Attachment 13 2021 BRFSS Field test questionniare

Attachment 13 2021 BRFSS Field test questionniare.docx

[NCCDPHP] Behavioral Risk Factor Surveillance System (BRFSS)

Attachment 13 2021 BRFSS Field test questionniare

OMB: 0920-1061

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Attachment 13:



2021 BRFSS Field Test Questionnaire











OMB Header and Introductory Text


Read if necessary

Read

Interviewer instructions

(not read)

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


Form Approved

OMB No. 0920-1061

Exp. Date 3/31/2021


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


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

States may opt not to mention the state name to avoid refusals by out of state residents in the cell phone sample.


If cell phone respondent objects to being contacted by state where they have never lived, say:

“This survey is conducted by all states and your information will be forwarded to the correct state of residence”




Cell Phone Introduction


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)








CP01.


Is this a safe time to talk with you?

SAFETIME


1 Yes

Go to CP02



2 No

([set appointment if possible]) TERMINATE]

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

CP02.


Is this [PHONE NUMBER]?

CTELNUM1


1 Yes

Go to CP03



2 No

TERMINATE


CP03.


Is this a cell phone?

CELLFON5


1 Yes

Go to CADULT1



2 No

TERMINATE

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

CP04.


Are you 18 years of age or older?

CADULT1


1 Yes





2 No

TERMINATE

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

CP05.

Are you male or female?


CELLSEX

1 Male

2 Female


We ask this question to determine which health related questions apply to each respondent. For example, persons who report males as their sex at birth might be asked about prostate health issues.


3 Nonbinary

7 Don’t know/Not sure

9 Refused






MSAB.01

What was your sex at birth? Was it male or female?

BIRTHSEX

1 Male

2 Female



This question refers to the original birth certificate of the respondent. It does not refer to amended birth certificates.


7 Don’t know/Not sure

9 Refused

TERMINATE

CP06.


Do you live in a private residence?

PVTRESD3


1 Yes

Go to CP08

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

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


2 No

Go to CP07


CP07.


Do you live in college housing?

CCLGHOUS


1 Yes

Go to CP08

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


2 No

TERMINATE

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

CP08.


Do you currently live in___(state)____?

CSTATE1


1 Yes

Go to CP10



2 No

Go to CP09


CP09.


In what state do you currently live?

RSPSTAT1


1 Alabama

2 Alaska

4 Arizona

5 Arkansas

6 California

8 Colorado

9 Connecticut

10 Delaware

11 District of Columbia

12 Florida

13 Georgia

15 Hawaii

16 Idaho

17 Illinois

18 Indiana

19 Iowa

20 Kansas

21 Kentucky

22 Louisiana

23 Maine

24 Maryland

25 Massachusetts

26 Michigan

27 Minnesota

28 Mississippi

29 Missouri

30 Montana

31 Nebraska

32 Nevada

33 New Hampshire

34 New Jersey

35 New Mexico

36 New York

37 North Carolina

38 North Dakota

39 Ohio

40 Oklahoma

41 Oregon

42 Pennsylvania

44 Rhode Island

45 South Carolina

46 South Dakota

47 Tennessee

48 Texas

49 Utah

50 Vermont

51 Virginia

53 Washington

54 West Virginia

55 Wisconsin

56 Wyoming

66 Guam

72 Puerto Rico

78 Virgin Islands




77 Live outside US and participating territories

99 Refused

TERMINATE

Read: Thank you very much, but we are only interviewing persons who live in the US.

CP11.

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

HHADULT

_ _ Number

77 Don’t know/ Not sure

99 Refused

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



Transition to section 1.



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





Core Section 1: Health Status



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CHS.01


Would you say that in general your health is—

GENHLTH

Read:

1 Excellent

2 Very Good

3 Good

4 Fair

5 Poor

Do not read:

7 Don’t know/Not sure

9 Refused








Core Section 2: Healthy Days



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CHD.01


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

PHYSHLTH

_ _ Number of days (01-30)

88 None

77 Don’t know/not sure

99 Refused


88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.


CHD.02

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

MENTHLTH

_ _ Number of days (01-30)

88 None

77 Don’t know/not sure

99 Refused


88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.






Skip CHD.03 if CHD.01, PHYSHLTH, is 88 and CHD.02, MENTHLTH, is 88



CHD.03

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

POORHLTH

_ _ Number of days (01-30)

88 None

77 Don’t know/not sure

99 Refused


88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.






Core Section 3: Health Care Access



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CHCA.01


What is the current primary source of your health insurance?


Read if necessary:


01 A plan purchased through an employer or union (including plans purchased through another person's employer)

02 A private nongovernmental plan that you or another family member buys on your own

03 Medicare

04 Medigap

05 Medicaid

06 Children's Health Insurance Program (CHIP)

07 Military related health care: TRICARE (CHAMPUS) / VA health care / CHAMP- VA

08 Indian Health Service

09 State sponsored health plan

10 Other government program

88 No coverage of any type


77 Don’t Know/Not Sure 99 Refused



If respondent has multiple sources of insurance, ask for the one used most often.

