0920-0950 MEC Interview & Examination
[NCHS] National Health and Nutrition Examination Survey (NHANES)
Att_3e_MEC Interview & Exam_revised_2022OCT13
OMB: 0920-0950
Attachment 3e
Mobile Exam Center (MEC) Interview and Examination
Data Collection Forms
2021-2022
Form Approved
OMB No. 0920-0950
Exp. Date XX/XX/20XX
Notice – CDC estimates the average public reporting burden for this collection of information as 2.5 hours per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0950).
Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2018 (CIPSEA Pub. L. No. 115-435, 132 Stat. 5529 § 302). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.
National Health and Nutrition Examination Survey (NHANES)
Mobile Examination Center (MEC) Interview & Exam
TABLE OF CONTENTS
CURRENT HEALTH STATUS – HSQ 27
PHYSICAL ACTIVITY AND PHYSICAL FITNESS – PAQ 28
SEXUAL BEHAVIOR – SXQ (Female) 47
SEXUAL BEHAVIOR – SXQ (Male) 51
ANTHROPOMETRY - BODY MEASURES 58
covid-19 – COQ
Target Group: SPs Birth +
ISIS INSTRUCTION: USE THE GENDER STATUS PASSED IN TO DISPLAY THE GENDER SPECIFIC TEXT IN THE QUESTION. DISPLAY PROXY FILLS FOR SPS <16 YEARS OLD.
CAPI DISPLAY INSTRUCTIONS FOR ALL QUESTIONS IN COQ MEC SECTION: DISPLAY DATE ENCODED IN SIA.085 IN “MONTH, DD, YYYY” FORMAT FOR PRE-FILLS SPECIFIED AS “SP INTERVIEW DATE”.
COQ.410 {Have you/Has SP} had COVID-19, or the illness caused by the Coronavirus Disease 2019 since we interviewed {you/him/her} at home on {SP INTERVIEW DATE}?
INTERVIEWER INSTRUCTIONS:
CODE ‘MAYBE’ IF THE SP THINKS S/HE MAY HAVE HAD COVID-19 DUE TO EXPERIENCING CERTAIN SYMPTOMS BUT DID NOT GET TESTED OR IS UNSURE OF THE RESULTS. CODE ‘DON’T KNOW’ IF THE SP DOES NOT KNOW IF S/HE HAS HAD COVID-19.
YES 1
NO 2 (COQ.430)
MAYBE 3
REFUSED 7 (COQ.430)
DON’T KNOW 9 (COQ.430)
COQ.420 How would {you/SP} describe {your/his/her} symptoms when they were at their worst? Would you say…
No symptoms 1
Mild symptoms 2
Moderate symptoms 3
Severe symptoms 4
REFUSED 7
DON’T KNOW 9
COQ.430 Now I’m going to ask you about testing for active COVID infections, which is done through a nasal or throat swab or a saliva test. This does not include blood tests for COVID-19.
{Have you/Has SP} been tested for coronavirus or COVID-19 since we interviewed {you/him/her} at home on {SP INTERVIEW DATE}?
YES 1
NO 2 (COQ.460)
REFUSED 7 (COQ.460)
DON’T KNOW 9 (COQ.460)
COQ.440 Did the swab or saliva test find that {you/SP} had coronavirus or COVID-19?
INTERVIEWER INSTRUCTION: IF TESTED MULTIPLE TIMES, CODE ANY POSITIVE RESULT RECEIVED AS YES.
YES 1
NO 2 (COQ.460)
DID NOT RECEIVE RESULTS 3 (COQ.460)
REFUSED 7 (COQ.460)
DON’T KNOW 9 (COQ.460)
COQ.450M/Y What was the date of {your/SP’s} positive COVID-19 test? Please tell me the month and year of {your/his/her} most recent positive test since {SP INTERVIEW DATE}. This does not include the blood test.
INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.
|___|___|
ENTER MONTH
REFUSED 77
DON'T KNOW 99
|___|___|___|___|
ENTER YEAR
REFUSED 7777
DON'T KNOW 9999
CAPI INSTRUCTIONS:
HARD EDIT VALUE FOR MONTH: 01-12
HARD EDIT VALUE FOR YEAR: YEAR MUST BE FOUR DIGITS
HARD EDIT: DATE MUST BE BETWEEN CURRENT MONTH AND YEAR AND MONTH AND YEAR OF THE SP INTERVIEW IN SIA085.
ERROR MESSAGE: “THE DATE THE VACCINE WAS RECEIVED MUST BE BETWEEN THE SP INTERVIEW DATE AND TODAY. PLEASE VERIFY.”
COQ.460 Since {SP INTERVIEW DATE}, {have you/has SP} had an antibody blood test to determine if {you/s/he} had coronavirus or COVID-19?
YES 1
NO 2 (COQ.480)
REFUSED 7 (COQ.480)
DON’T KNOW 9 (COQ.480)
COQ.470 Did the blood test find that {you/SP} had antibodies for coronavirus or COVID-19?
INTERVIEWER INSTRUCTION: IF TESTED MULTIPLE TIMES, CODE ANY POSITIVE RESULT RECEIVED AS YES.
YES 1
NO 2 (COQ.480)
DID NOT RECEIVE RESULTS 3 (COQ.480)
REFUSED 7 (COQ.480)
DON’T KNOW 9 (COQ.480)
COQ.475M/Y What was the date of this blood test? Please tell me the month and year of the most recent date that the blood test found {you/SP} had antibodies for COVID-19 since {SP INTERVIEW DATE}?
INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.
|___|___|
ENTER MONTH
REFUSED 77
DON'T KNOW 99
|___|___|___|___|
ENTER YEAR
REFUSED 7777
DON'T KNOW 9999
CAPI INSTRUCTIONS:
HARD EDIT VALUE FOR MONTH: 01-12
HARD EDIT VALUE FOR YEAR: YEAR MUST BE FOUR DIGITS
HARD EDIT: DATE MUST BE BETWEEN CURRENT MONTH AND YEAR AND MONTH AND YEAR OF THE SP INTERVIEW IN SIA085.
ERROR MESSAGE: “THE DATE THE VACCINE WAS RECEIVED MUST BE BETWEEN THE SP INTERVIEW DATE AND TODAY. PLEASE VERIFY.”
COQ.480 {Our records show that {you/SP} received a vaccine for COVID-19 on . . .}
LIST OF VACCINE BRAND(S) AND VACCINATION DATE(S) REPORTED IN SP INTERVIEW, SORT BY DOSE.}
{Have you/Has SP} received {another dose of the/a} vaccine for COVID-19 {since {SP INTERVIEW DATE}}?
YES 1
NO 2 (COQ.500)
REFUSED 7 (COQ.500)
DON’T KNOW 9 (COQ.500)
CAPI INSTRUCTIONS:
IF COQ.080 = 1 IN THE SP COQ SECTION, DISPLAY THE FOLLOWING:
“Our records show that {you/SP} received a vaccine for COVID-19 on . . .”
“LIST OF VACCINE BRAND(S) AND VACCINATION DATE(S) REPORTED”
“another dose of the”, AND
“since {SP INTERVIEW DATE}”
IF COQ.080 ≠ 1 IN THE SP COQ SECTION, DISPLAY “a”
COQ.486 How many doses of COVID-19 vaccine {have you/has he/has she} received since {SP INTERVIEW DATE}? Please include booster shots and any additional doses.
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT HESITATES OR IS NOT SURE ABOUT THE ANSWER, ENCOURAGE THE RESPONDENT TO GET THE VACCINE CARD OR CHECK THE VACCINATION RECORD TO HELP ANSWER THE QUESTION.
|___|___|
ENTER THE NUMBER OF DOSES
REFUSED 77
DON'T KNOW 99
CAPI INSTRUCTIONS:
HARD EDIT: 1-20.
IF NUMBER OF DOSES = 0, DISPLAY “PLEASE ENTER A VALUE GREATER THAN ZERO TO CONTINUE. IF NO DOSES WERE RECEIVED, GO TO COQ.480 AND UPDATE RESPONSE TO ‘NO.’” INCLUDE GO TO OPTIONS FOR COQ.486 AND COQ.480.
SOFT EDIT: IF NUMBER OF DOSES > 9 DISPLAY, “CONFIRM NUMBER OF DOSES WITH RESPONDENT.” IF NUMBER IS CORRECT, PRESS SUPPRESS TO CONTINUE. OTHERWISE, GO TO COQ.486 TO UPDATE VALUE.” INCLUDE GO TO OPTION FOR COQ.486.
HARD EDIT: IF NUMBER OF VACCINE DOSES REPORTED IN THE SP INTERVIEW (COQ.086) PLUS NUMBER OF DOSES ENTERED FOR COQ.486 IS GREATER THAN 25, DISPLAY “THE TOTAL NUMBER OF VACCINE DOSES REPORTED IN THE HOME AND MEC TOGETHER CANNOT BE GREATER THAN 25. PLEASE PRESS CLOSE AND CHANGE THE RESPONSE TO CONTINUE. ENTER A NOTE IF NECESSARY.”
BOX 1
CHECK ITEM COQ.445:
LOOP 1:
ASK COQ.487 – COQ.495M/Y FOR EACH VACCINE.
COQ.487/488 Which COVID-19 vaccine did {you/SP} receive {for your/for his/for her} {first/second/third/fourth/… dose} since {SP INTERVIEW DATE}? Was it Johnson & Johnson, Moderna, Pfizer-BioNTech, or something else?
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT HESITATES OR IS NOT SURE ABOUT THE ANSWER, ENCOURAGE THE RESPONDENT TO GET THE VACCINE CARD OR CHECK THE VACCINATION RECORD TO HELP ANSWER THE QUESTION.
VACCINE |
BRAND |
OTHER BRAND |
MONTH |
YEAR |
ANY OTHERS? |
Orig. reported doses |
|
|
|
|
|
1st Dose |
Brand reported in COQ.087 |
Brand in COQ.088 |
M in COQ.095M |
Y in COQ.095Y |
|
2nd Dose |
Brand reported in COQ.087 |
Brand in COQ.088 |
M in COQ.095M |
Y in COQ.095Y |
|
3rd Dose |
Brand reported in COQ.087 |
Brand in COQ.088 |
M in COQ.095M |
Y in COQ.095Y |
|
Newly reported doses |
|
|
|
|
|
1st Dose |
|
|
|
|
|
2nd Dose |
|
|
|
|
|
. . . |
|
|
|
|
|
JOHNSON & JOHNSON (JANSSEN) 1
MODERNA 2
PFIZER-BIONTECH 3
OTHER BRAND 4 (COQ.488)
REFUSED 7
DON’T KNOW 9
CAPI INSTRUCTION:
DISPLAY A NONEDITABLE VACCINE ROSTER WITH VACCINES ORIGINALLY REPORTED IN SP INTERVIEW AND ADD ROW(S) PER NUMBER OF VACCINES INDICATED IN COQ.486 (SEE EXAMPLE GRID ABOVE).
ALLOW UP TO 20 ADDITIONAL VACCINES TO BE ENTERED.
ALLOW UP TO 25 VACCINES TOTAL TO BE ENTERED ON THE GRID WHEN INCLUDING BOTH THE SP AND MEC APPLICATIONS.
DISPLAY “for your/for his/for her” “first/second/third/fourth/… dose” BASED ON THE DOSE NUMBER, IF 1 < COQ.486 AND COQ.486 ≠ (77 OR 99).
FOR ITEMS COQ.487-COQ.495M/Y, DISPLAY A GRID WITH NUMBER OF ROWS EQUAL TO THE NUMBER OF VACCINES INDICATED IN COQ.486 (SEE EXAMPLE GRID ABOVE). IF COQ.486 = (77 OR 99), DISPLAY ONE ROW (1ST DOSE) FOR ‘VACCINE’ IN THE GRID. INCLUDE COLUMNS ‘VACCINE,’ ‘BRAND,’ ‘OTHER BRAND,’ ‘MONTH,’ ‘YEAR,’ AND ‘ANY OTHERS.’ EACH COLUMN WILL FUNCTION AS FOLLOWS:
VACCINE: PREFILL WITH “1st Dose,” “2nd Dose, “3rd Dose,” etc. FOR EACH ROW. NOT EDITABLE FIELD.
BRAND: VALUE FOR COQ.487. ALLOW ENTRY OF VACCINE BRAND USING DROP-DOWN LIST FOR EACH DOSE.
HARD EDIT: IF COQ.487 IS EMPTY DISPLAY, “YOU MUST ENTER A BRAND TO CONTINUE. IF NO ADDITIONAL VACCINE DOSES RECEIVED, GO TO GRID AND SELECT ‘NO’ FOR ‘ANY OTHERS’ ON THE PREVIOUS ROW. IF NO DOSES WERE RECEIVED AT ALL, GO TO COQ.480 AND UPDATE RESPONSE TO ‘NO.’ IF RESPONDENT DOES NOT KNOW OR REFUSES TO GIVE THE NAME OF THE BRAND, GO TO COQ.487 (BRAND) AND UPDATE RESPONSE TO ‘DON’T KNOW’ OR ‘REFUSED.’”
