0920-1408 NCHS Rapid Survey System Round 1 Questionnaire

[NCHS] National Center for Health Statistics (NCHS) Rapid Surveys System (RSS)

SSA_Att D RSS1 Full Questionnaire 30-Day

OMB: 0920-1408

Document [docx]
Download: docx | pdf


Attachment D – Round 1 Questionnaire


OMB No. 0920-xxxx

Expiration Date xx/xx/xxxx



NCHS Rapid Survey System - BY R1

MODE = WEB, CATI


REFUSALS/DON’T KNOW:

CAWI REFUSALS/DK:

DO NOT INCLUDE DON’T KNOW/REFUSED OPTIONS ON SCREEN FOR CAWI UNLESS SPECIFIED IN ITEM RESPONSE OPTIONS. CODE REFUSALS/SKIPS AS FOLLOWS:

IMPLICIT REFUSAL/WEB SKIP = -6

CATI REFUSALS/DK:

INCLUDE THE FOLLOWING DON’T KNOW/REFUSED OPTIONS FOR INTERVIEWERS ON SCREEN FOR ALL QUESTIONS IN CATI. INTERVIEWERS SHOULD NOT READ REF/DK OPTIONS UNLESS OTHERWISE SPECIFIED IN RESPONSE OPTIONS. CODE AS FOLLOWS:

REFUSAL = -7

DON’T KNOW = -9


LEGITIMATE SKIPS

CODE ALL LEGITIMATE SKIPS FOR CATI AND CAWI AS FOLLOWS:

LEGITIMATE SKIP = -8

QUESTION INFORMATION FORMATTING:

ALL QUESTION INFORMATION WILL BE FORMATTED AS FOLLOWS:

[UNIVERSE/SKIP LOGIC]

[QUESTION TYPE]

S = SINGLE RESPONSE

M = MULTI-CHECK

NUMBOX = NUMERIC INPUT

TEXTBOX = TEXT INPUT

GRID

VARIABLE NAME

QUESTION STEM

IF CAWI/CATI QUESTION TEXT IS DIFFERENT, “[CAWI]” AND “[CATI]” WILL PRECEDE MODE SPECIFIC TEXT

CAWI RESPONSE OPTIONS

CATI RESPONSE OPTIONS

CATI INSTRUCTIONS AND RESPONSE OPTIONS THAT SHOULD NOT BE READ WILL BE IN ALL CAPS. CATI RESPONSE OPTIONS WILL ALSO INCLUDE “DO NOT READ” INSTRUCTIONS; ELSE CATI TEXT/RESPONSE OPTIONS SHOULD BE READ BY INTERVIEWER

ON WEB DISPLAY ONE ITEM PER PAGE UNLESS OTHERWISE SPECIFIED.



CREATE VARIABLES:

QUEX_LANG
BASED ON LANGUAGE SELECTED IN INSTRUMENT:

ENGLISH = 1

SPANISH = 2

GROUP

RANDOMLY ASSIGN 25% OF PARTICIPANTS TO EACH OF FOUR GROUPS

GROUP = 1-4

PRELOAD PROFILE DEMOGRAPHICS AND RENAME/CREATE VARIABLES AS FOLLOWS:

HHSIZE

NUMERIC HH SIZE, CAPPED AT 6+

AGE

NORC = DOB (RECODE DOB TO AGE IN YEARS)

IPSOS = AGECONS

NUMERIC AGE IN YEARS

SEX

NORC = GENDER_BIRTH
IPSOS = QGENDER

1 MALE

2 FEMALE

EDUCATION

NORC = EDUCATION
IPSOS = Q15 AND Q15A (RECODE INTO ONE VARIABLE)

1 No formal education

2 1st, 2nd, 3rd, or 4th grade

3 5th or 6th grade

4 7th or 8th grade

5 9th grade

6 10th grade

7 11th grade

8 12th grade NO DIPLOMA

9 HIGH SCHOOL GRADUATE - high school DIPLOMA or the equivalent (GED)

10 Some college, no degree

11 Associate degree

12 Bachelor's degree

13 Master's degree

15 Professional or Doctorate degree

RACE

NORC = RACE_1
IPSOS = CPSRACE & CPSASIAN (RECODE INTO ONE VARIABLE)

1 White

2 Black or African American

3 American Indian or Alaska Native

4 Asian Indian

5 Chinese

6 Filipino

7 Japanese

8 Korean

9 Vietnamese

10 Other Asian

11 Native Hawaiian

12 Guamanian or Chamorro

13 Samoan

14 Other Pacific Islander

15 Some other race

HISPAN

NORC = HISPAN
IPSOS = Q13

  1. Not Hispanic

  2. Mexican, Mexican American, Chicano

  3. Puerto Rican

  4. Cuban

  5. Other Spanish/Hispanic/Latino

INCOME

NORC = INCOME
IPSOS = Q35 & Q36 (RECODE INTO ONE VARIABLE)

  1. Less than $5,000

  2. $5,000 to $9,999

  3. $10,000 to $14,999

  4. $15,000 to $19,999

  5. $20,000 to $24,999

  6. $25,000 to $29,999

  7. $30,000 to $34,999

  8. $35,000 to $39,999

  9. $40,000 to $49,999

  10. $50,000 to $59,999

  11. $60,000 to $74,999

  12. $75,000 to $84,999

  13. $85,000 to $99,999

  14. $100,000 to $124,999

  15. $125,000 to $149,999

  16. $150,000 to $174,999

  17. $175,000 to $199,999

  18. $200,000 or more



NORC/IPSOS: AS NECESSARY, INCLUDE YOUR STANDARD PANEL CAWI INTRO SCREENS AND CATI INBOUND/OUTBOUND/CALLBACK/VOICEMAIL SCRIPTS BEFORE “INTRODUCTION.”

INTRODUCTION

[DISPLAY IF CAWI]

The National Center for Health Statistics, part of the Centers for Disease Control and Prevention, is conducting a study and we need your help. We are interested in your health and wellness and will be asking you a series of questions about your health history, behaviors, and opinions. This should take about 20 minutes or less to complete. Participation in this survey is completely voluntary, and you may skip any question(s) you do not want to answer and may quit the survey at any time. The information being collected is for research purposes only and will assist NCHS and CDC in their ongoing efforts to track the health of the American public. Your data will be kept confidential, will be used for statistical purposes only, and will not be disclosed or released to other persons without your consent in accordance with Section 308(d) of the Public Health Service Act [42 U.S.C. 242m(d)] and the Confidential Information and Statistical Efficiency Act Protection and Statistical Efficiency Act of 2018 (CIPSEA Pub. L. No. 115-435, 132 Stat. 5529 § 302).

If you have any questions about your rights as a participant in this research study, call NCHS’ Confidentiality Officer at (888) 642-1459.   

[PROGRAMMER: REDUCE TEXT SIZE SLIGHTLY; TEXT BELOW BOARDED BY THIN BLACK BOX/OUTLINE]

CDC estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0214).

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 (42 U.S.C. 242m(d)), and the Confidential Information Protection and Statistical Efficiency Act (44 U.S.C. 3561-3583). 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.






[DISPLAY IF CATI]

  • We are asking for your help on behalf of the National Center for Health Statistics, part of the Centers for Disease Control and Prevention.  

  • This survey will take on average 20 minutes to complete.  

  • Participation in this survey is completely voluntary, and you may skip any question(s) you do not want to answer and may quit the survey at any time.

  • The information being collected is for research purposes only and will assist NCHS and CDC in their ongoing efforts to track the health of the American public.

  • Your data will be kept confidential, and will be used for statistical purposes only by NCHS staff and agents and will not be disclosed or released to other persons without your consent. 

  • If you have any questions about your rights as a participant in this research study, call NCHS’ Confidentiality Officer at (888) 642-1459.   

[PROGRAMMER: REDUCE TEXT SIZE SLIGHTLY; TEXT BELOW BOARDED BY THIN BLACK BOX/OUTLINE]

[CATI] READ THE FOLLOWING IF THE RESPONDENT HAS ADDITIONAL QUESTIONS ABOUT BURDEN, PRIVACY, OR CONFIDENTIALITY

CDC estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0214).

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 (42 U.S.C. 242m(d)), and the Confidential Information Protection and Statistical Efficiency Act (44 U.S.C. 3561-3583). 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.




[PROGRAMMER: SECTION HEADERS ARE FOR INTERNAL USE ONLY. DO NOT PROGRAM TO APPEAR ON SCREEN.]

