Questionnaire

NHIS Cognitive Testing Questionnaire

Roster

INTRO - Welcome to the National Health Interview Survey. Please answer the following questions to determine who in your household will be selected for an interview.

VERADD – Your address is listed as:

[PROVIDE ADDRESS]

Is this your exact address?

1. Yes

2. No

RESCHECK – Do you live at this address?

1. Yes

2. No

AGECHECK - Are you at least 18 years old

1. Yes

2. No

NAME_FNAME – Including yourself, are the names of all the people living or staying at this address?

“Add person” button

The following people are listed as living at this address:

[NAME LIST]

MISPERS_MCHILD - Are there any babies or small children missing from this list?

1. Yes

2. No

If “Yes” to MISPERS_MCHILD, display the following below.

MISPERS_MCHILD_ADD-Enter the name(s) and then click Next.

“Add person” button

MISPERS_MSCHOOL - Are there any people who usually live here, but are away now at school or college?

[NAME LIST]

1. Yes

2. No

If “Yes” to MISPERS_MSCHOOL, display the following below.

MISPERS_MSCHOOL_ADD-Enter the name(s) and then click Next.

“Add person” button

MISPERS_MELSE - Are there any people who usually live here, including people who are not related to you or people who are away traveling?

[NAME LIST]

1. Yes

2. No

If “Yes” to MISPERS_MELSE, display the following below.

MISPERS_MELSE_ADD-Enter the name(s) and then click Next.

“Add person” button

USUALRES – Does everyone on this list usually live or stay at this address?

[NAME LIST]

1. Yes

2. No

IF “NO” TO USUALRES

USUALRES_NOT – Please select the individuals who do NOT usually stay or live at this address

Select all that apply

[NAMELIST] --- new list FINAL_NAMELIST generated after this question

HHRESP

From the list below, who would you say could answer questions about all members of this household? Select all the apply.

[NAMES]

[checkbox] No one on this list fits this description.

[Demographics --- For testing, we will cycle through the demographics by each person in the roster.]

SEX - Some of the questions in this survey are about topics like breast and prostate cancer, so it is important to know which questions apply. [Are you/Is NAME] male or female?

1. Male

2. Female

AGE – What is [your/NAME] age?

[UNIT] [PERIOD]

EDUC - What is the highest level of school [you have/NAME has] completed or the highest degree [you have/NAME has] received?

• Never attended/kindergarten only

• Grade 1-11

• 12^th grade, no diploma

• GED or equivalent

• High school graduate

• Some college, no degree

• Associate degree: occupational, technical, or vocational program

• Associate degree: academic program

• Bachelor’s degree (Example: BA, AB, BS, BBA)

• Master’s degree (Example: MA, MS, MEng, MEd, MBA)

• Professional School degree (Example: MD, DDS, DVM, JD)

• Doctoral degree (Example: PhD, EdD)

WHOPAR

[if person less than 18 in the household]

Which people living in this household are [NAME} parents?

Please include biological, step, adoptive, or foster parents or other relatives who may act as parents.

Select all that apply.

1. [NAME LIST]

2. No biological, step, adoptive, or foster parents

ALLFAM – You have been selected to participate in the National Health Interview Survey

Is everyone in the list above a member of the same family?

1. Yes

2. No [go to WHOFAM]

WHOFAM – Please select the individuals from the household who are members of your family.

Select all that apply.

[FINAL_NAMELIST]

Cardiovascular Conditions

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

	Yes	No
Coronary heart disease
Angina, also called angina pectoris
A heart attack, also called myocardial infarction
A stroke

Cancer

CANEV_A

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

1. Yes

2. No

If yes, go to CANKIND1_A

If no, end section.

CANKIND1_A

What kind of cancer was it?

