module: VET(Adult.VET)
Universe: AFVET_A=1
Question Text:
Response:
Do you have a VA service-connected disability rating?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto VAHOSP_A]
Question ID: VET.0050.00.1
Variable name: VAHOSP_A
Interview module: VET(Adult.VET)
Universe: AFVET_A=1
Question Text:
During the past 12 months, did you receive any care at a Veteran's Health
Administration facility or receive any other health care paid for by the VA?
Read if necessary: Veteran's Health Administration facilities include VA hospitals, VA
medical centers, VA outpatient clinics, and VA nursing homes.
Response:
Page 237 of 306
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto next section]
<2,RF,DK> if 1 IN Adult.INS.MILSPC_A [goto next section]
else [goto VACAREEV]
Question ID: VET.0060.00.1
Variable name: VACAREEV_A
Interview module: VET(Adult.VET)
Universe: VAHOSP_A IN (2,RF,DK) and 1 NOT IN Adult.INS.MILSPC_A
Question Text:
Response:
Have you ever enrolled in or used VA health care?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: NAT.0010.00.1
Question Text:
Response:
Fills:
Variable name: NATUSBORN_A
Interview module: NAT(Adult.NAT)
^Askverify_A Were you born in the United States or a U.S. territory?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^Askverify_A
If GEN.SARESPSC_FLG=1, fill "*Ask or verify:"
Skip Instructions: <1> [goto NATSTBORN_A]
<2> [goto NATUSYR_A]
[goto next section]
Page 238 of 306
Question ID: NAT.0020.00.1
Variable name: NATSTBORN_A
Interview module: NAT(Adult.NAT)
Universe: NATUSBORN_A=1
Question Text:
Response:
In what state or U.S. territory were you born?
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto CITIZEN_A]
else [goto next section]
Question ID: NAT.0040.00.1
Variable name: NATUSYR_A
Interview module: NAT(Adult.NAT)
Universe: NATUSBORN_A=2
Question Text:
Response:
In what year did you come to the United States to stay?
DK:
RF:
Don't Know
Refused
Skip Instructions: <1900-Current Year,RF,DK> if NATUSYR_A is a future year [goto
ERR1_NATUSYR_A]
if NATUSYR_A lt VFY.BYEAR_A [goto ERR2_NATUSYR_A]
else [goto CITIZEN_A]
Check Name: ERR1_NATUSYR_A
Text:
{check ERR1_NATUSYR_A}
Future year invalid. Please correct.
Hard / Soft Edit: Hard
Universe: NATUSYR_A = future year
Page 239 of 306
Check Name: ERR2_NATUSYR_A
Text:
{check ERR2_NATUSYR_A}
Year is prior to date of birth. Please correct.
Hard / Soft Edit: Hard
Universe: NATUSYR_A LT VFY.BYEAR_A
Question ID: NAT.0050.00.1
Variable name: CITIZEN_A
Interview module: NAT(Adult.NAT)
Universe: NATUSBORN_A=2 or NATSTBORN_A=American Samoa
Question Text:
Response:
Are you a citizen of the United States?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto NATCTZN_A]
<2,RF,DK> [goto next section]
Question ID: NAT.0060.00.1
Variable name: NATCTZN_A
Interview module: NAT(Adult.NAT)
Universe: (NATUSBORN_A=2 or NATSTBORN_A=AS) and CITIZEN_A=1
Question Text:
Response:
Were you born abroad to an American parent, born abroad and adopted by an
American parent, or did you become a U.S. citizen by naturalization?
1.
2.
3.
DK:
RF:
Born abroad to American parent
Born abroad and adopted by an American parent
Became U.S. citizen by naturalization
Don't Know
Refused
Page 240 of 306
Skip Instructions: <1-3,RF,DK> [goto next section]
Question ID: SCH.0010.00.1
Question Text:
Response:
Variable name: SCHCURENR_A
Interview module: SCH(Adult.SCH)
Are you currently enrolled in or attending school? Read if necessary: School
includes high school, college, trade school, and professional school. Students may be
enrolled part-time or full-time.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto SCHDYSMSS_A]
<2,RF,DK> [goto next section]
Question ID: SCH.0020.00.1
Variable name: SCHDYSMSS_A
Interview module: SCH(Adult.SCH)
Universe: SCHCURENR_A=1
Question Text:
Response:
During the past 12 months, about how many days of school did you miss
because you had an illness, injury, or disability?
DK:
RF:
Don't Know
Refused
Skip Instructions: <0-99,RF,DK> [goto next section]
<100-365> [goto ERR1_SCHDYSMSS_A]
Page 241 of 306
Check Name: ERR1_SCHDYSMSS_A
Text:
{signal ERR1_SCHDYSMSS_A} ^SCHDYSMSS_A is an unusually large number.
Did you miss ^SCHDYSMSS_A days of school because of illness, injury, or
disability? Please verify.
Hard / Soft Edit: Soft
Fills:
^SCHDYSMSS_A
Fill value from SCHDYSMSS_A
Universe: SCHDYSMSS_A=100-365
Question ID: EMP.0010.00.1
Question Text:
Response:
Fills:
Variable name: EMPLASTWK_A
Interview module: EMP(Adult.EMP)
LAST WEEK, did you work for pay at a job or business?
If the respondent
says ^heshetheywork, but not for pay, at a family-owned job or business, enter '1' for
yes.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^heshetheywork
elseif GEN.SEX_FINAL=1 fill "he works"
elseif GEN.SEX_FINAL=2 fill "she works"
elseif GEN.SEX_FINAL=DK,RF fill "they work"
Skip Instructions: <1> [goto EMPHOURS_A]
<2> [goto EMPNOWRK_A]
[goto next section]
Page 242 of 306
Question ID: EMP.0020.00.1
Variable name: EMPNOWRK_A
Interview module: EMP(Adult.EMP)
Universe: EMPLASTWK_A=2
Question Text:
Response:
Did you have a job or business LAST WEEK, but were temporarily absent due
to illness, vacation, family or maternity leave, or some other reason?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto EMPHOURS_A]
<2> [goto EMPWHYNOT_A]
[goto next section]
Question ID: EMP.0030.00.1
Variable name: EMPWHYNOT_A
Interview module: EMP(Adult.EMP)
Universe: EMPNOWRK_A=2
Question Text:
Response:
What is the MAIN reason you were not working for pay at a job or business last
week? Probe if necessary.
1.
2.
3.
4.
5.
6.
7.
8.
DK:
RF:
Can't find work, laid off, looking for work
Seasonal/contract work
Retired
Unable to work for health reasons/disabled
Taking care of house or family
Going to school
Working at a family-owned job or business not for pay
Other
Don't Know
Refused
Skip Instructions: <1-6,8,RF,DK> [goto EMPWHENWRK_A]
<7> [goto EMPHOURS_A]
Page 243 of 306
Question ID: EMP.0040.00.1
Variable name: EMPWHENWRK_A
Interview module: EMP(Adult.EMP)
Universe: EMPWHYNOT_A IN (1-6,8,RF,DK)
Question Text:
Response:
When was the last time you worked for pay at a job or business, even if only for
a few days?
1.
2.
3.
4.
DK:
RF:
Within the past 12 months
1-5 years ago
Over 5 years ago
Never worked
Don't Know
Refused
Skip Instructions: <1> if EMPWHYNOT_A=2 [goto EMPHOURS_A]
else[goto EMPSICKLV_A]
<2-4,RF,DK> [goto next section]
Question ID: EMP.0050.00.1
Variable name: EMPHOURS_A
Interview module: EMP(Adult.EMP)
Universe: EMPLASTWK_A=1 or EMPNOWRK_A=1 or
(EMPWHYNOT_A=2 and EMPLASTWRK_A=1)
Question Text:
Response:
Fills:
EMPWHYNOT_A=7
^Whenwork many hours do you USUALLY work in total at ALL jobs or
businesses?
DK:
RF:
Don't Know
Refused
^Whenwork
If EMPWHYNOT_A=2 then
Skip Instructions: <1-94> [goto EMPSICKLV_A]
<95-168> [goto ERR_EMPHOURS_A], then [goto EMPSICKLV_A]
[goto EMPFULLTIM_A]
Page 244 of 306
or
Check Name: ERR_EMPHOURS_A
Text:
{signal ERR_EMPHOURS_A} ^EMPHOURS_A hours is unusually high. Please
verify. Make corrections if necessary.
Hard / Soft Edit: Soft
Fills:
^EMPHOURS_A
Fill value from Adult.EMP.EMPHOURS_A
Universe: EMPHOURS_A=95-168
Question ID: EMP.0060.00.1
Variable name: EMPFULLTIM_A
Interview module: EMP(Adult.EMP)
Universe: EMPHOURS_A IN (RF,DK)
Question Text:
Response:
Fills:
^WhenworkDo you USUALLY work 35 hours or more per week in total at ALL
jobs or businesses?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^WhenworkDo
If EMPWHYNOT_A=2 fill: "When you are doing your
seasonal or contract work, do"; else "Do"
Skip Instructions: <1,2,RF,DK> [goto EMPSICKLV_A]
Page 245 of 306
Question ID: EMP.0070.00.1
Variable name: EMPSICKLV_A
Universe: EMPLASTWK_A=1 or
EMPWHENWRK_A=1
Question Text:
Response:
Fills:
EMPNOWRK_A=1
Interview module: EMP(Adult.EMP)
or
EMPWHYNOT_A=7
or
^LASTJOB paid sick leave available if you need it?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^LASTJOB
When you last work/ Regarding you job or business
Skip Instructions: <1,2,RF,DK> [goto EMPHEALINS_A]
Question ID: EMP.0080.00.1
Variable name: EMPHEALINS_A
Universe: EMPLASTWK_A=1 or
EMPWHENWRK_A=1
Question Text:
Response:
Fills:
EMPNOWRK_A=1
Interview module: EMP(Adult.EMP)
or
EMPWHYNOT_A=7
or
^LASTJOB health insurance offered to you through your workplace?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^LASTJOB
When you last work/ Regarding you job or business
Skip Instructions: <1,2,RF,DK> [goto EMPDAYMISS_A]
Page 246 of 306
Question ID: EMP.0090.00.1
Variable name: EMPDAYMISS_A
Universe: EMPLASTWK_A=1 or
EMPWHENWRK_A=1
Question Text:
Response:
Fills:
EMPNOWRK_A=1
Interview module: EMP(Adult.EMP)
or
EMPWHYNOT_A=7
or
During the past 12 months, about how many days of work did you miss
because you had an illness, injury, or disability?
Read if necessary: Do not
include family or ^paternitymaternity leave.
DK:
RF:
Don't Know
Refused
^paternitymaternity
If GEN.SEX_FINAL=1 fill "paternity"
else if GEN.SEX_FINAL=2 fill "maternity"
else if GEN.SEX_FINAL=DK,RF fill "maternity or
paternity"
Skip Instructions: <0-99,RF,DK> [goto next section]
<100-365> [goto ERR_EMPDAYMISS_A], then [goto next section]
Check Name: ERR_EMPDAYMISS_A
Text:
{signal ERR_EMPDAYMISS_A} ^EMPDAYMISS_A days is unusually high. Please
verify. Make corrections if necessary.
