Form 0920-1061 Even-Numbered Year BRFSS Core Questionnaire

2019 Field Test Behavioral Risk Factor Surveillance System (BRFSS)

Attachment 3a Even- Numbered Year Core Questionnaire (2)

BRFSS Core Survey

OMB: 0920-1061

Document [docx]
Download: docx | pdf



Attachment 3a

Even - numbered Year

2020, 2022 Core Questionnaire






OMB Header and Introductory Text


Read if necessary

Read

Interviewer instructions

(not read)

Public reporting burden of this collection of information is estimated to average 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).


Form Approved

OMB No. 0920-1061

Exp. Date 3/31/2018


Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at ivk7@cdc.gov.


HELLO, I am calling for the (health department). My name is (name). We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.




Landline Introduction


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

LL01.


Is this [PHONE NUMBER]?

CTELENM1


1 Yes

Go to LL02


63

2 No

TERMINATE

Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time.

LL02.


Is this a private residence?

PVTRESD1


1 Yes

Go to LL04

Read if necessary: By private residence we mean someplace like a house or apartment.

Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.

64

2 No


Go to LL03

If no, business phone only: thank you very much but we are only interviewing persons on residential phones lines at this time.

NOTE: Business numbers which are also used for personal communication are eligible.

3 No, this is a business


Read: Thank you very much but we are only interviewing persons on residential phones at this time.

LL03.


Do you live in college housing?

COLGHOUS


1 Yes

Go to LL04

Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.

65

2 No

TERMINATE

Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.

LL04.


Do you currently live in__(state)____?

STATERE1


1 Yes

Go to LL05


66

2 No

TERMINATE

Thank you very much but we are only interviewing persons who live in [STATE] at this time.

LL05.

Is this a cell phone?

CELPHONE

1 Yes, it is a cell phone

TERMINATE

Read: Thank you very much but we are only interviewing by landline telephones in private residences or college housing at this time.

67

2 Not a cell phone

Go to LL06

Read if necessary: By cell phone we mean a telephone that is mobile and usable outside your neighborhood.

Do not read: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).

LL06.


Are you 18 years of age or older?

LADULT1


1 Yes


[CATI NOTE: IF COLLEGE HOUSING = “YES,” CONTINUE; OTHERWISE GO TO ADULT RANDOM SELECTION]


68

2 No

TERMINATE

Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.

LL07.

Are you male or female?


COLGSEX

1 Male

2 Female


ONLY for respondents who are LL and COLGHOUS= 1.



69

7 Don’t know/Not sure

9 Refused

TERMINATE

Thank you for your time, your number may be selected for another survey in the future.

LL08.

I need to randomly select one adult who lives in your household to be interviewed. Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older?

NUMADULT


1

Go to Transition to Section 1.

Go to LL09

Read: Are you that adult?

If yes: Then you are the person I need to speak with.

If no: May I speak with the adult in the household?

70-71

2-6 or more

Go to LL10.


LL09.

Are you male or female?


LANDSEX

1 Male

2 Female


GO to Transition Section 1.


72

7 Don’t know/Not sure

9 Refused

TERMINATE

Thank you for your time, your number may be selected for another survey in the future.

LL10.

How many of these adults are men?

NUMMEN


_ _ Number

77 Don’t know/ Not sure

99 Refused



73-74

LL11.

So the number of women in the household is [X]. Is that correct?

NUMWOMEN



Do not read: Confirm the number of adult women or clarify the total number of adults in the household.

Read: The persons in your household that I need to speak with is [Oldest/Youngest/ Middle//Male /Female].

75-76

LL12

The person in your household that I need to speak with is [Oldest/Youngest/ Middle//Male /Female]. Are you the [Oldest/Youngest/ Middle//Male /Female] in this household?

RESPSLCT

1 Male

2 Female




77

7 Don’t know/Not sure

9 Refused

TERMINATE

Thank you for your time, your number may be selected for another survey in the future.

Transition to Section 1.



I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).


Do not read: Introductory text may be reread when selected respondent is reached.