OTHER BRAND: VALUE FOR COQ.488.
IF CODE 4 (OTHER) IS SELECTED FOR COQ.487, ACTIVATE A TEXT FIELD WITH OTHER VACCINE BRANDS IN A LOOKUP LIST. INCLUDE ‘NOT LISTED’ AS AN OPTION IN THE LIST.
FOR QUESTION TEXT DISPLAY,
“PRESS BS TO START THE LOOKUP.
ENTER NAME OF OTHER BRAND.
SELECT OTHER BRAND FROM LIST.
IF OTHER BRAND NOT ON LIST, PRESS BS TO DELETE ENTRY.
TYPE ‘**’ TO SELECT ‘**NOT LISTED.’
PRESS ENTER TO SELECT.
IF THE RESPONDENT HESITATES OR IS NOT SURE ABOUT THE ANSWER, ENCOURAGE THE RESPONDENT TO GET THE VACCINE CARD OR CHECK THE VACCINATION RECORD TO HELP ANSWER THE QUESTION.
HARD EDIT: IF COQ.488 IS EMPTY DISPLAY, “YOU MUST ENTER A BRAND TO CONTINUE. IF NO ADDITIONAL VACCINE DOSES RECEIVED, GO TO GRID AND SELECT ‘NO’ FOR ‘ANY OTHERS’ ON THE PREVIOUS ROW. IF NO DOSES WERE RECEIVED AT ALL, GO TO COQ.480 AND UPDATE RESPONSE TO ‘NO.’ IF RESPONDENT DOES NOT KNOW OR REFUSES TO GIVE THE NAME OF THE BRAND, GO TO COQ.487 (BRAND) AND UPDATE RESPONSE TO ‘DON’T KNOW’ OR ‘REFUSED.’”
MONTH AND YEAR: VALUES FOR COQ.495M/Y. TEXT FIELD.
ANY OTHERS: ALLOW INTERVIEWER TO ADD OR REMOVE ROW(S) IF ADDITIONAL OR LESS DOSE(S) REPORTED. DROPDOWN FIELD WILL DEFAULT TO ‘YES’ FOR ALL ROWS EXCEPT THE LAST ROW THAT WILL BE EMPTY. IF LAST ROW IS UPDATED TO YES, ANOTHER ROW IS CREATED. IF LAST ROW IS ‘NO,’ INSTRUMENT ADVANCES TO BOX 2. IF ROW COUNT IS CHANGED, STORED VALUE FOR COQ.486 WILL BE UPDATED ACCORDINGLY.
DISPLAY “ANY OTHERS?”
FOR GRID:
HARD EDIT: 1-20.
IF NUMBER OF NEWLY REPORTED DOSES IS GREATER THAN 20, OR THE TOTAL NUMBER OF DOSES BETWEEN THE SP INTERVIEW AND MEC IS GREATER THAN 25, DISPLAY “ YOU CANNOT ENTER MORE THAN 20 DOSES AT THE MEC, OR MORE THAN 25 DOSES IN TOTAL BETWEEN THE HOME INTERVIEW AND THE MEC. PLEASE PRESS CLOSE AND UPDATE THE LAST ANY OTHERS FIELD TO ‘NO’ TO CONTINUE. ENTER A NOTE IF NECESSARY.”
COQ.495M/Y In what month and year did {you/he/she} receive the {first/second/third/fourth/… dose of the} vaccine since {SP INTERVIEW DATE} for COVID-19?
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT HESITATES OR IS NOT SURE ABOUT THE ANSWER, ENCOURAGE THE RESPONDENT TO GET THE VACCINE CARD OR CHECK THE VACCINATION RECORD TO HELP ANSWER THE QUESTION.
PROBE FOR ANY MISSING PORTIONS OF DATE.
REVIEW THE ENTRIES WITH THE RESPONDENT ONCE THE ENTIRE GRID IS COMPLETED.
|___|___|
ENTER MONTH
REFUSED 77
DON'T KNOW 99
|___|___|___|___|
ENTER YEAR
REFUSED 7777
DON'T KNOW 9999
CAPI INSTRUCTIONS:
HARD EDIT VALUE FOR MONTH: 01-12
HARD EDIT VALUE FOR YEAR: YEAR MUST BE FOUR DIGITS
HARD EDIT: DATE MUST BE BETWEEN CURRENT MONTH AND YEAR AND MONTH AND YEAR OF THE SP INTERVIEW IN SIA085.
ERROR MESSAGE: “THE DATE THE VACCINE WAS RECEIVED MUST BE BETWEEN THE SP INTERVIEW DATE AND TODAY. PLEASE VERIFY.”
IF DATE FOR 2ND DOSE OR LATER IS EARLIER THAN THE DATE OF THE PREVIOUS DOSE ENTERED DISPLAY, “DATE OF VACCINE MUST BE LATER THAN THE DATE OF THE PREVIOUS VACCINE. GO TO THE CORRECT FIELD TO UPDATE THE DATE.
DISPLAY “first/second/third/fourth/… dose of the” IF MORE THAN 1 ROW ENTERED IN COQ.487.
BOX 2
CHECK ITEM COQ.455:
END LOOP 1:
ASK COQ.487 - COQ.495M/Y FOR THE NEXT VACCINE.
IF INFORMATION COLLECTED FOR ALL VACCINES, CONTINUE TO COQ.500.
COQ.500 {Have you/Has SP} had an overnight stay in a hospital for suspected or confirmed COVID-19 since {SP INTERVIEW DATE}?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
BOX 3
CHECK ITEM COQ.550:
IF COQ.160 = 1, GO TO COQ.580.
ELSE IF COQ.160 = (2 OR 7 OR 9), CONTINUE TO COQ.560.
ELSE IF [THE SP INTERVIEW DATE IS 4 WEEKS OR EARLIER THAN MEC VISIT DATE] AND [COQ.410 = (1 OR 3) OR COQ.440 = (1 OR 3)], CONTINUE TO COQ.560.
ELSE GO TO COQ.510.
COQ.560 Did {you/SP} experience any symptoms four weeks or later after being infected with COVID-19 or suspecting to have been infected with COVID-19? These symptoms can sometimes appear after recovering from the initial infection. Please look at card COQ1 for some examples of commonly reported post-COVID symptoms.
HAND CARD COQ1
INTERVIEWER INSTRUCTION:
IF INFECTED WITH COVID-19 MULTIPLE TIMES, CODE ANY EXPERIENCE OF POST-COVID SYMPTOMS AS YES.
DAY 1 OF A COVID-19 INFECTION IS THE FIRST FULL DAY AFTER THE SP STARTED EXPERIENCING SYMPTOMS. IF THE SP DID NOT HAVE ANY INITIAL SYMPTOMS, IT IS THE FIRST FULL DAY AFTER THE SAMPLE WAS COLLECTED FOR THE POSITIVE COVID-19 TEST.
YES 1
NO 2 (COQ.510)
REFUSED 7 (COQ.510)
DON’T KNOW 9 (COQ.510)
COQ.570/ 570O {[}Among all of the post-COVID symptoms that {you have/SP has} experienced, which ones bothered {you/him/her} the most? You can tell me up to three different symptoms. You can refer again to card COQ1 for some examples of commonly reported post-COVID symptoms.{]}
What is the {first/second/third} symptom that bothered {you/SP} the most?
HAND CARD COQ1
|
SYMPTOM |
OTHER SYMPTOM |
ANY OTHERS? |
Item[1] |
|
|
|
Item[2] |
|
|
|
Item[3] |
|
|
|
CHANGE OR LOSS OF SMELL OR TASTE 10
CHANGES IN MENSTRUAL CYCLES 11
CHEST PAIN 12
COUGH 13
DEPRESSION OR ANXIETY 14
DIARRHEA 15
DIFFICULTY BREATHING OR SHORTNESS OF BREATH 16
DIFFICULTY THINKING OR CONCENTRATING (SOMETIMES REFERRED TO
AS “BRAIN FOG”) 17
DIFFICULTY WITH MEMORY 18
DIZZINESS WHEN YOU STAND UP (LIGHTHEADEDNESS) 19
FAST-BEATING OR POUNDING HEART (ALSO KNOWN AS HEART PALPITATIONS) 20
FEVER 21
HEADACHE 22
JOINT OR MUSCLE PAIN 23
PINS-AND-NEEDLES FEELINGS 24
RASH 25
SLEEP PROBLEMS 26
STOMACH PAIN 27
SYMPTOMS THAT GET WORSE AFTER PHYSICAL OR MENTAL EFFORT
(ALSO KNOWN AS “POST-EXERTIONAL MALAISE”) 28
TIREDNESS OR FATIGUE THAT INTERFERES WITH DAILY LIFE 29
OTHER SYMPTOM 666 (COQ.570O)
REFUSED 777
CAPI INSTRUCTION:
FOR ITEMS COQ.570 AND COQ.570O, DISPLAY A GRID THAT CAN ACCOMMODATE UP TO THREE ROWS (SEE EXAMPLE ABOVE).
DO NOT ALLOW DUPLICATE ENTRIES. ALLOW DUPLICATE OF DK/RF/OTHER SYMPTOM
INCLUDE COLUMNS “SYMPTOM,” “OTHER SYMPTOM,” AND “ANY OTHERS.” EACH COLUMN WILL FUNCTION AS FOLLOWS:
SYMPTOM:
ENTER SYMPTOM WITH A LOOKUP LIST. INCLUDE ‘OTHER SYMPTOM’ AS AN OPTION IN THE LIST.
FOR BASE QUESTION TEXT, FILL “first” FOR LINE 1, “second” FOR LINE 2, AND “third” FOR LINE 3. INCLUDE BRACKETS IN QUESTION TEXT FOR SECOND AND THIRD LINE.
BELOW BASE QUESTION TEXT DISPLAY,
“PRESS BS TO START THE LOOKUP.
ENTER SYMPTOM REPORTED.
SELECT SYMPTOM FROM LIST.
IF REPORTED SYMPTOM NOT ON LIST, PRESS BS TO DELETE ENTRY.
TYPE ‘**’ TO SELECT ‘**OTHER SYMPTOM.’
PRESS ENTER TO SELECT.”
OTHER SYMPTOM:
IF “**OTHER SYMPTOM” IS SELECTED FOR COQ.570, ACTIVATE “OTHER SYMPTOM” FIELD (COQ.570O). REQUIRE ENTRY TO CONTINUE. DO NOT ALLOW DK/RF.
BELOW BASE QUESTION TEXT DISPLAY, “ENTER OTHER SYMPTOM”
ANY OTHERS?
DISPLAY QUESTION TEXT AS, “Are there any other symptoms?”
ALLOW INTERVIEWER TO ADD OR REMOVE ROW(S) IF ADDITIONAL OR LESS SYMPTOM(S) REPORTED. DROPDOWN FIELD WILL DEFAULT TO ‘YES’ FOR ALL ROWS EXCEPT THE LAST ROW THAT WILL BE EMPTY. IF LAST ROW IS UPDATED TO ‘YES,’ ANOTHER ROW IS CREATED (UP TO THREE ROWS). IF LAST ROW IS ‘NO,’ INSTRUMENT ADVANCES TO COQ.580.
COQ.580 {Post-COVID symptoms are new, recurring, or ongoing symptoms you experienced four weeks or later after first being infected with COVID-19 or suspecting to have been infected with COVID-19.}
The next few questions refer to all of the post-COVID symptoms that {you have/SP has} experienced.
In the last 30 days, have any of these symptoms reduced {your/SP’s} ability to carry out day-to-day activities compared with the time before {you/he/she} had COVID-19? Would you say…
INTERVIEWER INSTRUCTIONS:
DAY 1 OF A COVID-19 INFECTION IS THE FIRST FULL DAY AFTER THE SP STARTED EXPERIENCING SYMPTOMS. IF THE SP DID NOT HAVE ANY INITIAL SYMPTOMS, IT IS THE FIRST FULL DAY AFTER THE SAMPLE WAS COLLECTED FOR THE POSITIVE COVID-19 TEST.
yes, a lot; 1
yes, a little; or 2
no, not at all? 3
REFUSED 7
DON’T KNOW 9
HELP SCREEN:
Post-COVID symptoms: These refer to any new, recurring, or ongoing symptoms you experienced four weeks or later after being infected with COVID-19 or suspecting to have been infected with COVID-19. These symptoms can sometimes appear after recovering from the initial infection.
CAPI INSTRUCTIONS:
IF COQ.160 = 1 IN THE SP COQ SECTION, DISPLAY “Post-COVID symptoms are new, recurring, or ongoing symptoms you experienced four weeks or later after first being infected with COVID-19 or suspecting to have been infected with COVID-19.”
COQ.590 {Do you/Does SP} still experience any of these symptoms now?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
BOX 4
CHECK ITEM COQ.595:
IF COQ.190 = 2 AND COQ.580 = 3 AND COQ.590 = 2, GO TO COQ.510.
ELSE CONTINUE.
