CDC Core
Section 1: Health Status
1.1
Data Results 1.1
Would you say that in general your health is:
  • Excellent
  • Very good
  • Good
  • Fair
  • Poor
Crosstabulation Table:
 
CDC Core
Section 2: Healthy Days - Health Related Quality of Life
2.1
Data Results 2.1
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?
2.2
Data Results 2.2
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?
Crosstabulation Table:
2.3
Data Results 2.3
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?
 
 
CDC Core
Section 3: Health Care Access
3.1
Data Results 3.1
Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?
Crosstabulation Table:
 
3.2
Data Results 3.2
Do you have one person you think of as your personal doctor or health care provider?

(If "No", ask: "Is there more than one or is there no person who you think of as your personal doctor or health care provider?")
Crosstabulation Table:
3.3
Data Results 3.3
Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?
3.4
Data Results 3.4
About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.
 
CDC Core
Section 4: Exercise
4.1
Data Results 4.1
During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
Crosstabulation Table:
 
CDC Core
Section 5: Diabetes
5.1
Data Results 5.1
Have you EVER been told by a doctor that you have diabetes?

Note: If respondent says 'pre-diabetes or borderline diabetes', use response Code 4.

(If "Yes" and respondent is female, ask: "Was this only when you were pregnant?")
Crosstabulation Table:
 
 
CDC Core
Section 6: Oral Health
6.1
Data Results 6.1
How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists.
6.2
Data Results 6.2
How many of your permanent teeth have been removed because of tooth decay or gum disease? Include teeth lost to infection, but do not include teeth lost for other reasons, such as injury or orthodontics.
NOTE: If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth.
Crosstabulation Table:
6.3
Data Results 6.3
How long has it been since you had your teeth cleaned by a dentist or dental hygienist?
 
 
CDC Core
Section 7: Cardiovascular Disease Prevalence
Now I would like to ask you some questions about cardiovascular disease.
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.
7.1
Data Results 7.1
Ever told you had a heart attack, also called a myocardial infarction?
Crosstabulation Table:
7.2
Data Results 7.2
(Ever told) you had angina or coronary heart disease?
7.3
Data Results 7.3
(Ever told) you had a stroke?
 
CDC Core
Section 8: Asthma
8.1
Data Results 8.1
Have you EVER been told by a doctor, nurse, or other health professional that you had asthma?
8.2
Data Results 8.2
Do you still have asthma?
Crosstabulation Table:
 
 
CDC Core
Section 9: Disability
The following questions are about health problems or impairments you may have.
9.1
Data Results 9.1
Are you limited in any way in any activities because of physical, mental, or emotional problems?
Crosstabulation Table:
9.2
Data Results 9.2
Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?
Include occasional use or use in certain circumstances.
Crosstabulation Table:
 
 
CDC Core
Section 10: Tobacco Use
10.1
Data Results 10.1
Have you smoked at least 100 cigarettes in your entire life?
[Interviewer: 5 packs = 100 cigarettes]
10.2
Data Results 10.2
Do you now smoke cigarettes every day, some days, or not at all?
Crosstabulation Table:
10.3
Data Results 10.3
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
 
 
CDC Core
Section 11: Demographics
11.1
Data Results 11.1
What is your age?
11.2
Data Results 11.2
Are you of Hispanic or Latino?
11.3
Data Results 11.3
Which one or more of the following would you say is your race?
11.4
Data Results 11.4
Which one of these groups would you say BEST represents your race?
11.5
Data Results 11.5
Are you:
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
11.6
Data Results 11.6
How many children less than 18 years of age live in your household ?
11.7
Data Results 11.7
What is the highest grade or year of school you completed?
11.8
Data Results 11.8
Are you currently:
  • Employed for wages
  • Self-employed
  • Out of work for more than 1 year
  • Out of work for less than 1 year
  • Homemaker
  • Student
  • Retired
  • Unable to work
11.9
Data Results 11.9
Is your annual household income from all sources:
  • Less than $25,000 ($20,000 to less than $25,000)
  • Less than $20,000 ($15,000 to less than $20,000)
  • Less than $15,000 ($10,000 to less than $15,000)
  • Less than $10,000