Do not read: The sentence “Any information you give me will not be connected to any personal information” may be replaced by “Any personal information that you provide will not be used to identify you.” If the state coordinator approves the change.




Cell Phone Introduction


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)








CP01.


Is this a safe time to talk with you?

SAFETIME


1 Yes

Go to CP02


78

2 No

([set appointment if possible]) TERMINATE]

Thank you very much. We will call you back at a more convenient time.

CP02.


Is this [PHONE NUMBER]?

CTELNUM1


1 Yes

Go to CP03


79

2 No

TERMINATE


CP03.


Is this a cell phone?

CELLFON5


1 Yes

Go to CADULT


80

2 No

TERMINATE

If "no”: thank you very much, but we are only interviewing persons on cell telephones at this time

CP04.


Are you 18 years of age or older?

CADULT1


1 Yes




81

2 No

TERMINATE

Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.

CP05.

Are you male or female?


CELLSEX

1 Male

2 Female



82

7 Don’t Know/ Not sure

9 Refused

TERMINATE

Thank you for your time, your number may be selected for another survey in the future.

CP06.


Do you live in a private residence?

PVTRESD3


1 Yes

Go to CP08

Read if necessary: By private residence we mean someplace like a house or apartment

Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.

83

2 No

Go to CP07


CP07.


Do you live in college housing?

CCLGHOUS


1 Yes

Go to CP08

Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.

84

2 No

TERMINATE

Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.

CP08.


Do you currently live in___(state)____?

CSTATE1


1 Yes

Go to CP10


85

2 No

Go to CP09


CP09.


In what state do you currently live?

RSPSTAT1


1 Alabama

2 Alaska

4 Arizona

5 Arkansas

6 California

8 Colorado

9 Connecticut

10 Delaware

11 District of Columbia

12 Florida

13 Georgia

15 Hawaii

16 Idaho

17 Illinois

18 Indiana

19 Iowa

20 Kansas

21 Kentucky

22 Louisiana

23 Maine

24 Maryland

25 Massachusetts

26 Michigan

27 Minnesota

28 Mississippi

29 Missouri

30 Montana

31 Nebraska

32 Nevada

33 New Hampshire

34 New Jersey

35 New Mexico

36 New York

37 North Carolina

38 North Dakota

39 Ohio

40 Oklahoma

41 Oregon

42 Pennsylvania

44 Rhode Island

45 South Carolina

46 South Dakota

47 Tennessee

48 Texas

49 Utah

50 Vermont

51 Virginia

53 Washington

54 West Virginia

55 Wisconsin

56 Wyoming

66 Guam

72 Puerto Rico

78 Virgin Islands

99 Refused



86-87

CP10.


Do you also have a landline telephone in your home that is used to make and receive calls?

LANDLINE


1 Yes

2 No

7 Don’t know/ Not sure

9 Refused


Read if necessary: By landline telephone, we mean a regular telephone in your home that is used for making or receiving calls. Please include landline phones used for both business and personal use.

88

CP11.

How many members of your household, including yourself, are 18 years of age or older?

HHADULT

_ _ Number

77 Don’t know/ Not sure

99 Refused

If CP07 = yes then number of adults is automatically set to 1


89-90

Transition to section 1.



I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).





Core Section 1: Health Status


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C01.01


Would you say that in general your health is—

GENHLTH

Read:

1 Excellent

2 Very Good

3 Good

4 Fair

5 Poor

Do not read:

7 Don’t know/Not sure

9 Refused



101



Core Section 2: Healthy Days


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C02.01


Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

PHYSHLTH

_ _ Number of days (01-30)

88 None

77 Don’t know/not sure

99 Refused



102-103

C02.02

Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

MENTHLTH

_ _ Number of days (01-30)

88 None

77 Don’t know/not sure

99 Refused



104-105

C02.03

During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

POORHLTH

_ _ Number of days (01-30)

88 None

77 Don’t know/not sure

99 Refused

Skip if C02.01, PHYSHLTH, is 88 and C02.02, MENTHLTH, is 88


106-107



Core Section 3: Healthcare Access


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C03.01


Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Service?