If respondents give the name of a health plan rather than the type of coverage

ask whether this is insurance purchased independently, through their employer, or whether it is through Medicaid or CHIP.



CHCA.02

Do you have one person or a group of doctors that you think of as your personal health care provider?


1 Yes, only one

2 More than one

3 No

7 Don’t know / Not sure

9 Refused


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


NOTE: if the respondent had multiple doctor groups then it would be more than one—but if they had more than one doctor in the same group it would be one.


CHCA.03

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


1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CHCA.04

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

CHECKUP1

Read if necessary:

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

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

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

4 5 or more years ago

Do not read:

7 Don’t know / Not sure

8 Never

9 Refused


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






Core Section 4: Chronic Health Conditions



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue

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






CCHC.01


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

CVDINFR4


1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.02

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

CVDCRHD4


1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.03

(Ever told) (you had) a stroke?

CVDSTRK3


1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.04

(Ever told) (you had) asthma?

ASTHMA3

1 Yes




2 No

7 Don’t know / Not sure

9 Refused

Go to CCHC.06


CCHC.05

Do you still have asthma?

ASTHNOW

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.06

(Ever told) (you had) skin cancer that is not melanoma?

***NEW***


1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.07

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

***NEW***

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.08

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

CHCCOPD3


1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.09

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

ADDEPEV3


1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.10

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

CHCKDNY2


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


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


CCHC.11

(Ever told) (you had) some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?

HAVARTH4


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Do not read: Arthritis diagnoses include: rheumatism, polymyalgia rheumatic, osteoarthritis (not osteoporosis), tendonitis, bursitis, bunion, tennis elbow, carpal tunnel syndrome, tarsal tunnel syndrome, joint infection, Reiter’s syndrome, ankylosing spondylitis; spondylosis, rotator cuff syndrome, connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome, vasculitis, giant cell arteritis, Henoch-Schonlein purpura, Wegener’s granulomatosis, polyarteritis nodosa)


CCHC.12

(Ever told) (you had) diabetes?

DIABETE4


1 Yes



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


2 Yes, but female told only during pregnancy

3 No

4 No, pre-diabetes or borderline diabetes

7 Don’t know / Not sure

9 Refused

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


CCHC.13

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

DIABAGE3

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

98 Don‘t know / Not sure

99 Refused

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



Core Section 5: Demographics



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CDEM.01

What is your age?

AGE


_ _ Code age in years

07 Don’t know / Not sure

09 Refused




CDEM.02

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

HISPANC3


If yes, read: Are you…

1 Mexican, Mexican American, Chicano/a

2 Puerto Rican

3 Cuban

4 Another Hispanic, Latino/a, or Spanish origin

Do not read:

5 No

7 Don’t know / Not sure

9 Refused


One or more categories may be selected.


CDEM.03

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

MRACE1


Please read:

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

88 No additional choices

77 Don’t know / Not sure

99 Refused

.

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

One or more categories may be selected.






If more than one response to CDEM.03; continue. Otherwise, go to CDEM.05



CDEM.04

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

ORACE3


Please read:

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

77 Don’t know / Not sure

99 Refused


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


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







If using SOGI module, insert here. Sex at birth module may be inserted here if not used in the screening section.



Prologue

The next two questions are about sexual orientation and gender identity





If sex= male (using BIRTHSEX, CELLSEX, LANDSEX ) continue, otherwise go to MSOGI.01b.



MSOGI.01a


Which of the following best represents how you think of yourself?

SOMALE

1 = Gay

2 = Straight, that is, not gay

3 = Bisexual

4 = Something else

7 = I don't know the answer

9 = Refused


Read if necessary: We ask this question in order to better understand the health and health care needs of people with different sexual orientations.


Please say the number before the text response. Respondent can answer with either the number or the text/word.

551





If sex= female (using BIRTHSEX, CELLSEX, LANDSEX ) continue, otherwise go to MSOGI.02.



MSOGI.01b

Which of the following best represents how you think of yourself?

SOFEMALE

1 = Lesbian or Gay

2 = Straight, that is, not gay

3 = Bisexual

4 = Something else

7 = I don't know the answer

9 = Refused

.

Read if necessary: We ask this question in order to better understand the health and health care needs of people with different sexual orientations.


Please say the number before the text response. Respondent can answer with either the number or the text/word.

552

MSOGI.02

Do you consider yourself to be transgender?