[drop down of answers of the following]

1. Bladder

2. Blood

3. Bone

4. Brain

5. Breast

6. Cervix/Cervical

7. Colon

8. Esophagus/Esophageal

9. 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

22. Skin (melanoma)

23. Skin (non-melanoma)

24. Skin (don’t know kind)

25. Stomach

26. Testis/testicular

27. Throat-pharynx

28. Thyroid

29. Uterus/Uterine

30. Other (specify-[write in field])

All answers go to CANAGE1_A

CANAGE1_A

How old were you when a doctor or other health professional first told you that you had this cancer?

[range of values]

All answers go to CANKIND2_Part1_A

CANKIND2_Part1_A

Have you ever had any other kinds of cancer?

1. Yes

2. No

If yes, go to CANKIND2_Part2_A

CANKIND2_Part2_A

What kind of cancer was it?

[drop down of answers of the following]

1. Bladder

2. Blood

3. Bone

4. Brain

5. Breast

6. Cervix/Cervical

7. Colon

8. Esophagus/Esophageal

9. 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

22. Skin (melanoma)

23. Skin (non-melanoma)

24. Skin (don’t know kind)

25. Stomach

26. Testis/testicular

27. Throat-pharynx

28. Thyroid

29. Uterus/Uterine

30. Other (specify-[write in field])

Diabetes

PREDIB_A

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

1. Yes

2. No

If female, go to GESDIB_A, else go to DIBEV_A

GESBIB_A

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

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

1. Yes

2. No

All answers go to DIBEV_A

DIBEV_A

Has a doctor or other health professional EVER told you that you had diabetes?

Do not include gestational diabetes or prediabetes.

1. Yes

2. No

If yes, go to DIBAGE_A

If no, if PREDIB_A=yes, go to DIBPILL_A

Else if PREDIB_A=no, go to cancer section

DIBAGE_A

How old were you when a doctor or other health professional FIRST told you that you had diabetes? Do not include gestational diabetes or prediabetes.

[Enter value]

Goto DIBPILL_A

DIBPILL_A

Are you NOW taking diabetic pills to lower your blood sugar?

These are sometimes called oral agents or oral hypoglycemic agents.

1. Yes

2. No

All answers go to DIBINS_A

DIBINS_A

Are you NOW taking insulin?

Insulin can be taken by shot or pump.

1. Yes

2. No

DIBGLP_A_V1

[If DIBINS_A=”Yes”]

Other than insulin, are you now taking any injectable medications to lower your blood sugar or lose weight?

1. Yes

2. No

DIBGLP_A_V2

[If DIBINS_A=”No”]

Are you taking any injectable medications to lower your blood sugar or lose weight?

1. Yes

2. No

DIBTYPE_A

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

1. Type 1

2. Type 2

3. Other type of diabetes

4. Don’t remember

Other Chronic Conditions

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

	Yes	No
Chronic Obstructive Pulmonary Disease, C.O.P.D., emphysema, or chronic bronchitis
Some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia
Dementia, including Alzheimer’s disease
Any type of anxiety disorder
Any type of depression

Health Insurance

Color Key:

General Question and Probes/Single Service Plans

Medicare

Medicaid

Private Health Plan

State Sponsored Health Plan

Other Government Program

Military Health Care

Uninsurance

Name: HICOVKIND_A

Universe Description: Sample Adults 18+

Question Text:

.

What kinds of health insurance or health care coverage do you have, if any?

• Include health insurance obtained through employment or purchased directly as well as government programs like Medicare, Medicaid, that provide medical care or help pay medical bills.

• Select all that apply

1 Private health insurance

2 Medicare (including Medicare Advantage)

3 Medicare supplement (Medigap)

4 Medicaid

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

_________________________________________________________________________________

6 Indian Health Service

7 State-sponsored health plan

8 Other government program

9 I do not have health insurance or health care coverage

Skip Instructions: If age is 65+ and HICOVKIND is not 2 or 3, ask MCAREPRB prior to HINOTYR; if age is <65 and HICOVKIND is not 4, ask MCAIDPRB prior to HINOTYR

Else [goto SINCOVDE_A]

Name: MCAREPRB_A

Universe Description: Sample Adults 65+ who have not indicated they had Medicare in HIKIND_A

Question Text:

Are you covered by Medicare?