HLTHPLN1


1 Yes

If using Healthcare Access (HCA) Module go to HCA.01, else continue


108

2 No

7 Don’t know/Not Sure

9 Refused



C03.02

Do you have one person you think of as your personal doctor or health care provider?

PERSDOC2


1 Yes, only one

2 More than one

3 No

7 Don’t know / Not sure

9 Refused


If No, read: Is there more than one, or is there no person who you think of as your personal doctor or health care provider?

109

C03.03

Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?

MEDCOST


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



110

C03.04

About how long has it been since you last visited a doctor for a routine checkup?

CHECKUP1

Read if necessary:

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

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 5 years (2 years but less than 5 years ago)

4 5 or more years ago

Do not read:

7 Don’t know / Not sure

8 Never

9 Refused


Read if necessary: A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.

111



Core Section 4: Exercise


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C04.01

During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

EXERANY2

1 Yes


If respondent does not have a regular job or is retired, they may count the physical activity or exercise they spend the most time doing in a regular month.

223

2 No

7 Don’t know/Not Sure

9 Refused

Go to C 11.08

Core Section 5: Inadequate Sleep


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C05.01


On average, how many hours of sleep do you get in a 24-hour period?

CHOLCHK2

_ _ Number of hours [01-24]

77 Don’t know / Not sure

99 Refused






Core Section 6: Chronic Health Conditions


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C06.01


Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You’re Not Sure.

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

CVDINFR4


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



117

C06.02

(Ever told) (you had) angina or coronary heart disease?

CVDCRHD4


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



118

C06.03

(Ever told) (you had) a stroke?

CVDSTRK3


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



119

C06.04

(Ever told) (you had) asthma?

ASTHMA3

1 Yes



120

2 No

7 Don’t know / Not sure

9 Refused

Go to C06.06


C06.05

Do you still have asthma?

ASTHNOW

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



121

C06.06

(Ever told) (you had) skin cancer?

CHCSCNCR


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



122

C06.07

(Ever told) (you had) any other types of cancer?

CHCOCNCR


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



123

C06.08

(Ever told) (you had) chronic obstructive pulmonary disease, C.O.P.D., emphysema or chronic bronchitis?

CHCCOPD1


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



124

C06.09

(Ever told) (you had) a depressive disorder (including depression, major depression, dysthymia, or minor depression)?

ADDEPEV2


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



125

C06.10

Not including kidney stones, bladder infection or incontinence, were you ever told you have kidney disease?

CHCKDNY2


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Read if necessary: Incontinence is not being able to control urine flow.

126

C06.11

(Ever told) (you had) diabetes?

DIABETE3


1 Yes



If yes and respondent is female, ask: was this only when you were pregnant? If respondent says pre-diabetes or borderline diabetes, use response code 4.

127

2 Yes, but female told only during pregnancy

3 No

4 No, pre-diabetes or borderline diabetes

7 Don’t know / Not sure

9 Refused

Go to Pre-Diabetes Optional Module (if used). Otherwise, go to next section.


C06.12

How old were you when you were told you have diabetes?

DIABAGE2

_ _ Code age in years [97 = 97 and older]

98 Don‘t know / Not sure

99 Refused

Go to Diabetes Module if used, otherwise go to next section.


128-129



Core Section 7: Oral Health


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C07.01

Including all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists as well as dental hygienists, how long has it been since you last visited a dentist or a dental clinic for any reason?


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

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 5 years (2 years but less than 5 years ago)

4 5 or more years ago


Do not read:

7 Don’t know / Not sure

8 Never




C07.02

Not including teeth lost for injury or orthodontics, how many of your permanent teeth have been removed because of tooth decay or gum disease?


1 1 to 5

2 6 or more but not all

3 All

8 None

DO NOT READ

7 Don’t know / Not sure

9 Refused






Core Section 8: Demographics


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue





Read if necessary:

I will ask you some questions about yourself in the next section. We include these questions so that we can compare health indicators by groups.


C08.01

What is your age?