TRNSGNDR

1 Yes, Transgender, male-to-female

2 Yes, Transgender, female to male

3 Yes, Transgender, gender nonconforming

4 No

7 Don’t know/not sure

9 Refused


Read if necessary: Some people describe themselves as transgender when they experience a different gender identity from their sex at birth. For example, a person born into a male body, but who feels female or lives as a woman would be transgender. Some transgender people change their physical appearance so that it matches their internal gender identity. Some transgender people take hormones and some have surgery. A transgender person may be of any sexual orientation – straight, gay, lesbian, or bisexual.


If asked about definition of gender non-conforming: Some people think of themselves as gender non-conforming when they do not identify only as a man or only as a woman.


If yes, ask Do you consider yourself to be 1. male-to-female, 2. female-to-male, or 3. gender non-conforming?


Please say the number before the text response. Respondent can answer with either the number or the text/word.

553








CDEM.05

Are you…

MARITAL


Please read:

1 Married

2 Divorced

3 Widowed

4 Separated

5 Never married

Or

6 A member of an unmarried couple

Do not read:

9 Refused




CDEM.06

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

EDUCA


Read if necessary:

1 Never attended school or only attended kindergarten

2 Grades 1 through 8 (Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

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

6 College 4 years or more (College graduate)

Do not read:

9 Refused




CDEM.07

Do you own or rent your home?

RENTHOM1


1 Own

2 Rent

3 Other arrangement

7 Don’t know / Not sure

9 Refused


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

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


CDEM.08

In what county do you currently live?

CTYCODE2


_ _ _ANSI County Code

777 Don’t know / Not sure

999 Refused

888 County from another state




CDEM.09

What is the ZIP Code where you currently live?

ZIPCODE1


_ _ _ _ _

77777 Do not know

99999 Refused








If cell interview go to CDEM12



CDEM.13

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

VETERAN3


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


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


CDEM.14

Are you currently…?

EMPLOY1


Read:

1 Employed for wages

2 Self-employed

3 Out of work for 1 year or more

4 Out of work for less than 1 year

5 A Homemaker

6 A Student

7 Retired

Or

8 Unable to work

Do not read:

9 Refused


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


CDEM.15

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

CHILDREN


_ _ Number of children

88 None

99 Refused




CDEM.16

Is your annual household income from all sources—

***NEW***


Read if necessary:

01 Less than $10,000?

02 Less than $15,000? ($10,000 to less than $15,000)

03 Less than $20,000? ($15,000 to less than $20,000)

04 Less than $25,000

05 Less than $35,000 If

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

06 Less than $50,000 If

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

07 Less than $75,000? ($50,000 to less than $75,000)

08 Less than $100,000? ($75,000 to less than $100,000)

09 Less than $150,000? ($100,000 to less than $150,000)?

10 Less than $200,000? ($150,000 to less than $200,000)

11 $200,000 or more


Do not read:

77 Don’t know / Not sure

99 Refused

SEE CATI information of order of coding;


Start with category 05 and move up or down categories.

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







Skip if Male (MSAB.01, BIRTHSEX, is coded 1). If MSAB.01=missing and (CP05=1 or LL12=1; or LL09 = 1 or LL07 =1).

Or Age >49



CDEM.17

To your knowledge, are you now pregnant?

PREGNANT


1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CDEM.18

About how much do you weigh without shoes?

WEIGHT2


_ _ _ _ Weight (pounds/kilograms)

7777 Don’t know / Not sure

9999 Refused


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


CDEM.19

About how tall are you without shoes?

HEIGHT3


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

77/ 77 Don’t know / Not sure

99/ 99 Refused


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




Core Section 6: Disability

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CDIS.01

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

DEAF


1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CDIS.02

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

BLIND


1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CDIS.03

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

DECIDE


1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CDIS.04

Do you have serious difficulty walking or climbing stairs?

DIFFWALK

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CDIS.05

Do you have difficulty dressing or bathing?

DIFFDRES

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CDIS.06

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

DIFFALON

1 Yes

2 No

7 Don’t know / Not sure

9 Refused







Core Section 7: Colorectal Cancer Screening


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If Section CDEM.01, AGE, is less than 45 go to next module.



CCRC.01

Colonoscopy and sigmoidoscopy are exams to check for colon cancer. Have you ever had either of these exams?

HADSIGM3

1 Yes

Go to CCRC.02



2 No

7 Don’t know/ not sure

9 Refused

Go to CCRC.06

CCRC.02

Have you had a colonoscopy, a sigmoidoscopy, or both?


1 Colonoscopy


Go to CCRC.03



2 Sigmoidoscopy

Go to CCRC.04

3 Both

7 Don’t know/Not sure

Go to CCRC.05

9 Refused

Go to CCRC.06

CCRC.03

How long has it been since your most recent colonoscopy?


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

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

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

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

5 5 or more years ago

Do not read:

7 Don't know / Not sure

9 Refused

Go to CCRC.06



CCRC.04

How long has it been since your most recent sigmoidoscopy?