[CREATE “START_TIME” AND “START_DATE”; RECORD START_TIME IN HH:MM:SS; RECORD START_DATE IN MM:DD:YYYY]

HIS - SELF-REPORTED HEALTH STATUS

[CREATE “START_HIS” AND RECORD TIME IN HH:MM:SS]

[SHOW ALL]

[S]

HIS_GENERAL

[CAWI] Would you say your health in general is…

[CATI] Would you say your health in general is excellent, very good, good, fair, or poor?

[CAWI RESPONSE OPTIONS:]

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 EXCELLENT

2 VERY GOOD

3 GOOD

4 FAIR

5 POOR

[CREATE “END_HIS” AND RECORD TIME IN HH:MM:SS]



CHR - CHRONIC CONDITIONS

[CREATE “START_CHR” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

CHR_HYPEV

Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?

[CATI] ENTER '1' (YES) IF RESPONDENT IS TAKING MEDICATION TO CONTROL HIS/HER HIGH BLOOD PRESSURE.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No



[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF CHR_HYPEV= 1]

[S]

CHR_HYPDIF

Were you told on two or more different visits that you had hypertension or high blood pressure?

[CATI] ENTER '1'(YES) IF RESPONDENT IS TAKING MEDICATION TO CONTROL HIS/HER HIGH BLOOD PRESSURE.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF CHR_HYPDIF = 1]

[S]

CHR_HYP12M

During the past 12 months, have you had hypertension or high blood pressure?

[CATI] ENTER '1' IF RESPONDENT IS TAKING MEDICATION TO CONTROL HIS/HER HIGH BLOOD PRESSURE.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF CHR_HYPEV= 1]

[S]

CHR_HYPMED

Are you now taking any medication prescribed by a doctor for your high blood pressure?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW ALL]

[S]

CHR_CHLEV

Have you ever been told by a doctor or other health professional that you had high cholesterol?

[CATI] ENTER '1' IF RESPONDENT IS TAKING MEDICATION TO CONTROL HIS/HER HIGH CHOLESTEROL.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW ALL]

[S]

CHR_CHDEV

Have you ever been told by a doctor or other health professional that you had coronary heart disease?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW ALL]

[S]

CHR_ASEV

Have you ever been told by a doctor or other health professional that you had asthma?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO






[SHOW ALL]

[S]

CHR_CANEV

Have you ever been told by a doctor or other health professional that you had cancer or malignancy of any kind?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

  1. NO

[CREATE “END_CHR” AND RECORD TIME IN HH:MM:SS]



DIB - DIABETES

[CREATE “START_DIB” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

DIB_PREDIB

Has a doctor or other health professional ever told you that you had prediabetes or borderline diabetes?


[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF SEX = 2]

[S]

DIB_GESDIB

Has a doctor or other health professional ever told you that you had gestational diabetes, a type of diabetes that only occurs during pregnancy?

[CAWI] Gestational diabetes is a diabetes that you did not have prior to being pregnant and goes away after you are pregnant. Pregnant women are usually screened for gestational diabetes during the 24th to 28th week of pregnancy.

[CATI] READ IF NECESSARY: Gestational diabetes is a diabetes that you did not have prior to being pregnant and goes away after you are pregnant. Pregnant women are usually screened for gestational diabetes during the 24th to 28th week of pregnancy.



[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW ALL]

[S]

DIB_DIBEV

[IF DIB_GESDIB = 1 AND DIB_PREDIB = 0, -6,-7,-9, FILL: Not including gestational diabetes, has; IF DIB_PREDIB = 1 AND DIB_GESDIB = 0, -6,-7,-9, FILL: Not including prediabetes, has; IF DIB_GESDIB = 1 AND DIB_PREDIB = 1, FILL: Not including prediabetes or gestational diabetes, has; ELSE, FILL: Has] a doctor or other health professional ever told you that you had diabetes?


[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO

[CREATE “END_DIB” AND RECORD TIME IN HH:MM:SS]



BMI - BMI/OBESITY

[CREATE “START_BMI” AND RECORD TIME IN HH:MM:SS]


[SHOW IF SEX = 2 AND AGE <=49]

[S]

BMI_PREGNOW

Are you currently pregnant?


[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO






[SHOW ALL]

[NUMBOX]

BMI_HEIGHT

How tall are you without shoes?


[CATI] IF HEIGHT IS LESS THAN 2 FEET, ENTER 2. IF HEIGHT IS GREATER THAN 7 FEET, ENTER 7.

[PROGRAMMER: INCLUDE SEPARATE NUMBOX FOR FEET AND INCHES ON SAME ROW WITH CORRESPONDING LABELS; ALSO INCLUDE A SINGLE SELECT OPTION TO REPORT HEIGHT IN CENTIMETERS DIRECTLY BELOW NUMBOX ENTRIES.]

BMI_HEIGHTFT

[NUMBOX] feet [RANGE = 2-9]

BMI_HEIGHTIN

[NUMBOX] inches [RANGE = 0-11]

  1. Report height in centimeters


[PROMPT IF BMI_HEIGHTFT OUT OF RANGE: PLEASE ENTER A NUMBER OF FEET BETWEEN 2 AND 9.]

[PROMPT IF BMI_HEIGHTIN OUT OF RANGE: PLEASE ENTER A NUMBER OF INCHES BETWEEN 0 AND 11.]


[IF BMI_HEIGHT = 1, SHOW BMI_CEN ON SAME SCREEN AND HIDE BMI_HEIGHTFT AND BMI_HEIGHTIN]

[NUMBOX]

BMI_CEN.


[NUMBOX] centimeters [RANGE = 60-213]


[PROMPT IF BMI_CEN OUT OF RANGE: PLEASE ENTER A NUMBER OF CENTIMETERS BETWEEN 60 AND 213.]



[SHOW ALL]

[NUMBOX]

BMI_WEIGHT

[IF BMI_PREGNOW = 1, FILL: How much did you weigh before your pregnancy?; ELSE, FILL: How much do you weigh?]


[CATI] IF WEIGHT IS LESS THAN 50 POUNDS, ENTER 50. IF WEIGHT IS GREATER THAN 500 POUNDS, ENTER 500.

[PROGRAMMER: INCLUDE SEPARATE NUMBOX FOR POUNDS WITH CORRESPONDING LABEL; ALSO INCLUDE A SINGLE SELECT OPTION TO REPORT HEIGHT IN KILOGRAMS DIRECTLY BELOW NUMBOX.]

BMI_LB

[NUMBOX] pounds [RANGE = 10-999]

  1. Report weight in kilograms


[PROMPT IF OUT OF RANGE: PLEASE ENTER A NUMBER OF POUNDS BETWEEN 10 AND 999.]


[IF BMI_WEIGHTLB = 1, SHOW BMI_KILO ON SAME SCREEN AND HIDE BMI_LB]

BMI_KILO.

[NUMBOX] kilograms [RANGE = 5-453]


[PROMPT IF OUT OF RANGE: PLEASE ENTER A NUMBER OF KILOGRAMS BETWEEN 5 AND 453.]

[CREATE “END_BMI” AND RECORD TIME IN HH:MM:SS]



SOC - SOCIAL/WORK LIMITATIONS

[CREATE “START_SOC” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

SOC_ERRANDS

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone, such as visiting a doctor's office or shopping? [CATI] Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?


[CAWI RESPONSE OPTIONS:]

1 No difficulty

2 Some difficulty

3 A lot of difficulty

4 Cannot do this at all


[CATI RESPONSE OPTIONS - DO NOT READ:]

1 NO DIFFICULTY

2 SOME DIFFICULTY

3 A LOT OF DIFFICULTY

4 CANNOT DO THIS AT ALL



[SHOW ALL]

[S]

SOC_PARACTIV

Because of a physical, mental, or emotional condition, do you have difficulty participating in social activities, such as visiting friends, attending clubs and meetings, or going to parties? [CATI] Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?


[CAWI RESPONSE OPTIONS:]

1 No difficulty

2 Some difficulty

3 A lot of difficulty

4 Cannot do this at all






[CATI RESPONSE OPTIONS - DO NOT READ:]

1 NO DIFFICULTY

2 SOME DIFFICULTY

3 A LOT OF DIFFICULTY

4 CANNOT DO THIS AT ALL



[SHOW ALL]

[S]

SOC_SCWRKLIM

Are you limited in the kind or amount of work you can do because of a physical, mental, or emotional problem?