1 Yes

2 No

Skip Instructions: <1,2,RF,DK> [goto SINCOVDE_A]

Name: MCAIDPRB_A

Universe Description: Sample Adults 18-64 who have indicated they are uninsured, refused, or don't know their type of health insurance

Question Text:

.

^STATEMA Are you covered by Medicaid?

Medicaid is a program that pays for health care for persons in need.

1 Yes

2 No

Skip Instructions: <1,2,RF,DK> [goto SINCOVDE_A]

Name: SINCOVDE_A, SINCOVVS_A, SINCOVRX_A

Universe Description: Sample Adults 18+

Question Text:

In addition to other plans selected, are you covered by a separate plan that only pays for any of the following?

Select all that apply.

1. Dental services

2. Vision services

3. Prescriptions

*.

Skip Instructions: <1-3,RF,DK> [go to applicable section]

Name: MCPART_A

Universe Description: Sample Adults 18+ with Medicare

Question Text:

What type of Medicare coverage do you have?

1 Part A- hospital only

2 Part B- medical only

3 Both Part A and Part B

Skip Instructions: <1> [goto MCPARTD_A]

<2-3,RF,DK> [goto MCCHOICE_A]

Name: MCCHOICE_A

Universe Description: Sample Adults 18+ with Medicare that have part B Medicare or don't know or refused if they have part B Medicare

Question Text:

Are you enrolled in a Medicare Advantage plan?

1 Yes

2 No

Skip Instructions: <1,2,RF,DK> [goto MCHMO_A]

Name: MCHMO_A

SAS Name: MCHMO_A

Universe Description: Sample Adults 18+ with Medicare that have part B Medicare or don't know or refused if they have part B Medicare

Question Text:

Are you under a Medicare managed care arrangement, such as a Health Maintenance Organization (HMO)?

1 Yes

2 No

Skip Instructions: <1> [goto MCANAME_A]

<2,RF,DK> if MCCHOICE_A=1 [goto MCANAME_A] elseif MCCHOICE_A IN (2,RF,DK) [goto MCPARTD_A]

Name: MCANAME_A

Universe Description: Sample Adults 18+ with a Medicare Advantage plan or a Medicare managed care

arrangement

Question Text: What is the name of your Medicare Advantage or Medicare HMO plan?

ADD IN TEXT FIELD HERE

Skip Instructions: <allow 80,RF,DK> [goto applicable section]

Name: MACHMN_A

Universe Description: Sample Adults 18+ with Medicaid coverage

Question Text:

What is the name of your Medicaid health plan?

ADD IN TEXT FIELD HERE

Skip Instructions: <allow 80,RF,DK> [goto MAXCHNG_A]

Name: MAXCHNG_A

Universe Description: Sample Adults 18+ with Medicaid coverage

Question Text:

Was your Medicaid obtained through Healthcare.gov or the Health Insurance Marketplace?

1 Yes

2

No

Skip Instructions: <1,2,RF,DK> [goto MAPREM_A]

Name: MAPREM_A

Universe Description: Sample Adults 18+ with Medicaid coverage

Question Text:

Do you or a family member pay a premium for this Medicaid plan?

A health insurance premium is the amount you or a family member pay each month for health care coverage.

1 Yes

2 No

Skip Instructions: <1,2,RF,DK> [goto MADEDUC_A]

Name: MADEDUC_A

Universe Description: Sample Adults 18+ with Medicaid coverage

Question Text:

Does your Medicaid plan have an annual deductible?

• A deductible is the amount you have to pay for health care before your health insurance or health coverage plan will start paying your medical bills.

1		Yes
2		No

Skip Instructions: <1> [goto MAHDHP_A]

<2,RF,DK> [goto next relevant section]

Name: MAHDHP_A

Universe Description: Sample Adults 18+ with Medicaid coverage who have a deductible

Question Text:

Is the annual deductible for medical care for this plan less than$1650 or $1650 or more?

