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?
Crosstabulation Table:
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: Sleep
4.1
Data Results 4.1
The next question is about getting enough rest or sleep.

During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?
Crosstabulation Table:
Summary Index Table:
 
 
CDC Core
Section 5: Exercise
5.1
Data Results 5.1
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 6: Diabetes
6.1
Data Results 6.1
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 7: Oral Health
7.1
Data Results 7.1
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.
7.2
Data Results 7.2
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:
7.3
Data Results 7.3
How long has it been since you had your teeth cleaned by a dentist or dental hygienist?
Crosstabulation Table:
 
 
CDC Core
Section 8: 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.
8.1
Data Results 8.1
Ever told you had a heart attack, also called a myocardial infarction?
Crosstabulation Table:
8.2
Data Results 8.2
(Ever told) you had angina or coronary heart disease?
8.3
Data Results 8.3
(Ever told) you had a stroke?
Crosstabulation Table:
 
 
CDC Core
Section 9: Asthma
Crosstabulation Table:
Summary Index Table:
9.1
Data Results 9.1
Have you EVER been told by a doctor, nurse, or other health professional that you had asthma?
9.2
Data Results 9.2
Do you still have asthma?
 
 
CDC Core
Section 10: Disability
The following questions are about health problems or impairments you may have.
10.1
Data Results 10.1
Are you limited in any way in any activities because of physical, mental, or emotional problems?
Crosstabulation Table:
10.2
Data Results 10.2
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 11: Tobacco Use
11.1
Data Results 11.1
Have you smoked at least 100 cigarettes in your entire life? [NOTE: 5 packs = 100 cigarettes]
11.2
Data Results 11.2
Do you now smoke cigarettes every day, some days, or not at all?
Crosstabulation Table:
Summary Index Table:
11.3
Data Results 11.3
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
Crosstabulation Table:
Note: If Q11.2 = 3 (Not at all); continue. Otherwise, go to Q11.5.
11.4
Data Results 11.4
How long has it been since you last smoked cigarettes regularly?
11.5
Data Results 11.5
Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?

NOTE: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.
Crosstabulation Table:
 
 
CDC Core
Section 12: Demographics
12.1
Data Results 12.1
What is your age?
12.2
Data Results 12.2
Are you of Hispanic or Latino?
12.3
Data Results 12.3
Which one or more of the following would you say is your race?
12.4
Data Results 12.4
Which one of these groups would you say BEST represents your race?
12.5
Data Results 12.5

Have you ever served on active duty in the United States Armed Forces, either in the regular military or in the Nationsl Guard or military reserve unit? Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.

Crosstabulation Table:
12.6
Data Results 12.6
Are you:
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
12.7
Data Results 12.7
How many children less than 18 years of age live in your household ?
12.8
Data Results 12.8
What is the highest grade or year of school you completed?
12.9
Data Results 12.9
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
12.10
Data Results 12.10
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 'employed', 'self-employed', 'a homemaker', 'a student', or 'retired' from Question 12.9]. 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.)
12.11 About how much do you weigh without shoes?
[Round fractions up]
12.12 About how tall are you without shoes?
[Round fractions down]
Crosstabulation Table:
Summary Index Table:
12.13 What county do you live in?
12.14 What is your ZIP Code where you live?
12.15
Data Results 12.15
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.
12.16
Data Results 12.16
How many of these phone numbers are residential numbers?
12.17
Data Results 12.17
During the past 12 months, has your household been without landline telephone service for 1 week or more? Do not include interruptions of landline telephone service because of weather or natural disasters.
Cell Phone Questions (12.18a-12.18d)
12.18a
Data Results 12.18a
Do you have a cell phone for personal use? Please include cell phones used for both business and personal use.
CATI INTERVIEWER INSTRUCTION: If Q12.18a = 1 (Yes), skip to Q12.18c.
12.18b
Data Results 12.18b
Do you share a cell phone for personal use (at least one-third of the time) with other adults?
CATI INTERVIEWER INSTRUCTION: If Q12.18b = 1 (Yes), skip to Q12.18d. Otherwise, skip to Q12.19.
12.18c
Data Results 12.18c
Do you usually share this cell phone (at least one-third of the time) with any other adults?
12.18d
Data Results 12.18d
Thinking about all the phone calls that you receive on your landline or cell phone, what percent, between 0 and 100, are received on your cell phone?
12.19
Data Results 12.19
Indicate sex of respondent. Ask Only if Necessary
12.20
Data Results 12.20
To your knowledge, are you now pregnant?
 