  • or
  • Less than $35,000 ($25,000 to less than $35,000)
  • Less than $50,000 ($35,000 to less than $50,000)
  • Less than $75,000 ($50,000 to less than $75,000)
  • $75,000 or more
State-Added Module 1: Hours Worked
Skipped out of the core to ask the following question.
1.
Data Results SA1.1
Previously, you indicated you were (a) [insert response from core, Question 11.8]. On the average, how many hours per week, if any, do you work at a job or business?
Skip back into core, and continue with the survey.
11.10 About how much do you weigh without shoes?
[Round fractions up]
11.11 About how tall are you without shoes?
[Round fractions down]
Crosstabulation Table:
11.12 What county do you live in?
11.13
What is your ZIP Code where you live?
11.14
Data Results 11.14
Do you have more than one telephone number in your household?
Do not include cell phones or numbers that are only used by a computer or
fax machine.
11.15
Data Results 11.15
How many of these phone numbers are residential numbers?
11.16
Data Results 11.16
During the past 12 months, has your household been without telephone service for 1 week or more? Do not include interruptions of phone service due to weather or natural disasters.
11.17
Data Results 11.17
Indicate sex of respondent. Ask Only if Necessary
11.18
Data Results 11.18
To your knowledge, are you now pregnant?
 
CDC Core
Section 12: Veteran's Status
12.1
The next question relates to military service in the United States Armed Forces, either in the regular military or in a National Guard or Reserve unit.

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?
 
CDC Core
Section 13: Alcohol Consumption
13.1
Data Results 13.1
During the past 30 days, have you had at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?
13.2
Data Results 13.2
During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage?
13.3
Data Results 13.3
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?
13.4
Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or more drinks on one occasion?
13.5
Data Results 13.5
During the past 30 days, what is the largest number of drinks you had on any occasion?
 
 
CDC Core
Section 14: Immunization/Adult Influenza Supplement
14.1
Data Results 14.1
A flu shot is an influenza vaccine injected in your arm. During the past 12 months, have you had a flu shot?
Read if necessary: We want to know if you had a flu shot injected in your arm.
Crosstabulation Table:
14.2
Data Results 14.2
During the past 12 months, have you had a flu vaccine that was sprayed in your nose? The flu vaccine that is sprayed in the nose is also called FluMist™.
Immunization Section questions 14.3s through 14.8s are intended for use only if the Adult Influenza Supplement is activated. The Beharioral Surveillance Branch will provide notification and instructions for implementing the Adult Influenza Supplement. It was NOT activated this year.
14.3s
 
During what month and year did you receive your most recent flu vaccination?
The most recent flu vaccination may have been either the flu shot or the flu spray.
14.4s
 
What is the MAIN reason you have NOT received a flu vaccination for this current flu season?
[Interviewer note: The current flu season = Sept. '05 - Mar. '06]
Do not read answer choices below. Select category that best matches response.
  • Need: Do not think need it / not recommended
  • Concern about vaccine: side effects / can cause flu / does not work
  • Access / cost / inconvenience
  • Vaccine shortage: saving vaccine for people who need it more
  • Vaccine shortage: tried to find vaccine, but could not get it
  • Vaccine shortage: not eligible to receive vaccine
  • Some other reason
  • Don't know/Not sure (Probe: "What was the main reason?")
  • Refused
14.5s
 
Has a doctor, nurse, or other health professional ever said that you have any of the following health problems?