COQ.600 How long {did/have} these symptoms {last/lasted}? {Was it/Has it been}…
INTERVIEWER INSTRUCTION: WHEN DETERMINING HOW LONG SYMPTOMS LASTED, CONSIDER THE TOTAL AMOUNT OF TIME BETWEEN THE START OF THE FIRST SYMPTOM AND THE END OF THE LAST SYMPTOM (OR UNTIL NOW, IF STILL EXPERIENCING SYMPTOMS).
1 month to less than 2 months, 1
2 months to less than 3 months, 2
3 months to less than 6 months, 3
6 months to less than 9 months, 4
9 months to less than 12 months, or 5
12 months or more? 6
REFUSED 77
DON’T KNOW 99
CAPI INSTRUCTIONS:
DISPLAY “did” AND “last” AND “Was it” IF COQ.590 = 2. ELSE, DISPLAY “have” AND “lasted” AND “Has it been”.
COQ.510 Has anyone else in {your/SP’s} household tested positive for coronavirus or COVID-19 since {SP INTERVIEW DATE}?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
HELP SCREEN:
Household: The entire group of persons who live in one dwelling unit. It may be several persons living together or one person living alone. It includes the household reference person and any of their relatives, as well as roomers, employees, and other non-related persons.
COQ.520 {Do you/Does SP} currently have a health condition that a doctor or other health professional told {you/him/her} weakens the immune system, making it easier for {you/him/her} to get sick?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
HELP SCREEN:
Immunocompromised: While chronic diseases like heart disease and obesity put people at higher risk of having a tougher course of COVID, these are different from illnesses that directly impact the immune system. Many conditions and treatments can cause a person to be immunocompromised or have a weakened immune system. Primary immunodeficiency is caused by genetic defects that can be inherited. Prolonged use of corticosteroids (steroids) or other immune weakening medicines can lead to secondary or acquired immunodeficiency.
People are considered to be moderately or severely immunocompromised if they have:
Been receiving active cancer treatment for tumors or cancers of the blood
Received an organ transplant and are taking medicine to suppress the immune system
Received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system
Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)
Advanced or untreated HIV infection
Active treatment with high-dose corticosteroids or other drugs that may suppress your immune response
Doctor: The term refers to both doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, but other doctoral degrees such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Health Care Professionals (Health Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, pharmacists, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.
COQ.530 Since {SP INTERVIEW DATE}, {have you/has SP} taken prescription medication or had any medical treatments that a doctor or other health professional told {you/him/her} would weaken {your/his/her} immune system?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
HELP SCREEN:
Doctor: The term refers to both doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, but other doctoral degrees such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Health Care Professionals (Health Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, pharmacists, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.
COQ.540 There are two types of flu vaccinations. One is a shot and the other is a spray, mist, or drop in the nose. Since {SP INTERVIEW DATE}, {have you/has SP} had a flu vaccination?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
SEXUAL ORIENTATION – SXQ-O
Target Group: SPs 18-59 Yeas
-
BOX 1
CHECK ITEM SXQ.300:
IF SP = FEMALE AND SP = 18 – 59 YEARS, CONTINUE WITH SXQ.295.
ELSE IF SP = MALE AND SP = 18 – 59 YEARS, CONTINUE WITH SXQ.296.
OTHERWISE, GO TO END OF SECTION.
SXQ.295 Do you think of yourself as lesbian or gay; straight, that is, not lesbian or gay; bisexual; something else; or you don’t know the answer?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Lesbian or gay 1 (END OF SECTION)
Straight, that is, not lesbian or gay 2 (END OF SECTION)
Bisexual 3 (END OF SECTION)
Something else 4 (END OF SECTION)
I don’t know the answer 9 (END OF SECTION)
REFUSED 77 (END OF SECTION)
DON’T KNOW 99 (END OF SECTION)
SXQ.296 Do you think of yourself as gay; straight, that is, not gay; bisexual; something else; or you don’t know the answer?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Gay 1
Straight, that is, not gay 2
Bisexual 3
Something else 4
I don’t know the answer 9
REFUSED 77
DON’T KNOW 99
DEPRESSION SCREEN – DPQ
Target Group: SPs 12+
DPQ.010_ The {first/next} questions are about how your feelings over the last 2 weeks.
CAPI INSTRUCTION:
IF SPs AGE = 12-17 AND 60+, DISPLAY = first
IF SPs AGE = 18 – 59, DISPLAY = next
DPQ.010 Over the last 2 weeks, how often have you been bothered by any of the following problems:
little interest or pleasure in doing things?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Not at all 0
Several days 1
More than half the days 2
Nearly every day 3
REFUSED 7
DON’T KNOW 9
DPQ.020 Over the last 2 weeks, how often have you been bothered by:
feeling down, depressed, or hopeless?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Not at all 0
Several days 1
More than half the days 2
Nearly every day 3
REFUSED 7
DON’T KNOW 9
DPQ.030 Over the last 2 weeks, how often have you been bothered by:
trouble falling or staying asleep, or sleeping too much?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Not at all 0
Several days 1
More than half the days 2
Nearly every day 3
REFUSED 7
DON’T KNOW 9
DPQ.040 Over the last 2 weeks, how often have you been bothered by:
feeling tired or having little energy?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Not at all 0
Several days 1
More than half the days 2
Nearly every day 3
REFUSED 7
DON’T KNOW 9
DPQ.050 Over the last 2 weeks, how often have you been bothered by:
poor appetite or overeating?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Not at all 0
Several days 1
More than half the days 2
Nearly every day 3
REFUSED 7
DON’T KNOW 9
DPQ.060 Over the last 2 weeks, how often have you been bothered by:
feeling bad about yourself – or that you are a failure or have let yourself or your family down?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Not at all 0
Several days 1
More than half the days 2
Nearly every day 3
REFUSED 7
DON’T KNOW 9
DPQ.070 Over the last 2 weeks, how often have you been bothered by:
trouble concentrating on things, such as reading the newspaper or watching TV?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Not at all 0
Several days 1
More than half the days 2
Nearly every day 3
REFUSED 7
DON’T KNOW 9
DPQ.080 Over the last 2 weeks, how often have you been bothered by:
moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Not at all 0
Several days 1
More than half the days 2
Nearly every day 3
REFUSED 7
DON’T KNOW 9
DPQ.090 Over the last 2 weeks, how often have you been bothered by the following problem:
Thoughts that you would be better off dead or of hurting yourself in some way?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Not at all 0
Several days 1
More than half the days 2
Nearly every day 3
REFUSED 7
DON’T KNOW 9
BOX 2
CHECK ITEM DPQ.095:
IF RESPONSE TO ANY OF QUESTIONS DPQ.010 – DPQ.090 = 1, 2, OR 3, GO TO DPQ.100.
OTHERWISE, GO TO NEXT SECTION.
DPQ.100 How difficult have these problems made it for you to do your work, take care of things at home, or get along with people?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Not at all difficult 0
Somewhat difficult 1
Very difficult 2
Extremely difficult 3
REFUSED 7
DON’T KNOW 9
REPRODUCTIVE HEALTH – RHQ
Target Group: Female SPs Ages 12+
RHQ.010_ The next series of questions are about your reproductive history. Help is available for many of the questions.
RHQ.010 How old were you when you had your first menstrual period?
INSTRUCTIONS TO SP:
Please enter an age or enter zero if you have not started your period.
CAPI INSTRUCTION:
SOFT EDIT VALUES: AGE ≤8 YEARS.
ERROR MESSAGE: “You reported 8 years or younger as the age of your first menstrual period. If that is correct, please press the “Next” button to continue. If that is not correct, press the “Back” button, press “Clear,” and enter another age.”
SOFT EDIT VALUES: AGE ≥ 25 YEARS.
ERROR MESSAGE: “You reported 25 years or older as the age of your first menstrual period. If that is correct, please press the “Next” button to continue. If that is not correct, press the “Back” button, press “Clear,” and enter another age.”
HARD EDIT VALUES: AGE OF 1ST PERIOD CANNOT BE GREATER THAN CURRENT AGE.
ERROR MESSAGE: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”
SOFT EDIT: DISPLAY EDIT WHEN AGE OF SP IS GREATER THAN OR EQUAL TO 20 AND RHQ.010 IS CODED ‘0’.
ERROR MESSAGE: “You reported never starting your menstrual period. If that is correct, please press the “Next” button to continue. If that is not correct, press the “Back” button, press “Clear,” and enter another age.”
|___|___|
ENTER AGE IN YEARS
REFUSED 777
DON’T KNOW 999
-
BOX 1
CHECK ITEM RHQ.015:
IF PERIODS HAVEN’T STARTED (CODED ‘0’), GO TO END OF SECTION.
OTHERWISE, GO TO RHQ.031.
RHQ.031 Have you had at least one menstrual period in the past 12 months?
INSTRUCTIONS TO SP:
Please select . . .
HELP TEXT: If you have had at least one very light period in the past 12 months because you use hormonal birth control, such as pills, injectables or IUDs, select “Yes.”
If you have not had a period in the past 12 months, but you had bleeding due to medical conditions, hormone therapy, or surgeries, select “No”
SOFT EDIT: DISPLAY EDIT WHEN AGE OF SP IS GREATER THAN OR EQUAL TO 60 AND RHQ.031 IS CODED YES.
ERROR MESSAGE: “If you have not had a period in the past 12 months, but you had bleeding due to medical conditions, hormone therapy, or surgeries, please press the “Back” button and select “No.” Otherwise, press the “Next” button to continue.”
Yes 1
No 2 (RHQ.043)
REFUSED 7 (RHQ.060)
DON’T KNOW 9 (RHQ.060)
-
BOX 1A
CHECK ITEM RHQ.033:
IF SP < 20 YEARS OLD AND RHQ.031 = 1, GO TO BOX 5.
IF SP 20+ YEARS OLD AND RHQ.031 = 1, GO TO RHQ.282.
OTHERWISE, CONTINUE.
RHQ.043 What is the reason that you have not had a period in the past 12 months?
INSTRUCTIONS TO SP:
Please select one of the following choices.
HELP TEXT: Select “some other reason” if you have not had a period in the past 12 months, for reasons including, but not limited to: hormonal birth control use; cancer; a thyroid condition; chemotherapy; excessive exercise; anorexia; low body weight.
SOFT EDIT: DISPLAY EDIT WHEN AGE OF SP IS YOUNGER THAN 45 AND RHQ.043 IS CODED 7 (MENOPAUSE/CHANGE OF LIFE).
ERROR MESSAGE: “You reported that the reason you have not had a period in the past 12 months is because of menopause, meaning your periods have completely stopped. If that is correct, please press the “Next” button to continue. If that is not correct, press the “Back” button, press “Clear,” and select a different reason.”
Pregnancy 1 (BOX 5)
Breast feeding 2
Hysterectomy 3
Menopause or the change of life 7
Some other reason 9
REFUSED 77
DON’T KNOW 99
RHQ.282 Have you had a hysterectomy, including a partial hysterectomy, that is, surgery to remove your uterus or womb?
INSTRUCTIONS TO SP:
Please select . . .
CAPI INSTRUCTION:
IF RHQ.043 = 3, fill = 1
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
RHQ.305 Have you had both of your ovaries removed {either when you had your uterus removed or at any other time}?
HELP TEXT: It is possible to have both ovaries removed, only one ovary removed, or only part of an ovary removed. Ovaries may be removed during a hysterectomy. Select “Yes” only if a surgeon completely removed both ovaries.
INSTRUCTIONS TO SP:
Please select . . .
CAPI INSTRUCTION: IF RHQ.282 = 1 DISPLAY {either when you had your uterus removed or at any other time}”
Yes 1
No 2 (BOX 1B)
REFUSED 7 (RHQ.060)
DON’T KNOW 9 (RHQ.060)
RHQ.332 How old were you when you had your ovaries removed or last ovary removed if removed at different times?
INSTRUCTIONS TO SP:
Please enter an age.
CAPI INSTRUCTION:
HARD EDIT: RHQ.332 MUST BE EQUAL TO OR LESS THAN AGE OF SP.
ERROR MESSAGE: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”
|___|___|___|
ENTER AGE IN YEARS
REFUSED 7777
DON’T KNOW 9999
-
BOX 1B
CHECK ITEM RHQ.334:
IF RHQ.031 = 1 AND RHQ.282 = 2 AND RHQ.305 = 2, GO TO BOX 5.
OTHERWISE, CONTINUE.
RHQ.060 About how old were you when you had your last menstrual period?
INSTRUCTIONS TO SP:
Please enter an age.
SOFT EDIT: DISPLAY EDIT WHEN RHQ.060 IS GREATER THAN 59.
ERROR MESSAGE: “You reported your last menstrual period after age 59. If that is correct, please press the “Next” button to continue. If that is not correct, press the “Back” button, press “Clear,” and try again.”
SOFT EDIT: RHQ.060 MUST BE LESS THAN OR EQUAL TO RHQ.332.
ERROR MESSAGE: “You reported the age of your last menstrual period after the age that both of your ovaries were removed. If that is correct, please press the “Next” button to continue. If that is not correct, press the “Back” button, press “Clear,” and try again.”
HARD EDIT: RHQ.060 MUST BE EQUAL TO OR LESS THAN AGE OF SP.