[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

  1. NO

[CREATE “END_SOC” AND RECORD TIME IN HH:MM:SS]



PAY - SOCIAL DETERMINANTS: PAYING MEDICAL BILLS

[CREATE “START_PAY” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

PAY_PAYWORRY

If you get sick or have an accident, how worried are you that you will be able to pay your medical bills? [CATI] Are you very worried, somewhat worried, or not at all worried?


1 Very worried

2 Somewhat worried

3 Not at all worried


[CATI RESPONSE OPTIONS - DO NOT READ:]

1 VERY WORRIED

2 SOMEWHAT WORRIED

3 NOT AT ALL WORRIED

[CREATE “END_PAY” AND RECORD TIME IN HH:MM:SS]





CVL - LONG COVID

[CREATE “START_CVL” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

CVL_HEARDEV

When people have symptoms for weeks, months, or even years after COVID-19 infection, it is called Long COVID. Some people also refer to it as Post-COVID Conditions.


Before today, had you ever heard of Long COVID?


[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF CVL_HEARDEV=1]

CVL_DSPL

How much do you agree or disagree with each of the following statements about Long COVID? [CATI] Would you say you strongly disagree, somewhat disagree, somewhat agree, strongly agree, or don’t know?


[CATI] INTERVIEWER - REPEAT RESPONSE OPTIONS IF NECESSARY.


[PROGRAMMER: RANDOMIZE ORDER OF CVL_REAL-CVL_PASSED. SPLIT QUESTIONS ACROSS TWO SCREENS WITH 4 STATEMENTS ON EACH PAGE. REPEAT RESPONSE CATEGORIES UNDER EACH STATEMENT. REPEAT CVL_DSPL ON EACH PAGE.]


[SHOW IF CVL_HEARDEV=1]

[S]

CVL_REAL

Long COVID is a real illness.


[CAWI RESPONSE OPTIONS:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[CATI RESPONSE OPTIONS – REPEAT IF NECESSARY:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[SHOW IF CVL_HEARDEV=1]

[S]

CVL_SERIOUS

Long COVID can be debilitating and should be taken seriously.


[CAWI RESPONSE OPTIONS:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[CATI RESPONSE OPTIONS - REPEAT IF NECESSARY:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[SHOW IF CVL_HEARDEV=1]

[S]

CVL_DEPRESS

People with Long COVID may just be depressed.


[CAWI RESPONSE OPTIONS:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[CATI RESPONSE OPTIONS - REPEAT IF NECESSARY:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[SHOW IF CVL_HEARDEV=1]

[S]

CVL_NORMPAIN

Long COVID symptoms are often just the normal aches and pains of life.

[CAWI RESPONSE OPTIONS:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[CATI RESPONSE OPTIONS - REPEAT IF NECESSARY:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[SHOW IF CVL_HEARDEV=1]

[S]

CVL_EMPLOYER

Employers should provide reasonable accommodations for people with Long COVID.


[CAWI RESPONSE OPTIONS:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[CATI RESPONSE OPTIONS - REPEAT IF NECESSARY:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[SHOW IF CVL_HEARDEV=1]

[S]

CVL_MEDIA

The media and news reports exaggerate the problems that people with Long COVID face.


[CAWI RESPONSE OPTIONS:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[CATI RESPONSE OPTIONS - REPEAT IF NECESSARY:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[SHOW IF CVL_HEARDEV=1]

[S]

CVL_PASSED

Long COVID can be passed from one person to another.


[CAWI RESPONSE OPTIONS:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know


[CATI RESPONSE OPTIONS - REPEAT IF NECESSARY:]

1 Strongly disagree

2 Somewhat disagree

3 Somewhat agree

4 Strongly agree

-9 Don’t know



[SHOW ALL]

[S]

CVL_COVIDEV

Have you ever had COVID-19?


[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF CVL_COVIDEV=1]

[S]

CVL_SYMPT3M

Did you have any symptoms lasting 3 months or longer that you did not have prior to having COVID-19?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF CVL_HEARDEV=1 AND CVL_COVIDEV=1]

[S]

CVL_LONGCVEV

Did a doctor or other health care professional ever tell you that you had Long COVID?


[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF CVL_HEARDEV=1]

[S]

CVL_LONGOTH

Do you know anyone [IF CVL_LONGCVEV=1, FILL: else] such as a neighbor, friend, or coworker who has ever been diagnosed with Long COVID?


[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW ALL]

[S]

CVL_LEARNMOR

If you wanted to learn more about Long COVID, which of the following would you do first?


[CAWI RESPONSE OPTIONS:]

1 Talk with a doctor or other health care professional

2 Talk with family or friends

3 Get information from the CDC

4 Get information from your state or local health department

5 Search the internet

6 Something else


[CATI RESPONSE OPTIONS:]

1 Talk with a doctor or other health care professional

2 Talk with family or friends

3 Get information from the CDC

4 Get information from your state or local health department

5 Search the internet

6 Something else


[CREATE “END_CVL” AND RECORD TIME IN HH:MM:SS]



ACC - ACCESS/UTILIZATION

[CREATE “START_ACC” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

ACC_DNCINTRO

These next questions ask about your dental care.

[SHOW ALL]

[S]

ACC_DNCEXAM

About how long has it been since you last had a dental examination or cleaning?

[CAWI] Include cleanings from all types of dental care such as dentists, orthodontists, oral surgeons, dental hygienists, and all other dental specialists.

[CATI] READ IF NECESSARY: Include cleanings from all types of dental care such as dentists, orthodontists, oral surgeons, dental hygienists, and all other dental specialists.


[CAWI RESPONSE OPTIONS:]

1 Less than 12 months ago

2 More than 1 year but less than 2 years ago

3 More than 2 years but less than 3 years ago

4 More than 3 years but less than 5 years ago

5 More than 5 years but less than 10 years ago

6 10 years ago or more

0 Never

[CATI RESPONSE OPTIONS – READ IF NECESSARY:]

1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)

2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)

3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)

4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)

5 Within the last 10 (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)

6 10 years ago or more

0 Never




[SHOW ALL]

[S]

ACC_DNCDELAY

During the past 12 months, have you delayed getting dental care because of the cost?



[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW ALL]

[S]

ACC_DNCCOST

During the past 12 months, was there any time when you needed dental care, but did not get it because of the cost?


[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW ALL]

ACC_HTHINTRO

Now, we would like to ask you about your health care, not including dental care.

[SHOW ALL]

[S]

ACC_HTHLAST

About how long has it been since you last saw a doctor or other health professional about your health?

[CAWI] Include doctors seen while a patient in a hospital. Do not include dental care.

[CATI] READ IF NECESSARY: Include doctors seen while a patient in a hospital. Do not include dental care.


[CAWI RESPONSE OPTIONS:]

1 Less than 12 months ago

2 More than 1 year but less than 2 years ago

3 More than 2 years but less than 3 years ago

4 More than 3 years but less than 5 years ago

5 More than 5 years but less than 10 years ago

6 10 years ago or more

0 Never

[CATI RESPONSE OPTIONS – READ IF NECESSARY:]

1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)

2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)

3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)

4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)

5 Within the last 10 (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)

6 10 years ago or more

0 Never



[SHOW ALL]

[S]

ACC_HTHUSUAL

Is there a place that you usually go to if you are sick and need health care?


[CAWI RESPONSE OPTIONS:]

  1. Yes, there is a single place

3 Yes, there is more than one place

2 No, there is no place

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

2 THERE IS NO PLACE

3 THERE IS MORE THAN ONE PLACE



[SHOW IF ACC_HTHUSUAL = 1, 3]

[S]

ACC_HTHTYPE

What kind of place [IF ACC_HTHUSUAL=1, FILL: is it; ELSE, FILL: do you go most often]? [CATI] A doctor's office or health center; an urgent care center, a clinic in a drug store or grocery store; a hospital emergency room; a VA medical center or VA outpatient clinic; or some other place?


[CAWI] A doctor's office or health center is a place where you see the same doctor or the same group of doctors every visit, where you usually need to make an appointment ahead of time, and where your medical records are on file.

Urgent care centers and clinics in a drug store or grocery store are places where you do not need to make an appointment ahead of time, and usually do not see the same health care provider at each visit.

[CATI] READ IF NECESSARY - A doctor's office or health center is a place where you see the same doctor or the same group of doctors every visit, where you usually need to make an appointment ahead of time, and where your medical records are on file.

Urgent care centers and clinics in a drug store or grocery store are places where you do not need to make an appointment ahead of time, and usually do not see the same health care provider at each visit.