Hard / Soft Edit: Soft
Fills:
^EMPDAYMISS_A
Fill value from Adult.EMP.EMPDAYMISS_A
Universe: EMPDAYMISS_A=100-365
Page 247 of 306
Question ID: EMD.0010.00.2
Question Text:
Response:
Fills:
Variable name: EMDWHOWRK1_A
Interview module: EMD(Adult.EMD)
^JOBFOR whom ^dodid you work ^job?
Enter the name of the company,
business or employer. Read if necessary for those with more than one MAIN job or
business: Where ^dodid you work for the most amount of time?
DK:
RF:
Don't Know
Refused
^dodid
If
EMP.EMPLASTWK_A=1
EMP.EMPNOWRK_A=1
EMP.EMPRSNOWK_A=2,7, fill: "do"
If EMP.EMPLSTWRK_A=1, fill: "did"
or
or
^JOBFOR
Intro to whom worked
^job
if (EMPLASTWK_A=1 or EMPNOWRK_A=1 or
EMPRSNOWK_A IN (2,7)) fill: "at your MAIN job or
business"
else no fill
Skip Instructions: [goto EMDINDUST_A]
Question ID: EMD.0020.00.2
Question Text:
Response:
Fills:
Variable name: EMDINDUST_A
Interview module: EMD(Adult.EMD)
What kind of business or industry ^iswas this?
Read if necessary: For
example: hospital, newspaper publishing, mail order house, auto engine
manufacturing, bank.
DK:
RF:
^iswas
Don't Know
Refused
If
EMP.EMPLASTWK_A=1
OR
EMP.EMPNOWRK_A=1 OR EMP.EMPWHYNOT_A
IN (2,7) fill: "is"
elseIf EMP.EMPWHENWRK_A=1, fill: "was"
Page 248 of 306
Skip Instructions: [goto EMDKIND_A]
Question ID: EMD.0030.00.2
Question Text:
Response:
Fills:
Variable name: EMDKIND1_A
Interview module: EMD(Adult.EMD)
What kind of work ^arewere you doing? Read if necessary: For example:
registered nurse, personnel manager, supervisor of order department, secretary,
accountant.
DK:
RF:
Don't Know
Refused
^hacer_A
Spanish only
^arewere
If
EMP.EMPLASTWK_A=1
or
EMP.EMPNOWRK_A=1 or EMP.EMPWHYNOT_A
IN (2,7), fill: "are"
If EMP.EMPWHENWRK_A=1, fill: "were"
Skip Instructions: [goto EMDIMPACT1_A]
Question ID: EMD.0040.00.2
Question Text:
Response:
Fills:
Variable name: EMDIMPACT_A
Interview module: EMD(Adult.EMD)
What ^arewere your most important activities or duties on this job or
business? Read if necessary: For example: patient care, directing hiring policies,
supervising order clerks, typing and filing, reconciling financial records.
DK:
RF:
^arewere
Don't Know
Refused
If
EMP.EMPLASTWK_A=1
or
EMP.EMPNOWRK_A=1 or EMP.EMPWHYNOT_A
IN (2,7), fill: "are"
If EMP.EMPWHENWRK_A=1, fill: "were"
Page 249 of 306
Skip Instructions: [goto EMDSPRVIS_A]
Question ID: EMD.0050.00.2
Question Text:
Response:
Fills:
Variable name: EMDSUPER_A
Interview module: EMD(Adult.EMD)
^DoDid you supervise other employees as part of your job?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^DoDid
If
EMP.EMPLASTWK_A=1
or
EMP.EMPNOWRK_A=1 or EMP.WHYNOT_A IN
(2,7), fill: "Do"
If EMP.EMPWHENWRK_A=1, fill: "Did"
Skip Instructions: <1,2,RF,DK> [goto EMDWRKCAT1_A]
Question ID: EMD.0060.00.2
Question Text:
Response:
Fills:
Variable name: EMDWRKCAT1_A
Interview module: EMD(Adult.EMD)
Which of these BEST describes your MAIN job or ^WRKCAT?
choices.
1.
2.
3.
4.
5.
6.
DK:
RF:
Read answer
Employee of a PRIVATE company for wages
A FEDERAL government employee
A STATE government employee
A LOCAL government employee
Self-employed in OWN business, professional practice or farm
Working WITHOUT PAY in a family-owned business or farm
Don't Know
Refused
^WRKCAT
If
EMP.EMPLASTWK_A=1
or
EMP.EMPNOWRK_A=1
orEMP.EMPWHYNOT_A
IN (2,7), fill: "work situation"
If EMP.EMPWHENWRK_A=1, fill: "business in the
past 12 months"
Page 250 of 306
Skip Instructions: <1-6,RF,DK> [goto next section]
Question ID: JOB.0010.00.3
Variable name: JOBTAX_A
Interview module: JOB(Adult.JOB)
Universe: EMD.EMDWRKCAT_A in [1,2,3,4]
Question Text:
Response:
Fills:
^JOBDoesDid your employer deduct or withhold taxes from your pay?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^JOBDoesDid
Does if currently employed, Did if employed in the
past year
Skip Instructions: <1,2,RF,DK> goto [JOBCHGEARN_A]
Question ID: JOB.0020.00.3
Variable name: JOBCHGEARN_A
Interview module: JOB(Adult.JOB)
Universe: EMP.EMPLASTWK_A=1
or
EMP.EMPNOWRK_A=1
EMP.EMPWHYNOT_A=7 or EMP.EMPWHENWRK_A=1
Question Text:
Response:
or
How much ^JOBdodid your earnings change from month to month? Would
you say...
1.
2.
3.
4.
DK:
RF:
Not at all
A small amount
A moderate amount
A large amount
Don't Know
Refused
Page 251 of 306
Fills:
^JOBdodid
do if currently employed; did if employed in the past
year
Skip Instructions: <1-4,RF,DK> goto [JOBSHIFT_A]
Question ID: JOB.0030.00.3
Variable name: JOBSHIFT_A
Interview module: JOB(Adult.JOB)
Universe: EMP.EMPLASTWK_A=1
or
EMP.EMPNOWRK_A=1
EMP.EMPWHYNOT_A=7 or EMP.EMPWHENWRK_A=1
Question Text:
Response:
Fills:
or
Which of the following best describes your usual hours of work on your
^JOBmostrecent main job? Would you say... Read if Necessary: Daytime Most hours between 6am and 6pm Evening - Most hours between 2 pm and midnight
Night - Most hours between 9 pm and 8 am Rotating - Change periodically between
day and evening shift, or between night shift and day or evening
1.
2.
3.
4.
5.
DK:
RF:
Daytime shift
Evening shift
Night shift
Rotating shift
Some other shift
Don't Know
Refused
^JOBmostrecent
If
(EMP.EMPWHENWRK_A=1
EMP.EMPWHYNOT_A ne 2) fill: "most recent"
Skip Instructions: <1-5,RF,DK> goto [JOBCHGSCH_A]
Page 252 of 306
and
Question ID: JOB.0040.00.3
Variable name: JOBCHGSCH_A
Interview module: JOB(Adult.JOB)
Universe: EMP.EMPLASTWK_A=1
or
EMP.EMPNOWRK_A=1
EMP.EMPWHYNOT_A=7 or EMP.EMPWHENWRK_A=1
Question Text:
Response:
Fills:
or
How easy ^iswas it for you to change your work schedule to do things that are
important to you or your family? Would you say...
1.
2.
3.
4.
DK:
RF:
Very easy
Somewhat easy
Somewhat difficult
Very difficult
Don't Know
Refused
^iswas
If
EMP.EMPLASTWK_A=1
OR
EMP.EMPNOWRK_A=1 OR EMP.EMPWHYNOT_A
IN (2,7) fill: "is"
elseIf EMP.EMPWHENWRK_A=1, fill: "was"
Skip Instructions: <1-4,RF,DK> goto [JOBVARYSCH_A]
Question ID: JOB.0050.00.3
Variable name: JOBVARYSCH_A
Interview module: JOB(Adult.JOB)
Universe: EMP.EMPLASTWK_A=1
or
EMP.EMPNOWRK_A=1
EMP.EMPWHYNOT_A=7 or EMP.EMPWHENWRK_A=1
Question Text:
Response:
or
^JOBDoesDid your work schedule at your main job change on a regular basis?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 253 of 306
Fills:
^JOBDoesDid
Does if currently employed, Did if employed in the
past year
Skip Instructions: <1> goto [JOBADVSCH_A]
<2,RF,DK> goto [JOBLOSS_A]
Question ID: JOB.0060.00.3
Variable name: JOBADVSCH_A
Universe: (EMP.EMPLASTWK_A=1
EMP.EMPWHYNOT_A=7
JOBVARYSCH_A=1
Question Text:
Response:
Fills:
or
or
Interview module: JOB(Adult.JOB)
EMP.EMPNOWRK_A=1
EMP.EMPWHENWRK_A=1)
or
and
Approximately how far in advance ^doyoudoesemployer the hours that you will
need to work on any given day?
1.
2.
3.
4.
5.
6.
DK:
RF:
1 day or less
2 to 3 days
4 to 6 days
1 to 2 weeks
2 to 4 weeks
More than 1 month
Don't Know
Refused
^doyoudoesemployer
fill for JOBADVSCH_A
Skip Instructions: <1-6,RF,DK> goto [JOBLKYLOSS_A]
Page 254 of 306
Question ID: JOB.0070.00.3
Variable name: JOBLKYLOSS_A
Universe: EMP.EMPLASTWK_A=1
EMP.EMPWHYNOT_A=7
EMP.EMPWHENWRK_A=1)
Question Text:
Response:
or
or
Interview module: JOB(Adult.JOB)
EMP.EMPNOWRK_A=1
(EMP.EMPWHYNOT_A=2
or
&
Thinking about the next 12 months, how likely do you think it is that you will
lose your job or be laid off? Would you say...
1.
2.
3.
4.
DK:
RF:
Very likely
Fairly likely
Somewhat likely
Not at all likely
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> goto [JOBWRKSICK_A]
Question ID: JOB.0080.00.3
Variable name: JOBWRKSICK_A
Universe: EMP.EMPLASTWK_A=1
EMP.EMPWHYNOT_A=7
EMP.EMPWHENWRK_A=1)
Question Text:
Response:
or
or
Interview module: JOB(Adult.JOB)
EMP.EMPNOWRK_A=1
(EMP.EMPWHYNOT_A=2
or
&
During the past 3 months, how many days did you work while physically ill?
DK:
RF:
Don't Know
Refused
Skip Instructions: <0-30,RF,DK> goto [JOBMISS_A]
Page 255 of 306
Question ID: JOB.0090.00.3
Variable name: JOBMISS_A
Universe: EMP.EMPLASTWK_A=1
EMP.EMPWHYNOT_A=7
EMP.EMPWHENWRK_A=1)
Question Text:
Response:
or
or
Interview module: JOB(Adult.JOB)
EMP.EMPNOWRK_A=1
(EMP.EMPWHYNOT_A=2
or
&
During the past 3 months, about how many days of work did you miss
because you were ill or because there was chance you had COVID-19?