ERROR MESSAGE: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”
|___|___|
ENTER AGE IN YEARS
REFUSED 777
DON’T KNOW 999
-
BOX 5
CHECK ITEM RHQ.086:
IF SP IS 12-17 YEARS OLD, GO TO RHQ.131.
IF SP IS 18-59 YEARS OLD, CONTINUE.
OTHERWISE, END OF SECTION.
RHQ.078 Have you ever been treated for an infection in your fallopian tubes, uterus or ovaries, also called a pelvic infection, pelvic inflammatory disease, or PID?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
RHQ.131_ The next questions are about your pregnancy history.
RHQ.131 Have you ever been pregnant? Please include current pregnancy, live births, miscarriages, stillbirths, tubal pregnancies and abortions.
INSTRUCTIONS TO SP:
Please select . . .
HELP TEXT:
Miscarriage is the loss of a baby before the 20th week of pregnancy.
Stillbirth is the loss of a baby at or after 20 weeks of pregnancy.
Tubal Pregnancy is a pregnancy that occurs in the fallopian tube.
Abortion is the termination of a pregnancy using induced methods.
Yes 1
No 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON’T KNOW 9 (END OF SECTION)
-
BOX 6
CHECK ITEM RHQ.136:
IF THE SP HAS EXPERIENCED MENOPAUSE (RHQ.043 = 7), GO TO RHQ.167.
IF THE SP HAD HYSTERECTOMY (RHQ.043 = 3 OR RHQ.282 = 1), GO TO RHQ.167.
OTHERWISE, CONTINUE.
RHQ.143 Are you pregnant now?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
RHQ.167 How many vaginal or Cesarean deliveries have you had? Please count all stillbirths as well as live births.
If you delivered twins or had any other multiple birth, count it as one delivery.
INSTRUCTIONS TO SP:
Please enter the total number of deliveries.
|___|___|
ENTER NUMBER
REFUSED 777
DON’T KNOW 999
-
BOX 7B
CHECK ITEM RHQ.170A:
IF THE NUMBER OF DELIVERIES IN RHQ.167 EQUALS ZERO, GO TO END OF SECTION.
OTHERWISE, CONTINUE.
RHQ.200 Are you now breast feeding a child?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
CURRENT HEALTH STATUS – HSQ
Target Group: SPs 16+
HSQ.590_ The first question is about the test for HIV, the virus that causes AIDS.
HSQ.590 Except for tests you may have had as part of blood donations, have you ever been tested for HIV?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
PHYSICAL ACTIVITY AND PHYSICAL FITNESS – PAQ
Target Group: SPs 12-15 Years
PAQ.706_ The first questions are about your activities.
PAQ.706 During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.
INSTRUCTIONS TO SP:
Please select one of the following choices.
0 days 0
1 day 1
2 days 2
3 days 3
4 days 4
5 days 5
6 days 6
7 days 7
REFUSED 77
DON’T KNOW 99
PAQ.711 On a typical day during the school year, about how many hours do you usually spend playing with a smartphone or computer, watching TV or movies, or playing video games?
INSTRUCTIONS TO SP:
Please enter a number.
|___|___|
ENTER NUMBER OF HOURS
REFUSED 77
DON'T KNOW 99
SOFT EDIT: 18 – 24 HOURS.
ERROR MESSAGE: “You said on a typical day during the school year, you usually spend 18 hours or more playing with a smartphone or computer, watching TV or movies, or playing video games. If that is correct, please press the “Next” button to continue. If that is not correct, press the “Back” button, press “Clear,” and try again.”
HARD EDIT: 25 HOURS OR MORE.
ERROR MESSAGE: “Please enter a number between 0 and 24. Please press the “Back” button, press “Clear,” and try again.”
TOBACCO – SMQ
Target Group: SPs 12+
BOX 1
CHECK ITEM SMQ.605:
IF SP AGED 18+, GO TO SMQ.681_.
OTHERWISE, CONTINUE.
SMQ.621__ The following questions are about cigarette smoking and other tobacco use. Do not include cigars or marijuana.
SMQ.621 About how many cigarettes have you smoked in your entire life?
INSTRUCTIONS TO SP:
Please select . . .
I have never smoked, not even a puff 1 (SMQ.681_)
1 or more puffs but never a whole cigarette 2 (SMQ.681_)
1 cigarette 3
2 to 5 cigarettes 4
6 to 15 cigarettes 5
16 to 25 cigarettes 6
26 to 99 cigarettes 7
100 or more cigarettes 8
REFUSED 77 (SMQ.681_)
DON’T KNOW 99 (SMQ.681_)
SMQ.632 How old were you when you smoked a whole cigarette for the first time?
SMQ.632a
INSTRUCTIONS TO SP:
Please enter an age.
CAPI INSTRUCTION:
COMBINATION CONTROL: NUMBER PAD: ENTER AGE
ACCEPTABLE VALUES: 6-18 YEARS, REFUSED, DON’T KNOW.
IF R ENTERS 1-5, STORE 6 YEARS.
HARD EDIT: IF SMQ.632 > RIAAGEYR THEN ERROR.
ERROR MESSAGE: “Your response is older than your recorded age. Please press the “Back” button, press “Clear,” and try again.”
HARD EDIT: IF SMQ.632 = 0 THEN ERROR.
ERROR MESSAGE: “Your response must be greater than zero. Please press the “Back” button, press “Clear,” and try again.”
|___|___|
ENTER AGE
AGE 1-18
REFUSED 77
DON’T KNOW 99
SMQ.641 On how many of the past 30 days did you smoke cigarettes?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
CAPI INSTRUCTION:
ACCEPTABLE VALUES: 0-30, REFUSED, DON’T KNOW
HARD EDIT: IF SMQ.641 > 30 THEN ERROR.
ERROR MESSAGE: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”
|___|___|
ENTER NUMBER OF DAYS
REFUSED 77
DON’T KNOW 99
BOX 1A
CHECK ITEM SMQ.645:
(IF ‘NONE’ (CODE ‘00’), ‘REFUSED’ (CODE ‘77’), OR ‘DON’T KNOW’ (CODE ‘99’) IN SMQ.641) AND SMQ.621 NOT EQUAL TO 8, GO TO SMQ.681_.
(IF ‘NONE’ (CODE ‘00’), ‘REFUSED’ (CODE ‘77’), OR ‘DON’T KNOW’ (CODE ‘99’) IN SMQ.641) AND SMQ.621 = 8, CONTINUE.
OTHERWISE, GO TO SMQ.650.
SMQ.050 How long has it been since you quit smoking cigarettes?
Q/U
INSTRUCTIONS TO SP:
Please enter the number of days, weeks, months, or years, then select the unit of time.
|___|___|___|
ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
REFUSED 77777
DON’T KNOW 99999
ENTER UNIT
Days 1
Weeks 2
Months 3
Years 4
REFUSED 7
DON’T KNOW 9
BOX 1A1
CHECK ITEM SMQ.051:
IF SMQ.050 LESS THAN 30 DAYS GO TO SMQ.650.
OTHERWISE, GO TO SMQ.681_.
SMQ.650 On average, when you smoked during the past 30 days, how many cigarettes did you smoke a day?
SMQ.650a
INSTRUCTIONS TO SP:
Please enter a number.
CAPI INSTRUCTION:
IF R SAYS 95 OR MORE CIGARETTES PER DAY, STORE 95 IN SMQ650a.
HARD EDIT: IF SMQ.650 = 0 THEN ERROR.
ERROR MESSAGE: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.”
|___|___|___|
ENTER NUMBER OF CIGARETTES
REFUSED 7777
DON’T KNOW 9999
SMQ.681_ The following questions ask about use of tobacco products in the past 5 days.
SMQ.682 During the past 5 days, including today, did you smoke {cigarettes,} pipes, regular cigars, cigarillos, or little filtered cigars, water pipes, or hookahs with tobacco?
INSTRUCTIONS TO SP:
Please select . . .
CAPI INSTRUCTIONS:
IF SMQ.621 = 1 OR 2 OR SMQ.641 = 00 THEN DO NOT DISPLAY {“cigarettes, “}
RECORDING NOTE: 2 WAVE FILES NEEDED ONE WITH AND ONE WITHOUT THE WORD CIGARETTES.
Yes 1
No 2 (SMQ.846)
REFUSED 7 (SMQ.846)
DON’T KNOW 9 (SMQ.846)
BOX 1C
CHECK ITEM SMQ.850:
IF SMQ.621 = 1 OR 2 OR SMQ.641 = 00, GO TO SMQ.692B.
OTHERWISE, CONTINUE WITH SMQ.692A.
SMQ.692A Which of these products did you smoke? (CHECK ALL THAT APPLY)
INSTRUCTIONS TO SP:
Please select all that you used.
Cigarettes 1 (BOX 2)
Pipes 2 (BOX 2)
Regular
cigars, cigarillos, or little filtered
cigars 3 (BOX 2)
Water pipes or Hookahs with tobacco 4 (BOX 2)
REFUSED 77 (SMQ.846)
DON’T KNOW 99 (SMQ.846)
SMQ.692B Which of these products did you smoke? (CHECK ALL THAT APPLY)
INSTRUCTIONS TO SP:
Please select all that you used.
Pipes 1
Regular
cigars, cigarillos, or little filtered
cigars 2
Water pipes or Hookahs with tobacco 3
REFUSED 77 (SMQ.846)
DON’T KNOW 99 (SMQ.846)
BOX 2
CHECK ITEM SMQ.701:
IF ‘CIGARETTES’ (CODE 1) IN SMQ.692A, GO TO SMQ.710.
IF ‘PIPES’ (CODE 2) IN SMQ.692A OR (CODE 1) IN SMQ.692B, GO TO SMQ.740.
IF ‘CIGARS’ (CODE 3) IN SMQ.692A OR (CODE 2) IN SMQ.692B, GO TO SMQ.771.
IF ‘WATER PIPE OR HOOKAH’ (CODE 4) IN SMQ.692A OR (CODE 3) IN SMQ.692B, GO TO SMQ.845.
SMQ.710 During the past 5 days, including today, on how many days did you smoke cigarettes?
INSTRUCTIONS TO SP:
Please enter a number.
CAPI INSTRUCTIONS:
HARD EDIT: IF SMQ.710 < 1 OR SMQ.710 > 5 THEN ERROR.
ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON’T KNOW 9
SMQ.720 During the past 5 days, including today, on the days you smoked, how many cigarettes did you smoke
SMQ.720a each day?
INSTRUCTIONS TO SP:
Please enter a number.
CAPI INSTRUCTION:
IF R SAYS 95 OR MORE CIGARETTES PER DAY, STORE 95 IN SMQ720a.
HARD EDIT: IF SMQ.720 = 0 THEN ERROR.
ERROR MESSAGE: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.”
|___|___|___|
ENTER NUMBER OF CIGARETTES
REFUSED 7777
DON’T KNOW 9999
SMQ.725 When did you smoke your last cigarette? Was it . . .
Today 1
Yesterday 2
3 to 5 days ago 3
REFUSED 7
DON’T KNOW 9
BOX 3
CHECK ITEM SMQ.731:
IF ‘PIPES’ (CODE 2) IN SMQ.692A OR (CODE 1) IN SMQ.692B, GO TO SMQ.740.
IF ‘CIGARS’ (CODE 3) IN SMQ.692A OR (CODE 2) IN SMQ.692B, GO TO SMQ.771.
IF ‘WATER PIPE OR HOOKAH (CODE 4) IN SMQ.692A OR (CODE 3) IN SMQ.692B, GO TO SMQ.845.
OTHERWISE, GO TO SMQ.846.
SMQ.740 During the past 5 days, including today, on how many days did you smoke a pipe?
INSTRUCTIONS TO SP:
Please enter a number.
CAPI INSTRUCTIONS:
HARD EDIT: IF SMQ.740 < 1 OR SMQ.740 > 5 THEN ERROR.
ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON’T KNOW 9
BOX 4
CHECK ITEM SMQ.761:
IF ‘CIGARS’ (CODE 3) IN SMQ.692A OR (CODE 2) IN SMQ.692B, GO TO SMQ.771.
IF ‘WATER PIPES OR HOOKAH’ (CODE 4) IN SMQ.692A OR (CODE 3) IN SMQ.692B, GO TO SMQ.SMQ.845.
OTHERWISE, GO TO SMQ.846.
SMQ.771 During the past 5 days, including today, on how many days did you smoke regular cigars, cigarillos, or little filtered cigars?
INSTRUCTIONS TO SP:
Please enter a number.
CAPI INSTRUCTIONS:
HARD EDIT: IF SMQ.771 < 1 OR SMQ.771 > 5 THEN ERROR.
ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON’T KNOW 9
BOX 5
CHECK ITEM SMQ.791:
IF ‘WATERPIPE’ (CODE 4) IN SMQ.692A OR (CODE 3) IN SMQ.692B, GO TO SMQ.845.
OTHERWISE, GO TO SMQ.846.
SMQ.845 During the past 5 days, including today, on how many days did you smoke tobacco in a water pipe or hookah?
INSTRUCTIONS TO SP:
Please enter a number.