[CAWI RESPONSE OPTIONS:]

  1. A doctor’s office or health center

  2. Urgent care center or clinic in a drug store or grocery store

  3. Hospital emergency room

  4. A VA medical center or VA outpatient clinic

  5. Some other place

  1. I do not go to one place most often


[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. A DOCTOR’S OFFICE OR HEALTH CENTER

  2. URGENT CARE CENTER OR CLINIC IN A DRUG STORE OR GROCERY STORE

  3. HOSPITAL EMERGENCY ROOM

  4. A VA MEDICAL CENTER OR VA OUTPATIENT CLINIC

  5. SOME OTHER PLACE

  1. I DO NOT GO TO ONE PLACE MOST OFTEN



[SHOW ALL]

[S]

ACC_HOSP12M

During the past 12 months, have you been hospitalized overnight? Do not include an overnight stay in the emergency room.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW ALL]

[S]

ACC_EYE12M

During the past 12 months, have you had an eye exam from an eye specialist, such as an optometrist, ophthalmologist, or eye doctor?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO




[SHOW ALL]

[S]

ACC_THER12M

During the past 12 months, did you receive physical therapy, speech therapy, rehabilitative therapy, or occupational therapy?

[CAWI] Do not include mental health therapy.

[CATI] READ IF NECESSARY - Do not include mental health therapy.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[CREATE “END_ACC” AND RECORD TIME IN HH:MM:SS]



INT - INTERNET/HIT


[CREATE “START_INT” AND RECORD TIME IN HH:MM:SS]

[SHOW IF MODE = CATI; AUTO PUNCH 1 (YES) IF MODE = CAWI]

[S]

INT_ACCESS

Do you have access to the Internet?

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF INT_ACCESS=1]

[S]

INT_HOMEACC

Do you have access to the Internet from your home?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO






[SHOW IF INT_ACCESS=1]

INT_DSPL

During the past 12 months, have you used the Internet for any of the following reasons?


[SHOW IF INT_ACCESS=1]

[S]

INT_USEMED

To look for health or medical information.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO

[SHOW IF INT_ACCESS=1]

[S]

INT_USEDOC

To communicate with a doctor or doctor’s office.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF INT_ACCESS=1]

[S]

INT_USETEST

To look up medical test results.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[PROGRAMMER: DISPLAY INT_USEMED - INT_USETEST ON SAME PAGE]


[CREATE “END_INT” AND RECORD TIME IN HH:MM:SS]





PRV - PREVENTIVE CARE

[CREATE “START_PRV” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

PRV_BPCHECK

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

[CAWI RESPONSE OPTIONS:]

  1. Less than 12 months ago

  2. More than 1 year but less than 2 years ago

  3. More than 2 years but less than 3 years ago

  4. More than 3 years but less than 5 years ago

  5. More than 5 years but less than 10 years ago

  6. 10 years ago or more

0 Never

[CATI RESPONSE OPTIONS – READ IF NECESSARY:]

1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)

2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)

3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)

4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)

5 Within the last 10 (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)

6 10 years ago or more

0 Never



[SHOW ALL]

[S]

PRV_CHLCHECK

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

[CAWI RESPONSE OPTIONS:]

  1. Less than 12 months ago

  2. More than 1 year but less than 2 years ago

  3. More than 2 years but less than 3 years ago

  4. More than 3 years but less than 5 years ago

  5. More than 5 years but less than 10 years ago

  6. 10 years ago or more

0 Never

[CATI RESPONSE OPTIONS – READ IF NECESSARY:]

1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)

2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)

3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)

4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)

5 Within the last 10 (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)

6 10 years ago or more

0 Never



[SHOW IF DIB_DIBEV= 0, -6, -7, -9]

[S]

PRV_DIBCHECK

When was the last time you had a blood test for high blood sugar or diabetes by a doctor, nurse, or other health professional?


[CAWI RESPONSE OPTIONS:]

  1. Less than 12 months ago

  2. More than 1 year but less than 2 years ago

  3. More than 2 years but less than 3 years ago

  4. More than 3 years but less than 5 years ago

  5. More than 5 years but less than 10 years ago

  6. 10 years ago or more

0 Never

[CATI RESPONSE OPTIONS – READ IF NECESSARY:]

1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)

2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)

3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)

4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)

5 Within the last 10 (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)

6 10 years ago or more

0 Never

[CREATE “END_PRV” AND RECORD TIME IN HH:MM:SS]




CAN - CANCER SCREENING – BREAST DENSITY

[CREATE “START_CAN” AND RECORD TIME IN HH:MM:SS]


[SHOW IF SEX=2 AND AGE >= 30]

[S]

CAN_MAMMEV

Have you ever had a mammogram?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF CAN_MAMMEV=1]

[S]

CAN_RECENTM

About how long has it been since your most recent mammogram?

[CAWI RESPONSE OPTIONS:]

  1. Less than 12 months ago

  2. More than 1 year but less than 2 years ago

  3. More than 2 years but less than 3 years ago

  4. More than 3 years but less than 5 years ago

  5. More than 5 years but less than 10 years ago

  6. 10 years ago or more

0 Never

[CATI RESPONSE OPTIONS – READ IF NECESSARY:]

1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)

2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)

3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)

4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)

5 Within the last 10 (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)

6 10 years ago or more

0 Never



[SHOW IF CAN_MAMMEV=1]

[S]

CAN_BDENSITY

After your most recent mammogram, did you receive any information about whether or not you had dense breasts?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF CAN_MAMMEV=1 AND CAN_BDENSITY = 1]

[M]

CAN_BDENSINF

After your most recent mammogram, how were you informed about whether or not you had dense breasts? Please [CAWI: select; CATI: tell me] all that apply.

[CAWI RESPONSE OPTIONS:]

1 Conversation in-person or over the phone

2 Letter in the mail

3 Electronic health record online portal

4 Another way

[CATI RESPONSE OPTIONS:]

1 Conversation in-person or over the phone

2 Letter in the mail

3 Electronic health record online portal

4 Another way



[SHOW IF CAN_MAMMEV=1]

[S]

CAN_DENSE

Did your most recent mammogram show that you did have dense breast tissue or did not have dense breast tissue?

[CAWI RESPONSE OPTIONS:]

1 Did have dense breast tissue

  1. Did not have dense breast tissue

[CATI RESPONSE OPTIONS – DO NOT READ:]

1 DID HAVE DENSE BREAST TISSUE

  1. DID NOT HAVE DENSE BREAST TISSUE

[CREATE “END_CAN” AND RECORD TIME IN HH:MM:SS]



OVA - OVARIAN CANCER

[CREATE “START_OVA” AND RECORD TIME IN HH:MM:SS]


[SHOW IF SEX=2]

Have you ever had any of the following procedures?


[SHOW IF SEX=2]

[S]

OVA_TUBETIED

Fallopian tubes tied

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF SEX=2]

[S]

OVA_TUBEREM

Both fallopian tubes removed

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF SEX=2]

[S]

OVA_OVARIES

Both ovaries removed

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[PROGRAMMER: DISPLAY OVA_TUBETIE – OVA_OVARIES ON SAME PAGE]


[CREATE “END_OVA” AND RECORD TIME IN HH:MM:SS]



GEN - CONCERNS ABOUT PRIVACY OF GENETIC TESTS

[CREATE “START_GEN” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

GEN_INTRO
The next few questions refer to genetic testing for cancer risk where your blood or saliva is tested to see if you carry genes which may predict a greater chance of developing cancer at some point in your life. This does not include tests to determine if you have cancer now.

Have you ever heard of genetic testing to determine if a person is at greater risk of developing cancer?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO





[SHOW IF GEN_INTRO=1]

[CAWI] How concerned are you that the results of genetic testing for cancer risk would impact your ability to get or keep…


[CATI] How concerned are you that the results of genetic testing for cancer risk would impact your ability to get or keep the following? Would you say you are not at all concerned, a little concerned, somewhat concerned, very concerned?


[SHOW IF GEN_INTRO=1]

[S]

GEN_HLTHINS

Health insurance?

[CAWI RESPONSE OPTIONS:]

  1. Not at all concerned

  2. A little concerned

  3. Somewhat concerned

  4. Very concerned

[CATI RESPONSE OPTIONS - DO NOT READ:]

  1. NOT AT ALL CONCERNED

  2. A LITTLE CONCERNED

  3. SOMEWHAT CONCERNED

  4. VERY CONCERNED


[SHOW IF GEN_INTRO=1]

[S]

GEN_LIFEINS

Life insurance?