Read each problem listed below:
  • Lung problems, including asthma
  • Heart problems
  • Diabetes
  • Kidney problems
  • Weakened immune system caused by a chronic illness, such as
    cancer or HIV/AIDS, or medicines, such as steroids
  • Sickle cell anemia or other anemia
14.6s
 
Do you still have (this/any of these) problem(s)?
14.7s
 
Do you currently work in a health care facility, such as a medical clinic, hospital, or nursing home? This includes part-time and volunteer work.
14.8s
 
Do you have direct face-to-face or hands-on contact with patients as a part of your routine work?
14.9
Data Results 14.9
A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you EVER had a pneumonia shot?
Crosstabulation Tables:
14.10
Data Results 14.10
Have you EVER received the hepatitis B vaccine? The hepatitis B vaccine is completed after the third shot is given.
14.11
Data Results 14.11
Tell me if ANY of these statements is true for YOU. Do NOT tell me WHICH statement or statements are true for you, just if ANY of them are:
  • You have hemophilia and have received clotting factor concentrate
  • You are a man who has had sex with other men, even just one time
  • You have taken street drugs by needle, even just one time
  • You traded sex for money or drugs, even just one time
  • You have tested positive for HIV
  • You have had sex (even just one time) with someone who would answer "yes" to any of these statements
  • You had more than two sex partners in the past year

 
CDC Core
Section 15: Falls
If respondent is 45 years or older continue, otherwise go to next section.
The next questions ask about recent falls. By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.
15.1
Data Results 15.1
In the past 3 months, how many times have you fallen?
15.2
Data Results 15.2
How many of these falls caused an injury? By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor.
 
CDC Core
Section 16: Seatbelt Use
16.1
Data Results 16.1
How often do you use seat belts when you drive or ride in a car? Would you say: Always, Nearly always, Sometimes, Seldom and Never
Crosstabulation Table:
 
CDC Core
Section 17: Drinking and Driving
17.1
Data Results 17.1
During the past 30 days, how many times have you driven when you've had perhaps too much to drink?
 
 
CDC Core
Section 18: Women's Health
If respondent is male, go to the next section.
18.1
Data Results 18.1
A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
18.2
Data Results 18.2
How long has it been since you had your last mammogram?
Crosstabulation Table:
18.3
Data Results 18.3
A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you ever had a clinical breast exam?
18.4
Data Results 18.4
How long has it been since your last breast exam?
18.5
Data Results 18.5
A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?
18.6
Data Results 18.6
How long has it been since you had your last Pap test?
Crosstabulation Table:
18.7
Data Results 18.7
Have you had a hysterectomy?
Read only if necessary: A hysterectomy is an operation to remove the uterus (womb).
 
CDC Core
Section 19: Prostate Cancer Screening
If respondent is <39 years of age, or is female, go to next section.
19.1
Data Results 19.1
A Prostate-Specific Antigen test, also called a PSA test, is a blood test used to check men for prostate cancer. Have you ever had a PSA test?
19.2
Data Results 19.2
How long has it been since you had your last PSA test?
Crosstabulation Table:
19.3
Data Results 19.3
A digital rectal exam is an exam in which a doctor, nurse, or other health professional places a gloved finger into the rectum to feel the size, shape, and hardness of the prostate gland. Have you ever had a digital rectal exam?
19.4
Data Results 19.4
How long has it been since your last digital rectal exam?
19.5
Data Results 19.5
Have you ever been told by a doctor, nurse, or other health professional that you had prostate cancer?
 
CDC Core
Section 20: Colorectal Cancer Screening
If respondent is < 49 years of age, go to next section.
20.1
Data Results 20.1
A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?
20.2
Data Results 20.2
How long has it been since you had your last blood stool test using a home kit?
Crosstabulation Table:
20.3
Data Results 20.3
Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. Have you ever had either of these exams?
Crosstabulation Table:
20.4
Data Results 20.4
How long has it been since you had your last sigmoidoscopy or colonoscopy?
 
CDC Core
Section 21: HIV/AIDS
The next few questions are about the national health problem of HIV, the virus that causes AIDS. Please remember that your answers are strictly confidential and that you do not have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.
21.1
Data Results 21.1
Have you EVER been tested for HIV? Do not count tests you may have had as part of a blood donation.
Include test using fluid from your mouth.
21.2 Not including blood donations, in what month and year was your last HIV test?
Note: If response is before January 1985, code “Don’t know.”
21.3
Data Results 21.3
Where did you have your last HIV test, at a private doctor or HMO office, at a counseling and testing site, at a hospital, at a clinic, in a jail or prison, at home, drug treatment facility or somewhere else?
21.4
Data Results 21.4
Was it a rapid test where you could get your results within a couple of hours?
 