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?
Crosstabulation Table:
13.4
Data Results 13.4
Considering all types of alcoholic beverages, how many times during the past 30 days did you have
['5' for men, '4' for women]
or more drinks on an occasion?
Crosstabulation Table:
15.5
Data Results 15.5
During the past 30 days, what is the largest number of drinks you had on any 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 28: Novel H1N1 Adult Immunization [Asked January 1, 2010 - June 30, 2010]
There are currently vaccines available for two kinds of flu - the seasonal flu and the 2010 H1N1 flu. I will first ask you questions about vaccination for H1N1 flu, which is sometimes called swine flu or pandemic flu, and then ask you questions about vaccination for seasonal flu.
S28.1

There are two ways to get the H1N1 flu vaccination. One is a shot in the arm and the other is a spray, mist or drop in the nose.

Since September, 2009, have you been vaccinated either way for the H1N1 flu?

[Interviewer INTERVIEWER INSTRUCTION: If asked why asking about H1N1 vaccinations when not available please say: "The distribution of the H1N1 Vaccines has already started. We are trying to find out if vaccinations are currently taking place in Kansas."

IF S28.1 = 1 "Yes" continue, else go to Section 14.
S28.2
During what month did you receive your H1N1 flu vaccine?
S28.3
Was this a shot or was it a vaccine sprayed in the nose?
 
 
CDC Core
Section 14: Immunization
[Changes were made to the wording of these questions in October, 2010 to differentiate between the H1N1 flu and the seasonal flu.]
14.1
Data Results 14.1
Now I will ask you questions about seasonal flu. A flu shot is an influenza vaccine injected into your arm. During the past 12 months, have you had a seasonal flu shot?
Crosstabulation Table:
14.2 During what month and year did you receive your most recent seasonal flu shot?
14.3
Data Results 14.3
The seasonal flu vaccine sprayed in the nose is also called FluMist™. During the past 12 months, have you had a seasonal flu vaccine that was sprayed in your nose?
Crosstabulation Table:
14.4 During what month and year did you receive your most recent seasonal flu vaccine that was sprayed in your nose?
14.5
Data Results 14.5
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 Table:
 
 
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
If ONE fall reported ask: "Did this fall cause an injury?".
If MULTIPLY falls reported ask: "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.
Crosstabulation Table:
 
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
If Q13.1 = 2 (No); go to next section.
The next question is about 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?
Crosstabulation Table:
 
 
CDC Core
Section 18: Women's Health
If respondent is male, go to the next section.
The next questions are about breast and cervical cancer.
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 less than 40 years of age, or is female, go to next section.
Now, I will ask you some questions about prostate cancer screening.
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 < 50 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
For a SIGMOIDOSCOPY, a flexible tube is inserted into the retum to look for problems. A COLONOSCOPY is similar, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. Was your MOST RECENT exam a sigmoidoscopy or a colonoscopy?
20.5
Data Results 20.5
How long has it been since you had your last sigmoidoscopy or colonoscopy?
 