AGE


_ _ Code age in years

07 Don’t know / Not sure

09 Refused



137-138

C08.02

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

HISPANC3


If yes, read: Are you…

1 Mexican, Mexican American, Chicano/a

2 Puerto Rican

3 Cuban

4 Another Hispanic, Latino/a, or Spanish origin

Do not read:

5 No

7 Don’t know / Not sure

9 Refused


One or more categories may be selected.

139-142

C08.03

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

MRACE1


Please read:

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

88 No additional choices

77 Don’t know / Not sure

99 Refused

If more than one response to C08.04; continue. Otherwise, go to C08.06.

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

One or more categories may be selected.

143-170

C08.04

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

ORACE3


Please read:

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other


77 Don’t know / Not sure

99 Refused


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


If respondent has selected multiple races in previous and refuses to select a single race, code refused


171-172

C08.05

Are you…

MARITAL


Please read:

1 Married

2 Divorced

3 Widowed

4 Separated

5 Never married

Or

6 A member of an unmarried couple

Do not read:

9 Refused



173

C08.06

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

EDUCA


Read if necessary:

1 Never attended school or only attended kindergarten

2 Grades 1 through 8 (Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

5 College 1 year to 3 years (Some college or technical school)

6 College 4 years or more (College graduate)

Do not read:

9 Refused



174

C08.07

Do you own or rent your home?

RENTHOM1


1 Own

2 Rent

3 Other arrangement

7 Don’t know / Not sure

9 Refused


Other arrangement may include group home, staying with friends or family without paying rent. Home is defined as the place where you live most of the time/the majority of the year.

Read if necessary: We ask this question in order to compare health indicators among people with different housing situations.

175

C08.08

In what county do you currently live?

CTYCODE2


_ _ _ANSI County Code

777 Don’t know / Not sure

999 Refused



176-178

C08.09

What is the ZIP Code where you currently live?

ZIPCODE1


_ _ _ _ _

77777 Do not know

99999 Refused



179-183


C08.10

Not including cell phones or numbers used for computers, fax machines or security systems, do you have more than one telephone number in your household?

NUMHHOL3


1 Yes


If cellular telephone interview skip to 8.13 (Veteran3)


184

2 No

7 Don’t know / Not sure

9 Refused

Go to C08.13


C08.11

How many of these telephone numbers are residential numbers?

NUMPHON3


__ Enter number (1-5)

6 Six or more

7 Don’t know / Not sure

8 None

9 Refused



185

C08.12

How many cell phones do you have for personal use?

CPDEMO1B


__ Enter number (1-5)

6 Six or more

7 Don’t know / Not sure

8 None

9 Refused

Last question needed for partial complete.

Read if necessary: Include cell phones used for both business and personal use.

186

C08.13

Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?

VETERAN3


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Read if necessary: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.

187

C08.14

Are you currently…?

EMPLOY1


Read:

1 Employed for wages

2 Self-employed

3 Out of work for 1 year or more

4 Out of work for less than 1 year

5 A Homemaker

6 A Student

7 Retired

Or

8 Unable to work

Do not read:

9 Refused


If more than one, say “select the category which best describes you”.

188

C08.15

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

CHILDREN


_ _ Number of children

88 None

99 Refused



189-190

C08.16

Is your annual household income from all sources—

INCOME2


Read if necessary:

04 Less than $25,000

If no, ask 05; if yes, ask 03 ($20,000 to less than $25,000)

03 Less than $20,000 If no, code 04; if yes, ask 02 ($15,000 to less than $20,000)

02 Less than $15,000 If no, code 03; if yes, ask 01 ($10,000 to less than $15,000)

01 Less than $10,000 If no, code 02

05 Less than $35,000 If no, ask

06 ($25,000 to less than $35,000)

06 Less than $50,000 If no, ask

07 ($35,000 to less than $50,000)

07 Less than $75,000 If no, code 08

($50,000 to less than $75,000)

08 $75,000 or more

Do not read:

77 Don’t know / Not sure

99 Refused


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


191-192

C08.17

About how much do you weigh without shoes?