DK:
RF:
Don't Know
Refused
Skip Instructions: <0-30,RF,DK> goto [next section]
Question ID: SDW.0010.00.4
Variable name: CURJOBSD1_A
Universe: EMP.EMPLASTWK_A=1
EMP.EMPWHYNOT_A=7
EMP.EMPWHENWRK_A=1)
Question Text:
Response:
or
or
Interview module: SDW(Adult.SDW)
EMP.EMPNOWRK_A=1
(EMP.EMPWHYNOT_A=2
or
&
Thinking about your MAIN job or business, are there currently social distancing
measures in effect to help keep people apart? If this person is working from
home full-time because of COVID-19, answer '1' for yes.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto WRKCLSSD1_A]
<2,RF,DK> [goto WRKCLSOFT1_A]
Page 256 of 306
Question ID: SDW.0020.00.4
Variable name: WRKCLSSD1_A
Interview module: SDW(Adult.SDW)
Universe: CURJOBSD1_A=1
Question Text:
Response:
Currently, at your MAIN job or business, how often do you still need to work
closer than 6 feet to other people? Would you say all of the time, most of the
time, some of the time, or none of the time? If person works from home full-time
and does not know how to answer, ask, "Does your job require you to be face-to-face
with any people you don't live with?" If no, answer '4' for "none of the time." If yes,
ask, "How much of your time at work is spent with people who are closer than 6 feet?"
1.
2.
3.
4.
DK:
RF:
All of the time
Most of the time
Some of the time
None of the time
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto WRKCLSNOSD1_A]
Question ID: SDW.0030.00.4
Variable name: WRKCLSNOSD1_A
Interview module: SDW(Adult.SDW)
Universe: CURJOBSD1_A=1
Question Text:
Response:
When social distancing measures were NOT in effect, how often did you need
to work closer than 6 feet to other people? Would you say all of the time, most
of the time, some of the time, or none of the time? Enter '5' if respondent only
worked at main job when social distancing measures were in effect. If person
worked from home full-time and does not know how to answer, ask, "Did your job
require you to be face-to-face with any people you didn't live with?" If no, answer '4'
for "none of the time." If yes, ask, "How much of your time at work was spent with
people who were closer than 6 feet?"
1.
2.
All of the time
Most of the time
Page 257 of 306
3.
4.
5.
DK:
RF:
Some of the time
None of the time
Only worked at current main job while social distancing measures were in
effect
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto next section]
Question ID: SDW.0040.00.4
Variable name: WRKCLSOFT1_A
Interview module: SDW(Adult.SDW)
Universe: CURJOBSD1_A IN (2,RF,DK)
Question Text:
Response:
Currently, at your MAIN job or business, how often do you need to work closer
than 6 feet to other people? Would you say all of the time, most of the time,
some of the time, or none of the time? If person works from home full-time and
does not know how to answer, ask, "Does your job require you to be face-to-face with
any people you don't live with?" If no, answer '4' for "none of the time." If yes, ask,
"How much of your time at work is spent with people who are closer than 6 feet?"
1.
2.
3.
4.
DK:
RF:
All of the time
Most of the time
Some of the time
None of the time
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto SDMSRS1_A]
Question ID: SDW.0050.00.4
Variable name: SDMSRS1_A
Interview module: SDW(Adult.SDW)
Universe: CURJOBSD1_A IN (2,RF,DK)
Question Text:
At any time since the start of the coronavirus pandemic, did your MAIN job or
business put social distancing measures into effect? If this person was
working from home full-time because of COVID-19, answer '1' for yes. If person
started job while social distancing measures were in effect, answer '1' for yes.
Response:
Page 258 of 306
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto SDMSRSOFT1_A]
<2,RF,DK> [goto next section]
Question ID: SDW.0060.00.4
Variable name: SDMSRSOFT1_A
Interview module: SDW(Adult.SDW)
Universe: SDMSRS1_A=1
Question Text:
Response:
When social distancing measures were in effect, how often did you need to
work closer than 6 feet to other people? Would you say all of the time, most of
the time, some of the time, or none of the time? Enter '5' if respondent did not
work at main job when social distancing measures were in effect. If person worked
from home full-time and does not know how to answer, ask, "Did your job require you
to be face-to-face with any people you didn't live with?" If no, answer '4' for "none of
the time." If yes, ask, "How much of your time at work was spent with people who
were closer than 6 feet?"
1.
2.
3.
4.
5.
DK:
RF:
All of the time
Most of the time
Some of the time
None of the time
Did not work at main job when social distancing measures were in effect
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto next section]
Page 259 of 306
Question ID: SDW.0070.00.4
Variable name: RECJOBSD1_A
Interview module: SDW(Adult.SDW)
Universe: EMP.EMPWHENWRK_A=1 & EMP.EMPWHYNOT_A ne 2
Question Text:
Response:
Thinking about the MAIN job you held in the past 12 months, were there ever
any social distancing measures in effect while you worked there? That is, were
there ever practices in place to help keep people apart? If this person was
working from home full-time because of COVID-19, answer '1' for yes.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> [goto RJCLSSD1_A]
<2,RF,DK> [goto RJCLSOFT1_A]
Question ID: SDW.0080.00.4
Variable name: RJCLSSD1_A
Interview module: SDW(Adult.SDW)
Universe: RECJOBSD1_A=1
Question Text:
Response:
When social distancing measures were in effect, how often did you still need to
work closer than 6 feet to other people? Would you say all of the time, most of
the time, some of the time, or none of the time? If person worked from home
full-time and does not know how to answer, ask, "Did your job require you to be
face-to-face with any people you didn't live with?" If no, answer '4' for "none of the
time." If yes, ask, "How much of your time at work was spent with people who were
closer than 6 feet?"
1.
2.
3.
4.
DK:
RF:
All of the time
Most of the time
Some of the time
None of the time
Don't Know
Refused
Page 260 of 306
Skip Instructions: <1-4,RF,DK> [goto RJCLSNOSD1_A]
Question ID: SDW.0090.00.4
Variable name: RJCLSNOSD1_A
Interview module: SDW(Adult.SDW)
Universe: RECJOBSD1_A=1
Question Text:
Response:
When social distancing measures were NOT in effect, how often did you need
to work closer than 6 feet to other people? Would you say all of the time, most
of the time, some of the time, or none of the time? Enter '5' if respondent only
worked at main job when social distancing measures were in effect. If person
worked from home full-time and does not know how to answer, ask, "Did your job
require you to be face-to-face with any people you didn't live with?" If no, answer '4'
for "none of the time." If yes, ask, "How much of your time at work was spent with
people who were closer than 6 feet?"
1.
2.
3.
4.
5.
DK:
RF:
All of the time
Most of the time
Some of the time
None of the time
Only worked at main job while social distancing measures were in effect
Don't Know
Refused
Skip Instructions: <1-5,RF,DK> [goto next section]
Question ID: SDW.0100.00.4
Variable name: RJCLSOFT1_A
Interview module: SDW(Adult.SDW)
Universe: RECJOBSD1_A IN (2,RF,DK)
Question Text:
How often did you need to work closer than 6 feet to other people? Would you
say all of the time, most of the time, some of the time, or none of the time? If
person worked from home full-time and does not know how to answer, ask, "Did your
job require you to be face-to-face with any people you didn't live with?" If no, answer
'4' for "none of the time." If yes, ask, "How much of your time at work was spent with
people who were closer than 6 feet?"
Response:
Page 261 of 306
1.
2.
3.
4.
DK:
RF:
All of the time
Most of the time
Some of the time
None of the time
Don't Know
Refused
Skip Instructions: <1-4,RF,DK> [goto next section]
Question ID: FEM.0010.00.1
Question Text:
Response:
Variable name: FEMINTRO_A
Interview module: FEM(Adult.FEM)
Now I'm going to ask you about some of the other members of your family.
Enter '1' to continue.
1.
Enter 1 to Continue
Skip Instructions: <1>[goto tblFEM_A]
Question ID: FEM.0030.00.1
Question Text:
Response:
Fills:
Variable name: FEMWORK_A
Interview module: FEM(Adult.FEM.tblFEM_A.blkPerson
Does ^ALIASNAME work for pay at a job or business? If the respondent says
^heshetheywork, but not for pay, at a family-owned job or business, enter '1' for yes.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^ALIASNAME
Fill value from Roster.HHC.ALIAS[PX]
^heshetheywork
elseif GEN.SEX_FINAL=1 fill "he works"
elseif GEN.SEX_FINAL=2 fill "she works"
elseif GEN.SEX_FINAL=DK,RF fill "they work"
Page 262 of 306
Skip Instructions: <1> [goto FEMWKFT_A]
<2,RF,DK> if there is another adult in the family [goto FEMWORK_A] for the
next adult 18+
else [goto next section]
Question ID: FEM.0040.00.1
Variable name: FEMWKFT_A
Interview module: FEM(Adult.FEM.tblFEM_A.blkPerson
Universe: FEMLSTWK_A[PX]=1
Question Text:
Response:
Fills:
Does ^ALIASNAME usually work 35 hours or more per week in total at
^hishertheir job or jobs?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^ALIASNAME
Fill value from Roster.HHC.ALIAS[PX]
^hishertheir
If GEN.SEX_FINAL=1 fill "his";
else if GEN.SEX_FINAL=2 fill "her";
else if GEN.SEX_FINAL IN (DK, RF) fill "their"
Skip Instructions: <1,2,RF,DK> if another adult in the family [goto FEMWORK_A] for the next
adult 18+
else [goto next section]
Question ID: INC.0010.00.1
Question Text:
Variable name: INCINTRO_A
Interview module: INC(Adult.INC)
The next questions are about your total ^FAMILY income in ^LASTYEAR
BEFORE TAXES. ^INCSAFAM Read if necessary: Income is important in
analyzing the health information we collect. For example, with this information, we
can learn whether persons in one income group use certain types of medical services
more or less often than those in another group. Please be assured that, like all other
information you have provided, these answers will remain confidential. Enter '1' to
continue.
Response:
Page 263 of 306
1.