CDC Core
Section 22: Emotional Support and Life Satisfaction
The next two questions are about emotional support and your satisfaction with life.
22.1
Data Results 22.1
How often do you get the social and emotional support you need?
22.2
Data Results 22.2
In general, how satisfied are you with your life?
 
CDC Module
Module 1: Random Child Selection
If Core Question 13.6 = 88, or 99 (no children under age 18 in the household, or refused), [Go to CDC Module 9 Adult Asthma. If Core Question 13.6 = 1;

INTERVIEWER: "Previously, you indicated there was one child age 17 or younger in your household. I would like to ask you some questions about that child." [Go to Question 1. If Core 13.6 is >1 and Core Question 13.6 does not equal to 88 or 99;

INTERVIEWER: "Previously, you indicated there were [number] children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest. The oldest child is the first child and the youngest child is the last child." Please include children with the same birth date, including twins, in the order of their birth.
INTERVIEWER: "I have some additional questions about one specific child. The child I will be referring to is the "X"th child in your household. All following questions about children will be about the "Xth" child."

Note: If there are two children with the same birth date, randomly select one.
1
Data Results M10.1
What is the birth month and year of the “Xth” child?
2
Data Results M10.2
Is the child a boy or a girl?
3
Data Results M10.3
Is the child Hispanic or Latino?
4
Which one or more of the following would you say is the race of the child?
[Check all that apply]
5
Which one of these groups would you say best represents the child's race?
6
How are you related to the child?
 
CDC Module
Module 3: Childhood Asthma Prevalence
The next two questions are about the "Xth" child.
1
Data Results M11.1
Has a doctor, nurse, or other health professional EVER said that the child has asthma?
2
Data Results M11.2
Does the child still have asthma?
Crosstabulation Table:
 
 
State-Added
Module 2: Asthma Call Back Survey Information
1
We would like to call you again within the next 2 weeks to talk in more detail about [your/your child's] experiences with asthma. The information will be used to help develop and improve the quality of life of Kansans with asthma. The information you gave us today and any you give us in the future will be kept confidential. If you agree to this, we will keep your first name or initials and phone number on file, separate from the answers collected today. Even if you agree now, you may refuse to participate in the future.

Would it be okay if we called you back to ask additional asthma-related questions at a later time?
 
This year the State of Kansas BRFSS questionnaire is a split questionnaire. That is, the core questions above and the one state-added module is asked of every respondent. However, the additional CDC modules and state-added modules that follow are seperated into two parts: Part A and Part B. Each record was pre-determined to be asked either Part A or Part B.
 
Part A
CDC Optional
Module 4: Diabetes
1
Data Results M1.1
How old were you when you were told you have diabetes?
2
Data Results M1.2
Are you now taking insulin?
3
Data Results M1.3
Are you now taking diabetes pills?
4
About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional.
5
Data Results M1.5
About how often do you check your feet for any sores or irritations? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional.
6
Data Results M1.6
Have you EVER had any sores or irritations on your feet that took more than four weeks to heal?
7
About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
8
A test for "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for "A one C" ?
9
About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
10
When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.
11
Data Results M1.11
Has a doctor EVER told you that diabetes has affected your eyes or that you had retinopathy?
12
Data Results M1.12
Have you EVER taken a course or class in how to manage your diabetes yourself?
 