WEIGHT2


_ _ _ _ Weight (pounds/kilograms)

7777 Don’t know / Not sure

9999 Refused


If respondent answers in metrics, put 9 in first column. Round fractions up

193-196

C08.18

About how tall are you without shoes?

HEIGHT3


_ _ / _ _ Height (ft / inches/meters/centimeters)

77/ 77 Don’t know / Not sure

99/ 99 Refused


If respondent answers in metrics, put 9 in first column. Round fractions down

197-200

C08.19

To your knowledge, are you now pregnant?

PREGNANT


1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Skip if M28.01, BIRTHSEX, is coded 1; or CP05=1 or LL12=1; or LL09 = 1 or LL07 =1

or C08.01, AGE, is greater than 49


201

C08.20

Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone. Are you deaf or do you have serious difficulty hearing?

DEAF


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



202

C08.21

Are you blind or do you have serious difficulty seeing, even when wearing glasses?

BLIND


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



203

C08.22

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

DECIDE


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



204

C08.23

Do you have serious difficulty walking or climbing stairs?

DIFFWALK

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



205

C08.24

Do you have difficulty dressing or bathing?

DIFFDRES

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



206

C08.25

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

DIFFALON

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



207


Core Section 9: Tobacco Use


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C09.01


Have you smoked at least 100 cigarettes in your entire life?

SMOKE100


1 Yes


Do not include: electronic cigarettes (e-cigarettes, njoy, bluetip), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs) or marijuana.

5 packs = 100 cigarettes

208

2 No

7 Don’t know/Not Sure

9 Refused

Go to C09.05


C09.02

Do you now smoke cigarettes every day, some days, or not at all?

SMOKDAY2


1 Every day

2 Some days



209

3 Not at all


Go to C09.04


7 Don’t know / Not sure

9 Refused

Go to C09.05


C09.03

During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

STOPSMK2


1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Go to C09.05


210

C09.04

How long has it been since you last smoked a cigarette, even one or two puffs?

LASTSMK2


Read if necessary:

01 Within the past month (less than 1 month ago)

02 Within the past 3 months (1 month but less than 3 months ago)

03 Within the past 6 months (3 months but less than 6 months ago)

04 Within the past year (6 months but less than 1 year ago)

05 Within the past 5 years (1 year but less than 5 years ago)

06 Within the past 10 years (5 years but less than 10 years ago)

07 10 years or more

08 Never smoked regularly

77 Don’t know / Not sure

99 Refused



211-212

C09.05

Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?

USENOW3

1 Every day

2 Some days

3 Not at all

7 Don’t know / Not sure

9 Refused


Read if necessary: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.

213



Core Section 10: Alcohol Consumption

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C10.01


During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?

ALCDAY5


1 _ _ Days per week

2 _ _ Days in past 30 days


INTERVIEWER NOTE:

One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor.

214-216

888 No drinks in past 30 days

777 Don’t know / Not sure

999 Refused

Go to next section


C10.02

One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?

AVEDRNK2


_ _ Number of drinks

88 None

77 Don’t know / Not sure

99 Refused


Read if necessary: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.

217-218

C10.03

Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion?

DRNK3GE5


_ _ Number of times

88 None

77 Don’t know / Not sure

99 Refused

CATI X = 5 for men, X = 4 for women


219-220

C10.04

During the past 30 days, what is the largest number of drinks you had on any occasion?

MAXDRNKS

_ _ Number of drinks

77 Don’t know / Not sure

99 Refused



221-222



Core Section 11: Immunization


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C13.01

During the past 12 months, have you had either a flu vaccine that was sprayed in your nose or a flu shot injected into your arm?

FLUSHOT7

1 Yes



A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.

261

2 No

7 Don’t know / Not sure

9 Refused

Go to C13.03

C13.02

During what month and year did you receive your most recent flu vaccine that was sprayed in your nose or flu shot injected into your arm?

FLSHTMY3

_ _ / _ _ _ _ Month/ Year

777777 Don’t know/ Not sure

999999 Refused

Module on Place of Flu Shot Vaccination may be inserted after this question.