Fills:
Enter 1 to Continue
^FAMILY
If PCNT_A > 1 fill "family"
^LASTYEAR
Fill year prior to current year
^INCSAFAM
If more than one person in the Sample Adult's family,
fill "Based on questions asked earlier we have that
your family consists of^SAFAM."
else no fill
Skip Instructions: <1> [goto INCWRKO_A]
Question ID: INC.0020.00.1
Question Text:
Response:
Fills:
Variable name: INCWRKO_A
Interview module: INC(Adult.INC)
In ^LASTYEAR, did ^YOUFAM18YRS receive income from wages, salaries,
commissions, bonuses, tips, or self-employment? ^INCSAFAMoptional
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^YOUFAM18YRS
If PCNT18UP_A=1 fill "you"
else if PCNT18UP_A GT 1 fill "you or any family
members 18 or older"
^INCSAFAMoptional
If more than one person in the Sample Adult's family,
fill"*Read if necessary:For the purpose of this survey,
your family includes ^FAMVERSA_fill."
else no fill
^LASTYEAR
Fill year prior to current year
Page 264 of 306
Skip Instructions: <1,2,RF,DK> [goto INCINTER_A]
Question ID: INC.0030.00.1
Question Text:
Response:
Fills:
Variable name: INCINTER_A
Interview module: INC(Adult.INC)
In ^LASTYEAR, did ^YOUFAMHERE receive income from interest-bearing
accounts or investments, dividends from stocks or mutual funds, net rental
income, royalty income, or income from estates and trusts?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^YOUFAMHERE
If PCNT_A=1 fill "you"
else if PCNT_A GT 1 fill "you or any family
members"
^LASTYEAR
Fill year prior to current year
Skip Instructions: <1,2,DK> [goto INCSSRR_A]
if INCWRKO_A IN (1,2,DK) [goto INCSSRR_A]
else [goto next section]
Question ID: INC.0040.00.1
Variable name: INCSSRR_A
Interview module: INC(Adult.INC)
Universe: INCINTER_A IN (1,2,DK) or INCWRKO_A IN (1,2,DK)
Question Text:
Response:
Read if necessary: In ^LASTYEAR, did ^YOUFAMHERE receive... Income from
Social Security or Railroad Retirement?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 265 of 306
Fills:
^LASTYEAR
Fill year prior to current year
^YOUFAMHERE
If PCNT_A=1 fill "you"
else if PCNT_A GT 1 fill "you or any family
members"
Skip Instructions: <1,2,RF,DK> [goto INCSSISSDI_A]
Question ID: INC.0050.00.1
Variable name: INCSSISSDI_A
Interview module: INC(Adult.INC)
Universe: INCINTER_A IN (1,2,DK) or INCWRKO_A IN (1,2,DK)
Question Text:
Response:
Fills:
Read if necessary: In ^LASTYEAR, did ^YOUFAMHERE receive... Supplemental
Security Income, SSI, or Social Security Disability Income, SSDI, which are
different from Social Security?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^LASTYEAR
Fill year prior to current year
^YOUFAMHERE
If PCNT_A=1 fill "you"
else if PCNT_A GT 1 fill "you or any family
members"
Skip Instructions: <1> [goto SSISSDIBTH_A]
<2,RF,DK> [goto INCWELF_A]
Page 266 of 306
Question ID: INC.0060.00.1
Variable name: SSISSDIBTH_A
Interview module: INC(Adult.INC)
Universe: INCSSISSDI_A=1
Question Text:
Response:
Was this Supplemental Security Income, SSI, Social Security Disability Income,
SSDI, or both?
1.
2.
3.
DK:
RF:
SSI
SSDI
Both SSI and SSDI
Don't Know
Refused
Skip Instructions: <1-3,RF,DK> [goto SSISSDIDSB_A]
Question ID: INC.0070.00.1
Variable name: SSISSDIDSB_A
Universe: INCSSISSDI_A=1
Question Text:
Response:
Was this received as a disability benefit?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1> if GEN.PCNT_A gt 1 [goto SSISSDIP_A]
elseif GEN.PCNT_A=1 [goto INCWELF_A]
<2,RF,DK> [goto INCWELF_A]
Page 267 of 306
Interview module: INC(Adult.INC)
Question ID: INC.0090.00.1
Variable name: SSISSDIP_A
Interview module: INC(Adult.INC)
Universe: SSISSDIDSB_A=1 and GEN.PCNT_A gt 1
Question Text:
Response:
In ^LASTYEAR, who received this disability benefit? Read if necessary: Do
NOT include a benefit received on behalf of someone else. Enter all that apply,
separate with commas.
01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
DK:
RF:
^ALIASNAME[1]
^ALIASNAME[2]
^ALIASNAME[3]
^ALIASNAME[4]
^ALIASNAME[5]
^ALIASNAME[6]
^ALIASNAME[7]
^ALIASNAME[8]
^ALIASNAME[9]
^ALIASNAME[10]
^ALIASNAME[11]
^ALIASNAME[12]
^ALIASNAME[13]
^ALIASNAME[14]
^ALIASNAME[15]
^ALIASNAME[16]
^ALIASNAME[17]
^ALIASNAME[18]
^ALIASNAME[19]
^ALIASNAME[20]
^ALIASNAME[21]
^ALIASNAME[22]
^ALIASNAME[23]
^ALIASNAME[24]
^ALIASNAME[25]
Don't Know
Refused
Page 268 of 306
Fills:
^LASTYEAR
Fill year prior to current year
Skip Instructions: <1-25,RF,DK> [goto INCWELF_A]
Question ID: INC.0100.00.1
Variable name: INCWELF_A
Interview module: INC(Adult.INC)
Universe: INCINTER_A IN (1,2,DK) or INCWRKO_A IN (1,2,DK)
Question Text:
Response:
Fills:
In ^LASTYEAR, did ^YOUFAMHERE receive... Any public assistance or welfare
payments from the state or local welfare office?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^LASTYEAR
Fill year prior to current year
^YOUFAMHERE
If PCNT_A=1 fill "you"
else if PCNT_A GT 1 fill "you or any family
members"
Skip Instructions: <1,2,RF,DK> [goto INCRETIRE_A]
Question ID: INC.0110.00.1
Variable name: INCRETIRE_A
Interview module: INC(Adult.INC)
Universe: INCINTER_A IN (1,2,DK) or INCWRKO_A IN (1,2,DK)
Question Text:
Response:
Read if necessary: In ^LASTYEAR, did ^YOUFAMHERE receive... Income from
retirement, survivor, or disability pensions?
1.
Yes
Page 269 of 306
2.
DK:
RF:
Fills:
No
Don't Know
Refused
^LASTYEAR
Fill year prior to current year
^YOUFAMHERE
If PCNT_A=1 fill "you"
else if PCNT_A GT 1 fill "you or any family
members"
Skip Instructions: <1,2,RF,DK> [goto INCOTHR_A]
Question ID: INC.0120.00.1
Variable name: INCOTHR_A
Interview module: INC(Adult.INC)
Universe: INCINTER_A IN (1,2,DK) or INCWRKO_A IN (1,2,DK)
Question Text:
Response:
Fills:
Read if necessary: In ^LASTYEAR, did ^YOUFAMHERE receive... Any other
sources of income such as VA payments from the Veterans Benefits
Administration, unemployment compensation, child support, or alimony?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^YOUFAMHERE
If PCNT_A=1 fill "you"
else if PCNT_A GT 1 fill "you or any family
members"
^LASTYEAR
Fill year prior to current year
Skip Instructions: <1,2,RF,DK> [goto INCTOTAL_A]
Page 270 of 306
Question ID: INC.0130.00.1
Variable name: INCTOTAL_A
Interview module: INC(Adult.INC)
Universe: INCINTER_A IN (1,2,DK) or INCWRKO_A IN (1,2,DK)
Question Text:
Response:
Fills:
^INCALLFAM What is your best estimate of ^TOTALINCOME from all sources,
before taxes, in ^LASTYEAR? Enter '999995' if the reported income $999,995 or
greater.
DK:
RF:
Don't Know
Refused
^INCALLFAM
IF PCNT_A GT 1 fill "When answering this next
question, please remember to include your income
PLUS the income of all family members living in this
household."
^TOTALINCOME
If PCNT_A=1 fill "your total income" else if PCNT_A
GT 1 fill "the total income of all family members"
^LASTYEAR
Fill year prior to current year
Skip Instructions: <0-999> [goto ERR1_INCTOTAL_A]
<250001-999995> [goto ERR2_INCTOTAL_A]
<1000-250000> [goto next section]
[goto INC250PCT_A]
Check Name: ERR1_INCTOTAL_A
Text:
{signal ERR1_INCTOTAL_A} Do not read to the respondent.
unusually low. Make corrections if necessary.
Hard / Soft Edit: Soft
Fills:
^INCTOTAL_A
Fill value from INCTOTAL_A
Universe: INCTOTAL_A=0-999
Page 271 of 306
^INCTOTAL_A is
Check Name: ERR2_INCTOTAL_A
Text:
{signal ERR2_INCTOTAL_A} Do not read to the respondent.
unusually high. Make corrections if necessary.
^INCTOTAL_A is
Hard / Soft Edit: Soft
Fills:
^INCTOTAL_A
Fill value from INCTOTAL_A
Universe: INCTOTAL_A=250001-999995
Question ID: INC.0150.00.1
Variable name: INC250PCT_A
Interview module: INC(Adult.INC)
Universe: INCTOTAL_A IN (DK,RF)
Question Text:
Response:
Fills:
Was your total ^FAMILY income from all sources less than ^250POVERTY_A or
^250POVERTY_A or more?
1.
2.
DK:
RF:
Less than ^250POVERTY_A
^250POVERTY_A or more
Don't Know
Refused
^FAMILY
If PCNT_A > 1 fill "family"
^250POVERTY_A
Fill value stored in Adult.INC.INC250FILL_A
Skip Instructions: <1> [goto INC138PCT_A]
<2> if GEN.PCNT_A IN (1,2) [goto INC75K_A]
else if GEN.PCNT_A=4 or GEN.PCNT_A ge 7 [goto INC400PCT_A]
else if GEN.PCNT_A IN (3,5,6) [goto INC100K_A]
[goto next section]
Page 272 of 306
Question ID: INC.0160.01.1
Variable name: INC138PCT_A
Interview module: INC(Adult.INC)
Universe: INC250PCT_A=1
Question Text:
Response:
Fills:
Was your total ^FAMILY income from all sources less than ^138POVERTY_A or
^138POVERTY_A or more?
1.
2.
DK:
RF:
Less than ^138POVERTY_A
^138POVERTY_A or more
Don't Know
Refused
^FAMILY
If PCNT_A > 1 fill "family"
^138POVERTY_A
Fill value stored in Adult.INC.INC138FILL_A
Skip Instructions: <1> [goto INC100PCT_A]
<2> [goto INC200PCT_A]
[goto next section]
Question ID: INC.0170.01.1
Variable name: INC100PCT_A
Interview module: INC(Adult.INC)
Universe: INC138PCT_A=1
Question Text:
Response:
Fills:
Was your total ^FAMILY income from all sources less than ^100POVERTY_A or
^100POVERTY_A or more?
1.
2.
DK:
RF:
Less than ^100POVERTY_A
^100POVERTY_A or more
Don't Know
Refused
^FAMILY
If PCNT_A > 1 fill "family"
^100POVERTY_A
Fill value stored in Adult.INC.INC100FILL_A
Page 273 of 306
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: INC.0180.01.1
Variable name: INC200PCT_A
Interview module: INC(Adult.INC)
Universe: INC138PCT_A=2
Question Text:
Response:
Fills:
Was your total ^FAMILY income from all sources less than ^200POVERTY_A or
^200POVERTY_A or more?
1.
2.
DK:
RF:
Less than ^200POVERTY_A
^200POVERTY_A or more
Don't Know
Refused
^FAMILY
If PCNT_A > 1 fill "family"
^200POVERTY_A
Fill value stored in Adult.INC.INC200FILL_A
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: INC.0190.00.1
Variable name: INC75K_A
Interview module: INC(Adult.INC)
Universe: INC250PCT_A=2 and GEN.PCNT_A IN (1,2)
Question Text:
Response:
Fills:
Was your total ^FAMILY income from all sources less than $75,000 or $75,000
or more?
1.
2.