CDC Core
Section 21: HIV/AIDS
If respondent is 65 years of age or older, go to next section.
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?
If Q2 = within last 12 months; continue. Otherwise, go to Q5.
21.4
Data Results 21.4
Was it a rapid test where you could get your results within a couple of hours?
21.5
Data Results 21.5
I'm going to read you a list. When I'm done, please tell me if any of the situations apply to you. You do not need to tell me which one.
  • You have used inravenous drugs in the past year.
  • You have been treated for a sexually transmitted or veneral disease in the past year.
  • You have given or received money or drugs in exchange for sex in the past year.
  • You had anal sex without a condom in the past year.
Do any of these situations apply to you?
Crosstabulation Table:
 
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? NOTE: If asked, say: "Please include support from any source."
22.2
Data Results 22.2
In general, how satisfied are you with your life?
Crosstabulation Table:
 
CDC Section
Section 23: Adult ILI (Influenza Like Illness) [Asked January 1, 2010 - March 31, 2010]
We would like to ask you some questions about recent respiratory illnesses.
S23.1 During the past month, were you ill with a fever?
CATI NOTE: If S23.1 = 1 "Yes" continue, otherwise go to S23.8.
S23.2 Did you also have a cough and/or sore throat?
CATI NOTE: If S23.2 = 1 "Yes" continue, otherwise go to S23.8.
S23.3 When did you first become ill with fever, cough or sore throat?

INTERVIEWER NOTE: Choose the most specific answer.
  • Within the past week [past 1-7 days]
  • 2 weeks ago [past 8-14 days]
  • 3-4 weeks ago [past 15-30 days before today]
S23.4 Did you visit a doctor, nurse, or other health professional for this illness?
CATI NOTE: If S23.4 = 1 "Yes" continue, otherwise go to S23.8.
S23.5 What did the doctor, nurse, or other health professional tell you? Did they say...
  • You had regular influenza or the flu.
  • You had swine flu, also known as H1N1 or novel H1N1.
  • You had some other illness, but not the flu.
CATI NOTE:

If S23.5 = 3 "Some other illness, not the flu", only 1 adult in the household and no children in the household then go to next section.

Otherwise if S23.5 = 3 "Some other illness, but not the flu" go to S23.8.
S23.6 Did you have a flu test that was positive for this illness? Usually a swab from you nose or throat is tested. Would you say...
  • Yes, had flu test and it was positive.
  • No, had flu test but it was negative.
  • No, flu test was not done.
S23.7 Did you receive Tamiflu® or oseltamivir [o sel TAM i veer] or an inhaled medicine called Relenza® or zanamivir [za NA mi veer] to treat this illness?
CATI NOTE:

If household has one adult, no children & adult has NOT been ill in the past month (S23.1 or S23.2 = 2 "No" ,7 "Don't know/Not sure" or 9 "Refused", then go to next section.

If household has one adult, no children and adult HAS been ill in the past month (S23.1 or S23.2 = 1 "Yes", then go to S23.10.
S23.8 Did any other members of your household have a fever with cough or sore throat during the past month?
CATI NOTE:

If S23.8 = 2 "No", S23.1 = 1 "Yes" and S23.2 = 1 "Yes", then go to S23.10.

Otherwise if S23.8 = 2 "No" go to next section.
S23.9 How many household members [CATI NOTE: If S23.1 = 1 "Yes" and E1.2 = 1 "Yes" then insert ", including you,".] were ill during the past month?
CATI NOTE:

If (S23.1 = 1 "Yes" and S23.2 = 1 "Yes") or E1.8 = 1 "Yes" continue to E1.10.

Otherwise skip to next section.
S23.10 How many people in your household, including you, were hospitalized for flu during the past month?

INTERVIEWER NOTE: If needed, "Hospitalized means admitted to a hospital to receive medical treatment."
 