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

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

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

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

5 5 or more years ago

Do not read:

7 Don't know / Not sure

9 Refused

Go to CCRC.06



CCRC.05

How long has it been since your most recent colonoscopy or sigmoidoscopy?

LASTSIG3

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

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

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

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

5 5 or more years ago

Do not read:

7 Don't know / Not sure

9 Refused




CCRC.06

Have you ever had any other kind of test for colorectal cancer, such as virtual colonoscopy, CT colonography, blood stool test, FIT DNA, or Cologuard test?




1 Yes

Go to CCRC.07



2 No

7 Don’t Know/Not sure

9 Refused

Go to Next Module

CCRC.07

A virtual colonoscopy uses a series of X-rays to take pictures of inside the colon. Have you ever had a virtual colonoscopy?


1 Yes

Go to CCRC.08

CT colonography, sometimes called virtual colonoscopy, is a new type of test that looks for cancer in the colon. Unlike regular colonoscopies, you do not need medication to make you sleepy during the test. In this new test, your colon is filled with air and you are moved through a donut-shaped X-ray machine as you lie on your back and then your stomach.


2 No

7 Don’t Know/Not sure

9 Refused

Go to CCRC.09

CCRC.08

When was your most recent CT colonography or virtual colonoscopy?


Read if necessary:

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

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

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

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

5 5 or more years ago

Do not read:

7 Don’t know / Not sure

9 Refused




CCRC.09


One stool test uses a special kit to obtain a small amount of stool at home and returns the kit to the doctor or the lab. Have you ever had this test?


1 Yes

Go to CCRC.10

The blood stool or occult blood test, fecal immunochemical or FIT test determine whether you have blood in your stool or bowel movement and can be done at home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab.


2 No

7 Don’t know/ not sure

9 Refused

Go to CCRC.11

CCRC.10

How long has it been since you had this test?


Read if necessary:

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

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

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

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

5 5 or more years ago

Do not read:

7 Don’t know / Not sure

9 Refused




CCRC.11

Another stool test uses a special kit to obtain an entire bowel movement at home and returns the kit to a lab. Have you ever had this Cologuard test?


1 Yes

Go to CCRC.12

Cologuard is a new type of stool test for colon cancer. Unlike other stool tests, Cologuard looks for changes in DNA in addition to checking for blood in your stool. The Cologuard test is shipped to your home in a box that includes a container for your stool sample.


2 No

7 Don’t Know/Not sure

9 Refused

Go to Next Module

CCRC.12

Was the blood stool or FIT (you reported earlier) conducted as part of a Cologuard test?


1 Yes

2 No

7 Don’t Know/Not sure

9 Refused




CCRC.13

How long has it been since you had this test?


Read if necessary:

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

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

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

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

5 5 or more years ago

Do not read:

7 Don’t know / Not sure

9 Refused






Core Section 8: Tobacco Use



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CTOB.01


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

SMOKE100


1 Yes


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

5 packs = 100 cigarettes.


2 No

7 Don’t know/Not Sure

9 Refused

Go to CTOB.03


CTOB.02

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

SMOKDAY2


1 Every day

2 Some days

3 Not at all

7 Don’t know / Not sure

9 Refused




CTOB.03

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

USENOW3

1 Every day

2 Some days

3 Not at all

7 Don’t know / Not sure

9 Refused


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


CTOB.04

Do you now use e-cigarettes or other electronic vaping products every day, some days or not at all?


1 Every day

2 Some days

3 Not at all

4 Never used e-cigs

7 Don’t know / Not sure

9 Refused


Electronic cigarettes (e-cigarettes) and other electronic vaping products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy. Brands you may have heard of are JUUL, NJOY, or blu.

Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.









Core Section 9: Lung Cancer Screening


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If CTOB.01=1 (yes) and CTOB.02 = 1, 2, or 3 (every day, some days, or not at all) continue, else go to LCSCTSCN.



CLC.01




You’ve told us that you have smoked in the past or are currently smoking. The next questions are about screening for lung cancer.


How old were you when you first started to smoke cigarettes regularly?

LCSFIRST


_ _ _ Age in Years (001 – 100)

777 Don't know/Not sure

999 Refused


Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all).

If respondent indicates age inconsistent with previously entered age, verify that this is the correct answer and change the age of the respondent regularly smoking or make a note to correct the age of the respondent.


888 Never smoked cigarettes regularly

Go to LCSCTSCN

CLC.02

How old were you when you last smoked cigarettes regularly?

LCSLAST

_ _ _ Age in Years (001 – 100)

777 Don't know/Not sure

999 Refused




CLC.03

On average, when you [smoke/ smoked] regularly, about how many cigarettes {do/did} you usually smoke each day?

LCSNUMCG

_ _ _ Number of cigarettes

777 Don't know/Not sure

999 Refused


Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all).