CAPI INSTRUCTIONS:
HARD EDIT: IF SMQ.845 < 1 OR SMQ.845 > 5 THEN ERROR.
ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON’T KNOW 9
SMQ.846 During the past 5 days, including today, did you use e-cigarettes? You may also know them as JUULTM, vape-pens, vapes, hookah-pens, e-hookahs, or vaporizers. These are battery-powered, usually contain liquid nicotine, and produce vapor instead of smoke?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2 (SMQ.851)
REFUSED 7 (SMQ.851)
DON’T KNOW 9 (SMQ.851)
SMQ.849 During the past 5 days, including today, on how many days did you use e-cigarettes?
INSTRUCTIONS TO SP:
Please enter a number.
CAPI INSTRUCTIONS:
HARD EDIT: IF SMQ.849 < 1 OR SMQ.849 > 5 THEN ERROR.
ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON’T KNOW 9
SMQ.851_ Smokeless tobacco products are placed in the mouth or nose and can include chewing tobacco, snuff, dip, snus, or dissolvable tobacco.
SMQ.851 During the past 5 days, including today, did you use any smokeless tobacco?
INSTRUCTIONS TO SP:
Please do not include nicotine replacement therapy products like patches, gum, lozenge or spray which are considered products to help you stop smoking.
Please select . . .
Yes 1
No 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON’T KNOW 9 (END OF SECTION)
SMQ.853 Which of these products did you use?
INSTRUCTIONS TO SP:
Please select all that you used.
(CHECK ALL THAT APPLY)
Chewing tobacco 1
Snuff 2
Snus 3
Dissolvables 4
Dip 5
REFUSED 77
DON’T KNOW 99
BOX 6
CHECK ITEM SMQ.610:
IF SP AGED 12 - 17, GO TO END OF SECTION.
OTHERWISE, CONTINUE.
SMQ.863 During the past 5 days, including today, did you use any nicotine replacement therapy products such as nicotine patches, gum, lozenges, inhalers, or nasal sprays?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
ALCOHOL USE – ALQ
Target Group: SPs 12+
BOX 1A
CHECK ITEM ALQ.005:
IF SP AGED 18+, GO TO ALQ.111_.
OTHERWISE, CONTINUE.
ALQ.010_ The following questions ask about alcohol use. This includes beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. This does not include drinking a few sips of wine for religious purposes.
ALQ.022 During your life, on how many days have you had at least one drink of alcohol?
INSTRUCTIONS TO SP:
Please select one of the following choices.
0 days 1 (END OF SECTION)
1 or 2 days 2
3 to 9 days 3
10 to 19 days 4
20 to 39 days 5
40 to 99 days 6
100 or more days 7
REFUSED 77
DON'T KNOW 99
ALQ.010 How old were you when you had your first drink of alcohol, other than a few sips?
INSTRUCTIONS TO SP:
Please select one of the following choices.
HARD EDIT: IF (RIAAGEYR < 17 AND ALQ.010 = 7) OR (RIAAGEYR < 15 AND ALQ.010 IN (6, 7)) OR (RIAAGEYR < 13 AND ALQ.010 IN (5, 6, 7)) THEN ERROR.
Error message: “Your response is older than your recorded age. Please press the “Back” button, press “Clear,” and try again.”
8 years old or younger 2
9 or 10 years old 3
11 or 12 years old 4
13 or 14 years old 5
15 or 16 years old 6
17 years old or older 7
REFUSED 77
DON'T KNOW 99
ALQ.031 During the past 30 days, on how many days did you have at least one drink of alcohol?
INSTRUCTIONS TO SP:
Please select one of the following choices.
HARD EDIT: IF (ALQ.022 = 2 AND ALQ.031 IN (3,4,5,6,7)) OR (ALQ.022 = 3 AND ALQ.031 IN (5,6,7)) OR (ALQ.022 = 4 AND ALQ.031 IN (6,7)) THEN ERROR.
Error message: “Your response is not consistent with your lifetime use. Please press the “Back” button, press “Clear,” and try again.”
0 days 1 (END OF SECTION)
1 or 2 days 2
3 to 5 days 3
6 to 9 days 4
10 to 19 days 5
20 to 29 days 6
All 30 days 7
REFUSED 77
DON'T KNOW 99
ALQ.042 During the past 30 days, on how many days did you have {DISPLAY NUMBER} or more drinks of alcohol in a row, that is, within a couple of hours?
INSTRUCTIONS TO SP:
Please select one of the following choices.
CAPI INSTRUCTION:
IF SP = MALE, DISPLAY = 5
IF SP = FEMALE, DISPLAY = 4
HARD EDIT: IF (ALQ.031 = 2 AND ALQ.042 IN (4,5,6,7)) OR (ALQ.031 = 3 AND ALQ.042 IN (5,6,7)) OR (ALQ.031 = 4 AND ALQ.042 IN (6,7)) OR (ALQ.031 = 5 AND ALQ.042 = 7) THEN ERROR.
Error message: “Your response is not consistent with your use in the past 30 days. Please press the “Back” button, press “Clear,” and try again.”
0 days 1 (END OF SECTION)
1 day 2 (END OF SECTION)
2 days 3 (END OF SECTION)
3 to 5 days 4 (END OF SECTION)
6 to 9 days 5 (END OF SECTION)
10 to 19 days 6 (END OF SECTION)
20 or more days 7 (END OF SECTION)
REFUSED 77 (END OF SECTION)
DON'T KNOW 99 (END OF SECTION)
ALQ.111_ The next questions are about drinking alcoholic beverages. Included are liquor (such as whiskey or gin), beer, wine, wine coolers, and any other type of alcoholic beverage.
ALQ.111 In your entire life, have you had at least 1 drink of any kind of alcohol, not counting small tastes or sips? By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.
INSTRUCTIONS TO SP:
Please select . . .
CAPI INSTRUCTION: SHOW IMAGES OF 12 OZ BEER, 5 OZ WINE, AND 1.5 OZ LIQUOR.
Yes 1
No 2 (END OF SECTION)
REFUSED 7
DON'T KNOW 9
ALQ.121 During the past 12 months, about how often did you drink any type of alcoholic beverage?
In other words, how many days per week, per month, or per year did you drink?
INSTRUCTIONS TO SP:
Please select one of the following choices.
HELP SCREEN: If you only drank part of the year, report what your drinking pattern was for most of the year. If you drank half of the year but did not drink during the other half of the year, report your current drinking pattern. Choose the closest response when a perfect option is not available.
Every day 1
Nearly every day 2
3 to 4 times a week 3
2 times a week 4
Once a week 5
2 to 3 times a month 6
Once a month 7
7 to 11 times in the last year 8
3 to 6 times in the last year 9
1 to 2 times in the last year 10
Never in the last year 0
REFUSED 77
DON’T KNOW 99
BOX 1
CHECK ITEM ALQ.125:
IF SP DIDN'T DRINK (CODED '0') IN ALQ.121, GO TO ALQ.151.
OTHERWISE, CONTINUE WITH ALQ.130.
ALQ.130 During the past 12 months, on those days that you drank alcoholic beverages, on average, how many drinks did you have? By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.
INSTRUCTIONS TO SP:
Please enter a number.
CAPI INSTRUCTIONS:
SHOW IMAGES OF 12 OZ BEER, 5 OZ WINE, AND 1.5 OZ LIQUOR.
IF R ENTERS LESS THAN 1 DRINK, STORE '1'.
IF R ENTERS 95 DRINKS OR MORE, STORE '95'.
SOFT EDIT: IF RESPONSE >=20, THEN DISPLAY “You said on the days that you drink you have on average 20 or more drinks. If that is correct, please press the “Next” button to continue. If that is not correct, press the “Back” button, press “Clear,” and try again.”
|___|___|___|
ENTER # OF DRINKS
REFUSED 777
DON'T KNOW 999
ALQ.142 During the past 12 months, about how often did you have {DISPLAY NUMBER} or more drinks of any alcoholic beverage?
In other words, how many days per week, per month, or per year did you have {DISPLAY NUMBER} or more drinks in a single day?
INSTRUCTIONS TO SP:
Please select one of the following choices.
CAPI INSTRUCTION:
IF SP = MALE, DISPLAY = 5
IF SP = FEMALE, DISPLAY = 4
HARD EDIT: ALQ.142 CANNOT HAVE A LOWER CODED VALUE THAN ALQ.121, UNLESS ALQ.142 IS CODED ‘0’.
ERROR MESSAGE: “Your response is not consistent with your previous response about how often you drank during the past 12 months. Please press the “Back” button, press “Clear,” and try again.”
Every day 1
Nearly every day 2
3 to 4 times a week 3
2 times a week 4
Once a week 5
2 to 3 times a month 6
Once a month 7
7 to 11 times in the last year 8
3 to 6 times in the last year 9
1 to 2 times in the last year 10
Never in the last year 0 (ALQ.151)
REFUSED 77
DON’T KNOW 99
ALQ.270 During the past 12 months, about how often did you have {DISPLAY NUMBER} or more drinks in a period of two hours or less?
INSTRUCTIONS TO SP:
Please select one of the following choices.
CAPI INSTRUCTION:
IF SP = MALE, DISPLAY = 5
IF SP = FEMALE, DISPLAY = 4
HARD EDIT: ALQ.270 CANNOT HAVE A LOWER CODED VALUE THAN ALQ.121, UNLESS ALQ.270 IS CODED ‘0’.
ERROR MESSAGE: “Your response is not consistent with your previous response about how often you drank during the past 12 months. Please press the “Back” button, press “Clear,” and try again.”
Every day 1
Nearly every day 2
3 to 4 times a week 3
2 times a week 4
Once a week 5
2 to 3 times a month 6
Once a month 7
7 to 11 times in the last year 8
3 to 6 times in the last year 9
1 to 2 times in the last year 10
Never in the last year 0
REFUSED 77
DON’T KNOW 99
ALQ.280 During the past 12 months, about how often did you have 8 or more drinks in a single day?
INSTRUCTIONS TO SP:
Please select one of the following choices.
HARD EDIT: ALQ.280 CANNOT HAVE A LOWER CODED VALUE THAN ALQ.121, UNLESS ALQ.280 IS CODED ‘0’.
ERROR MESSAGE: “Your response is not consistent with your previous response about how often you drank during the past 12 months. Please press the “Back” button, press “Clear,” and try again.”
Every day 1
Nearly every day 2
3 to 4 times a week 3
2 times a week 4
Once a week 5
2 to 3 times a month 6
Once a month 7
7 to 11 times in the last year 8
3 to 6 times in the last year 9
1 to 2 times in the last year 10
Never in the last year 0 (ALQ.151)
REFUSED 77
DON’T KNOW 99
ALQ.151 Was there ever a time or times in your life when you drank {DISPLAY NUMBER} or more drinks of any kind of alcoholic beverage almost every day?
INSTRUCTIONS TO SP:
Please select . . .
CAPI INSTRUCTION:
IF SP = MALE, DISPLAY = 5
IF SP = FEMALE, DISPLAY = 4
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
BOX 2
CHECK ITEM ALQ.152:
IF ALQ.121 = 0, OR ALQ.142 = 0, GO TO END OF SECTION.
OTHERWISE, CONTINUE TO ALQ.170.
ALQ.170 Considering all types of alcoholic beverages, during the past 30 days, how many times did you have {DISPLAY NUMBER} or more drinks on an occasion?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
HELP SCREEN: An occasion is a period of several hours on the same day.
CAPI INSTRUCTION:
IF SP = MALE, DISPLAY = 5
IF SP = FEMALE, DISPLAY = 4
SOFT EDIT: IF RESPONSE IS > 60 TIMES, THEN DISPLAY “You said that in the past 30 days, you had {DISPLAY NUMBER} or more drinks of any kind of alcohol on an occasion, more than 60 times. If that is correct, please press the “Next” button to continue. If that is not correct, press the “Back” button, press “Clear,” and try again.
|___|___|
ENTER QUANTITY
REFUSED 777
DON'T KNOW 999
KIDNEY CONDITIONS - KIQ
Target Group: SPs 20+
KIQ.005_ The next few questions ask about urine leakage.
KIQ.005 Many people have leakage of urine. How often do you have urinary leakage?
INSTRUCTIONS TO SP:
Please select one of the following choices.
HELP SCREEN: Other terms for urinary leakage are not being able to hold your urine until you can reach a toilet, not being able to control your bladder, loss of urine control.
never 1 (KIQ.042)
less than once a month 2
a few times a month 3
a few times a week 4
every day and/or night 5
REFUSED 7 (KIQ.042)
DON’T KNOW 9 (KIQ.042)
KIQ.010 How much urine do you lose each time?
INSTRUCTIONS TO SP:
Please select one of the following choices.
drops 1
small splashes 2
more 3
REFUSED 7
DON’T KNOW 9
KIQ.042 During the past 12 months, have you leaked or lost control of even a small amount of urine with an activity like coughing, lifting or exercise?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
KIQ.044 During the past 12 months, have you leaked or lost control of even a small amount of urine with an urge or pressure to urinate and you couldn’t get to the toilet fast enough?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
BOX 1
CHECK ITEM KIQ.048A:
IF 'YES' (CODED '1') IN KIQ.042 OR KIQ.044, CONTINUE WITH KIQ.052.