If there is a separate deductible for prescriptions drugs, hospitalization, or out of network care, do not include those deductible amounts here.

__________________________________________________________________________________________

1 Less than $1650

2 $1650 or more

Skip Instructions: <1,2,RF,DK> [goto next relevant section]

else [goto HINOTYR_A]

Name: HIPNAM1_A

Universe Description: Sample Adults 18+ enrolled in a Medigap plan or private health insurance

Question Text:

What is the complete name of your private health insurance plan? .

Do NOT include plans that only provide extra cash while in the hospital or plans that pay for only one type of service such as long term care, accidents, or dental care.

ADD TEXT FIELD HERE

Skip Instructions: <allow 80,RF,DK> [goto MORPLAN_A]

Name: MORPLAN_A

Universe Description: Sample Adults 18+ enrolled in a private health plan where the name of the plan was given or don't know or refused or the sample adult only shared one private plan with the Sample Child.

Question Text:

Are you covered by any other private health insurance plans?

1 Yes

2 No

Skip Instructions: <1> [goto HIPNAM2_A]

<2,RF,DK> [goto next relevant plan]

else [goto HINOTYR_A]

Name: HIPNAM2_A

Universe Description: Sample Adults 18+ with a second private health insurance plan

Question Text:

What is the name of that private health insurance plan?

Read if necessary: Do you have a health plan card or something with the plan name on it?

ADD TEXT FIELD HERE

Skip Instructions: <allow 80,RF,DK> [goto bPlan[1].POLHLD_A]

Name: POLHLD_A

Universe Description: Sample Adults 18+ with private health insurance coverage where a plan name was given or refused or don't know.

Question Text:

Are you the policyholder for this plan?

Health insurance plans are usually obtained in one person’s name even if other family members are covered by that plan. That person is called the policy holder.

___________________________________________________________________________________________

1 Yes

2 No

Skip Instructions: <1,RF,DK> [goto PRPLCOV_A]

<2> [goto PRPOLH_A]

Name: PRPLCOV_A

Universe Description: Sample Adults 18+ with private health insurance coverage where a plan name was given or refused or don't know and where the Sample Adult is the policyholder or refused or don't know

Question Text Does this plan cover someone other than yourself?

1 Yes

2 No

Skip Instructions: <1,2,RF,DK> [goto PLNWRK_A]

Name: PLNWRK_A

Universe Description: Sample Adults 18+ with private health insurance coverage where a plan name was given or refused or don't know

Question Text:

Which one of these categories best describes how this plan was obtained?

1 Through an employer, union, or professional association

2 Purchased directly

3 Through Healthcare.gov or the Affordable Care Act (Obamacare)

4 Through a state or local government or community program

5 Other, please specify: [write-in]

Skip Instructions: <1,3> [goto PLNPAY_A]

<2,4,RF,DK> [goto PLNEXCHG_A]

<5> [goto PLNWKSP_A]

Name: PLNEXCHG_A

Universe Description: Sample Adults 18+ with private health insurance coverage where a plan name was given or refused or don't know that is directly purchased, or obtained through a state, local, government or community program, or obtained another way, or refused/don't know how obtained

Question Text:

Was the plan obtained through Healthcare.gov or the Health Insurance Marketplace?

1 Yes

2 No

Skip Instructions: <1,2,RF,DK> [goto PLNPAY_A]

Name: PLNPAY_A

Universe Description: Sample Adults 18+ with private health insurance coverage where a plan name was given or refused or don't know.

Question Text: Who pays for this health insurance plan?