Respondents may answer in packs instead of number of cigarettes. Below is a conversion table: 0.5 pack = 10 cigarettes/ 1.75 pack = 35 cigarettes/ 0.75 pack = 15 cigarettes/ 2 packs = 40 cigarettes/ 1 pack = 20 cigarettes/ 2.5 packs= 50 cigarettes/ 1.25 pack = 25 cigarettes/ 3 packs= 60 cigarettes/ 1.5 pack = 30 cigarettes


CLC.04

The next question is about CT or CAT scans of your chest area. During this test, you lie flat on your back and are moved through an open, donut shaped x-ray machine.

In the last 12 months, did you have a CT or CAT scan?


1 Yes

2 No

7 Don't know/not sure

9 Refused




CLC.04

Were any of the CT or CAT scans of your chest area done mainly to check or screen for lung cancer?


1 Yes

2 No

7 Don't know/not sure

9 Refused




CLC.05

When did you have your most recent CT or CAT scan of your chest area mainly to check or screen for lung cancer?


Read only if necessary:

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

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

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

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

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

6 or more years ago

Do not read:

7 Don’t know / Not sure

9 Refused







Core Section 10: Alcohol Consumption

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CALC.01


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

ALCDAY5


1 _ _ Days per week

2 _ _ Days in past 30 days


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


888 No drinks in past 30 days

777 Don’t know / Not sure

999 Refused

Go to next section

CALC.02

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

AVEDRNK3


_ _ Number of drinks

88 None

77 Don’t know / Not sure

99 Refused


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


CALC.03

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

DRNK3GE5


_ _ Number of times

77 Don’t know / Not sure

88 no days

99 Refused

CATI X = 5 for men, X = 4 for women (states may use sex at birth to determine sex if module is adopted)



CALC.04

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

MAXDRNKS

_ _ Number of drinks

77 Don’t know / Not sure

99 Refused




CALC.05

When answering the questions about the number of drinks you had on an occasion, which of the following best describes how you thought of an “occasion”?

Was it a few hours, such as an evening or going out for the night, one day, one weekend, a special event or celebration such as a birthday, wedding, or sporting event?


1 A few hours, such as an evening or going out for the night, 2 one day,

3 One weekend,

4 A special event or celebration such as a birthday, wedding, or sporting event

5 Other

7 Don’t know/ Not sure

9 Refused




CALC.06

Earlier I described a standard drink size as equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. In thinking about the size of your drinks, how do they compare to the standard drink size? Are the drinks you described generally larger than the standard drink size, generally smaller than the standard drink size or about the same size as a standard drink.


1 Generally larger than the standard drink size,

2 Generally smaller than the standard drink size or





3 about the same size as a standard drink

7 Don’t know/ Not sure

9 Refused

Go to next section


CALC.07

When answering questions about the number of drinks you had, did you base your answer on

the size of your drinks or the size of a standard drink?


1 the size of your drinks

2 the size of a standard drink

7 Don’t know/ Not sure

9 Refused







Emerging Core: Long-term COVID Effects

Question Number

Question text

Variable names


Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

COVID.01

Has a doctor, nurse, or other health professional ever told you that you tested positive for COVID 19?

***NEW***


1 Yes



Positive tests include antibody or blood testing as well as other forms of testing for COVID, such a nasal swabbing or throat swabbing.

Do not include instances where a healthcare professional told you that you likely had the virus without a test to confirm.



2 No

7 Don’t know / Not sure

9 Refused

Go to next section

COVID.02

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

***NEW***


1 Yes



Long term conditions may be an indirect effect of COVID 19. These long term conditions may not be related to the virus itself



2 No

7 Don’t know / Not sure

9 Refused

Go to next section

COVID.03

Which of the following was the primary symptom that you experienced? Was it….

***NEW***


READ

1 Tiredness or fatigue

2 Difficulty thinking or concentrating or forgetfulness/memory problems (sometimes referred to as “brain fog”)

3 Difficulty breathing or shortness of breath

4 Joint or muscle pain

5 Fast-beating or pounding heart (also known as heart palpitations) or chest pain

6 Dizziness on standing

7 Depression, anxiety, or mood changes

8 Symptoms that get worse after physical or mental activities

9 You did not have any long-term symptoms that limited your activities.77 Don’t know/Not sure

99 Refused







Module 1: COVID Vaccination


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)








MCOV.01

Have you had a COVID-19 vaccination?

COVIDVAC

1 Yes


Go to MCOV.03 (COVIDNUM)



2 No


Go to MCOV.02 (COVACGET)

7 Don’t know / Not sure

9 Refused

Go to next section

MCOV.02

Would you say you will definitely get a vaccine, will probably get a vaccine, will probably not get a vaccine, will definitely not get a vaccine, or are you not sure?