 
CDC Section
Section 26: Adult ILI (Influenza Like Illness) [Asked October 1, 2010 - December 31, 2010]
We would like to ask you some questions about recent respiratory illnesses.
S26.1 Last month (i.e. [CATI NOTE: insert previous months name] ), were you ill with a
fever?
CATI NOTE: If S26.1 = 1 "Yes" continue, otherwise go to S26.8.
S26.2 Did you also have a cough and/or sore throat?
CATI NOTE: If S26.2 = 1 "Yes" continue, otherwise go to S26.8.
S26.3 Did you visit a doctor, nurse, or other health professional for this illness?
CATI NOTE: If S26.3 = 1 "Yes" continue, otherwise go to S26.8.
S26.4 When did you visit the doctor, nurse, or other health professional for this illness? Would you say...
  • Within two days of getting ill
  • Within three to 7 days of getting ill
  • More than 7 days of getting ill
S26.5

What did the doctor, nurse, or other health professional tell you? Did they say...

Interviewer Note: If respondent says they had either H1N1 or seasonal influenza,
please code as “1 = You had influenza or the flu”.

  • You had regular influenza or the flu.
  • You had some other illness, but not the flu.
S26.6 Did you have a flu test that was positive for this illness? Usually a swab from you nose or throat is tested. Would you say...
  • Yes, had flu test and it was positive.
  • No, had flu test but it was negative.
  • No, flu test was not done.
S26.7 Did you receive Tamiflu® or oseltamivir [o sel TAM i veer] or an inhaled medicine called Relenza® or zanamivir [za NA mi veer] to treat this illness?
CATI NOTE:

If household has one adult, no children & adult has NOT been ill in the past month (S26.1 or S26.2 = 2 "No" ,7 "Don't know/Not sure" or 9 "Refused", then go to next section.

If household has one adult, no children and adult HAS been ill in the past month (S26.1 or S26.2 = 1 "Yes", then go to S26.10.
S26.8 Did any other members of your household have a fever with cough or sore throat last
month (i.e. [CATI NOTE: insert previous month’s name] )?
CATI NOTE:

If S26.8 = 2 "No", S26.1 = 1 "Yes" and S26.2 = 1 "Yes", then go to S26.10.

Otherwise if S26.8 = 2 "No" go to next section.
S26.9 How many household members [CATI NOTE: If S23.1 = 1 "Yes" and E1.2 = 1 "Yes" then insert ", including you,".] were ill during the past month (i.e. [CATI NOTE: insert previous month’s name] )?
CATI NOTE:

If (S26.1 = 1 "Yes" and S26.2 = 1 "Yes") or E6.8 = 1 "Yes" continue to E6.10.

Otherwise skip to next section.
S26.10

How many people in your household, including you, were hospitalized for flu during the past month (i.e. [CATI NOTE: insert previous month’s name] )?

INTERVIEWER NOTE: If needed, "Hospitalized means admitted to a hospital to receive medical treatment."

 
 
CDC Optional
Module 32: High Risk/Health Care Worker [Asked January - June]
The next few questions ask about health care work and chronic illness.
1
Data Results M32.1
Do you currently volunteer or work in a hospital, medical clinic, doctor's office, dentist's office, nursing home or some other health-care facility? This includes part-time or unpaid work in a health care facility as well as professional nursing care provided in the home.

INTERVIEWER NOTE: If necessary say: "This includes non-health professionals, such as administrative staff, who work in a health-care facility."
2
Data Results M32.2
Do you provide direct patient care as part of your routine work? By direct patient care we mean physical or hands-on contact with patients.

INTERVIEWER NOTE: If necessary say: If respondent answers 'don't know' or 'not sure' repeat question.
3
Data Results M32.3
Has a doctor, nurse, or other health professional ever said that you have…
  • Lung problems, other than asthma,
  • Kidney problems,
  • Anemia, including Sickle Cell or
  • A weakened immune system caused by a chronic illness or by medicines taken for a chronic illness?
CATI NOTE: If M32.3 = 1 "Yes" continue, otherwise go to next section.
4
Data Results M32.4
Do you still have (this/any of these) problem(s)?
 