 
State-Added
Module 3: Diabetes Accessory
1
How often are you told to remove your socks and shoes before you see the doctor or other health professional for your diabetes? Would you say always, nearly always, sometimes, or seldom?
2
Earlier you said that you check your blood for sugar or glucose, please tell me what steps you take when you find that your blood sugar or glucose is elevated. Include times when you are helped by family members or friends to take those steps. [Mark all that apply]
  • Exercise
  • Take or adjust my does of insulin
  • Go to the nearest emergency room
  • Call my doctor
  • Nothing
  • Other (specify:_____)
3
Knowing that you have diabetes, please tell me what steps you take to avoid having an elevated blood sugar.[Mark all that apply]
  • Control carbohydrate intake/awareness of carbohydrate intake
  • Count carbohydrates
  • Exercise
  • Test blood sugar or glucose
  • Adjust medication
  • Nothing
  • Other (specify:_____)
 
 
State-Added
Module 4: Diabetes Assessment
1
Data Results SA4.1

Which of the following family members, if any, have been told by a doctor that they have diabetes? Include only blood relatives. Do not include adoptive or those related only by marriage.

  • Mother
  • Father
  • Brothers [Interviewer note: include half brother]
  • Sisters [Interviewer note: include half sister]
  • No one

If respondent is female, continue.
2
Data Results SA4.2
Have you had a baby weighing more then 9 pounds at birth?
 
 
CDC Module
Module 9: Folic Acid
1
Data Results M9.1
Do you currently take any vitamin pills or supplements? Include liquid supplements.
2
Data Results M9.2
Are any of these a multivitamin?
3
Data Results M9.3
Do any of the vitamin pills or supplements you take contain folic acid?
4
Data Results M9.4
How often do you take this vitamin pill or supplement?
If respondent is 45 years old or older, go to next module.
5
Data Results M9.5
Some health experts recommend that women take 400 micrograms of the B vitamin folic acid, for which one of the following reasons…
 
State-Added
Module 5: Folic Acid Awareness
If respondent is male, go to next module.
If respondent is female and 45 years or older, go to next module
1
Data Results SA5.1
Has a doctor or other health professional ever talked with you about use of folic acid?
2
Where did you hear or read that 400 micrograms of folic acid can prevent birth defects?
 
State-Added
Module 6: Smoking and Pregnancy
If respondent is male, skip to next module.
If female respondent is ages 18-44 continue, else skip to next module.
If pregnant now ("Yes" to core Q11.18), go to Q2.
1
Data Results SA6.1
Have you been pregnant in the last 5 years?
2
[FORMER SMOKER:] Previously you reported you have smoked at least 100 cigarettes in your life but currently do not smoke cigarettes. During your last pregnancy, did you smoke cigarettes:

[CURRENT SMOKER:] Previously you reported you have smoked at least 100 cigarettes in your life and currently smoke every day or some days. During your last pregnancy, did you smoke cigarettes:

Please read:
  • Every day
  • Some days
  • Not at all

3
During your last pregnancy, did any doctor, nurse, or other health professional advise you not to smoke?
 
 
State-Added
Module 7: Other Tobacco Products
1
Data Results SA7.1
Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff?
2
Do you currently use chewing tobacco or snuff every day, some days, or not at all?
3
Data Results SA7.3
Do you currently use any tobacco products other than cigarettes, such as cigars, pipes, bidis, kreteks, or any other tobacco product?

Note: Bidis are small, brown, hand-rolled cigarettes from India and other southeast Asian countries.
Kreteks are clove cigarettes made in Indonesia that contain clove extract and tobacco.
 
 
State-Added
Module 8: COPD
1
Data Results SA8.1
Have you ever been told by a doctor or health professional that you have chronic obstructive pulmonary disease (COPD), emphysema or chronic bronchitis?
 
Part B
CDC Module
Module 14: Anxiety and Depression
Now, I am going to ask you some questions about your mood. When answering these questions, please think about how many days each of the following has occurred in the past 2 weeks.
1.
Data Results M14.1
Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?
2.
Data Results M14.2
Over the last 2 weeks, how many days have you felt down, depressed or hopeless?
3.
Data Results M14.3
Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?
4.
Data Results M14.4
Over the last 2 weeks, how many days have you felt tired or had little energy?
5.
Data Results M14.5
Over the last 2 weeks, how many days have you had a poor appetite or ate too much?
6.
Data Results M14.6
Over the last 2 weeks, how many days have you felt bad about yourself or that you were a failure or had let yourself or your family down?
7.
Data Results M14.7
Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching the TV?
8.
Data Results M14.8
Over the last 2 weeks, how many days have you moved or spoken so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you were moving around a lot more than usual?
9.
Data Results M14.9
Has a doctor or other healthcare provider EVER told you that you had an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder)?
10.
Data Results M14.10
Has a doctor or other healthcare provider EVER told you that you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?
 