[CAWI RESPONSE OPTIONS:]

  1. Not at all concerned

  2. A little concerned

  3. Somewhat concerned

  4. Very concerned

[CATI RESPONSE OPTIONS - DO NOT READ:]

  1. NOT AT ALL CONCERNED

  2. A LITTLE CONCERNED

  3. SOMEWHAT CONCERNED

  4. VERY CONCERNED


[SHOW IF GEN_INTRO=1]

[S]

GEN_DISAINS

Long-term care or disability insurance?

[CAWI RESPONSE OPTIONS:]

  1. Not at all concerned

  2. A little concerned

  3. Somewhat concerned

  4. Very concerned

[CATI RESPONSE OPTIONS - DO NOT READ:]

  1. NOT AT ALL CONCERNED

  2. A LITTLE CONCERNED

  3. SOMEWHAT CONCERNED

  4. VERY CONCERNED


[SHOW IF GEN_INTRO=1]

[S]

GEN_JOB

Employment at a job?

[CAWI RESPONSE OPTIONS:]

  1. Not at all concerned

  2. A little concerned

  3. Somewhat concerned

  4. Very concerned

[CATI RESPONSE OPTIONS - DO NOT READ:]

  1. NOT AT ALL CONCERNED

  2. A LITTLE CONCERNED

  3. SOMEWHAT CONCERNED

  4. VERY CONCERNED


[PROGRAMMER: DISPLAY GEN_HLTHINS – GEN_JOB ON SAME PAGE]



[SHOW IF GEN_INTRO=1]

[S]

GEN_TESTEV

Have you ever had a genetic test to determine if you are at greater risk of developing cancer in the future?

[CAWI] Include any genetic testing for cancer done by a medical provider or genetic counselor, or from genetic health tests, such as 23andMe or Color Genomics ordered online or bought in stores.

[CATI] Include any genetic testing for cancer done by a medical provider or genetic counselor, or from genetic health tests, such as 23andMe or Color Genomics ordered online or bought in stores.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO

[CREATE “END_GEN” AND RECORD TIME IN HH:MM:SS]



CRI - CANCER RISK – ALCOHOL

[CREATE “START_CRI” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

CRI_ALCOHOL

How do you think drinking alcoholic beverages affects the risk of getting cancer?

[CAWI RESPONSE OPTIONS:]

  1. Decreases risk

  2. No effect

  3. Increases risk

[CATI RESPONSE OPTIONS:]

  1. Decreases risk

  2. No effect

  3. Increases risk

[CREATE “END_CRI” AND RECORD TIME IN HH:MM:SS]



SUN - SUNCREEN SAFETY

[CREATE “START_SUN” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

SUN_USEFACE

[CAWI] When you are outdoors in the sun, in warm weather, how often do you use sunscreen on your face?

Do not include makeup or moisturizer that contains sunscreen.


[CATI] When you are outdoors in the sun, in warm weather, how often do you use sunscreen on your face? Do not include makeup or moisturizer that contains sunscreen. Would you say you never, rarely, sometimes, most of the time, or always?

[CAWI RESPONSE OPTIONS:]

  1. Never

  2. Rarely

  3. Sometimes

  4. Most of the time

  5. Always

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. NEVER

  2. RARELY

  3. SOMETIMES

  4. MOST OF THE TIME

  5. ALWAYS



[SHOW ALL]

[S]

SUN_USESKIN

When you are outdoors in the sun, in warm weather, how often do you use sunscreen on other exposed skin? [CATI] Would you say you never, rarely, sometimes, most of the time, or always?

[CAWI RESPONSE OPTIONS:]

  1. Never

  2. Rarely

  3. Sometimes

  4. Most of the time

  5. Always

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. NEVER

  2. RARELY

  3. SOMETIMES

  4. MOST OF THE TIME

  5. ALWAYS



[SHOW ALL]

How important are the following features to you when purchasing sunscreen? [CATI] Would you say you not important at all, slightly important, moderately important, very important?


[SHOW ALL]

[S]

SUN_AFFORD

The sunscreen is affordable.


[CAWI RESPONSE OPTIONS:]

  1. Not important at all

  2. Slightly important

  3. Moderately important

  4. Very important

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. NOT IMPORTANT AT ALL

  2. SLIGHTLY IMPORTANT

  3. MODERATELY IMPORTANT

  4. VERY IMPORTANT





[SHOW ALL]

[S]

SUN_INGRED

The sunscreen’s ingredients.

[CAWI RESPONSE OPTIONS:]

  1. Not important at all

  2. Slightly important

  3. Moderately important

  4. Very important

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. NOT IMPORTANT AT ALL

  2. SLIGHTLY IMPORTANT

  3. MODERATELY IMPORTANT

  4. VERY IMPORTANT


[SHOW ALL]

[S]

SUN_SPRAY

The sunscreen can be sprayed on the skin.

[CAWI RESPONSE OPTIONS:]

  1. Not important at all

  2. Slightly important

  3. Moderately important

  4. Very important

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. NOT IMPORTANT AT ALL

  2. SLIGHTLY IMPORTANT

  3. MODERATELY IMPORTANT

  4. VERY IMPORTANT

[SHOW ALL]

[S]

SUN_FEEL

How the sunscreen feels on my skin.

[CAWI RESPONSE OPTIONS:]

  1. Not important at all

  2. Slightly important

  3. Moderately important

  4. Very important

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. NOT IMPORTANT AT ALL

  2. SLIGHTLY IMPORTANT

  3. MODERATELY IMPORTANT

  4. VERY IMPORTANT

[PROGRAMMER: DISPLAY SUN_AFFORD – SUN_FEEL ON SAME PAGE]



[SHOW ALL]

SUN_KNOWINT

[CAWI: Do you; [CATI: Please tell me whether you] strongly disagree, somewhat disagree, somewhat agree, or strongly agree with the following statements.


[SHOW ALL]

[S]

SUN_NOHARM

Sunburn is not really harmful in the long run.

[CAWI RESPONSE OPTIONS:]

  1. Strongly disagree

  2. Somewhat disagree

  3. Somewhat agree

  4. Strongly agree

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. STRONGLY DISAGREE

  2. SOMEWHAT DISAGREE

  3. SOMEWHAT AGREE

  4. STRONGLY AGREE

[SHOW ALL]

[S]

SUN_REAPPLY

It is a hassle to reapply sunscreen.

[CAWI RESPONSE OPTIONS:]

  1. Strongly disagree

  2. Somewhat disagree

  3. Somewhat agree

  4. Strongly agree

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. STRONGLY DISAGREE

  2. SOMEWHAT DISAGREE

  3. SOMEWHAT AGREE

  4. STRONGLY AGREE

[SHOW ALL]

[S]

SUN_SAFETY

I’m concerned about the safety of ingredients in sunscreen.

[CAWI RESPONSE OPTIONS:]

  1. Strongly disagree

  2. Somewhat disagree

  3. Somewhat agree

  4. Strongly agree

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. STRONGLY DISAGREE

  2. SOMEWHAT DISAGREE

  3. SOMEWHAT AGREE

  4. STRONGLY AGREE

[SHOW ALL]

[S]

SUN_CLOUDY

On cloudy days I don’t need to worry about the sun.

[CAWI RESPONSE OPTIONS:]

  1. Strongly disagree

  2. Somewhat disagree

  3. Somewhat agree

  4. Strongly agree

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. STRONGLY DISAGREE

  2. SOMEWHAT DISAGREE

  3. SOMEWHAT AGREE

  4. STRONGLY AGREE


[PROGRAMMER: DISPLAY SUN_NOHARM – SUN_CLOUDS ON SAME PAGE]

[CREATE “END_SUN” AND RECORD TIME IN HH:MM:SS]



MTL - MENTAL HEALTH (ANXIETY AND DEPRESSION)

[CREATE “START_MTL” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

MTL_ANXIETY

How often do you feel worried, nervous or anxious?

[CAWI] If you take medication for these feelings, please answer based on your usual use of medication.

[CATI] Would you say daily, weekly, monthly, a few times a year, or never?

[CATI] READ IF NECESSARY: If you take medication for these feelings, please answer based on your usual use of medication.