Select all that apply

1		Self or family (living in the household)
2		Employer or union
3		Someone outside the household
4		Medicare
5		Medicaid
6		Other government program

Skip Instructions: if <1> IN PLNPAY_A [goto HICOSTN_A]

else if <2-6> IN PLNPAY_A or PLNPAY_A IN (RF,DK)[goto PRDEDUC_A]

Name: HICOSTN_A

Universe Description: Sample Adults 18+ with private health insurance coverage where a plan name was given or refused or don't know who paid for by self or family

Question Text:

How much (Do you/Does your family) currently spend for health insurance premiums for (name of health insurance plan)? .

Please include payroll deductions for premiums.

ADD FILL-IN TABLE WITH DROP DOWNS FOR REPORTING:

Name of plan (Fill In)

Payment amount (Fill In)

Frequency (Drop down)

See example below (from CPS ASEC):

Skip Instructions: <20000-99995> [goto ERR1_HICOSTN_A]

<1-19999> [goto HICOSTT_A]

<RF,DK> [goto PRDEDUC_A]

Name: PRDEDUC_A

Universe Description: Sample Adults 18+ with private health insurance plans where a plan name was

given or refused or don't know.

Question Text:

Does this health plan have an annual deductible?

• A deductible is the amount you have to pay for health care before your health insurance or health coverage plan will start paying your medical bills.

1 Yes

2 No

Skip Instructions: <1> [goto PRHDHP_A]

<2,RF,DK> [goto INTROCOV_A]

Name: PRHDHP_A

Universe Description: Sample Adults 18+ with private health insurance coverage where a plan name was given or refused or don't know with a deductible

Question Text:

Is the annual deductible for medical care for [NAME OF PLAN]:.

If there is a separate deductible for prescription drugs, hospitalization, or out-of-network care, do not include those deductible amounts here.

1 Less than ($1650/$3300)

2 ($1650/$3300) or more

Skip Instructions: <1> [goto INTROCOV_A]

<2,RF,DK> [goto HSAHRA_A]

Name: HSAHRA_A

Universe Description: Sample Adults 18+ with private health insurance coverage where a plan name was given or refused or don't know with a high deductible

Question Text:

Does this plan include any special accounts or funds that can be used to pay for medical expenses, not including Flexible Spending Accounts (FSAs)?

• These special accounts or funds are sometimes referred to as Health Savings Accounts (HSAs), Health Reimbursement Accounts (HRAs), Personal Care accounts, Personal Medical funds, or Choice funds.

1 Yes

2 No

Skip Instructions: <1,2,RF,DK> [goto INTROCOV_A]

Name: INTROCOV_A

Universe Description: Sample Adults 18+ with private health insurance coverage where the name of the plan was given or refused or don't know

Question Text: Does this plan pay for any of the following?

Select all that apply (even if only some costs are covered)

1. Medications prescribed by a doctor or other health professional?

2. Dental care?

3. Routine vision care, such as glasses and contact lenses?

Skip Instructions: <1-3,RF,DK> [goto next relevant type of health insurance]

else [goto HINOTYR_A]

Name: OPNAME_A

Universe Description: Sample Adults 18+ with a state-sponsored plan

Question Text:

What is the name of the state-sponsored plan you are covered by?

ADD TEXT FIELD HERE

Skip Instructions: <allow 80,RF,DK> [goto OPXCHNG_A]

Name: OPXCHNG_A

Universe Description: Sample Adults 18+ with a state-sponsored plan

Question Text:

Was your state-sponsored plan obtained through Healthcare.gov or the

Health Insurance Marketplace?

_______________________________

1 Yes

2 No

Skip Instructions: <1,2,RF,DK> [goto OPPREM_A]

Name: OPPREM_A

Universe Description: Sample Adults 18+ with a state-sponsored plan

Question Text:

Do you or a family member pay a health insurance premium for this state-sponsored plan?

A health insurance premium is the amount you or a family member pay each month for health care coverage.

1 Yes

2 No

Skip Instructions: <1,2,RF,DK> [goto OPDEDUC_A]

Name: OPDEDUC_A

Universe Description: Sample Adults 18+ with a state-sponsored plan

Question Text:

Does your state-sponsored plan have an annual deductible?