OTHERWISE, GO TO KIQ.481.
KIQ.052 During the past 12 months, how much did your leakage of urine affect your day-to-day activities?
INSTRUCTIONS TO SP:
Please select one of the following choices.
not at all 1
only a little 2
somewhat 3
very much 4
greatly 5
REFUSED 7
DON'T KNOW 9
KIQ.481 In the past 30 days, during a typical night, how many times did you wake up and urinate?
INSTRUCTIONS TO SP:
Please select one of the following choices.
0 0
1 1
2 2
3 3
4 4
5 or more 5
REFUSED 77
DON'T KNOW 99
DRUG USE – DUQ
Target Group: SPs 12 - 59 Yeas
DUQ.200_ The following questions ask about use of drugs. Please remember that your answers to these questions will be kept confidential.
DUQ.230 During the past 30 days, on how many days did you use marijuana or cannabis, also called pot or weed?
INSTRUCTIONS TO SP:
Please enter a number or enter zero if you have never used marijuana or cannabis.
IF DUQ.230 > 30, DISPLAY ERROR MESSAGE: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”
|___|___|
ENTER A NUMBER
REFUSED 77
DON'T KNOW 99
DUQ.250 Have you ever, even once, used cocaine including all the different forms of cocaine such as powder, ‘crack’, ‘free base’, and coca paste?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
DUQ.290 Have you ever, even once, used heroin?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
DUQ.330 Have you ever, even once, used methamphetamine, also known as crank, crystal, ice or speed?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
DUQ.370 Have you ever, even once, used a needle to inject a drug not prescribed by a doctor?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
SEXUAL BEHAVIOR – SXQ (Female)
Target Group: Female SPs 14-69 Years
SXQ.615_ The next set of questions is about your sexual history. By sex, we mean vaginal, oral, or anal sex. Please remember that your answers will be kept confidential.
-
BOX 1B
CHECK ITEM SXQ.773:
IF SP AGE GREATER THAN 17, GO TO SXQ.700.
OTHERWISE, CONTINUE.
SXQ.615 Have you ever had any kind of sex?
(Target 14-17)
INSTRUCTIONS TO SP:
Yes 1
No 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON’T KNOW 9 (END OF SECTION)
SXQ.700 Have you ever had vaginal sex, also called sexual intercourse, with a man? This means a man’s penis in your vagina?
(Target 14-69)
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
SXQ.703 Have you ever performed oral sex on a man? This means putting your mouth on a man’s penis or genitals.
(Target 14-69)
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
SXQ.706 Have you ever had anal sex? This means contact between a man’s penis and your anus or butt.
(Target 14-69)
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
SXQ.709 Have you ever had any kind of sex with a woman? By sex, we mean sexual contact with another woman’s vagina or genitals.
(Target 14-69)
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
BOX 1
CHECK ITEM SXQ.702:
IF SP 60-69 YEARS, GO TO END OF SECTION.
IF SXQ.700 = 2 AND SXQ.703 = 2 AND SXQ.706 = 2 AND SXQ.709 = 2, GO TO END OF SECTION.
IF SXQ.709 = 1 AND (SXQ.700, SXQ.703, AND SXQ.706 = 2), GO TO SXQ.736.
OTHERWISE, CONTINUE.
SXQ.712 In your lifetime, with how many men have you had any kind of sex?
(Target 14-59)
INSTRUCTIONS TO SP:
Please enter a number.
|___|___|___|___|
ENTER NUMBER
REFUSED 77777
DON’T KNOW 99999
HARD EDIT: SXQ.712 MUST BE GREATER THAN 0.
Error message: “Your response is not consistent with your previous responses about male sex partners. Please press the “Back” button, press “Clear,” and try again.”
SXQ.718 In the past 12 months, with how many men have you had any kind of sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 77777
DON’T KNOW 99999
HARD EDIT: SXQ.718 MUST BE EQUAL TO OR LESS THAN SXQ.712.
Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”
BOX 6
CHECK ITEM SXQ.733:
IF SXQ.709 = 1, GO TO SXQ.736.
OTHERWISE, GO TO BOX 7B.
|
|
SXQ.736 In your lifetime, with how many women have you had sex? By sex, we mean sexual contact with another woman’s vagina or genitals.
(Target 14-59)
INSTRUCTIONS TO SP:
Please enter a number.
|___|___|___|___|
ENTER NUMBER
REFUSED 77777
DON’T KNOW 99999
HARD EDIT: SXQ.736 MUST BE GREATER THAN ZERO.
Error message: “Your response is not consistent with your previous responses about sex with a female partner. Please press the “Back” button, press “Clear,” and try again.”
SXQ.739 In the past 12 months, with how many women have you had sex? By sex, we mean sexual contact with another woman’s vagina or genitals.
(Target 14-59)
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 77777
DON’T KNOW 99999
HARD EDIT: SXQ.739 MUST BE EQUAL TO OR LESS THAN SXQ.736.
Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear”, and try again.”
BOX 7B
CHECK ITEM SXQ.771:
IF SXQ.718 OR SXQ.739 GREATER THAN ‘0000’, GO TO SXQ.648.
OTHERWISE, GO TO SXQ.260.
SXQ.648 In the past 12 months, did you have any kind of sex with a person that you never had sex with before?
(Target 14-59)
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
SXQ.260 Has a doctor or other health care professional ever told you that you had genital herpes?
(Target 14-59)
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
SXQ.265 Has a doctor or other health care professional ever told you that you had genital warts?
(Target 14-59)
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
SEXUAL BEHAVIOR – SXQ (Male)
Target Group: Male SPs 14-69 Years
SXQ.615_ The next set of questions is about your sexual history. By sex, we mean vaginal, oral, or anal sex.
Please remember that your answers will be kept confidential.
-
BOX 1B
CHECK ITEM SXQ.873:
IF SP AGE GREATER THAN 17, GO TO SXQ.800.
OTHERWISE, CONTINUE.
SXQ.615 Have you ever had any kind of sex?
(Target 14-17)
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
REFUSED 7 (END OF SECTION)
DON’T KNOW 9 (END OF SECTION
SXQ.800 |
Have you ever had vaginal sex, also called sexual intercourse, with a woman? This means your penis in a woman’s vagina. |
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
SXQ.803 |
Have you ever performed oral sex on a woman? This means putting your mouth on a woman’s vagina or genitals. |
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
SXQ.806 |
Have you ever had anal sex with a woman? Anal sex means contact between your penis and a woman’s anus or butt. |
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
SXQ.809 Have you ever had any kind of sex with a man, including oral or anal?
(Target 14-69)
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
BOX 1
CHECK ITEM SXQ.802:
IF SP 60-69 YEARS, GO TO END OF SECTION.
IF SXQ.800 = 2 AND SXQ.806 = 2 AND SXQ.803 = 2 AND SXQ.809 = 2, GO TO END OF SECTION.
IF SXQ.809 = 1 AND (SXQ.800, SXQ.803, AND SXQ.806 = 2), GO TO SXQ.410.
OTHERWISE, CONTINUE.
SXQ.812 In your lifetime, with how many women have you had any kind of sex?
(Target 14-59)
INSTRUCTIONS TO SP:
Please enter a number.
|___|___|___|___|
ENTER NUMBER
REFUSED 77777
DON’T KNOW 99999
HARD EDIT: SXQ.812 MUST BE GREATER THAN ZERO.
Error message: “Your response is not consistent with your previous responses about female sex partners. Please press the “Back” button, press “Clear,” and try again.”
SXQ.818 In the past 12 months, with how many women have you had any kind of sex?
(Target 14-59)
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 77777
DON’T KNOW 99999
HARD EDIT: SXQ.818 MUST BE EQUAL TO OR LESS THAN SXQ.812.
Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear,” and try again.”
-
BOX 5
CHECK ITEM SXQ.833:
IF SXQ.809 = 1, GO TO SXQ.410.
OTHERWISE, GO TO BOX 9B.
SXQ.410 In your lifetime, with how many men have you had anal or oral sex?
(Target 14-59)
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 77777
DON’T KNOW 99999
HARD EDIT: SXQ.410 MUST BE GREATER THAN ZERO.
Error message: “Your response is not consistent with your previous responses about male sex partners. Please press the “Back” button, press “Clear,” and try again.”
SXQ.550 In the past 12 months, with how many men have you had anal or oral sex?
(Target 14-59)
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 77777
DON’T KNOW 99999
HARD EDIT: SXQ.550 MUST BE EQUAL TO OR LESS THAN SXQ.410.
Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”
-
BOX 9B
CHECK ITEM SXQ.871:
IF SXQ.818 OR SXQ.550 GREATER THAN ‘0000’, GO TO SXQ.648.
OTHERWISE, GO TO SXQ.260.
SXQ.648 |
In the past 12 months, did you have any kind of sex with a person that you never had sex with before? |
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
SXQ.260 Has a doctor or other health care professional ever told you that you had genital herpes?
(Target 14-59)
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
SXQ.265 Has a doctor or other health care professional ever told you that you had genital warts?
(Target 14-59)
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON’T KNOW 9
MEC Entry Screening
Anthropometry - Body Measures
Standing Balance
Dual Energy X-Ray Absorptiometry (DXA)
Blood Pressure Measurement
Liver Steatosis and Fibrosis Ultrasound Elastography
Urine Collection*
Venipuncture
*No data collection form for urine collection
MEC ENTRY SCREENING
MEC ENTRY SCREENING – MEQ
Target Group: SPs Birth +
MEQ.010 ENTER SP’S TEMPERATURE.
|___|___|___|.|___|
ENTER TEMPERATURE IN DEGREES FAHRENHEIT
BOX 1
CHECK ITEM MEQ.015:
IF THE TEMPERATURE ENTERED IS 100.4 DEGREES OR HIGHER, GO TO MEQ_END1.
IF THE TEMPERATURE ENTERED IS LESS THAN 100.4 DEGREES, CONTINUE.
MEQ.020 {Have you/Has SP} experienced any of the following symptoms in the past 48 hours that is not related to any of your existing chronic conditions or allergies?
CODE ALL THAT APPLY
Fever or chills 1
Cough 2
Shortness of breath or difficulty breathing 3
Fatigue 4
Muscle or body aches that are not caused by physical activities 5
Headache 6
New loss of taste or smell 7
Sore throat 8
Congestion or runny nose 9
Nausea or vomiting …10
NO SYMPTOMS REPORTED 0
REFUSED 77
DON’T KNOW 99
BOX 2
CHECK ITEM MEQ.025:
IF MEC.020a = 0, CONTINUE.
OTHERWISE, GO TO MEQ_END1.
MEQ.030 Within the past 14 days, {Have you/Has SP} been in close physical contact (that is 6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19, a person who is awaiting COVID-19 test results, or with anyone who has any symptoms consistent with COVID-19?
YES 1 (MEQ_END1)
NO 2
REFUSED 7 (MEQ_END1)
DON’T KNOW 9 (MEQ_END1)
MEQ.040 {Are you/Is SP} currently isolating or quarantining because {you were/SP was} diagnosed with COVID-19, {you/SP} may have been exposed to a person with COVID-19, or are {you/SP} worried that {you/he/she} may be sick with COVID-19?
YES 1 (MEQ_END1)
NO 2
REFUSED 7 (MEQ_END1)
DON’T KNOW 9 (MEQ_END1)
MEQ.050 {Are you/Is SP} currently waiting on the results of a COVID-19 test because you have experienced COVID-like symptoms or exposed to someone with COVID-19 or may have COVID-19?
YES 1 (MEQ_END1)
NO 2 (MEQ_END2)
REFUSED 7 (MEQ_END1)
DON’T KNOW 9 (MEQ_END1)
MEQ_END1 MEC ENTRY SCREENING FAILED
Thank you. Because {REASON FOR FAIL SCREENING}, at this time you will not be able to continue with the NHANES mobile examination center today. This is to ensure that everyone entering stays as safe as possible. We will have someone follow up with you and see if it’s possible to schedule a visit for a later date.
CAPI INSTRUCTION:
IF MEQ.010 = 100.4, DISPLAY “your temperature is 100.4 degree”.
IF MEQ.010 = 100.4, DISPLAY “your temperature is higher than 100.4 degree”.
IF MEQ.020 = 1, 7, OR 9, DISPLAY “you may be experiencing COVID-19-like symptoms”.
IF MEQ.030 = 1, 7, OR 9, DISPLAY “you may have had contact to individuals with COVID-19”.
IF MEQ.040 = 1, 7, OR 9, DISPLAY “you are currently isolating or quarantining”.
IF MEQ.050 = 1, 7, OR 9, DISPLAY “you are currently waiting on the results of a COVID-19 test”.
MEQ_END2 MEC ENTRY SCREENING APPROVED
Thank you for helping us protect you and others during this time. Please now follow me to enter our mobile examination center.
ANTHROPOMETRY - BODY MEASURES
(All ages)
AMPUTATION QUESTIONS:
Information is recorded during the body measurement examination for all ages. Questions may be asked if the information is not obvious to the examiner. The responses are used to interpret body measurement results, particularly the body weight data.