[CAWI RESPONSE OPTIONS:]

  1. Daily

  2. Weekly

  3. Monthly

  4. A few times a year

  1. Never



[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. DAILY

  2. WEEKLY

  3. MONTHLY

  4. A FEW TIMES A YEAR

  1. NEVER


[SHOW ALL]

[S]

MTL_ANXMEDS

Do you take prescription medication for these feelings?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[PROGRAMMER: DISPLAY MTL_ANXIETYMTL_ANXMEDS ON SAME PAGE]



[SHOW IF MTL_ANXIETY = 1, 2, 3, 4,-6,-7,-9 OR MTL_ANXMEDS = 1]

[S]

MTL_ANXLVL

Thinking about the last time you felt worried, nervous or anxious, how would you describe the level of these feelings? [CATI] Would you say a little, a lot, or somewhere in between?

[CAWI RESPONSE OPTIONS:]

  1. A little

  2. A lot

  3. Somewhere in between a little and a lot

[CATI RESPONSE OPTIONS - DO NOT READ:]

  1. A LITTLE

  2. A LOT

  3. SOMEWHERE IN BETWEEN A LITTLE AND A LOT



[SHOW ALL]

[S]

MTL_DEPRESS

How often do you feel depressed?

[CAWI] If you take medication for these feelings, please answer based on your usual use of medication.

[CATI] Would you say daily, weekly, monthly, a few times a year, or never?

[CATI] READ IF NECESSARY: If you take medication for these feelings, please answer based on your usual use of medication.

[CAWI RESPONSE OPTIONS:]

  1. Daily

  2. Weekly

  3. Monthly

  4. A few times a year

  1. Never

[CATI RESPONSE OPTIONS - DO NOT READ:]

  1. DAILY

  2. WEEKLY

  3. MONTHLY

  4. A FEW TIMES A YEAR

  1. NEVER

[SHOW ALL]

[S]

MTL_DEPMEDS

Do you take prescription medication for depression?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[PROGRAMMER: DISPLAY MTL_DEPRESS MTL_DEPMEDS ON SAME PAGE]



[SHOW IF MTL_DEPRESS = 1,2,3,4,-6,-7,-9 OR MTL_DEPMEDS =1]

[S]

MTL_DEPLVL

Thinking about the last time you felt depressed, how depressed did you feel? [CATI] Would you say a little, a lot, or somewhere in between?

[CAWI RESPONSE OPTIONS:]

  1. A little

  2. A lot

  3. Somewhere in between a little and a lot

[CATI RESPONSE OPTIONS - DO NOT READ:]

  1. A LITTLE

  2. A LOT

  3. SOMEWHERE IN BETWEEN A LITTLE AND A LOT


[CREATE “END_MTL” AND RECORD TIME IN HH:MM:SS]



CIG - HEALTH BEHAVIORS (CIGARETTE SMOKING)

[CREATE “START_CIG” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

CIG_SMKEV

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

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF CIG_SMKEV=1]

[S]

CIG_SMKNOW

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

[CAWI RESPONSE OPTIONS:]

  1. Every day

  2. Some days

  3. Not at all

[CATI RESPONSE OPTIONS - DO NOT READ:]

  1. EVERY DAY

  2. SOME DAYS

  3. NOT AT ALL

[CREATE “END_CIG” AND RECORD TIME IN HH:MM:SS]



CAR - EXPOSURE TO CARCINOGENS

[CREATE “START_CAR” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

CAR_USE

In the past 12 months, have you or someone else used chemical straighteners, relaxers, or pressing products on your hair?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF CAR_USE=1]

[S]

CAR_FREQUSE

In the past 12 months, how often have you or someone else used chemical straighteners, relaxers, or pressing products on your hair?

[CAWI RESPONSE OPTIONS:]

  1. 1-2 times a year

  2. Every 3-4 months

  3. Every 5-8 weeks

  4. Once a month

  5. More than once a month

[CATI RESPONSE OPTIONS:]

  1. 1-2 times a year

  2. Every 3-4 months

  3. Every 5-8 weeks

  4. Once a month

  5. More than once a month



[SHOW IF CAR_USE=1]

[S]

CAR_STOPUSE

In the past 12 months, has your used of chemical straighteners, relaxers, or pressing products on your hair changed? [CATI] Have you stopped use, used less, used about the same, or used more of these products?


[CAWI RESPONSE OPTIONS:]

  1. Stopped use

  2. Used less

  3. My use of these products has not changed

  4. Used more

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. STOPPED USE

  2. USED LESS

  3. MY USE OF THESE PRODUCTS HAS NOT CHANGED

  4. USED MORE

[CREATE “END_CAR” AND RECORD TIME IN HH:MM:SS]




VEN - VENTILATION

[CREATE “START_VEN” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

VEN_USE

A portable air cleaner or air purifier can remove particles like dust, pollen, viruses, bacteria, and mold from the air. Portable air cleaners or air purifiers are free-standing and can be moved around the home.


How often do you use a portable air cleaner or purifier in your home? [CATI] Would you say never, rarely, sometimes, or always?


[CAWI RESPONSE OPTIONS:]

  1. Never

  2. Rarely

  3. Sometimes

  4. Always

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. NEVER

  2. RARELY

  3. SOMETIMES

  4. ALWAYS



[SHOW IF VEN_USE=1, 2, 3]

What are the reasons you use a portable air cleaner or air purifier in your home?


[SHOW IF VEN_USE=1, 2, 3]

[S]

VEN_ACDUST

Remove dust, pollen, mold, or other allergens from the air.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF VEN_USE=1, 2, 3]

[S]

VEN_ACSMOKE

Remove smoke particles from the air.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF VEN_USE=1, 2, 3]

[S]

VEN_ACVIRUS

Remove virus particles that people exhale.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF VEN_USE=1, 2, 3]

[S]

VEN_ACOTHER

Some other reason.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[PROGRAMMER: DISPLAY VEN_ALLERGEN– VEN_OTHER ON SAME PAGE.]



[SHOW IF VEN_USE=1, 2, 3]

[S]

VEN_HEPAUSE

Portable high-efficiency particulate air or HEPA filter units trap particles in the air. Do any portable air cleaners or purifiers in your home use a HEPA filter?

[CAWI RESPONSE OPTIONS:]

1 Yes

  1. No

-9 I don’t know if I have a portable air cleaner or purifier that uses a HEPA filter

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF VEN_HEPAUSE=0]

What are the reasons why you do not use a portable air cleaner or purifier with a HEPA filter?


[SHOW IF VEN_HEPAUSE=0]

[S]

VEN_HPNOHEAR

I have never heard of a HEPA filter unit.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF VEN_HEPAUSE=0]

[S]

VEN_HPNONEED

I didn’t think a HEPA filter unit was needed.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF VEN_HEPAUSE=0]

[S]

VEN_HPNOCOST

HEPA filter units are too expensive.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[PROGRAMMER: DISPLAY VEN_HPNOHEARD – VEN_HPNOLOUD ON SAME PAGE.]





[SHOW IF VEN_HEPAUSE=0]

What are the reasons why you do not use a portable air cleaner or purifier with a HEPA filter?


[SHOW IF VEN_HEPAUSE=0]

[S]

VEN_HPNOLOUD

HEPA filter units are too noisy.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF VEN_HEPAUSE=0]

[S]

VEN_HPNOFIND

I couldn’t find a HEPA unit or filter in stores or online.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF VEN_HEPAUSE=0]

[S]

VEN_HPNOOTH

Some other reason.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[PROGRAMMER: DISPLAY VEN_HPNOLOUD – VEN_HPNOOTH ON SAME PAGE.]







[SHOW IF VEN_USE=1]

What are the reasons why you do not use a portable air cleaner or purifier?


[SHOW IF VEN_ USE=1]

[S]

VEN_ACNONEED

I didn’t think an air cleaner or air purifier was needed.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF VEN_ USE=1]

[S]

VEN_ACNOCOST

Air cleaners or air purifiers are too expensive.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF VEN_ USE=1]

[S]

VEN_ACNOLOUD

Air cleaners or air purifiers are too noisy.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW IF VEN_ USE=1]

[S]

VEN_ACNOOTH

Some other reason.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[PROGRAMMER: DISPLAY VEN_ACNONEED – VEN_ACNOOTH ON SAME PAGE.]



[CREATE “END_VEN” AND RECORD TIME IN HH:MM:SS]



IPV - INTIMATE PARTNER VIOLENCE

[CREATE “START_IPV” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[CAWI: We are; CATI I am] now going to ask you some questions related to physical acts you may have experienced.