• A deductible is the amount you have to pay for health care before your health insurance or health coverage plan will start paying your medical bills.

1		Yes
2		No

Skip Instructions: <1>[goto OPHDHP_A]

<2,RF,DK> [go to next relevant health insurance plan]

else [goto HINOTYR_A]

Name: OPHDHP_A

Universe Description: Sample Adults 18+ with a state-sponsored plan with a deductible

Question Text:

Is the annual deductible for medical care for this state-sponsored plan:

If there is a separate deductible for prescription drugs, hospitalization, or out-of-network care, do not include those deductible amounts here.

1 Less than $1650

2 $1650 or more

Skip Instructions: <1,2,RF,DK> [goto next relevant health insurance plan]

else [goto HINOTYR_A]

Name: OGNAME_A

Universe Description: Sample Adults 18+ who have an other government plan

Question Text:

What is the name of the other government plan that you are covered by?

ADD TEXT FIELD HERE

Skip Instructions: <allow 80,RF,DK> [goto OGXCHNG_A]

Name: OGXCHNG_A

Universe Description: Sample Adults 18+ who have an other government plan

Question Text:

Was your other government plan obtained through Healthcare.gov or the

Health Insurance Marketplace?

1 Yes

2 No

Skip Instructions: <1,2,RF,DK> [goto OGPREM_A]

Name: OGPREM_A

Universe Description: Sample Adults 18+ who have an other government plan

Question Text:

Do you or a family member pay a premium for your other government plan?

A health insurance premium is the amount you or a family member pays each month for health care coverage.

1 Yes

2 No

Skip Instructions: <1,2,RF,DK> [goto OGDEDUC_A]

Name: OGDEDUC_A

Universe Description: Sample Adults 18+ with an other government plan

Question Text:

Do you or a family member pay an annual deductible for this other government plan?

• A deductible is the amount you have to pay for health care before your health insurance or health coverage plan will start paying your medical bills.

1 Yes

2 No

Skip Instructions: <1> [goto OGHDHP_A]

<2,RF,DK> [goto next relevant health insurance plan]

else [goto HINOTYR_A]

Name: OGHDHP_A

Universe Description: Sample Adults 18+ with an other government plan with a deductible

Question Text:

Is the annual deductible for medical care for this other government plan:

If there is a separate deductible for prescription drugs, hospitalization, or out-of-network care, do not include those deductible amounts here.

1 Less than $1650

2 $1650 or more

Skip Instructions: <1,2,RF,DK> [goto next relevant health insurance plan] else [goto HINOTYR_A]

Name: MILSPC_A

Universe Description: Sample Adults 18+ with military related health care

Question Text:

What types of military related health care are you covered by?

Select all that apply

1		VA health care
2		TRICARE (CHAMPUS)
3		CHAMP-VA (do not include CHAMPUS)

Skip Instructions: <1-3,RF,DK> [goto HINOTYR_A]

Name: HILAST_A

Universe Description: Sample Adults 18+ without known health insurance and answered no, refused

ordon't know to the Medicaid probe or the Medicare probe.

Question Text: About how long has it been since you last had health care coverage that paid for doctor's

visits or hospital stays?

1		Less than 12 months ago
2		1 year ago or more, but less than 2 years ago
3		2 years ago or more but less than 3 years ago
4		3 years ago or more but less than 5 years ago
5		5 years ago or more but less than 10 years ago
6		10 years ago or more
7		Never have had this type of health care coverage.

Skip Instructions: <1> [goto HILASTMY_A]

<2,3> [goto HISTOPJOB_A]

<4,5,6,0,RF,DK> [goto RSNHICOST_A]

Name: HILASTMY_A

Universe Description: Sample Adults 18+ without known health insurance who last had insurance at some time within the last 12 months

Question Text: In the past 12 months, how many months were you without coverage?

.

If less than 1 month, enter ‘1’.