 
CDC Optional
Module 15: Random Child Selection

If Core Question 12.7 = 88, or 99 (no children under age 18 in the household, or refused), go to next module.

If Core Question 12.7 = 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 Q1]

If Core 12.7 is >1 and Core Question 12.7 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 M15.1
What is the birth month and year of the “Xth” child?
2
Data Results M15.2
Is the child a boy or a girl?
3
Data Results M15.3
Is the child Hispanic or Latino?
4
Data Results M15.4
Which one or more of the following would you say is the race of the child?
[Check all that apply]
5
Data Results M15.5
Which one of these groups would you say best represents the child's race?
6
Data Results M15.6
How are you related to the child?
 
CDC Emergency Module
Module 27: Childhood ILI - Influenza Like Illness [Asked January-March]
CATI NOTE: If Q12.7 = 88 "No children under age 18" or 99 "Refused", go to next module.
The next questions are about the "X"th child.
M27.1
Data Results M27.1
Has the child had a fever with cough and/or sore throat during the past month?
CATI NOTE: If M27.1 = 1 "Yes" continue, otherwise go to next module.
M27.2
Data Results M27.2
Did the child visit a doctor, nurse, or other health professional for this illness?
 
 
CDC Emergency Module
Module 34: Childhood ILI - Influenza Like Illness [Asked October-December]
CATI NOTE: If Q12.7 = 88 "No children under age 18" or 99 "Refused", go to next module.
The next questions are about the "X"th child.
M34.1
Data Results M34.1
Last month (i.e. [CATI NOTE: insert previous month's name] ), did the child have a fever with cough and/or sore throat?
CATI NOTE: If M34.1 = 1 "Yes" continue, otherwise go to next module.
M34.2
Data Results M34.2
Did the child visit a doctor, nurse, or other health professional for this illness?
 
 
CDC Emergency Module
Module 29: Novel H1N1 Childhood Immunization [Asked January - June]
CATI NOTE:
If response to Core Q12.7 = 88 (No children under age 18) or 99 (Refused), go to next module.

If selected child's age is greater then or equal to 6 months, continue. Otherwise, go to next module.
The next questions are about this child's immunization.

I will first ask you questions about vaccination for H1N1 flu, which is sometimes called swine flu or pandemic flu, and then ask you questions about vaccination for seasonal flu.

There are two ways to get the H1N1 flu vaccination. One is a shot in the arm and the other is a spray, mist or drop in the nose.
M29.1
Data Results M29.1
Since September, 2009, has [Fill: he/she] been vaccinated either way for the H1N1 flu?

INTERVIEWER NOTE: If asked why asking about H1N1 vaccinations when not available please say: "The distribution of the H1N1 Vaccines has already started. We are trying to find out if vaccinations are currently taking place in Kansas."
CATI NOTE:
If M29.1 = 1 "Yes" continue, otherwise go to M27.1.

If selected child's age is 10 years or older, go to M29.3. Otherwise, continue.
M29.2
Data Results M29.2
Since September, 2009, how many of these H1N1 vaccinations has [Fill: he/she] received?
CATI NOTE:
If M29.2 = 1 "One vaccination or dose" or 2 "Two or more vaccination or doses" continue, otherwise go to M27.1.
M29.3
Data Results M29.3
During what month did [Fill: he/she] receive [Fill: his/her]...

CATI Note:
If selected child's age is less than 10 years old, ask:
"...first H1N1 flu vaccine?"
Otherwise, ask:"...H1N1 flu vaccine?".
M29.4
Data Results M29.4
Was this a shot or was it a vaccine sprayed in the nose?
CATI NOTE:
If selected child's age is 10 years or older, go to next module.

If M29.2 = 2 "Two or more vaccination or doses" continue, otherwise go to next module.
M29.5
Data Results M29.5
During what month did [Fill: he/she] receive [Fill: his/her] second H1N1 flu vaccine?
M29.6
Data Results M29.6
Was this a shot or was it a vaccine sprayed in the nose?
 