DK:
RF:
^FAMILY
Less than $75,000
$75,000 or more
Don't Know
Refused
If PCNT_A > 1 fill "family"
Page 274 of 306
Skip Instructions: <1> [goto INC400PCT_A]
<2> [goto INC100K_A]
[goto next section]
Question ID: INC.0200.00.1
Variable name: INC100K_A
Interview module: INC(Adult.INC)
Universe: INC75K_A=2 or (INC250PCT_A=2 and GEN.PCNT_A IN (3,5,6))
Question Text:
Response:
Fills:
Was your total ^FAMILY income from all sources less than $100,000 or
$100,000 or more?
1.
2.
DK:
RF:
Less than $100,000
$100,000 or more
Don't Know
Refused
^FAMILY
If PCNT_A > 1 fill "family"
Skip Instructions: <1> if GEN.PCNT_A IN (1,2,5,6) [goto next section]
elseif GEN.PCNT_A=3 [goto INC400PCT_A]
<2> if GEN.PCNT_A IN (1,2,3) [goto INC150K_A]
elseif GEN.PCNT_A IN (5,6) [goto INC400PCT_A]
[goto next section]
Question ID: INC.0210.01.1
Variable name: INC400PCT_A
Interview module: INC(Adult.INC)
Universe: (INC75K_A=1 or (INC100K_A=1 and GEN.PCNT_A=3) or (INC100K_A=2 and
GEN.PCNT_A IN (5,6)) or (INC250PCT_A=2 and (GEN.PCNT_A=4 or
GEN.PCNT_A ge 7)))
Question Text:
Was your total ^FAMILY income from all sources less than ^400POVERTY_A or
^400POVERTY_A or more?
Response:
Page 275 of 306
1.
2.
DK:
RF:
Fills:
Less than ^400POVERTY_A
^400POVERTY_A or more
Don't Know
Refused
^FAMILY
If PCNT_A > 1 fill "family"
^400POVERTY_A
Fill value stored in Adult.INC.INC400FILL_A
Skip Instructions: <1> if GEN.PCNT_A ge 8 [goto INC150K_A]
else [goto next section]
<2> if GEN.PCNT_A IN (1,2,3) or GEN.PCNT_A ge 6 [goto next section]
else if GEN.PCNT IN (4,5) [goto INC150K_A]
[goto next section]
Question ID: INC.0220.00.1
Variable name: INC150K_A
Interview module: INC(Adult.INC)
Universe: (INC100K_A=2 and GEN.PCNT_A IN (1,2,3)) or (INC400PCT_A=2 and
GEN.PCNT_A IN (4,5)) or (INC400PCT_A=1 and GEN.PCNT_A ge 8)
Question Text:
Response:
Fills:
Was your total ^FAMILY income from all sources less than $150,000 or
$150,000 or more?
1.
2.
DK:
RF:
^FAMILY
Less than $150,000
$150,000 or more
Don't Know
Refused
If PCNT_A > 1 fill "family"
Skip Instructions: <1,2,RF,DK> [goto next section]
Page 276 of 306
Question ID: FOO.0010.00.1
Variable name: FSNAP12M_A
Interview module: FOO(Adult.FOO)
Universe: ((GEN.SAMEFAM_FLG=1
and
GEN.FOO_FLG_C=blank)
(GEN.SAMEFAM_FLG
ne
1)
or
(GEN.SAMEFAM_FLG=1
GEN.FOO_FLG_C=2 and GEN.SARESPSC_FLG NE 1))
Question Text:
Response:
Fills:
or
and
At any time in the last 12 months did ^YOUFAMLVHERE_A receive
^FSSNAPNM? Read if necessary: This program puts money on a SNAP EBT card
that you can only use to buy food.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^YOUFAMLVHERE_A
If GEN.PCNT_A=1, fill: "you";
elseif
GEN.PCNT_A
gt
1
and
Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMP
US ne 1, fill: "any family members living here"
elseif
GEN.PCNT_A
gt
1
and
Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMP
US=1, fill "you or any family members living at ^HNO
^HNOSUF ^STRNAME"
^FSSNAPNM
If AL then fill "Food Assistance Program or food
stamp benefits"
If AK then fill "Food Stamp Program (FSP) or food
stamp benefits"
If AZ then fill "Nutrition Assistance or food stamp
benefits"
If AR then fill "SNAP or food stamp benefits"
If CA then fill "CalFresh or food stamp benefits"
If CO then fill "SNAP or food stamp benefits"
If CT then fill "SNAP or food stamp benefits"
If DE then fill "Food Supplement Program or food
stamp benefits"
If DC then fill "SNAP or food stamp benefits"
If FL then fill "Food Assistance Program or food
stamp benefits"
If GA then fill "Food Stamp Program (FSP) or food
stamp benefits"
If HI then fill "SNAP or food stamp benefits"
If ID then fill "Food Stamp Program (FSP) or food
stamp benefits"
If IL then fill "SNAP or food stamp benefits"
If IN then fill "SNAP or food stamp benefits"
If IA then fill "Food Assistance Program or food
Page 277 of 306
stamp benefits"
If KS then fill "Food Assistance Program or food
stamp benefits"
If KY then fill "SNAP or food stamp benefits"
If LA then fill "SNAP or food stamp benefits"
If ME then fill "Food Supplement Program or food
stamp benefits"
If MD then fill "Food Supplement Program or food
stamp benefits"
If MA then fill "SNAP or food stamp benefits"
If MI then fill "Food Assistance Program (FSP) or
food stamp benefits"
If MN then fill "SNAP or food stamp benefits"
If MS then fill "SNAP or food stamp benefits"
If MO then fill "Food Stamp Program (FSP) or food
stamp benefits"
If MT then fill "SNAP or food stamp benefits"
If NE then fill "SNAP or food stamp benefits"
If NV then fill "SNAP or food stamp benefits"
If NH then fill "SNAP or food stamp benefits"
If NJ then fill "NJ SNAP or food stamp benefits"
If NM then fill "SNAP or food stamp benefits"
If NY then fill "SNAP or food stamp benefits"
If NC then fill "Food and Nutrition Services or food
stamp benefits"
If ND then fill "SNAP or food stamp benefits"
If OH then fill "Food Assistance Program or food
stamp benefits"
If OK then fill "SNAP or food stamp benefits"
If OR then fill "SNAP or food stamp benefits"
If PA then fill "SNAP or food stamp benefits"
If RI then fill "SNAP or food stamp benefits"
If SC then fill "SNAP or food stamp benefits"
If SD then fill "SNAP or food stamp benefits"
If TN then fill "SNAP or food stamp benefits"
If TX then fill "SNAP or food stamp benefits"
If UT then fill "SNAP or food stamp benefits"
If VT then fill "3SquaresVT or food stamp benefits"
If VA then fill "SNAP or food stamp benefits"
If WA then fill "Basic Food or food stamp benefits"
If WV then fill "SNAP or food stamp benefits"
If WI then fill "FoodShare Wisconsin or food stamp
benefits"
If WY then fill "SNAP or food stamp benefits"
Page 278 of 306
Skip Instructions: <1> [goto FSNAP30D_A]
<2,RF,DK> if PCNTF1255_A ge 1 or PCNTC05_A ge 1 [goto FWIC12M_A]
else if PCNTC517_A ge 1 [goto FLUNCH12M_A]
else [goto FINISH_FOO_A]
Question ID: FOO.0020.00.3
Variable name: FSNAP30D_A
Interview module: FOO(Adult.FOO)
Universe: FSNAP12M_A=1
Question Text:
Response:
Fills:
Did ^YOUFAMLVHERE_A receive ^FSSNAPNM in the LAST 30 days? Read if
necessary: This program puts money on a SNAP EBT card that you can only use to
buy food.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^YOUFAMLVHERE_A
If GEN.PCNT_A=1, fill: "you";
elseif
GEN.PCNT_A
gt
1
and
Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMP
US ne 1, fill: "any family members living here"
elseif
GEN.PCNT_A
gt
1
and
Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMP
US=1, fill "you or any family members living at ^HNO
^HNOSUF ^STRNAME"
^FSSNAPNM
If AL then fill "Food Assistance Program or food
stamp benefits"
If AK then fill "Food Stamp Program (FSP) or food
stamp benefits"
If AZ then fill "Nutrition Assistance or food stamp
benefits"
If AR then fill "SNAP or food stamp benefits"
If CA then fill "CalFresh or food stamp benefits"
If CO then fill "SNAP or food stamp benefits"
If CT then fill "SNAP or food stamp benefits"
If DE then fill "Food Supplement Program or food
stamp benefits"
If DC then fill "SNAP or food stamp benefits"
If FL then fill "Food Assistance Program or food
stamp benefits"
If GA then fill "Food Stamp Program (FSP) or food
stamp benefits"
If HI then fill "SNAP or food stamp benefits"
If ID then fill "Food Stamp Program (FSP) or food
Page 279 of 306
stamp benefits"
If IL then fill "SNAP or food stamp benefits"
If IN then fill "SNAP or food stamp benefits"
If IA then fill "Food Assistance Program or food
stamp benefits"
If KS then fill "Food Assistance Program or food
stamp benefits"
If KY then fill "SNAP or food stamp benefits"
If LA then fill "SNAP or food stamp benefits"
If ME then fill "Food Supplement Program or food
stamp benefits"
If MD then fill "Food Supplement Program or food
stamp benefits"
If MA then fill "SNAP or food stamp benefits"
If MI then fill "Food Assistance Program (FSP) or
food stamp benefits"
If MN then fill "SNAP or food stamp benefits"
If MS then fill "SNAP or food stamp benefits"
If MO then fill "Food Stamp Program (FSP) or food
stamp benefits"
If MT then fill "SNAP or food stamp benefits"
If NE then fill "SNAP or food stamp benefits"
If NV then fill "SNAP or food stamp benefits"
If NH then fill "SNAP or food stamp benefits"
If NJ then fill "NJ SNAP or food stamp benefits"
If NM then fill "SNAP or food stamp benefits"
If NY then fill "SNAP or food stamp benefits"
If NC then fill "Food and Nutrition Services or food
stamp benefits"
If ND then fill "SNAP or food stamp benefits"
If OH then fill "Food Assistance Program or food
stamp benefits"
If OK then fill "SNAP or food stamp benefits"
If OR then fill "SNAP or food stamp benefits"
If PA then fill "SNAP or food stamp benefits"
If RI then fill "SNAP or food stamp benefits"
If SC then fill "SNAP or food stamp benefits"
If SD then fill "SNAP or food stamp benefits"
If TN then fill "SNAP or food stamp benefits"
If TX then fill "SNAP or food stamp benefits"
If UT then fill "SNAP or food stamp benefits"
If VT then fill "3SquaresVT or food stamp benefits"
If VA then fill "SNAP or food stamp benefits"
If WA then fill "Basic Food or food stamp benefits"
If WV then fill "SNAP or food stamp benefits"
If WI then fill "FoodShare Wisconsin or food stamp
benefits"
Page 280 of 306
If WY then fill "SNAP or food stamp benefits"
Skip Instructions: <1,2,RF,DK> if PCNTF1255_A ge 1 or PCNTC05_A ge 1 [goto FWIC12M_A]
else if PCNTC517_A ge 1 [goto FLUNCH12M_A];
else [goto FINISH_FOO_A]
Question ID: FOO.0030.00.1
Variable name: FWIC12M_A
Interview module: FOO(Adult.FOO)
Universe: (PCNTF1255_A ge 1 or PCNTC05_A ge 1) AND
((GEN.SAMEFAM_FLG=1 and GEN.FOO_FLG_C=blank) or
(GEN.SAMEFAM_FLG ne 1) or
(GEN.SAMEFAM_FLG=1
and
GEN.FOO_FLG_C=2
GEN.SARESPSC_FLG NE 1) or
(GEN.SAMFAM_FLG=1
and
GEN.FOO_FLG_C=1
Child.FOO.FWIC12M_C = EMPTY))
Question Text:
Response:
Fills:
and
and
At any time in the last 12 months did ^YOUFAMLVHERE_A receive benefits
from the WIC program, that is, the Women, Infants, and Children program?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^YOUFAMLVHERE_A
If GEN.PCNT_A=1, fill: "you";
elseif
GEN.PCNT_A
gt
1
and
Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMP
US ne 1, fill: "any family members living here"
elseif
GEN.PCNT_A
gt
1
and
Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMP
US=1, fill "you or any family members living at ^HNO
^HNOSUF ^STRNAME"
Page 281 of 306
Skip Instructions: <1,2,RF,DK> if PCNTC517_A ge 1 [goto FLUNCH12M_A]
else [goto FINISH_FOO_A]
Question ID: FOO.0040.00.1
Variable name: FLUNCH12M_A
Interview module: FOO(Adult.FOO)
Universe: PCNTC517_A
ge
1
AND
((GEN.SAMEFAM_FLG=1
GEN.FOO_FLG_C=blank)
or
(GEN.SAMEFAM_FLG
ne
1)
(GEN.SAMEFAM_FLG=1
and
GEN.FOO_FLG_C=2
GEN.SARESPSC_FLG NE 1))
Question Text:
Response:
Fills:
and
or
and
At any time in the last 12 months, did ^SCCHILDFAM_A receive free or
reduced-cost breakfasts or lunches at school? Read if necessary: The National
School Lunch Program and the School Breakfast Program provide cash assistance to
states to operate breakfast and lunch programs in schools and residential childcare
institutions. The programs provide low-cost or free breakfasts and lunches to
low-income children in kindergarten through 12th grade.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^SCCHILDFAM_A
if PCNT517_A=1, fill: ^ALIASNAME of child in
Sample Adult family,
elseif PCNT517_Agt 1, fill "any child in your family",
Skip Instructions: <1,2,RF,DK> [goto FINISH_FOO_A]
Page 282 of 306
Question ID: FOO.0050.00.1
Variable name: FINISH_FOO_A
Interview module: FOO(Adult.FOO)
Universe: FOO_FINISH_A = EMPTY AND
((GEN.SAMEFAM_FLG=1 and GEN.FOO_FLG_C=blank) or
(GEN.SAMEFAM_FLG ne 1) or
(GEN.SAMEFAM_FLG=1
and
GEN.FOO_FLG_C=2
and
GEN.SARESPSC_FLG NE 1) or
(GEN.SAMFAM_FLG=1
and
GEN.FOO_FLG_C=1
and
Child.FOO.FWIC12M_C = EMPTY and (PCNTF1255_A ge 1 or PCNTC05_A
ge 1) ))
Question Text:
Response:
The Sample Adult food related programs section is now complete.