ADD TEXT FIELD HERE

Skip Instructions: <1-12,RF,DK> [goto HISTOPJOB_A]

Name: HISTOPJOB_A, HISTOPMISS_A, HISTOPAGE_A, HISTOPCOST_A, HISTOPELIG_A

Universe Description: Sample Adults 18+ who have been uninsured for less than 3 years

Question Text: What are the reasons your last health care coverage ended?

Select all that apply

1. I (or the policyholder) retired, lost a job, or changed employers.

2. I missed a deadline for signing up or paying for the coverage.

3. I became ineligible because of my age or because I left school.

4. The cost for my coverage increased.

5. I had Medicaid or other public coverage, but was no longer eligible.

6. Other, please specify: [text field]

Skip Instructions: <1-5,RF,DK> [goto RSNHICOST_A]

__________________________________________________________________________________________

Name: RSNHICOST_A

Universe Description: Sample Adults 18+ without known health insurance and answered no, refused or don't know to the Medicare probe or the Medicaid probe.

Question Text: If HILAST_A IN (1,2,3) fill: Are you currently uninsured for any of the following reasons?

Select all that apply

1. Coverage is not affordable

2. I do not need or want coverage.

3. The process of signing up for coverage is too difficult or confusing.

4. I cannot find a plan that meets my needs.

5. I have applied for coverage, but it has not started yet.

6. Other, please specify [write-in field]

<1,2,RF,DK> [goto RSNHIWANT_A]

___________________________________________________________________________________________

Name: HINOTYR_A

Universe Description: Sample Adults 18+ with known health insurance coverage or responded yes to the medicare probe or medicaid probe

Question Text: In the past 12 months, was there any time when you did NOT have health insurance or coverage?

1 Yes

2 No

Skip Instructions: <1> [goto HINOTMYR_A]

<2,RF,DK> [goto FINISH_A]

Name: HINOTMYR_A

Universe Description: Sample Adults 18+ with known health insurance coverage and did not have health insurance for some period of time in the past 12 months

Question Text: In the past 12 months, about how many months were you without coverage?

If less than 1 month, enter ‘1’.

ADD TEXT FIELD HERE.

Skip Instructions: <1-12,RF,DK> [goto next section]

Utilization

LASTDR_A

• Not including dental care, about how long has it been since you last saw a doctor or other health professional in person about your health?

Include doctors seen if you were a patient in a hospital.

• Less than 12 months ago

• 1 year ago or more but less than 2 years ago

• 2 years ago or more but less than 3 years ago

• 3 years ago or more but less than 5 years ago

• 5 years ago or more but less than 10 years ago

• 10 years ago or more

• Never have seen a doctor or other health professional about my health in person.

WELLNESS_A

(Direct here if LASTDR_A != “NEVER”)

• Was this a wellness visit, physical, or general purpose check-up?

  • Yes

  • No

WELLVIS_A

(Direct here if WELLNESS_A = “NO”)

• About how long has it been since you last saw a doctor or other health professional for a wellness visit, physical, or general purpose check-up?

  • Less than 12 months ago

  • 1 year ago or more but less than 2 years ago

  • 2 years ago or more but less than 3 years ago

  • 3 years ago or more but less than 5 years ago

  • 5 years ago or more but less than 10 years ago

  • 10 years ago or more

  • Never have seen a doctor or other health professional for a wellness visit, physical, or general purpose check-up.

USUALPL_A

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

  • Yes, there is a single place.

  • Yes, there is more than one place

  • No, there is no place

USPLKIND_A_V1

[Direct here if USUALPL_A=”Yes, there is a single place”]

• What kind of place is this?

  • A doctor’s office or health center

  • Urgent care center or clinic in a drug store or grocery store

  • Hospital emergency room

  • A VA Medical Center or VA outpatient clinic

  • Some other place

USPLKIND_A_V2

[Direct here if USUALPL_A=”Yes, there is more than one place”]

• What kind of places do you go to most often?

Select all that apply.