262-267

C13.03


At what kind of place did you get your last flu shot or vaccine?


01 A doctor’s office or health maintenance organization (HMO)

02 A health department

03 Another type of clinic or health center (a community health center)

04 A senior, recreation, or community center

05 A store (supermarket, drug store)

06 A hospital (inpatient)

07 An emergency room

08 Workplace

09 Some other kind of place

11 A school


Do not read:

10 Received vaccination in Canada/Mexico

77 Don’t know / Not sure (Probe: How would you describe the place where you went to get your most recent flu vaccine?)

99 Refused




C13.04

Have you ever had a pneumonia shot also known as a pneumococcal vaccine?

PNEUVAC4

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Read if necessary: There are two types of pneumonia shots: polysaccharide, also known as Pneumovax, and conjugate, also known as Prevnar.

269





Core Section 12: Falls


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C12.01


In the past 12 months, how many times have you fallen?



_ _ Number of times [76 = 76 or more]

88 None [Go to next section]

77 Don’t know / Not sure [Go to next section]

99 Refused[Go to next section]


INTERVIEWER NOTE: By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.

270

88 None

77 Don’t know / Not sure

99 Refused

Go to NEXT SECTION

C12.02

How many of these falls caused an injury that limited your regular activities for at least a day?


_ _ Number of falls [76 = 76 or more]

88 None

77 Don’t know / Not sure

99 Refused

[Fill in Did this fall (from Q12.1) cause an injury?]. If only one fall from Q12.1 and response is Yes (caused an injury); code 01. If response is No, code 88.

INTERVIEWER NOTE: By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.

271-276



Core Section 13: Seat Belt Use and Drinking and Driving

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C13.01


How often do you use seat belts when you drive or ride in a car? Would you say—



Read:


1 Always

2 Nearly always

3 Sometimes

4 Seldom

5 Never


Do not read:

7 Don’t know / Not sure

9 Refused



270

8 Never drive or ride in a car

Go to NEXT SECTION

C13.02

During the past 30 days, how many times have you driven when you’ve had perhaps too much to drink?


_ _ Number of times

88 None

77 Don’t know / Not sure

99 Refused






Core Section 14: Breast and Cervical Cancer Screening


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C14.01


Have you ever had a mammogram?


1 Yes

If male go to the next section.


270

2 No

7 Don’t know/ Not sure

9 Refused

Go to 14.3

C14.02

How long has it been since you had your last mammogram?


READ IF NECESSARY:

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

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 3 years (2 years but less than 3 years ago)

4 Within the past 5 years (3 years but less than 5 years ago)

5 5 or more years ago

7 Don’t know / Not sure

9 Refused




C14.03

Have you ever had a Pap test?


1 Yes


INTERVIEWER NOTE: A Pap test is a test for cancer of the cervix.


2 No

7 Don’t know/ Not sure

9 Refused

Go to 14.5

C14.04

How long has it been since you had your last Pap test?


READ IF NECESSARY:

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

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 3 years (2 years but less than 3 years ago)

4 Within the past 5 years (3 years but less than 5 years ago)

5 5 or more years ago

7 Don’t know / Not sure

9 Refused




C14.05

An H.P.V. test is sometimes given with the Pap test for cervical cancer screening. Have you ever had an H.P.V. test?


1 Yes


INTERVIEWER NOTE: HUMAN PAPILLOMAVIRUS (PAP-UH-LOH-MUH VIRUS)


2 No

7 Don’t know/ Not sure

9 Refused

Go to 14.7

C14.06

How long has it been since your last H.P.V. test?


READ IF NECESSARY:

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

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 3 years (2 years but less than 3 years ago)

4 Within the past 5 years (3 years but less than 5 years ago)

5 5 or more years ago

7 Don’t know / Not sure

9 Refused




C14.07

Have you had a hysterectomy?


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


INTERVIEWER NOTE: A hysterectomy is an operation to remove the uterus (womb).