 
State-Added
Module 9: Disability and Quality of Life
1.
Data Results SA9.1
Because of an impairment or health problem do you have problems with any of the following:

…..thinking, remembering or controlling emotions?
2.
Data Results M9.2for SADQL_206
[Because of an impairment or health problem do you have problems]:

….. seeing, hearing or communicating?
3.
Data Results M9.3for SADQL_306
[Because of an impairment or health problem do you have problems]:

…. heart, blood pressure or breathing?
4.
Data Results M9.4for SADQL_406
[Because of an impairment or health problem do you have problems]:

…. digestive system?
5.
Data Results SA9.5
[Because of an impairment or health problem do you have problems]:

... nerves, muscles or joints?
6.
Data Results M9.6
[Because of an impairment or health problem do you have problems]

… other bodily functions which are affected?
7.
Data Results M9.7
Does your impairment or health problem affect your ability with any of the following…

…. go to school or work?
8.
Data Results M9.8
[Does your impairment or health problem affect your ability to]

… perform personal care activities including bathing, dressing, grooming, using the toilet or getting in and out of bed?
9.
Data Results SA9.9
[Does your impairment or health problem affect your ability to]

… perform household activities including paying bills, shopping, cooking, or cleaning the house?
10.
Data Results M9.10
[Does your impairment or health problem affect your ability to]

…participate in physical activity?
11.
Data Results M9.11
[Does your impairment or health problem affect your ability to]

… move around including walking, using stairs, lifting or carrying objects?
12.
Data Results M9.12
Is your ability to move around due to any of the following:… paralysis?

Note: If asked "Paralysis is defined as loss of function or feeling that affects the ability to move your arms or legs but does not include amputation or missing limbs"
13.
Data Results SA9.13
[Is your ability to move around due to]

… amputation or missing limb?
14.
Data Results M9.14
[Is your ability to move around due to]

… a chronic disease such as diabetes or arthritis?
15.
Data Results M9.15
[Is your ability to move around due to]

… something else?
16.
Data Results M9.16
Are you restricted in any way to services you need such as doctor, counseling, case management, or financial?
17.
Data Results SA9.17
Is this restriction due to any of the following?

….lack of transportation?
18.
Data Results M9.18
[Is this restriction due to ]

…. cost of services?
19.
Data Results M9.19
[Is this restriction due to]

….physical access to buildings, offices or tools needed?
20.
Data Results M9.20
[Is this restriction due to]

…. restriction by another person such as a personal attendant or family member?
21.
Data Results M9.21
[Is this restriction due to]:

…lack of communication aids such as interpreters or alternate formats?
 
 
State-Added
Module 10: Oral Health
1
Data Results SA10.1
During the past 12 months, was there any time when you needed dental care but did not get it?
2
Data Results SA10.2
What was the main reason you did not receive the dental care you needed?
3
Data Results SA10.3
Do you have any kind of insurance coverage that pays for some or all of your routine dental care, including dental insurance, prepaid plans such as HMOs, or government plans such as Medicaid?
Crosstabulation Table:
If children in household and randomly selected child is 7 17 years of age, proceed to Q4, else skip to closing.
4
Data Results SA10.4
Earlier, I asked you questions about the [randomly selected child]. Next, I have a question related to the oral health of that child.

Dental sealants are special plastic coatings that are painted on the tops of the back teeth to prevent tooth decay. They are put on by a dentist or dental hygienist. They are different from fillings, caps, crowns, and fluoride treatments. Has the [randomly selected child] ever had dental sealants placed on [her/his] teeth?