continue.
1.
Enter '1' to
Enter 1 to Continue
Skip Instructions: <1> [goto next section]
Question ID: FDS.0010.00.3
Question Text:
Response:
Fills:
Variable name: FDSINTRO_A
Interview module: FDS(Adult.FDS)
These next questions are about whether ^youyourfamily_A ^waswere always
able to afford the food you needed in the last 30 days. I'm going to read you
several statements that people have made about their food situation. For these
statements, please tell me whether the statement was often true, sometimes
true, or never true for ^youyourfamily_A in the last 30 days. Enter '1' to
continue.
1.
Enter 1 to Continue
^youyourfamily_A
If PCNT_A=1 "you"
else "your family"
^waswere
If PCNT_A=1 "were"
else "was"
Page 283 of 306
Skip Instructions: <1> [goto FDSRUNOUT_A]
Question ID: FDS.0020.00.3
Question Text:
Response:
Fills:
Variable name: FDSRUNOUT_A
Interview module: FDS(Adult.FDS)
The first statement is "^IWe_A worried whether ^myour_A food would run out
before ^Iwe_A got money to buy more." Was that often true, sometimes true,
or never true for ^youyourfamily_A in the last 30 days?
1.
2.
3.
DK:
RF:
Often true
Sometimes true
Never true
Don't Know
Refused
^preocupar_A
Spanish only
^youyourfamily_A
If PCNT_A=1 "you"
else "your family"
^IWe_A
If PCNT_A=1 fill: "I"
else fill:"We"
^myour_A
If PCNT_A=1 fill: "my"
else fill: "our"
^Iwe_A
If PCNT_A=1 fill "I"
else fill "we"
Skip Instructions: <1-3,RF,DK> [goto FDSLAST_A]
Page 284 of 306
Question ID: FDS.0030.00.3
Question Text:
Response:
Fills:
Variable name: FDSLAST_A
Interview module: FDS(Adult.FDS)
"The food that ^Iwe_A bought just didn't last, and ^Iwe_A didn't have money to
get more." Was that often true, sometimes true, or never true for
^youyourfamily_A in the last 30 days?
1.
2.
3.
DK:
RF:
Often true
Sometimes true
Never true
Don't Know
Refused
^comprar_A
Spanish Only
^TENER_A
Spanish Only
^youyourfamily_A
If PCNT_A=1 "you"
else "your family"
^Iwe_A
If PCNT_A=1 fill "I"
else fill "we"
Skip Instructions: <1-3,RF,DK> [goto FDSBALANCE_A]
Question ID: FDS.0040.00.3
Question Text:
Response:
Variable name: FDSBALANCE_A
Interview module: FDS(Adult.FDS)
^IWe_A couldn't afford to eat balanced meals." Was that often true, sometimes
true, or never true for ^youyourfamily_A in the last 30 days?
1.
2.
3.
DK:
RF:
Often true
Sometimes true
Never true
Don't Know
Refused
Page 285 of 306
Fills:
^TENER_A
Spanish Only
^youyourfamily_A
If PCNT_A=1 "you"
else "your family"
^IWe_A
If PCNT_A=1 fill: "I"
else fill:"We"
Skip Instructions: <1-2> [goto FDSSKIP_A]
<3,RF,DK> if FDSRUNOUT_A IN (1,2) OR FDSLAST_A IN (1,2) [goto
FDSSKIP_A];
else [goto next section]
Question ID: FDS.0050.00.3
Variable name: FDSSKIP_A
Interview module: FDS(Adult.FDS)
Universe: FDSRUNOUT_A IN (1,2) or FDSLAST_A IN (1,2) or FDSBALANCE_A IN (1,2)
Question Text:
Response:
Fills:
In the last 30 days, did ^youorother_A ever cut the size of your meals or skip
meals because there wasn't enough money for food?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^youorother_A
If PCNT18UP_A=1: fill "you"
else "you or other adults in your family"
^dejar_A
Spanish only
Skip Instructions: <1> [goto FDSSKIPDYS_A]
<2,RF,DK> [goto FDSLESS_A]
Page 286 of 306
Question ID: FDS.0060.00.3
Variable name: FDSSKIPDYS_A
Interview module: FDS(Adult.FDS)
Universe: FDSSKIP_A=1
Question Text:
Response:
In the last 30 days, how many days did this happen?
DK:
RF:
Don't Know
Refused
Skip Instructions: <1-30,RF,DK> [goto FDSLESS_A]
Question ID: FDS.0070.00.3
Variable name: FDSLESS_A
Interview module: FDS(Adult.FDS)
Universe: FDSRUNOUT_A IN (1,2) or FDSLAST_A IN (1,2) or FDSBALANCE_A IN (1,2)
Question Text:
Response:
Fills:
In the last 30 days, did ^youorother_A ever eat less than you felt you should
because there wasn't enough money for food?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^COMER_A
Spanish Only
^pensar_A
Spanish only
^youorother_A
If PCNT18UP_A=1: fill "you"
else "you or other adults in your family"
Skip Instructions: <1,2,RF,DK> [goto FDSHUNGRY_A]
Page 287 of 306
Question ID: FDS.0080.00.3
Variable name: FDSHUNGRY_A
Interview module: FDS(Adult.FDS)
Universe: FDSRUNOUT_A IN (1,2) or FDSLAST_A IN (1,2) or FDSBALANCE_A IN (1,2)
Question Text:
Response:
Fills:
In the last 30 days, were ^youorother_A ever hungry but didn't eat because
there wasn't enough money for food?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^estar_A
Spanish Only
^youorother_A
If PCNT18UP_A=1: fill "you"
else "you or other adults in your family"
^COMER_A
Spanish Only
Skip Instructions: <1,2,RF,DK> [goto FDSWEIGHT_A]
Question ID: FDS.0090.00.3
Variable name: FDSWEIGHT_A
Interview module: FDS(Adult.FDS)
Universe: FDSRUNOUT_A IN (1,2) or FDSLAST_A IN (1,2) or FDSBALANCE_A IN (1,2)
Question Text:
Response:
In the last 30 days, did ^youorother_A lose weight because there wasn't
enough money for food?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Page 288 of 306
Fills:
^perder_A
Spanish only
^youorother_A
If PCNT18UP_A=1: fill "you"
else "you or other adults in your family"
Skip Instructions: <1> [goto FDSNOTEAT_A]
<2,RF,DK> if FDSSKIP_A=1 or FDSLESS_A=1 or FDSHUNGRY_A=1 [goto
FDSNOTEAT_A]; else [goto next section]
Question ID: FDS.0100.00.3
Variable name: FDSNOTEAT_A
Universe: (FDSSKIP_A=1
or
FDSWEIGHT_A=1)
Question Text:
Response:
Fills:
FDSLESS_A=1
Interview module: FDS(Adult.FDS)
or
FDSHUNGRY_A=1
or
In the last 30 days, did ^youorother_A ever not eat for a whole day because
there wasn't enough money for food?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^pasar_A
Spanish only
^youorother_A
If PCNT18UP_A=1: fill "you"
else "you or other adults in your family"
Skip Instructions: <1> [goto FDSNEDAYS_A]
<2,RF,DK> [goto next section]
Page 289 of 306
Question ID: FDS.0110.00.3
Variable name: FDSNEDAYS_A
Interview module: FDS(Adult.FDS)
Universe: FDSNOTEAT_A=1
Question Text:
Response:
In the last 30 days, how many days did this happen?
DK:
RF:
Don't Know
Refused
Skip Instructions: <1-30,RF,DK> [goto next section]
Question ID: HOU.0010.00.1
Question Text:
Response:
Fills:
Variable name: HOUYRSLIV_A
Interview module: HOU(Adult.HOU)
About how long ^YRSLIV?
1.
2.
3.
4.
5.