[CAWI] Remember, you don’t have to answer any question that you don’t want to. We suggest that you be in a private setting during the remainder of the survey. If, at any time, you do not feel physically or emotionally safe, you can just quit the survey by closing the browser. You can come back to the survey whenever you want. If at any point the questions are making you upset and you would like to speak with a trained professional, please refer to the Resources given <a> here</a>.


[CATI] Remember, you don’t have to answer any question that you don’t want to.  I suggest that you be in a private setting during the remainder of the survey.  If, at any time, you do not feel physically or emotionally safe, you can let me know you’d like to stop the survey. You can call back to complete the survey whenever you want or set up a time for us to call you back.  If at any point the questions are making you upset and you would like to speak with a trained professional, please let me know and I can share some <a> resources </a> with you.


PROGRAMMER: DISPLAY IN FOOTER/BOTTOM OF EACH SCREEN IN INTIMATE PARTNER VIOLENCE SECTION

Need help? Click <a> here</a> for resources.
[IF CATI: INTERVIEWER - USE THIS LINK TO ACCESS RESOURCES IF RESPONDENT NEEDS HELP/SUPPORT DURING INTERVIEW]

[PROGRAMMER: HYPERLINKS ABOVE SHOULD OPEN IN NEW WINDOW AND DISPLAY THE FOLLOWING:

Thank you for participating in this study. We realize that some of the topics covered are quite personal and can be difficult to think and talk about. We appreciate your willingness to be a part of this study and want you to know that we recognize the important contribution you have made. Sometimes when people have participated in a study like this, they realize that they are interested in following up on some of the issues that they have been asked about in the study with someone who is professionally trained to deal with these kinds of issues. 

 

Below are some toll-free numbers of resources that you can use now or in the future if you want to speak further with someone. 

  • You can reach the National Domestic Violence Hotline at 1-800-799-SAFE (7233). 

  • You can reach the National Sexual Assault Hotline at 1-800-656-HOPE (4673). 

  • You can reach the National Child Abuse Hotline at 1-800-4-A-Child (422-4453). 

  • You can reach the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).]




[SHOW ALL]

The next questions are related to physical acts you may have experienced with your current or ex-romantic or sexual partners.


For romantic or sexual partners, please think about anybody you have been involved with romantically or sexually, which might include spouses, boyfriends, girlfriends, people you have dated, people you were seeing, or people you hooked up with.

Do not include first dates or one-time hook-up situations.


[SHOW ALL]

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?


[SHOW ALL]

[S]

IPV_PUSH

Slapped, pushed, or shoved you?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW ALL]

[S]

IPV_HIT

Hit you with a fist or something hard?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW ALL]

[S]

IPV_KICK

Kicked or stomped on you?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW ALL]

[S]

IPV_HAIR

Hurt you by pulling your hair?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[PROGRAMMER: DISPLAY IPV_SLAP – IPV_HAIR ON SAME PAGE.]



[SHOW ALL]

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?


[SHOW ALL]

[S]

IPV_SLAM

Slammed you against something to hurt you?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO





[SHOW ALL]

[S]

IPV_CHOKE

Tried to hurt you by choking or suffocating you?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW ALL]

[S]

IPV_KNIFE

Used or threatened you with a knife?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[SHOW ALL]

[S]

IPV_GUN

Used or threatened you with a gun? Please include firearms such as pistols, revolvers, shotguns, and rifles (but not BB guns or paint ball guns).

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO


[PROGRAMMER: DISPLAY IPV_SLAM – IPV_GUN ON SAME PAGE.]


[CREATE “END_IPV” AND RECORD TIME IN HH:MM:SS]







DEM - RACE AND ETHNICITY

[CREATE “START_DEM” AND RECORD TIME IN HH:MM:SS]

[PROGRAMMER: SPLIT SAMPLE INTO FOUR GROUPS (SPLIT-BALLOT) AT SAMPLING STAGE. CREATE VARIABLE “GROUP” TO CAPTURE GROUP ASSIGNMENT WHERE GROUP = 1 OR 2 OR 3 OR 4. DISPLAY DEM_RACE QUESTION STEM CORRESPONDING TO GROUP ASSIGNMENT.]

DEM_RACE
[M]

[SHOW IF GROUP = 1]

What races or ethnicities are you? Please [CAWI: select; CATI: tell me] all that apply. Are you:

[SHOW IF GROUP = 2]
What races or ethnicities are you? Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:


[SHOW IF GROUP = 3]
What race or ethnicity are you? Please [CAWI: select; CATI: tell me] all that apply. Are you:


[SHOW IF GROUP = 4]

What race or ethnicity are you? Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:


[CAWI RESPONSE OPTIONS:]

1 White

2 Hispanic or Latino

3 Black or African American

4 Asian

5 American Indian or Alaska Native

6 Middle Eastern or North African

7 Native Hawaiian or Pacific Islander

[CATI RESPONSE OPTIONS:]

1 White

2 Hispanic or Latino

3 Black or African American

4 Asian

5 American Indian or Alaska Native

6 Middle Eastern or North African

7 Native Hawaiian or Pacific Islander









[SHOW ALL]

The next questions collect detailed information about each race or ethnicity you selected.

DEM_WHITE

[M]

[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=1)]

You said that you are White. Please [CAWI: select; CATI: tell me] all that apply. Are you:

[SHOW IF (GROUP = 2 OR 4 (AND DEM_RACE=1)]

You said that you are White. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:

[CAWI RESPONSE OPTIONS:]

1 German

2 Italian

3 Irish

4 Polish

5 English

6 French

7 Another White group, for example Scottish, Norwegian, Dutch, etc. [TEXTBOX; CHAR LIMIT = 50]

[CATI RESPONSE OPTIONS:]

1 German

2 Italian

3 Irish

4 Polish

5 English

6 French

7 Another White group, for example Scottish, Norwegian, Dutch, etc. [TEXTBOX; CHAR LIMIT = 50]



DEM_HISP

[M]

[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=2)]

You said that you are Hispanic or Latino. Please [CAWI: select; CATI: tell me] all that apply. Are you:

[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=2)]

You said that you are Hispanic or Latino. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:


[CAWI RESPONSE OPTIONS:]

1 Mexican or Mexican American

2 Salvadoran

3 Puerto Rican

4 Dominican

5 Cuban

6 Colombian

  1. Another Hispanic or Latino group, for example Guatemalan, Spaniard, Ecuadorian, etc. [TEXTBOX; CHAR LIMIT = 50]


[CAWI RESPONSE OPTIONS:]

1 Mexican or Mexican American

2 Salvadoran

3 Puerto Rican

4 Dominican

5 Cuban

6 Colombian

7 Another Hispanic or Latino group, for example Guatemalan, Spaniard, Ecuadorian, etc. [TEXTBOX; CHAR LIMIT = 50]




DEM_BLACK

[M]

[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=3)]

You said that you are Black or African American. Please [CAWI: select; CATI: tell me] All that apply. Are you:

[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=3)]

You said that you are Black or African American. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:

[CAWI RESPONSE OPTIONS:]

1 African American

2 Nigerian

3 Jamaican

4 Ethiopian

5 Haitian

6 Somali

7 Another Black or African American group, for example Ghanaian, South African, Barbadian, etc. [TEXTBOX; CHAR LIMIT = 50]

[CATI RESPONSE OPTIONS:]

1 African American

2 Nigerian

3 Jamaican

4 Ethiopian

5 Haitian

6 Somali

7 Another Black or African American group, for example Ghanaian, South African, Barbadian, etc. [TEXTBOX; CHAR LIMIT = 50]



DEM_ASIAN

[M]

[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=4)]

You said that you are Asian. Please [CAWI: select; CATI: tell me] all that apply. Are you:

[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=4)]

You said that you are Asian. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:

[CAWI RESPONSE OPTIONS:]

1 Chinese

2 Vietnamese

3 Filipino

4 Korean

5 Asian Indian

6 Japanese

7 Another Asian group, for example Pakistani, Cambodian, Hmong, etc. [TEXTBOX; CHAR LIMIT = 50]

[CATI RESPONSE OPTIONS:]

1 Chinese

2 Vietnamese

3 Filipino

4 Korean

5 Asian Indian

6 Japanese

7 Another Asian group, for example Pakistani, Cambodian, Hmong, etc. [TEXTBOX; CHAR LIMIT = 50]



DEM_AIAL

[TEXTBOX]

[SHOW IF GROUP = 1 OR 2 OR 3 OR 4 (AND DEM_RACE=5)]

You said that you are American Indian or Alaska Native. Are you Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, or some other group? Note, you may report more than one group.