COVACGET

1 = Will definitely get a vaccine

2 = Will probably get a vaccine

3 = Will probably not get a vaccine

4 = Will definitely not get a vaccine

7 = Don’t know/Not sure

9 = Refused

Go to next section



MCOV.03

How many COVID-19 vaccinations have you received?

COVIDNUM

1 One





2 Two or more

Go to MCOV.05



7 Don’t know / Not sure

9 Refused

Go to next module







Skip MCOV4 (COVINT) if COVIDNUM = 2.



MCOV.04

Which of the following best describes your intent to take the recommended COVID vaccinations…

Would you say you have already received all recommended doses, plan to receive all recommended doses or do not plan to receive all recommended doses?

COVIDINT

1 = Already received all recommended doses

2 = Plan to receive all recommended doses

3 = Do not plan to receive all recommended doses

7 = Don’t know/Not sure

9 = Refused




MCOV.05

During what month and year did you receive your (first) COVID-19 vaccination?

COVIDFST

_ _ / _ _ _ _ Month / Year

77 / 7777 Don’t know / Not sure

09 / 9999 Refused

If respondent indicated only one vaccine do not read word “first”



MCOV.06

During what month and year did you receive your second COVID-19 vaccination?

COVIDFST

_ _ / _ _ _ _ Month / Year

77 / 7777 Don’t know / Not sure

09 / 9999 Refused






Module 2: Prediabetes


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





Skip if CCHC.12, DIABETE4, is coded 1. To be asked following Core CCHC.12;



M01.01


Have you had a test for high blood sugar or diabetes within the past three years?

PDIABTST

1 Yes

2 No

7 Don’t know/ not sure

9 Refused








Skip if CCHC.12, DIABETE4, is coded 1; If CCHC.11, DIABETE4, is coded 4 automatically code M01.02, PREDIAB1, equal to 1 (yes)



M01.02

Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?

PREDIAB1

1 Yes

2 Yes, during pregnancy

3 No

7 Don’t know / Not sure

9 Refused


If Yes and respondent is female, ask: Was this only when you were pregnant?




Module 3: Diabetes


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





Skip if CCHC.12 is not equal to 1.



M02.01


According to your doctor or other health professional, what type of diabetes do you have?

***NEW***

1 Type 1

2 Type 2

7 Don’t know/ Not sure

9 Refused




M02.02

Are you now taking insulin?

INSULIN


1 Yes

2 No

7 Don’t know/ not sure

9 Refused




M02.03

About how often do you check your blood for glucose or sugar?


BLDSUGAR


1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

4 _ _ Times per year

888 Never

777 Don’t know / Not sure

999 Refused


Read if necessary: Include times when checked by a family member or friend, but do not include times when checked by a health professional.


Do not read: If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously), fill in ‘98 times per day.’


M02.04

Including times when checked by a family member or friend, about how often do you check your feet for any sores or irritations?

FEETCHK3


1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

4 _ _ Times per year

555 No feet

888 Never

777 Don’t know / Not sure

999 Refused




M02.05

About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?

DOCTDIAB


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

88 None

77 Don’t know / Not sure

99 Refused




M02.06

About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for A-one-C?

CHKHEMO3


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

88 None

98 Never heard of A-one-C test

77 Don’t know / Not sure

99 Refused


Read if necessary: A test for A-one-C measures the average level of blood sugar over the past three months.


M02.07

About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?

FEETCHK

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

88 None

77 Don’t know / Not sure

99 Refused

If M02.03 = 555 (No feet), go to M02.07



M02.08

When was the last time you had an eye exam in which the pupils were dilated, making you temporarily sensitive to bright light?

EYEEXAM1

Read if necessary:

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

2 Within the past year (1 month but less than 12 months ago)

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

4 2 or more years ago

Do not read:

7 Don’t know / Not sure

8 Never

9 Refused




M02.09

When was the last time a doctor, nurse or other health professional took a photo of the back of your eye with a specialized camera?

***NEW***

Read if necessary:

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

2 Within the past year (1 month but less than 12 months ago)

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

4 2 or more years ago

Do not read:

7 Don’t know / Not sure

8 Never

9 Refused




M02.10

Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?

DIABEYE

1 Yes

2 No

7 Don’t know/ not sure

9 Refused




M02.11


Have you ever taken a course or class in how to manage your diabetes yourself?

DIABEDU

1 Yes

2 No

7 Don’t know/ not sure

9 Refused






Module 4: Respiratory Health



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M7.01


During the past 3 months, did you have a cough on most days?

COPDCOGH

1 Yes

2 No

7 Don’t know/ not sure

9 Refused




M7.02

During the past 3 months, did you cough up phlegm [FLEM] or mucus on most days?

COPDFLEM

1 Yes

2 No

7 Don’t know/ not sure

9 Refused




M7.03

Do you have shortness of breath either when hurrying on level ground or when walking up a slight hill or stairs?