DK:
RF:
^YRSLIV
Less than 1 year
1 to 3 years
4 to 10 years
11 to 20 years
21 years or more
Don't Know
Refused
If
Roster.HHC.tblname.bPerson[PX_A]ONOFFCAMPU
S=1 fill "have you lived at ^HNO ^HNOSUF
^STRNAME"
else fill "have you lived in this house/apartment"
Skip Instructions: <1-5,RF,DK> if ((GEN.SAMEFAM_FLG=1 and GEN.HOU_FLG_C=empty) or
(GEN.SAMEFAM_FLG
ne
1)
or
(GEN.SAMEFAM_FLG=1
and
GEN.HOU_FLG_C=2
and
GEN.SARESPSC_FLG
ne
1))[goto
HOUTENURE_A]
else [goto next section]
If
GEN.AGE_FINAL[PX_A]
ERR1_HOUYRSLIV_A]
lt
Page 290 of 306
21
and
HOUYRSLIV_A=5
[goto
Check Name: ERR1_HOUYRSLIV_A
Text:
{check ERR1_HOUYRSLIV_A} Years in house/apartment exceed^SANAME's age.
Please correct.
Hard / Soft Edit: Hard
Fills:
^SANAME
Sample Adult's name
Universe: AGE_FINAL LT 21 and HOUYRSLIV_A=5
Question ID: HOU.0020.00.1
Variable name: HOUTENURE_A
Interview module: HOU(Adult.HOU)
Universe: ((GEN.SAMEFAM_FLG=1
and
GEN.HOU_FLG_C=blank)
(GEN.SAMEFAM_FLG
ne
1)
or
(GEN.SAMEFAM_FLG=1
GEN.HOU_FLG_C=2 and GEN.SARESPSC_FLG ne 1)
Question Text:
Response:
Fills:
^HOUTEN owned or rented by you ^SOMEFAM_A?
record as owned.
1.
2.
3.
DK:
RF:
or
and
If house has a mortgage,
Owned or being bought
Rented
Other arrangement
Don't Know
Refused
^SOMEFAM_A
If PCNT18UP_A=1 fill: blank
If PCNT18UP_A gt1 fill: "or someone in your family"
^HOUTEN
If
Roster.HHC.tblName.bPerson[PX_A].ONOFFCAMP
US=1, fill "Is the house/apartment at ^HNO
^HNOSUF ^STRNAME"
else fill "Is this house/apartment"
Page 291 of 306
Skip Instructions: <1,3,RF,DK> [goto next section]
<2> [goto HOUGVASST_A]
Question ID: HOU.0030.00.1
Variable name: HOUGVASST_A
Interview module: HOU(Adult.HOU)
Universe: HOUTENURE_A=2 and ((SAMEFAM_FLG=1 and HOU_FLG_C=blank) or
(SAMEFAM_FLG ne 1) or (SAMEFAM_FLG=1 and HOU_FLG_C=2 and
SARESPSC_FLG ne 1))
Question Text:
Response:
Fills:
^HOUGVT paying lower rent because the Federal, State, or local government is
paying part of the cost? Read if necessary: Federal, State, or Local government
housing programs for persons with low income may take many forms. Government
housing assistance could come from monetary assistance to help pay rent, a program
called "Section 8," direct payments to landlords, vouchers, or other types of
assistance from a local housing authority. Living in public housing is considered
housing assistance from the government.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^HOUGVT
If
Roster.HHC.tblName.bPerson[PX_A].ONOFFCAMP
US ne 1 and GEN.PCNT18UP_A=1, fill "Are you"
elseif
Roster.HHC.tblName.bPerson[PX_A].ONOFFCAMP
US ne 1 and PCNT18UP_A gt 1, fill "Are you or
anyone in your family"
elseif
Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMP
US=1, fill "Is your family at ^HNO ^HNOSUF
^STRNAME"
Page 292 of 306
Skip Instructions: <1,2,RF,DK> [goto next section]
Question ID: REC.0010.00.1
Question Text:
Response:
Variable name: LNKFNAME_A
Ask or verify: What is your full name?
DK:
RF:
Interview module: REC(Adult.REC)
Enter first name.
Don't Know
Refused
Skip Instructions: [goto LNKMNAME_A]
Question ID: REC.0020.00.1
Question Text:
Response:
Variable name: LNKMNAME_A
Enter middle name.
name.
DK:
RF:
Interview module: REC(Adult.REC)
Press "Enter" to skip to last name if respondent has no middle
Don't Know
Refused
Skip Instructions: [goto LNKLNAME_A]
Question ID: REC.0030.00.1
Question Text:
Response:
Variable name: LNKLNAME_A
Enter last name.
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto next section]
Page 293 of 306
Interview module: REC(Adult.REC)
Question ID: TEL.0010.00.1
Variable name: TELCURWRK_A
Interview module: TEL(Adult.TEL)
Universe: ((GEN.SAMEFAM_FLG=1
and
TELCURWRK_C=empty)
((GEN.SAMEFAM_FLG=1
and
TELCURWRK_C
IN
(DK,RF)
GEN.SARESPSC_FLG ne 1) or (GEN.SAMEFAM_FLG ne 1))
Question Text:
Response:
Fills:
or
and
Is there at least one telephone INSIDE ^HOME that is currently working and is
not a cell phone?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^HOME
If
Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMP
US=1, fill "your home at ^HNO ^HNOSUF
^STRNAME"
else fill "your home"
Skip Instructions: <1,2,RF,DK> [goto TELCEL_A]
Question ID: TEL.0020.00.1
Question Text:
Response:
Variable name: TELCEL_A
Interview module: TEL(Adult.TEL)
Do you have a working cell phone?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
Skip Instructions: <1>
if
TELCURWRK_A=1
or
(TELCURWRK_C=1
GEN.SAMEFAM_FLG=1)[goto PHONEUSE_A]
else[goto TLNO_TEL_SA]
and
<2,RF,DK> if (GEN.SAMEFAM_FLG=1 and PHONELIVE_C=empty) or
(GEN.SAMEFAM_FLG=1
and
PHONELIVE_C
IN
(RF,DK)
and
GEN.SARESPSC_A ne 1) or (GEN.SAMEFAM_FLG ne 1)) and GEN.PCNT_A
gt 1 [goto PHONELIVE_A]
else [goto TLNO_TEL_SA]
Page 294 of 306
Question ID: TEL.0030.00.1
Variable name: PHONELIVE_A
Interview module: TEL(Adult.TEL)
Universe: TELCEL_A
IN
(2,RF,DK)
and
((GEN.SAMEFAM_FLG=1
and
PHONELIVE_C=blank) or (GEN.SAMEFAM_FLG=1 and PHONELIVE_C IN
(DK,RF) and GEN.SARESPSC_FLG ne 1) or (GEN.SAMEFAM_FLG ne 1))
and GEN.PCNT_A gt 1
Question Text:
Response:
Fills:
Do you live with anyone ^ATHOME who has a working cell phone?
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^ATHOME
If
Roster.HHC.tblNAME.bPerson[PX_A].ONOFFCAMP
US=1, fill "at your home at ^HNO ^HNOSUF
^STRNAME"
else leave blank
Skip Instructions: <1,2,RF,DK> [goto TLNO_TEL_SA]
Question ID: TEL.0040.00.1
Variable name: PHONEUSE_A
Interview module: TEL(Adult.TEL)
Universe: TELCEL_A=1 and ((GEN.SAMEFAM_FLG=1 and TELCURWRK_C=1) or
(TELCURWRK_A=1))
Question Text:
Response:
Of all the telephone calls that you answer, are all or almost all on your cell
phones, some on your cell phone and some on your home phone, or very few
or none on your cell phones?
1.
2.
3.
DK:
RF:
All or almost all calls on cell phone
Some on cell phone and some on home phone
Very few or none on cell phone
Don't Know
Refused
Page 295 of 306
Skip Instructions: <1-3,RF,DK> [goto TLNO_TEL_SA]
Question ID: LNK.0010.00.1
Question Text:
Response:
Fills:
Variable name: LNKINTRO_A
Interview module: LNK(Adult.LNK)
?[F1] We would like the last four digits of your Social Security
Number^medicarenum. This information will help us link your survey data with
health-related records of other government agencies, and allow us to conduct
additional research without taking up your time with more questions. The
National Center for Health Statistics (NCHS) uses this information for research
purposes only. Providing this information is voluntary. There will be no effect
on your benefits if you do not provide this information. Federal laws authorize
us to ask for this information. Like all other answers you have provided, this
information will remain confidential. Read if necessary: The specific federal
laws protecting your privacy and the confidentiality of your data are the Public Health
Service Act (Title 42, U.S.C., Section 242m(d)), the Confidential Information
Protection and Statistical Efficiency Act of 2018 (Title III, Public Law No. 115-435),
and the Privacy Act of 1974 (5 U.S.C. § 552a).
Read if necessary: NCHS collects
health-related data from other government agencies, including records from Medicare
and Medicaid Services, Social Security, housing, and death certificates. If you agree,
NCHS will attempt to link records such as these with your survey data to give a fuller
picture of the kinds of things that affect health. NCHS does this linkage. Your name
and your information are not given to these agencies. Read if necessary: If asked:
Your data will not be linked to records from the IRS (Internal Revenue Service) or ICE
(Immigration and Customs Enforcement). Enter '1' to continue.
1.
Enter 1 to Continue
^medicarenum
If INS.HIKIND_A=2 or INS.MCAREPRB_A=1, fill ",
and the last four characters of your Medicare
number"
else, fill nothing
Skip Instructions: <1> [goto SSN4_A]
Page 296 of 306
Question ID: LNK.0020.00.1
Question Text:
Response:
Variable name: SSN4_A
Interview module: LNK(Adult.LNK)
?[F1] What are the last four digits of your Social Security Number? Read if
necessary: Providing this information is voluntary. There will be no effect on your
benefits if you do not provide this information. Federal laws authorize us to ask for
this information. Like all other information you have provided, these answers will
remain confidential. Read if asked about specific laws: The specific federal laws
protecting your privacy and the confidentiality of your data are the Public Health
Service Act, which is Title 42, U.S.C., Section 242m(d); the Confidential Information
Protection and Statistical Efficiency Act of 2018, which is Title III of Public Law No.
115-435; and the Privacy Act of 1974, which is 5 U.S.C. § 552a. Enter 'N' for no
Social Security Number.
DK:
RF:
Don't Know
Refused
Skip Instructions: if SSN4_A=000-999 [goto ERR2_SSN4_A]
elseif SSN4_A NOT IN (N,RF,DK,000-999,0001-9999) [goto ERR3_SSN4_A]
<0001-9999> if.Adult.INS.HIKIND_A=2 or Adult.INS.MCAREPRB_A=1 [goto
LAST4C_A]
else [goto next section]
if Adult.INS.HIKIND_A=2 or Adult.INS.MCAREPRB_A=1 [goto
LAST4C_A]
else [goto RLINK_A]
Check Name: ERR2_SSN4_A
Text:
{check ERR2_SSN4_A} You must enter all four of the last four digits of the Social
Security Number. Please correct.
Hard / Soft Edit: Hard
Universe: SSN4_A=000-999
Page 297 of 306
Check Name: ERR3_SSN4_A
Text:
{check ERR3_SSN4_A} The last 4 digits of a SSN should be between 0001-9999.
For a respondent who does not want to provide the SSN, enter 'Ctrl D' or 'Ctrl R' for
'Don't Know' or 'Refused.' If a respondent does not have a SSN, enter 'N'. Please
correct.