 
CDC Optional
Module 25: Childhood Immunization [Asked in Jan - June]
CATI NOTE:
If response to Core Q12.7 = 88 (No children under age 18) or 99 (Refused), go to next module.

If selected child's age is greater than or equal 6 months, continue. Otherwise, go to next module.
M27.1
Data Results M27.1M27.1
Now I will ask you questions about seasonal flu. There are two types of seasonal flu vaccinations. One is a shot and the other is a spray in the nose. During the past 12 months, has [Fill: he/she] had a seasonal flu vaccination?
CATI NOTE: If M27.1 = 1 "Yes" continue, otherwise go to next module.
M27.2 The flu vaccination may have been either the flu shot or the flu spray. The flu spray is the flu vaccination that is sprayed in the nose. During what month and year did [Fill: he/she] receive [Fill: his/her] most recent seasonal flu vaccination?
 
 
CDC Optional
Module 24: Childhood Asthma Prevalence
If response to Core Q12.7 = 88 (None) or 99 (Refused), go to next module.
The next two questions are about the "Xth" child.
1
Data Results M24.1
Has a doctor, nurse, or other health professional EVER said that the child has asthma?
2
Data Results M24.2
Does the child still have asthma?
Crosstabulation Table:
 
 
State-Added
Module 2: Asthma Call Back Survey Information
If Q8.1 = ‘yes” or Childhood Asthma Prevalence Module Q1 = ‘Yes’ and Random Child Selection Module Q6 = “Parent” (1) or “Foster parent or guardian” (3) then continue. Otherwise, go to next module.
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, two CDC optional modules and two state-added modules are asked of every respondent. However, the additional CDC optional 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
Summary Index Table:
CDC Optional
Module 1: Pre-Diabetes
Note: Only asked of those not responding "Yes" (code = 1) to Core Q6.1 (Diabetes awareness question).
1
Data Results M1.1
Have you had a test for high blood sugar or diabetes within the past three years?
Note: If Core Q6.1 = 4 (No, pre-diabetes or borderline diabetes); answer Q2 "Yes" (code = 1).
2
Data Results M1.2
Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?
Crosstabulation Table:
 
 
CDC Optional
Module 2: Diabetes
Note: To be asked following Core Q6.1; if response is "Yes" (code = 1)
1
Data Results M2.1
How old were you when you were told you have diabetes?
2
Data Results M2.2
Are you now taking insulin?
3
Data Results M2.3
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.
4
Data Results M2.4
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.
5
Data Results M2.5
About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
6
Data Results M2.6
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" ?
7
Data Results M2.7
About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
8
Data Results M2.8
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.
9
Data Results M2.9
Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
10
Data Results M2.10
Have you ever taken a course or class in how to manage your diabetes yourself?
 
 
State-Added
Module 3: Diabetes Assessment
1
Data Results SA3.1

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.

[Mark all that apply:]

  • Mother
  • Father
  • Brothers [Interviewer note: include half brother]
  • Sisters [Interviewer note: include half sister]
  • No one
Note: If respondent is female, continue; otherwise, go to next module.
2
Data Results SA3.2
Have you had a baby weighing more then 9 pounds at birth?
 
 
State-Added
Module 4: Heart Attack and Stroke
Now I would like to ask you about your knowledge of the signs and symptoms of a heart attack and stroke.

Which of the following do you think is a symptom of a heart attack? For each, tell me "yes," "no," or you're "not sure."
1
Data Results SA4.1
(Do you think) pain or discomfort in the jaw, neck, or back (are symptoms of a heart attack?)
2
Data Results SA4.2
(Do you think) feeling weak, lightheaded, or faint (are symptoms of a heart attack?)
3
Data Results SA4.3
(Do you think) chest pain or discomfort (are symptoms of a heart attack?)
4
Data Results SA4.4
(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a heart attack?)
5
Data Results SA4.5
(Do you think) pain or discomfort in the arms or shoulder (are symptoms of a heart attack?)
6
Data Results SA4.6
(Do you think) shortness of breath (is a symptom of a heart attack?)
Which of the following do you think is a symptom of a stroke?