[TEXTBOX; CHAR LIMIT = 150]



DEM_MENA

[M]

[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=6)]

You said that you are Middle Eastern or North African. Please [CAWI: select; CATI: tell me] all that apply. Are you:

[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=6)]

You said that you are Middle Eastern or North African. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:

[CAWI RESPONSE OPTIONS:]

1 Lebanese

2 Syrian

3 Iranian

4 Moroccan

5 Egyptian

6 Israeli

7 Another Middle Eastern or North African group, for example Algerian, Iraqi, Kurdish, etc. [TEXTBOX; CHAR LIMIT = 50]

[CATI RESPONSE OPTIONS:]

1 Lebanese

2 Syrian

3 Iranian

4 Moroccan

5 Egyptian

6 Israeli

7 Another Middle Eastern or North African group, for example Algerian, Iraqi, Kurdish, etc. [TEXTBOX; CHAR LIMIT = 50]



DEM_NHPI

[M]

[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=7)]

You said that you are Native Hawaiian or Pacific Islander. Please [CAWI: select; CATI: tell me] all that apply. Are you:

[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=7)]

You said that you are Native Hawaiian or Pacific Islander. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:

[CAWI RESPONSE OPTIONS:]

1 Native Hawaiian

2 Tongan

3 Samoan

4 Fijian

5 Chamorro

6 Marshallese

7 Another Native Hawaiian or Pacific Islander group, for example Palauan, Tahitian, Chuukese, etc. [TEXTBOX; CHAR LIMIT = 50]

[CATI RESPONSE OPTIONS:]

1 Native Hawaiian

2 Tongan

3 Samoan

4 Fijian

5 Chamorro

6 Marshallese

7 Another Native Hawaiian or Pacific Islander group, for example Palauan, Tahitian, Chuukese, etc. [TEXTBOX; CHAR LIMIT = 50]



[CREATE “END_DEM” AND RECORD TIME IN HH:MM:SS]



[CREATE “START_MAR” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

MAR_MARITAL

The next questions are about marriage and cohabitation. [CAWI] Are you now: [CATI] Are you now married, living with a partner together as an unmarried couple, or neither?

[CATI] INTERVIEWER - IF RESPONDENT ANSWERS BOTH MARRIED AND LIVING WITH A DIFFERENT PARTNER TOGETHER AS AN UNMARRIED COUPLE, ENTER LIVING WITH A PARTNER

[CAWI RESPONSE OPTIONS:]

  1. Married

  2. Living with a partner together as an unmarried couple

  3. Neither

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. MARRIED

  2. LIVING WITH A PARTNER TOGETHER AS AN UNMARRIED COUPLE

  3. NEITHER



[SHOW IF MAR_MARITAL = 2, 3, -6,-7,-9]

[S]

MAR_EVMARRY

Have you ever been married?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF MAR_MARITAL = 2 AND MAR_EVMARRY=1]

[S]

MAR_LEGAL

What is your current legal marital status?

[CATI: Are you married, widowed, divorced, or separated?]

[CAWI RESPONSE OPTIONS:]

  1. Married

  2. Widowed

  3. Divorced

  4. Separated

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. MARRIED

  2. WIDOWED

  3. DIVORCED

  4. SEPARATED



[SHOW IF MAR_MARTIAL = 3 AND MAR_EVMARRY=1]

[S]

MAR_WIDIVSEP

[CAWI] Are you… [CATI] Are you widowed, divorced, or separated?

[CAWI RESPONSE OPTIONS:]

  1. Widowed

  2. Divorced

  3. Separated

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. Widowed

  2. Divorced

  3. Separated



[CREATE “END_MAR” AND RECORD TIME IN HH:MM:SS]



[CREATE “START_EMP” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

EMP_EMPLOY

Last week, did you work for pay at a job or business?

[CAWI] If you work at a family business, but not for pay, select yes.

[CATI] INTERVIEWER - IF THE RESPONDENT SAYS THEY WORK, BUT NOT FOR PAY, AT A FAMILY-OWNED JOB OR BUSINESS, ENTER '1' FOR YES.

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF EMP_EMPLOY=0]

[S]

EMP_ABSENTWK

Did you have a job or business last week, but were temporarily absent due to illness, vacation, family or maternity leave, or some other reason?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW IF EMP_EMPLOY=0 AND EMP_ABSENTWK=0]

[S]

EMP_WHYNOWRK

What is the main reason you were not working for pay at a job or business last week?

[CAWI RESPONSE OPTIONS:]

  1. Unemployed, laid off, looking for work

  2. Seasonal/contract work

  3. Retired

  4. Unable to work for health reasons/disabled

  5. Taking care of house or family

  6. Going to school

  7. Working at a family-owned job or business, but not for pay

  8. Other

[CATI RESPONSE OPTIONS – READ IF NECESSARY:]

  1. Unemployed, laid off, looking for work

  2. Seasonal/contract work

  3. Retired

  4. Unable to work for health reasons/disabled

  5. Taking care of house or family

  6. Going to school

  7. Working at a family-owned job or business, but not for pay

  8. Other

[CREATE “END_EMP” AND RECORD TIME IN HH:MM:SS]



CIV - CIVIC ENGAGEMENT

[CREATE “START_CIV” AND RECORD TIME IN HH:MM:SS]


[SHOW ALL]

[S]

CIV_VOL12M

During the past 12 months, did you spend any time volunteering for any organization or association?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO




[SHOW IF CIV_VOL12M=0]

[S]

CIV_VOLOTH

Some people don’t think of activities they do infrequently or for children’s schools or youth organizations as volunteer activities. During the past 12 months, have you done any of these types of activities?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW ALL]

[S]

CIV_MEET

During the past 12 months, did you attend a public meeting, such as a zoning or school board meeting, that discussed a local issue?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

0 NO



[SHOW ALL]

[S]

CIV_VOTELOCL

Did you vote in the last local elections, such as for mayor, councilmembers, or school board?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

  1. NO

[CREATE “END_CIV” AND RECORD TIME IN HH:MM:SS]





LAN - LANGUAGE ITEMS

[CREATE “START_LAN” AND RECORD TIME IN HH:MM:SS]


[SHOW IF QUEX_LANGUAGE=1; AUTO PUNCH 1 (YES) IF QUEX_LANGUAGE=2 ]

[S]

LAN_OTHERLAN

Do you speak a language other than English at home?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

  1. NO



[SHOW IF LAN_OTHERLAN=1]

[S]

LAN_MEDIA

When you watch television, read news online or in print, or listen to the radio, which language do you use most often?

[CAWI RESPONSE OPTIONS:]

  1. English

  2. Spanish

  3. Another language

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. ENGLISH

  2. SPANISH

  3. ANOTHER LANGUAGE



[SHOW IF LAN_OTHERLAN=1]

[S]

LAN_DOCTOR

When you see a doctor or other health care professional, which language do you use most often?

[CAWI RESPONSE OPTIONS:]

  1. English

  2. Spanish

  3. Another language

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. ENGLISH

  2. SPANISH

  3. ANOTHER LANGUAGE



[SHOW IF LAN_OTHERLAN=1]

[S]

LAN_SOCIAL

When you participate in social activities, such as visiting friends, attending clubs, or going to parties, which language do you use most often?

[CAWI RESPONSE OPTIONS:]

  1. English

  2. Spanish

  3. Another language

[CATI RESPONSE OPTIONS – DO NOT READ:]

  1. ENGLISH

  2. SPANISH

  3. ANOTHER LANGUAGE

[CREATE “END_LAN” AND RECORD TIME IN HH:MM:SS]



TEL - TELEPHONE USE

[CREATE “START_TEL” AND RECORD TIME IN HH:MM:SS]

[SHOW ALL]

[S]

TEL_NONCELL

Is there at least one telephone inside your home that is currently working and is not a cell phone?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

  1. NO



[SHOW ALL]

[S]

TEL_CELL

Do you have a working cell phone?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

  1. NO



[SHOW IF TEL_CELL=0 AND HHSIZE>=2]

[S]

TEL_HHCELL

Do you live with anyone at your home who has a working cell phone?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

  1. NO


[CREATE “START_TEL” AND RECORD TIME IN HH:MM:SS]


[CREATE “END_TIME” AND RECORD TIME IN HH:MM:SS; CREATE END_DATE” AND RECORD DATE IN MM:DD:YYY]



89


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMaitland, Aaron K. (CDC/DDPHSS/NCHS/DHIS)
File Modified0000-00-00
File Created2023-12-11

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