COPDBRTH

1 Yes

2 No

7 Don’t know/ not sure

9 Refused




M7.04

Have you ever been given a breathing test to diagnose breathing problems?

COPDBTST

1 Yes

2 No

7 Don’t know/ not sure

9 Refused




M7.05

Over your lifetime, how many years have you smoked tobacco products?

COPDSMOK

_ _ Number of years (01-76)

88 Never smoked or smoked less than one year

77 Don’t know/Not sure

99 Refused







Module 5: Cancer Survivorship: Type of Cancer



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If CCHC.06 or CCHC.07 = 1 (Yes) continue, else go to next module.



MTOC.01


You’ve told us that you have had cancer. I would like to ask you a few more questions about your cancer.


How many different types of cancer have you had?

CNCRDIFF


1 Only one

2 Two

3 Three or more





7 Don’t know / Not sure

9 Refused

Go to next module

MTOC.02

At what age were you told that you had cancer?

CNCRAGE


_ _ Age in Years (97 = 97 and older)

98 Don't know/Not sure

99 Refused


If MTOC.01= 2 (Two) or 3 (Three or more), ask: At what age were you first diagnosed with cancer?

Read if necessary: This question refers to the first time they were told about their first cancer.






If CCHC.06 = 1 (Yes) and MTOC.01 = 1 (Only one): ask Was it Melanoma or other skin cancer? then code MTOC.03 as a response of 21 if Melanoma or 22 if other skin cancer




MTOC.03

What kind of cancer is it?

***NEW***


Read if respondent needs prompting for cancer type:

01 Bladder

02 Blood

03 Bone

04 Brain

05 Breast

06 Cervix/Cervical

07 Colon

08 Esophagus/Esophageal

09 Gallbladder

10 Kidney

11 Larynx-trachea

12 Leukemia

13 Liver

14 Lung

15 Lymphoma

16 Melanoma

17 Mouth/tongue/lip

18 Ovary/Ovarian

19 Pancreas/Pancreatic

20 Prostate

21 Rectum/Rectal

22 Skin (non-melanoma)

23 Skin (don't know what kind)

24 Soft tissue (muscle or fat)

25 Stomach

26 Testis/Testicular

27 Throat - pharynx

28 Thyroid

29 Uterus/Uterine

30 Other

Do not read:

77 Don’t know / Not sure

99 Refused


If MTOC.01 = 2 (Two) or 3 (Three or more), ask: With your most recent diagnoses of cancer, what type of cancer was it?








Module 6: Prostate Cancer Screening

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If respondent is ≤39 years of age or is female,

go to next module.



MPCS.01

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

PSATEST1


1 Yes


A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.


2 No

7 Don’t know / Not sure

9 Refused

Go to M11.04

MPCS.02

Who first suggested this PSA test: you, your doctor, or someone else?


1 Self

2 Doctor, nurse, health care professional

3 Someone else

7 Don’t Know / Not sure

9 Refused




MPCS.03

About how long has it been since your most recent P.S.A. test?


Read if necessary:

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

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

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

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

5 5 or more years ago

Do not read:

7 Don’t know / Not sure

9 Refused


A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.



MPCS.04

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

***NEW***

Read:

1 Part of a routine exam

2 Because of a problem

3 other reason

Do not read:

7 Don’t know / Not sure

9 Refused


A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.


MPCS.05


When you met with a doctor, nurse, or other health professional, did they talk about the advantages, the disadvantages, or both advantages and disadvantages of the prostate-specific antigen or PSA test?

***NEW***


1 Advantages 2 Disadvantages

3 Both Advantages and disadvantages

DO NOT READ

4. Neither

7 Don’t know/ not sure

9 Refused


A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.





Module 7: Marijuana Use


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MMU.01


During the past 30 days, on how many days did you use marijuana or cannabis?

MARIJAN1


_ _ 01-30 Number of days


These questions are about marijuana or cannabis. Do not include hemp-based or CBD-only products in your responses.


88 None

77 Don’t know/not sure

99 Refused

Go to next module

MMU.02

During the past 30 days, did you smoke it (for example, in a joint, bong, pipe, or blunt)

***NEW***

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




MMU.03

During the past 30 days, did you eat it (for example, in brownies, cakes, cookies, or candy)

***NEW***

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




MMU.04

During the past 30 days, did you drink it (for example, in tea, cola, or alcohol)

***NEW***

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




MMU.05

During the past 30 days, did you vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device)

***NEW***

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




MMU.06

During the past 30 days, did you dab it (for example, using a dabbing rig, knife, or dab pen)?

***NEW***

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




MMU.07

During the past 30 days, did you use it in some other way?

***NEW***

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused










Module 8: Other Tobacco Use


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MOTU.01

Currently, when you smoke cigarettes, do you usually smoke menthol cigarettes?