Hard / Soft Edit: Hard
Universe: SSN4_A NOT IN (N,RF,DK,000-999,0001-9999)
Question ID: LNK.0040.00.1
Variable name: LAST4C_A
Interview module: LNK(Adult.LNK)
Universe: INS.HIKIND_A=2 or INS.MCAREPRB_A=1
Question Text:
Response:
?[F1] 1 of 2 What are the last four characters of your Medicare or Health
Insurance Claim Number? Read if necessary: Providing this information is
voluntary. There will be no effect on your benefits if you do not provide this
information. Federal laws authorize us to ask for this information. Like all other
information you have provided, these answers will remain confidential. Read if
asked about specific laws: The specific federal laws protecting your privacy and the
confidentiality of your data are the Public Health Service Act, which is Title 42,
U.S.C., Section 242m(d); the Confidential Information Protection and Statistical
Efficiency Act of 2018, which is Title III of Public Law No. 115-435; and the Privacy
Act of 1974, which is 5 U.S.C. § 552a.
Reports from memory are acceptable if
the Medicare card (or some other form of documentation) is not available. Enter
the last four characters, which should be letter-letter-number-number.
DK:
RF:
Don't Know
Refused
Skip Instructions: if anything lt 4 alphanumeric characters [goto ERR1_LAST4C_A]
elseif SSN4_A IN (N,RF,DK) or LAST4C_A IN (RF,DK) [goto RLINK_A]
else [goto next section]
Page 298 of 306
Check Name: ERR1_LAST4C_A
Text:
{checkERR1_LAST4C_A} You must enter all four of the last four alphanumeric
characters of the Medicare number. Please correct.
Hard / Soft Edit: Hard
Universe: LAST4C_A = lt 4 alphanumeric characters
Question ID: LNK.0060.00.1
Variable name: RLINK_A
Interview module: LNK(Adult.LNK)
Universe: SSN4_A IN (N,RF,DK) or LAST4C_A IN (RF,DK)
Question Text:
Response:
Fills:
?[F1] May we try to link your survey data without a ^SSNMEDNUM?
Read if
necessary: Any data obtained are protected by strict federal laws, including the Public
Health Service Act, which is Title 42, U.S.C., Section 242m(d); the Confidential
Information Protection and Statistical Efficiency Act of 2018, which is Title III of Public
Law No. 115-435; and the Privacy Act of 1974, which is 5 U.S.C. § 552a.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^SSNMEDNUM
consent by SSN or Medicare number
Skip Instructions: <1,2,RF,DK>[goto next section]
Page 299 of 306
Question ID: BIO.0010.00.4
Question Text:
Response:
Fills:
Variable name: BIOINT1_A
Interview module: BIO(Adult.BIO)
Before we finish today, the National Center for Health Statistics, NCHS, would
like to invite you to participate in a follow-up study to the survey you have just
completed. The follow-up study is sponsored by NCHS, which is part of the
Centers for Disease Control and Prevention, CDC. The Census Bureau does
not have a role in the follow-up study. If you agree to participate, you will be
contacted by someone from ^BIOCOMPANY, the company that NCHS has hired
to conduct the follow-up. They will set up an appointment for a trained medical
professional to come to your home to complete a brief health examination. The
visit will take about 30 minutes. You will receive $75 as a token of NCHS's
appreciation for participating in the study. You will also receive a summary of
your results after your exam. NCHS will combine health exam results with
survey responses to form a more complete picture of the health of adults in the
United States. Enter '1' to continue.
1.
RF:
Enter 1 to Continue
Refused
^BIOCOMPANY
Fill "[COMPANY NAME]"
{Will provide instructions once NCHS secures a
contractor}
Skip Instructions: <1> [goto BIOINT2_A]
[goto BIORFWHY_A]
Question ID: BIO.0020.00.4
Variable name: BIOINT2_A
Interview module: BIO(Adult.BIO)
Universe: BIOINT1_A=1
Question Text:
During the health exam in your home, the medical professional will take your
height and weight, waist circumference, blood pressure, resting heart rate, and
a small sample of your blood. After the exam, a kit will be left with you to
collect and mail a urine sample. Your participation is voluntary. If you choose,
you can complete just part of the exam. I can leave a brochure with you, which
contains additional information about this health exam and the number of the
Medical Officer at NCHS.
Read if necessary: Your information will ONLY be used
for statistical research. Strict federal laws prevent NCHS and its contractors from
releasing information that could identify you or your family to anyone else without
your permission. All identifying information is removed from the data. Enter '1' to
continue.
Response:
Page 300 of 306
1.
RF:
Enter 1 to Continue
Refused
Skip Instructions: <1> [goto BIONAME_A]
[goto BIORFWHY_A]
Question ID: BIO.0030.00.4
Variable name: BIONAME_A
Interview module: BIO(Adult.BIO)
Universe: BIOINT2_A=1
Question Text:
Response:
Fills:
May we provide your name, address, and phone number to ^BIOCOMPANY so
they may contact you to schedule an exam?
Read if necessary: No other
information about your health will be provided to ^BIOCOMPANY.
1.
2.
DK:
RF:
Yes
No
Don't Know
Refused
^BIOCOMPANY
Fill "[COMPANY NAME]"
{Will provide instructions once NCHS secures a
contractor}
Skip Instructions: <1> [goto TLNO_BIO_SA]
<2,RF,DK> [goto BIORFWHY_A]
Question ID: BIO.0060.00.4
Variable name: BIODAY_A
Interview module: BIO(Adult.BIO)
Universe: TLNO_BIO_SA=valid number
Question Text:
What are the best days for ^BIOCOMPANY to contact you? Would you say
weekdays, weekends, or both?
Response:
Page 301 of 306
1.
2.
3.
DK:
RF:
Fills:
Weekdays
Weekends
Both weekdays and weekends
Don't Know
Refused
^BIOCOMPANY
Fill "[COMPANY NAME]"
{Will provide instructions once NCHS secures a
contractor}
Skip Instructions: <1-3,RF,DK> [goto BIOTIME_A]
Question ID: BIO.0070.00.4
Variable name: BIOTIME_A
Interview module: BIO(Adult.BIO)
Universe: TLNO_BIO_SA=valid number
Question Text:
Response:
Fills:
What is the best time of day for ^BIOCOMPANY to contact you? Would you say
mornings, afternoons, evenings, or anytime?
Enter all that apply, separate with
commas.
1.
2.
3.
4.
DK:
RF:
Morning
Afternoon
Evening
Anytime
Don't Know
Refused
^BIOCOMPANY
Fill "[COMPANY NAME]"
{Will provide instructions once NCHS secures a
contractor}
Skip Instructions: <1-4> if more than one answer selected and 4 IN BIOTIME_A [goto
ERR1_BIOTIME_A]
else [goto BIOPRECISE_A]
[goto BIOPRECISE_A]
Page 302 of 306
Check Name: ERR1_BIOTIME_A
Text:
{check ERR1_BIOTIME_A} Cannot mark "Anytime" and another type. Please
correct.
Hard / Soft Edit: Hard
Universe: if more than 1 answer selected at BIOTIME_A and 4 IN BIOTIME_A
Question ID: BIO.0080.00.4
Variable name: BIOPRECISE_A
Interview module: BIO(Adult.BIO)
Universe: TLNO_BIO_SA=valid number
Question Text:
If you'd like, you can provide a preferred time slot for ^BIOCOMPANY to
contact you, for example, between 8am and 10am on weekdays. Would you like
to do this? Enter 'N' if respondent doesn't provide a preferred time slot or refuses
or doesn't know a preferred time slot. Probe for as much detail as possible.
Response:
Fills:
^BIOCOMPANY
Fill "[COMPANY NAME]"
{Will provide instructions once NCHS secures a
contractor}
Skip Instructions: [goto BIOTEXT_A]
Question ID: BIO.0090.00.4
Variable name: BIOTEXT_A
Interview module: BIO(Adult.BIO)
Universe: TLNO_BIO_SA=valid number
Question Text:
Response:
^BIOCOMPANY may text you to schedule or remind you of an appointment. Is it
okay if ^BIOCOMPANY texts you? If respondent says phone can't receive texts,
enter 'no'.
DK:
RF:
Don't Know
Refused
Page 303 of 306
Fills:
^BIOCOMPANY
Fill "[COMPANY NAME]"
{Will provide instructions once NCHS secures a
contractor}
Skip Instructions: <1,2,RF,DK> [goto BIOEMAIL_A]
Question ID: BIO.0100.00.4
Variable name: BIOEMAIL_A
Interview module: BIO(Adult.BIO)
Universe: BIONAME_A=1
Question Text:
Response:
Fills:
^BIOCOMPANY may also want to contact you to schedule or remind you of an
appointment by e-mail. May I have your e-mail address? Enter e-mail address.
Enter 'N' for none.
DK:
RF:
Don't Know
Refused
^BIOCOMPANY
Fill "[COMPANY NAME]"
{Will provide instructions once NCHS secures a
contractor}
Skip Instructions: [goto next section]
if TLNO_BIO_SA IN (empty,RF,DK,0) [goto LATTEMPT_A]
else [goto next section]
Page 304 of 306
Question ID: BIO.0110.00.4
Variable name: LATTEMPT_A
Interview module: BIO(Adult.BIO)
Universe: BIONAME_A=1 and BIOEMAIL_A IN (N,RF,DK) and TLNO_BIO_SA IN
(empty,0,DK,RF)
Question Text:
Response:
You must provide either an e-mail address or a phone number to participate in
this follow-up study.
0.
1.
2.
DK:
RF:
Neither provided
Provide phone number
Provide e-mail
Don't Know
Refused
Skip Instructions: <0,RF,DK> [goto BIORFWHY_A]
<1> [goto TLNO_BIO_SA]
<2> [goto BIOEMAIL_A]
Question ID: BIO.0120.00.4
Variable name: BIORFWHY_A
Interview module: BIO(Adult.BIO)
Universe: BIOINT1_A=RF or BIOINT2_A=RF or BIONAME_A IN (2,RF,DK) or
LATTEMPT IN (0,RF,DK)
Question Text:
Response:
That's okay. If you don't mind my asking, can you tell me why? Use your best
judgement. If respondent is hostile or agitated, don't ask this question, just enter
CTRL-R. There will be an opportunity in the Back section for you to record your
impression of the respondent's reason(s) for refusal.
DK:
RF:
Don't Know
Refused
Skip Instructions: [goto next section]
Page 305 of 306
Question ID: THX.0080.001
Question Text:
Response:
Variable name: THANKS_A
Interview module: THX(Adult.THX)
Thank respondent for answering these questions. If there is a Sample Child interview
to complete, ask for appropriate person to respond to these questions. Enter '1' to
continue.
1.
Enter 1 to Continue
Skip Instructions: <1> [goto next section]
Check Name: Adult parallel tab finished
Text:
You have finished the Adult parallel tab. Press "Enter" or click OK to go back to the
main interview path. Then press the "END" key to jump to the next unanswered
question.
Hard / Soft Edit: Soft
Skip Instructions: Closing the box takes the user to the CASESTATUS screen
Page 306 of 306
| File Type | application/pdf |
| File Modified | 2020-12-22 |
| File Created | 2020-09-23 |