Core Section 15: Prostate Cancer Screening


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C15.01


Has a doctor, nurse, or other health professional ever talked with you about the advantages of the Prostate-Specific Antigen or P.S.A. test?


1 Yes

2 No

7 Don’t know/ Not sure

9 Refused

If respondent is <39 years of age, or is female, go to next section.


A prostate-specific antigen test, also called a P.S.A. test, is a blood test used to check men for prostate cancer.

270

C15.02

Has a doctor, nurse, or other health professional ever talked with you about the disadvantages of the P.S.A. test?


1 Yes

2 No

7 Don’t know/ Not sure

9 Refused




C15.03

Has a doctor, nurse, or other health professional ever recommended that you have a P.S.A. test?


1 Yes





2 No

7 Don’t know/ Not sure

9 Refused

Go to Next Section

C15.04

Have you ever had a P.S.A. test?


1 Yes

2 No

7 Don’t know/ Not sure

9 Refused




C15.05

How long has it been since you had your last P.S.A. test?


READ IF NECESSARY:

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

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 3 years (2 years but less than 3 years ago)

4 Within the past 5 years (3 years but less than 5 years ago)

5 5 or more years ago

7 Don’t know / Not sure

9 Refused




C15.06

What was the main reason you had this P.S.A. test – was it …?


Read:

1 Part of a routine exam

2 Because of a prostate problem

3 Because of a family history of prostate cancer

4 Because you were told you had prostate cancer

5 Some other reason


Do not read:


7 Don’t know / Not sure

9Refused






Core Section 16: Colorectal Cancer Screening


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C16.01


A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?


1 Yes


9 Refused

If respondent is < 49 years of age, go to next section.



2 No

7 Don’t know/ Not sure

9 Refused

Go to 16.3

C16.02

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


READ IF NECESSARY:

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

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 3 years (2 years but less than 3 years ago)

4 Within the past 5 years (3 years but less than 5 years ago)

5 5 or more years ago

7 Don’t know / Not sure

9 Refused




C15.03

For a sigmoidoscopy, a flexible tube is inserted into the rectum to look for problems. A colonoscopy is similar, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. Was your most recent exam a sigmoidoscopy or a colonoscopy?


1 Sigmoidoscopy

2 Colonoscopy





7 Don’t know/ Not sure

9 Refused

Go to Next Section

C16.04

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


READ IF NECESSARY:

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

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 3 years (2 years but less than 3 years ago)

4 Within the past 5 years (3 years but less than 5 years ago)

5 Within the past 10 years

6 10 or more years ago

7 Don’t know / Not sure

9 Refused





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

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C17.01


The next few questions are about the national health problem of H.I.V., the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don’t have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.


Including fluid testing from your mouth, but not including tests you may have had for blood donation, have you ever been tested for H.I.V?

HIVTST7


1 Yes




2 No

7 Don’t know/ not sure

9 Refused

Go to C17.03

C17.02

Not including blood donations, in what month and year was your last H.I.V. test?

HIVTSTD3


_ _ /_ _ _ _ Code month and year

77/ 7777 Don’t know / Not sure 99/ 9999 Refused

If response is before January 1985, code "777777".

INTERVIEWER NOTE: If the respondent remembers the year but cannot remember the month, code the first two digits 77 and the last four digits for the year.

271-276

C17.03

I am going to read you a list. When I am done, please tell me if any of the situations apply to you. You do not need to tell me which one.


You have injected any drug other than those prescribed for you in the past year. 

You have been treated for a sexually transmitted disease or STD in the past year.

You have given or received money or drugs in exchange for sex in the past year.

You had anal sex without a condom in the past year.

You had four or more sex partners in the past year. 

Do any of these situations apply to you?


Do any of these situations apply to you?

HIVRISK5

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



277



Closing Statement/ Transition to Modules


Read if necessary

Read

CATI instructions

(not read)

That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.


Read if no optional modules follow, otherwise continue to optional modules.



20

13 January 2021

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPierannunzi, Carol (CDC/ONDIEH/NCCDPHP)
File Modified0000-00-00
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