Are there any amputations? Recorder codes YES/NO
IF YES to the amputation question, continue with information on the site(s) of the amputation(s)
Target Age Groups: Anthropometry Measurements and Questions
Birth+ |
2mo+ |
2yr+ |
8yr+ |
12yr+ |
Weight |
Weight |
Weight
|
Weight |
Weight |
Recumbent length |
Recumbent length |
Recumbent length (through 47 mos.) |
|
|
Head circumference
|
Head circumference (through 6 mos.) |
|
|
|
|
|
Standing height |
Standing height |
Standing height |
|
Upper arm length |
Upper arm length |
Upper arm length |
Upper arm length |
|
Mid-upper arm circumference |
Mid-upper arm circumference |
Mid-upper arm circumference
|
Mid-upper arm circumference
|
|
|
Waist circumference |
Waist circumference |
Waist circumference |
|
|
|
|
Hip circumference |
|
|
|
Upper leg length |
Upper leg length |
Would you like to know your height and weight? |
Would you like to know your height and weight? |
Would you like to know your height and weight? |
Would you like to know your height and weight? |
Would you like to know your height and weight? |
STANDING BALANCE
20-69 Years
SCRIPTS: MRT FOR STANDING BALANCE
Health technician: Wand the participant’s bracelet for this exam and say:
Now we are going to check the things that keep you balanced when standing. First, I need to ask you some questions, then I’ll explain the test.
(See Page 48: Fall Safety Exclusion and Protocol Questions for MRT; Neck Safety Exclusion Questions for MRT). If responding “YES” to any of Neck Safety Exclusion Question they will be excluded from part 5 of MRT.
Health technician: If participant reports a neck problem during the safety exclusion questions, s/he is excluded from the 5th part of the MRT. The computer skips him/her out of the 5th part of the MRT.
Health technician: If participant is NOT excluded, say:
First I’m going to show you what I want you to try, so please stay seated and watch. You’re going to stand like this with your arms crossed and your feet together.
for up to 30 seconds.
(DEMONSTRATE CORRECT STANCE).
You may do this several times in different ways, for example, with your eyes open or your eyes closed.
I will be standing right here in case you lose your balance. I am going to put this safety belt around your waist (SHOW THE BELT) to help me steady you if you get off balance.
The whole test will take several minutes. Do you have any questions?
Health technician: Do not let participant stand in test position while you explain the condition- let them relax. Verify that the computer is ready to start Condition 1. When ready to start, say:
Stand on the stickers facing me. Once we start the test, do not talk. Cross your arms. Put your feet together. Look at the mark on the wall.
Health technician: As soon as the participant is ready for Condition 1 test, start the timer, and say to the participant:
Begin.
Health technician: At the end of the 15 seconds or if the participant is unable to maintain their balance, make sure that the participant is steady, and say:
Stop. You can relax.
If the participant was unable to maintain the stance for 15 seconds, say:
Can we try that again?
If the participant was able to maintain the stance for at least 15 seconds for one of the two trials, move on to Condition 2. Say to the participant:
This time we’ll do the same thing, but with your eyes closed.
Health technician: Make sure that the participant is positioned correctly (as done in the first test). Verify that the computer is ready to start Condition 2. Then tell the participant:
Ready? Cross your arms. Put your feet together.
When you close your eyes, we’ll start.
At the end of the 15 seconds or if the participant is unable to maintain their balance, make sure the participant is steadied and say:
Open your eyes and relax.
If the participant was unable to maintain the stance for 15 seconds, say:
Can we try that again?
If the participant was able to maintain the stance for at least 15 seconds for one of the two trials, move on to Condition 3.
Health technician: Show the participant the foam pad and say:
This time you’ll be doing the same thing but standing on this foam and looking at the mark on the wall.
Ready? Step up on the foam. Cross your arms. Put your feet together. Look at the mark.
Begin.
After 30 seconds or if participant is unable to maintain their balance, verify participant is steady and say: Step down.
If the participant was unable to maintain the stance for 30 seconds, say:
Can we try that again?
Switch to the other foam pad for this trial to allow the first pad to decompress fully.
If the participant was able to maintain the stance for at least 20 seconds for one of the two trials, move on to Condition 4.
Health Technician: Verify that computer is ready to start Condition 4. Tell participant:
Next, you’ll do the same thing, but with your eyes closed.
Ready? Step up on the foam. Cross your arms. Put your feet together.
When you close your eyes, we’ll start.
At the end of the 30 seconds or if the participant is unable to maintain their balance, make sure the participant is steady and say:
Open your eyes and step down.
If the participant was unable to maintain the stance for 30 seconds, say:
Can we try that again?
If the participant was able to maintain the stance for at least 20 seconds for one of the two trials, move on to Condition 5
Health technician: Say to the participant:
For the last test, you’ll do the same thing, but this time you’ll be moving your head from side-to-side to the this beat. [TURN ON METRONOME] Watch me. [DEMONSTRATE].
Ready? Step up on the foam. Cross your arms. Put your feet together.
Close your eyes When you start turning your head, we’ll start.
At the end of the 30 seconds or if the participant is unable to maintain their balance, make sure the participant is steady and say: Stop. Open your eyes and step down.
If the participant was unable to maintain the stance for 30 seconds, say:
Can we try that again?
At the end of the second trial or if the participant is unable to maintain their balance, make sure that the participant is steadied, and say:
We’re all done with the balance test. After I remove the belt, please have a seat while I finish recording these results.
Thank you for your hard work!
MEC Questions for Safety Exclusion
Pregnancy exclusion question for entire MRT evaluation:
Women with positive pregnancy tests will not be sent for the MRT.
Regardless, all women will still be asked if they think that they are currently pregnant. This information is generally prefilled from earlier components (namely phlebotomy or DEXA), but if this information is not available, then it will be asked before the MRT
Are you currently pregnant? (women 20-59)
Neck Safety Exclusion Questions Condition 5 of MRT:
The health technician will ask these questions to the participant in the MEC once. If eligible for the MRT it will be asked before this exam.
2) Do you have neck pain now? YES NO
3) Have you ever had surgery on your neck? YES NO
4) Have you ever had a neck problem that lasted more than six weeks?YESNO
5) Can you comfortably move your head 30 degrees to the left and right?YESNO
If responding “Yes” to question 1 or 2 or 3 or “No” to questions 4, then exclude from part 5 of MRT.
Fall Safety Exclusion and Protocol Questions for MRT:
The health technician will ask these questions to the participant the MEC before the MRT as safety exclusion questions. NHANES used these in 2019-2020 for the same purpose.
6) Can you stand on your own? yes no
Help screen: "On your own" means without assistance from another person; without use of a device, such as a cane, walker, or leg brace; and without relying on support from a wall, furniture, etc.
Those who cannot stand unassisted are excluded from the MRT.
7) Do you have any amputations of your legs or feet, other than toes? yes no
Those responding “Yes” to this question are excluded from the MRT.
8) Are you currently wearing a leg brace? yes no
Help screen: This question does not include any orthotic device below the waist, such as extra-depth or orthopedic shoes or orthotic inserts in shoes.
Those responding “Yes” to this question are excluded from the MRT.
9) Do you have an injury or surgery to your foot, leg, or hip that would hinder you from doing a balance Test while standing? yes no
Those with a leg brace are excluded from the MRT.
10) How much do you weigh without shoes or clothes?* _____ lbs
If refuse or don’t know, then ask: “Do you weigh less than 300 pounds?” YES NO
Those >315 lbs.(or state weighting more than 300 lbs.) are excluded from the MRT (due to limitations of the foam pad density that they will use when standing.)
11) Have you had a problem during the last 24 hours with dizziness, lightheadedness, feeling as if you are going to pass out or faint? yes no
12) Have you fallen during the past 12 months due to a problem with dizziness or Balance? (By falls or falling, we mean unexpectedly dropping to the floor or ground from a standing, walking or bending position.) yes no
Those saying “Yes” to the last 2 questions combined are excluded from the MRT
13) Are you OK to begin this balance test?” YES NO
Those saying “Yes” will have the test administered.
Protocol
Participants will stand with their feet together and their arms crossed at their waist, holding their elbows (see Figure 1). The technician will attach a safety belt around the participant’s waist. Participants will hold that stance for as long as they can under five separate conditions to a maximum of 15 seconds for condition 1 - 2 and 30 seconds for conditions 3 - 5):
Figure 1: Stance for modified Romberg test
Condition 1: Firm surface (no pad), eyes open
Condition 2: Firm surface (no pad), eyes closed
Condition 3: Compliant surface (foam pad), eyes open
Condition 4: Compliant surface (foam pad), eyes closed
Condition 5: Compliant surface (foam pad), eyes closed,
head moving side to side at 3 Hz
DUAL ENERGY X-RAY ABSORPTIOMETRY (DXA)
8-59 years
Body Composition
Excluded from scan if body weight is over 450 pounds or if yes to one of the following items;
Are you currently pregnant?
Have you had a medical test with contrast material such as dyes or barium in the last 7 days?
Whole Body Tissue Information:
Total mass (gm)
Bone mineral content (BMC) (gm)
Bone area (cm2)
Bone mineral density (BMD) (gm/cm2)
Fat mass (gm)
Lean mass excluding BMC (gm)
Lean mass including BMC (gm)
Percent body fat (%)
Values for each of the variables listed above will be given for the following regions:
Head
Left Arm
Right Arm
Trunk
Left Leg
Right Leg
Subtotal
Total
Whole Body Bone Information:
Area cm2
Bone Mineral Content grams
Bone Mineral Density grams/cm2
Values for each of the variables listed above will be given for the following regions:
Head
Left Arm
Right Arm
Left Ribs
Right Ribs
Thoracic Spine
Lumbar Spine
Pelvis
Left Leg
Right Leg
BLOOD PRESSURE MEASUREMENT
8+ Years
Have you had any of the following in the past 30 minutes? (food, coffee, alcohol, cigarettes) Check all that apply.
Arm selected Right/left/Could not obtain
Cuff size selected Infant/Child/Adult/Large Arm/Thigh
Heart Rate/Pulse Beats per minute
Pulse type
Radial/Brachial
Maximum Inflation Level mm Hg
Systolic Blood Pressure (Readings 1,2,3) mm Hg
Diastolic Blood Pressure (Readings 1,2,3) mm Hg
Average Blood Pressure mm Hg (mean of last 2 measurements will be used)
LIVER ELASTOGRAPHY
12+ years
Participants are excluded if they (1) are unable to lie down on the exam table, (2) are currently pregnant, (3) have an implanted electronic medical device, or (4) are wearing a bandage or have lesions on the right side of their abdomen by the ribs.
SP ID______________ Tech ID_______________
HEPATIC (liver) STEATOSIS TEST RESULTS Test complete Yes No Test result for median controlled attenuation parameter (CAP™) ____ decibel per meter, (dB/m)
REASONS TEST INCOMPLETE OR NOT DONE Physical limitation SP refusal SP ill/emergency Out of time Equipment failure Communication problem
HEPATIC (liver) FIBROSIS TEST RESULTS Test complete Yes No Test result for median Young’s Modulus (E) __________ kilopascals
REASONS TEST INCOMPLETE OR NOT DONE Physical limitation SP refusal SP ill/emergency Out of time Equipment failure Communication problem
|
VENIPUNCTURE
1+ years
Pesticide Use
Introduction
I am going to ask you a couple of questions about the use of pesticides and weed killers in your home, yard, and garden.
PESTICIDE USE – PUQ
6+ Years
PUQ.100 In the past 7 days, were any chemical products used in {your/his/her} home to control fleas, roaches, ants, termites, or other insects?
CAPI INSTRUCTION:
IF SP 8-17 YEARS, DISPLAY THE FOLLOWING INTERVIEWER INSTRUCTION: "THIS ITEM IS COLLECTED VIA PROXY FOR SPS 8-17."
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
PUQ.110 In the past 7 days, were any chemical products used in {your/his/her} lawn or garden to kill weeds?
CODE ‘NO’ IF THE RESPONDENT SAYS S/HE DOES NOT HAVE A LAWN OR GARDEN.
CAPI INSTRUCTION:
IF SP 8-17 YEARS, DISPLAY THE FOLLOWING INTERVIEWER INSTRUCTION: "THIS ITEM IS COLLECTED VIA PROXY FOR SPS 8-17."
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
Venipuncture
PRE VENIPUNCTURE QUESTIONS
1+ Years
I am now going to ask you a few questions about your health to determine if you are eligible to have your blood drawn. I will also ask a series of questions to determine the last time you had anything to eat or drink.
Participants Deemed Ineligible to Have Their Blood Collected:
“Based on your answers to the safety questions, you are not eligible to participate in the blood collection.”
Participants Eligible to Have Their Blood Collected:
“I am now going to prepare the supplies needed to draw your blood sample.”
<Perform Venipuncture for All Eligible Study Participants>
Phlebotomy Talking Points
Phlebotomy talking points for participants ages 1-2 years old
Complete Blood Count (CBC): We will check your child's hemoglobin level which may tell if your child has a low blood count.