• A doctor’s office or health center

• Urgent care center or clinic in a drug store or grocery store

• Hospital emergency room

• A VA Medical Center or VA outpatient clinic

• Some other place

RETAILHC12M_A

• During the past 12 months, how many times have you gone to a retail health clinic about your health?

Retail health clinics are located in a pharmacy, grocery store, or supercenter.

• Range of values 0-96

URGCC12M_A

• During the past 12 months, how many times have you gone to an urgent care center about your health?

This is different from a hospital emergency room.

• Range of values 0-96

EMERGE12M_A

• During the past 12 months, how many times have you gone to a hospital emergency room about your health?

  • Range of values 0-96

HOSPONGT_A

• During the past 12 months, have you been hospitalized overnight?

Do not include an overnight stay in the emergency room.

• Yes

• No

MEDDL12M_A

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

  • Yes

  • No

MEDNG12M_A

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

  • Yes

  • No

VIRAPP12M_A

• During the past 12 months, have you had an appointment with a doctor, nurse, or other health professional by video or by phone?

  • Yes

  • No

Immunization

SHTFLU12M_A

• During the past 12 months, have you had a flu vaccination, include either a shot or a spray, mist, or drop in the nose?

  • Yes

  • No

SHTFLUM_A

[If SHTFLU12M_A=”Yes”]

• During what month and year did you receive your most recent flu vaccine?

[DROP DOWN OF MONTHS] [DROP DOWN OF YEARS]

Cigarettes and e-cigarettes

SMKEV_A

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

Do not include using e-cigarettes.

• Yes

• No

SMKAGE_A

(Direct here if SMKEV_A = Yes)

• How old were you when you first started to smoke fairly regularly?

  • Range of values

SMKNOW_A

(Direct here if SMKEV_A = Yes)

• How often do you now smoke cigarettes?

  • Every day

  • Some days

  • Not at all

CIGNOW_A

• On average, about how many cigarettes do you now smoke a day?

  • Range of values 0-95

SMK30D_A

• On how many of the past 30 days did you smoke a cigarette?

  • Range of values 0-30

CIG30D_A

(Direct here if SMK30D_A != 0)

• On average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?

  • Range of values 1-95

ECIGEV_A

• Not including marijuana use, have you ever used an e-cigarette or other electronic vaping product, even just one time, in your entire life?

• Yes

• No

ECIGNOW_A

(Direct here if ECIGEV_A = Yes)

• How often do you now use e-cigarettes or other electronic vaping products?

  • Every day

  • Some days

  • Not at all

Marital Status

MARITAL_A

• Which of the following best describes you now?

  • Married

  • Living with a partner together as an unmarried couple

  • Neither

SPOUSLIV_A [IF MARITAL_A = “Married”]

• Does your spouse live at this address?

  • Yes

  • No

SPOUSEP_A [IF SPOUSLIV_A = “No”]

• Does your spouse not live at this address because you and your spouse are legally separated?

  • Yes

  • No

SPOUSWHO_A [IF SPOUSLIV_A = “Yes”]

• From the list of names below, which person is your spouse?

[NAME LIST INCLUDING EVERYONE 16+]

• My spouse isn’t on this list.

PARTNERWHO_A [IF MARITAL_A = “Living with a partner together as an unmarried couple”]

• From the list of names below, which person is your partner?

[NAME LIST INCLUDING EVERYONE 16+]

• My partner isn’t on this list.

EVRMARRIED_A [IF MARITAL_A = “Neither”]

• Have you ever been married?

  • Yes

  • No

LEGALSTAT_A [IF EVERMARRIED_A = “Yes” & MARITAL_A = “Living with a partner together as an unmarried couple”]

• What is your current legal marital status?

  • Married

  • Widowed

  • Divorced

  • Separated

WIDIVSEP_A [IF EVERMARRIED_A = “Yes” & MARITAL_A = “Neither]

• What is your current legal marital status?

  • Widowed

  • Divorced

  • Separated