***NEW***

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




MOTU.02

Currently, when you use e-cigarettes, do you usually use menthol e-cigarettes?

***NEW***

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




MOTU.03

Prologue: The next questions are about heated tobacco products. Some people refer to these as “heat not burn” tobacco products. These heat tobacco sticks or capsules to produce a vapor. Some brands of heated tobacco products include iQOS [eye-kos], Glo, and Eclipse.

***NEW***





MOTU.04

Do you now use heated tobacco products every day, some days or not at all?

***NEW***

1 Every day

2 Some days


Go to next module



3 Not at all

7 Don’t know / Not sure

9 Refused


MOTU.05

Before today, have you heard of heated tobacco products?

***NEW***

1 Yes

2 No

7 Don’t know / Not sure

9 Refused






Module 9: Family Planning


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





Skip if sex= male or age> 49



MFP.01

In the past 12 months, did you have sex where a penis is inserted into the vagina, sometimes called penile‐vaginal sex?



1 Yes

2 No [GO TO NEXT MODULE]




MFP.02

The last time you had sex, what did you or your partner do to keep you from getting pregnant?


Read if necessary:

01 Female sterilization (Tubal ligation, Essure, or Adiana)

02 Male sterilization (vasectomy)

03 Contraceptive implant

04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard)

05 Shots (Depo-Provera)

06 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra)

07 Condoms (male or female)

08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream

09 Had sex at a time when less likely to get pregnant (rhythm or natural family planning)

10 Withdrawal or pulling out

11 Emergency contraception or the morning after pill (Plan B or ella)

12 Other method




MFP.03

The last time you had sex, what else, if anything, did you or your partner do to keep you from getting pregnant?


00 Nothing else

01 Female sterilization (Tubal ligation, Essure, or Adiana)

02 Male sterilization (vasectomy)

03 Contraceptive implant

04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard)

05 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra)

06 Shots (Depo-Provera),

07 Condoms (male or female)

08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream

09 Had sex at a time when less likely to get pregnant (rhythm or natural family planning)

10 Withdrawal or pulling out

11 Emergency contraception or the morning after pill (Plan B or Ella)

12 Other method




MFP.04

Where did you get the [contractive response from Q3] you used when you last had sex?


01 Private doctor’s office [GO TO Q7]

02 Community health clinic, Community clinic, Public health clinic [GO TO Q7]

03 Family planning or Planned Parenthood Clinic [GO TO Q7]

04 School or school-based clinic [GO TO Q7]

05 Hospital outpatient clinic, emergency room, regular hospital room [GO TO Q7]

06 Urgent care center, urgi-care or walk-in facility [GO TO Q7]

07 In- store health clinic (like CVS, Target, or Walmart) [GO TO Q7]

08 Health care visit with a pharmacist [GO TO Q7]

09 Website or app [GO TO Q7]

10 Some other place [GO TO Q7]




MFP.05

What was your main reason for not doing anything to prevent pregnancy the last time you had sex?


01 You didn’t think you were going to have sex/no regular partner

02 You just didn’t think about it

03 You wanted a pregnancy

04 You didn’t care if you got pregnant

05 You or your partner didn’t want to use birth control (side effects, don’t like birth control)

06 You had trouble getting or paying for birth control

07 You didn’t trust giving out your personal information to medical personnel

08 Didn’t think you or your partner could get pregnant (infertile or too old)

09 You were using withdrawal or “pulling out”

10 You had your tubes tied (sterilization)

11 Your partner had a vasectomy (sterilization)

12 You were breast-feeding or you just had a baby

13 You were assigned male at birth

14 Other reasons




MFP.06

If you could use any birth control method you wanted, what method would you use?


01 Female sterilization (Tubal ligation, Essure, or Adiana) [GO TO NEXT MODULE]

02 Male sterilization (vasectomy) [GO TO NEXT MODULE]

03 Contraceptive implant [GO TO NEXT MODULE]

04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard) [GO TO NEXT MODULE]

05 Shots (Depo-Provera) [GO TO NEXT MODULE]

06 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra) [GO TO NEXT MODULE]

07 Condoms (male or female) [GO TO NEXT MODULE]

08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream [GO TO NEXT MODULE]

09 Having sex at a time when less likely to get pregnant (rhythm or natural family planning) [GO TO NEXT MODULE]

10 Withdrawal or pulling out [GO TO NEXT MODULE]

11 Emergency contraception or the morning after pill (Plan B or ella) [GO TO NEXT MODULE]

12 Other method [GO TO NEXT MODULE]

13 I am using the method that I want to use [GO TO NEXT MODULE]

14 I don’t want to use any method [GO TO NEXT MODULE]








Closing Statement


Read

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












28

12 December 2023

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPierannunzi, Carol (CDC/ONDIEH/NCCDPHP)
File Modified0000-00-00
File Created2023-12-12

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