Iron: Is an important nutrient that is vital for growth and development. We will do tests that will tell us if your child may have low iron.
Folate: Is an important nutrient for your child’s brain development.
Lead: Element found in the environment that may lower iron levels and cause anemia or low blood count, and may also affect brain development at high levels.
Mercury: Exposure to this environmental element is often from eating fish or seafood and high levels may affect (your) child’s brain and nervous system.
Hepatitis BSAb: A positive test result indicates your child is protected against hepatitis B virus
CMV (Cytomegalovirus) antibodies: A positive result means your child has had a CMV infection.
Phlebotomy talking points participants ages 3-5 years old
Complete Blood Count (CBC): We will check your child's hemoglobin level which may tell if your child has a low blood count.
Iron: Is an important nutrient that is vital for growth and development. We will do tests that will tell us if your child may have low iron.
Folate: Is an important nutrient for your child’s brain development.
Lead: Element found in the environment that may lower iron levels and cause anemia or low blood count, and may also affect brain development at high levels.
Mercury: Exposure to this environmental element is often from eating fish or seafood and high levels may affect your child’s brain and nervous system.
Hepatitis BSAb: A positive test result indicates your child is protected against hepatitis B virus.
CMV (Cytomegalovirus) antibodies: A positive result means your child has had a CMV infection.
Thyroid panel: This panel measures the function of your child’s thyroid gland, which plays a major role in the metabolism, growth and development of the human body. It also helps to regulate many bodily functions.
Cotinine: Will determine if your child has been exposed to secondhand smoke or tobacco products.
Phlebotomy talking points participants ages 6-11 years old
Complete Blood Count (CBC): We will check your child's hemoglobin level which may tell if your child has a low blood count.
Folate: Is an important nutrient for your infant child’s brain development.
C-Reactive Protein (CRP): High levels of CRP may be a sign of inflammation.
Lead: Element found in the environment that may lower iron levels and cause anemia or low blood count, and may also affect brain development at high levels.
Mercury: Exposure to this environmental element is often from eating fish or seafood and high levels may affect your child’s brain and nervous system.
Hepatitis profile: The hepatitis profile is a series of blood tests used to detect current or past infection of hepatitis A, hepatitis B, or hepatitis C.
Thyroid panel: This panel measures the function of your child’s thyroid gland, which plays a major role in the metabolism, growth and development of the human body. It also helps to regulate many bodily functions.
Lipid profile: Measures the amount of “good” and “bad” cholesterol and triglycerides, a type of fat, in your blood.
Cotinine: Will determine if your child has been exposed to secondhand smoke or tobacco products.
Steroid hormones: important hormones responsible for reproductive health and development, such as testosterone and estrogen.
Phlebotomy talking points participants ages 12-19 years old
Complete Blood Count (CBC): We will check your child's hemoglobin level which may tell if your child has a low blood count.
Iron: Is an important nutrient that is vital for growth and development. We will do tests called ferritin and transferrin receptor that will tell us if your infant may have low iron.
Folate: Is an important nutrient for your infant child’s brain development.
C-Reactive Protein (CRP): High levels of CRP may be a sign of inflammation.
Lead: Element found in the environment that may lower iron levels and cause anemia or low blood count, and may also affect brain development at high levels.
Mercury: Exposure to this environmental element is often from eating fish or seafood and high levels may affect your child’s brain and nervous system.
Diabetes Testing: This measures your fasting glucose and hemoglobin A1c which is a three month average of your glucose.
Biochemistry Panel: Measures liver, heart, kidney functions, as well as lipid metabolism and nutritional health.
Hepatitis profile: The hepatitis profile is a series of blood tests used to detect current or past infection of hepatitis A, hepatitis B, or hepatitis C.
Thyroid panel: This panel measures the function of your child’s thyroid gland, which plays a major role in the metabolism, growth and development of the human body. It also helps to regulate many bodily functions.
Lipid profile: Measure the amount of “good” and “bad” cholesterol and triglycerides, a type of fat, in your blood.
Cotinine: Will determine if your child has been exposed to secondhand smoke or tobacco products.
Steroid hormones: important hormones responsible for reproductive health and development, such as testosterone and estrogen.
Infectious Disease: Herpes Virus testing starting at 14 years, HIV starting at 18 years
Phlebotomy Distraction Cards
Phlebotomy Photo story
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Volatile Organic Compound (VOC)
The VOC section is applicable for only those SPs that are subsampled into VOC. To determine if a particular SP is subsampled into VOC, check the mec_sp_subsample. If the SP in question has a record for subsample 1, they are subsampled for VOC and so should get the VOC section.
Introduction:
“Finally, I have a few questions about potential environmental exposures you have had in the last 48 hours while engaged in routine activities, both in your home and at other locations.”
12+ Years
VTQ.210_ First, I would like to ask you a few questions about {your/SP's} home.
VTQ.220 Is the source of water for {your/her/his} home from a private well?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
VTQ.231a {Do you/Does she/Does he} currently use moth balls, moth crystals or toilet bowl deodorizers inside {your/her/his} home?
HELP SCREEN SHOULD READ: Some toilet bowl deodorizers clip onto the toilet rim, others, such as deodorant blocks and gels, are placed inside the tank or hang inside the wall of the tank. Brand names include Bully, 2000 Flushes, Vanish, X-14, Ty-D-Bol, Toilet Duck, Clorox, Lime-A-Way, and Sno Bol.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
VTQ.233a In the last three days, did {you/she/he} inhale smoke from any source for 10 or more minutes?
HELP SCREEN: Inhaled smoke includes smoke from campfires, fireplaces, marijuana, and tobacco products such as cigarettes, cigars and pipes.
YES 1
NO 2 (VTQ.241_)
REFUSED 7 (VTQ.241_)
DON'T KNOW 9 (VTQ.241_)
VTQ.233b When did {you/she/he} last spend 10 or more minutes inhaling smoke?
TODAY 1
YESTERDAY 2
MORE THAN 2 DAYS 3
REFUSED 7
DON'T KNOW 9
VTQ.241_ Now I am going to ask you a few questions about {your/SP’s} activities over the last 48 hours. This means today or yesterday.
VTQ.244a In the last 48 hours, did {you/she/he} pump gas into a car or other motor vehicle {yourself/herself/ himself}?
YES 1
NO 2 (VTQ.251a)
REFUSED 7 (VTQ.251a)
DON'T KNOW 9 (VTQ.251a)
VTQ.244b How long ago, in hours, did {you/she/he} pump gas into a car or other motor vehicle {yourself/herself/
G/Q/D/T himself}?
CAPI INSTRUCTION:
IF “1” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER NUMBER OF HOURS WITH A HARD EDIT RANGE OF 1 – 48.
IF “2” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER “DATE EVENT OCCURRED” WITH A CALENDAR WHERE DATE CAN BE SELECTED AND “TIME EVENT OCCURRED”. CALCULATE “HOURS SINCE EVENT OCCURRED” BASED ON THE CURRENT DATE AND TIME AND DISPLAY RESULT ON SCREEN. THE RESULT OF THE CALCULATION USING THE CALENDAR AND TIME GOES INTO Q. HARD EDIT RANGE IS 1 – 48.
THE APPLICATION WILL PERFORM THE FOLLOWING CONSISTENCY CHECKS AND ROUNDING RULE:
“DATE EVENT OCCURRED” AND “TIME EVENT OCCURRED” COMBINED MUST BE BEFORE CURRENT DATE AND TIME COMBINED.
WHEN “TIME SINCE EVENT OCCURRED” FALLS EXACTLY ON THE ONE-HALF, ROUND TO THE NEAREST EVEN WHOLE NUMBER.
|___|___|
HOURS
ENTER DATE AND TIME 2
REFUSED 77
DON'T KNOW 99
|___|___|
HOURS
ENTER DATE AND TIME 2
REFUSED 77
DON'T KNOW 99
VTQ.261a In the last 48 hours, did {you/she/he} use dry cleaning solvents, visit a dry cleaning shop or wear clothes that had been dry-cleaned within the last week?
HELP SCREEN: Examples of dry cleaning solvents include Guardsman Dry Cleaning Fluid, Amway prewash, LPS F-104 Dry Solvent, Dryel At-Home Dry Cleaning starter kit, Woolite Dry Clean at Home, and Bounce 15 minute Dry Cleaner.
YES 1
NO 2 (VTQ.271a)
REFUSED 7 (VTQ.271a)
DON'T KNOW 9 (VTQ.271a)
VTQ.261b How long ago, in hours, has it been since {you/she/he} used dry cleaning solvents, visited a dry
G/Q/D/T cleaning shop or wore clothes that had been dry-cleaned within the last week?
CAPI INSTRUCTION:
IF “1” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER NUMBER OF HOURS WITH A HARD EDIT RANGE OF 1 – 48.
IF “2” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER “DATE EVENT OCCURRED” WITH A CALENDAR WHERE DATE CAN BE SELECTED AND “TIME EVENT OCCURRED”. CALCULATE “HOURS SINCE EVENT OCCURRED” BASED ON THE CURRENT DATE AND TIME AND DISPLAY RESULT ON SCREEN. THE RESULT OF THE CALCULATION USING THE CALENDAR AND TIME GOES INTO Q. HARD EDIT RANGE IS 1 – 48.
THE APPLICATION WILL PERFORM THE FOLLOWING CONSISTENCY CHECKS AND ROUNDING RULE:
“DATE EVENT OCCURRED” AND “TIME EVENT OCCURRED” COMBINED MUST BE BEFORE CURRENT DATE AND TIME COMBINED.
WHEN “TIME SINCE EVENT OCCURRED” FALLS EXACTLY ON THE ONE-HALF, ROUND TO THE NEAREST EVEN WHOLE NUMBER.
|___|___|
HOURS
ENTER DATE AND TIME 2
REFUSED 77
DON'T KNOW 99
VTQ.271a In the last 48 hours, did {you/she/he} take a hot shower or bath for five minutes or longer?
YES 1
NO 2 (VTQ.281a)
REFUSED 7 (VTQ.281a)
DON'T KNOW 9 (VTQ.281a)
VTQ.271b How long ago, in hours, has it been since {your/SP’s} last shower or hot bath?
G/Q/D/T
CAPI INSTRUCTION:
IF “1” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER NUMBER OF HOURS WITH A HARD EDIT RANGE OF 1 – 48.
IF “2” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER “DATE EVENT OCCURRED” WITH A CALENDAR WHERE DATE CAN BE SELECTED AND “TIME EVENT OCCURRED”. CALCULATE “HOURS SINCE EVENT OCCURRED” BASED ON THE CURRENT DATE AND TIME AND DISPLAY RESULT ON SCREEN. THE RESULT OF THE CALCULATION USING THE CALENDAR AND TIME GOES INTO Q. HARD EDIT RANGE IS 1 – 48.
THE APPLICATION WILL PERFORM THE FOLLOWING CONSISTENCY CHECKS AND ROUNDING RULE:
“DATE EVENT OCCURRED” AND “TIME EVENT OCCURRED” COMBINED MUST BE BEFORE CURRENT DATE AND TIME COMBINED.
WHEN “TIME SINCE EVENT OCCURRED” FALLS EXACTLY ON THE ONE-HALF, ROUND TO THE NEAREST EVEN WHOLE NUMBER.
|___|___|
HOURS
ENTER DATE AND TIME 2
REFUSED 77
DON'T KNOW 99
VTQ.281a In the last 48 hours, did {you/she/he} breathe fumes from freshly painted indoor surfaces, paints, paint thinner, or varnish?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
VTQ.281b How long ago, in hours, has it been since {you/she/he} breathed fumes from freshly painted indoor
G/Q/D/T surfaces, paints, paint thinner, or varnish?
CAPI INSTRUCTION:
IF “1” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER NUMBER OF HOURS WITH A HARD EDIT RANGE OF 1 – 48.
IF “2” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER “DATE EVENT OCCURRED” WITH A CALENDAR WHERE DATE CAN BE SELECTED AND “TIME EVENT OCCURRED”. CALCULATE “HOURS SINCE EVENT OCCURRED” BASED ON THE CURRENT DATE AND TIME AND DISPLAY RESULT ON SCREEN. THE RESULT OF THE CALCULATION USING THE CALENDAR AND TIME GOES INTO Q. HARD EDIT RANGE IS 1 – 48.
THE APPLICATION WILL PERFORM THE FOLLOWING CONSISTENCY CHECKS AND ROUNDING RULE:
“DATE EVENT OCCURRED” AND “TIME EVENT OCCURRED” COMBINED MUST BE BEFORE CURRENT DATE AND TIME COMBINED.
WHEN “TIME SINCE EVENT OCCURRED” FALLS EXACTLY ON THE ONE-HALF, ROUND TO THE NEAREST EVEN WHOLE NUMBER.
|___|___|
HOURS
ENTER DATE AND TIME 2
REFUSED 77
DON'T KNOW 99
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | 2009 Dried Blood Spot Methodology Study – Phase I |
| Author | Brenda Lewis |
| File Modified | 0000-00-00 |
| File Created | 2023-08-26 |
© 2024 OMB.report | Privacy Policy