For each, tell me "yes," "no," or you're "not sure."
7
Data Results SA4.7
(Do you think) sudden confusion or trouble speaking (are symptoms of a stroke?)
8
Data Results SA4.8
(Do you think) sudden numbness or weakness of face, arm, or leg, especially on one side, (are symptoms of a stroke?)
9
Data Results SA4.9
(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a stroke?)
10
Data Results SA4.10
(Do you think) sudden chest pain or discomfort (are symptoms of a stroke?)
11
Data Results SA4.11
(Do you think) sudden trouble walking, dizziness, or loss of balance (are symptoms of a stroke?)
12
Data Results SA4.12
(Do you think) severe headache with no known cause (is a symptom of a stroke?)
13
Data Results SA4.13
If you thought someone was having a heart attack or a stroke, what is the first thing you would do?
  • Take them to the hospital
  • Tell them to call their doctor
  • Call 911
  • Call their spouse or a family member
  • Do something else
 
 
State-Added
Module 5: Tobacco Indicators
Now, I would like to ask you questions about tobacco related topics.
1
Data Results SA5.1
How much additional tax on a pack of cigarettes would you be willing to support?
2
Data Results SA5.2
Would you support or oppose increasing the tax on smokeless tobacco? Smokeless tobacco products include chewing tobacco, snuff and snus (snus rhymes with goose).

NOTE: Snus (Swedish for snuff) is moist smokeless tobacco, usually sold in small pouches, that is placed under the lip against the gum.
Note: If Q1 = 6 "No tax increase" & Q2 = 2 "Oppose", go to Q4. Otherwise, continue.
3
Data Results SA5.3
If the increased taxes from cigarettes and smokeless tobacco products are NOT used to support programs designed to reduce tobacco use or help people quit smoking, would you strongly support, somewhat support, are neutral, somewhat oppose or strongly oppose the increase in taxes on cigarettes or smokeless tobacco products?
Note: If Core Tobacco Use Section Q11.1 = 1 "Yes" smoked at least 100 cigarettes in your life, then continue. Otherwise, go to next module.
4
Data Results SA5.4
When you quit smoking or the last time you tried to quit smoking, did you use nicotine replacement therapy - gum, patches, lozenges, nasal spray, inhaler, or the medications Zyban/Wellbutrin/buproprion (ZEYE ban/Well BYOU trin/byou PRO pee on) or Chantix/varenicline (SHAN tix/VAR en i cline) to assist you?
Note: If Q4 = 2 "No", then continue. Otherwise, go to next module.
5
Data Results SA5.5
Was there a time when you wanted to use nicotine replacement therapy to help you quit smoking but could not because of cost?
 
 
State-Added
Module 9: Oral Health
SA9.1
Data Results SA9.1
During the past 12 months, was there any time when you needed dental care but did not get it?
SA9.2
Data Results SA9.2
What was the main reason you did not receive the dental care you needed?
SA9.3
Data Results SA9.3
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:
 
 
Part B
Summary Index Table:
CDC Optional
Module 17: 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 occured in the past 2 weeks.
M17.1
Data Results M17.1
Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?
M17.2
Data Results M17.2
Over the last 2 weeks, how many days have you felt down, depressed or hopless?
M17.3
Data Results M17.3
Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?
M17.4
Data Results M17.4
Over the last 2 weeks, how many days have you felt tired or had little energy?
M17.5
Data Results M17.5
Over the last 2 weeks, how many days have you had a poor appetite or eaten too much?
M17.6
Data Results M17.6
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?
M17.7
Data Results M17.7
Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching the TV?
M17.8
Data Results M17.8
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?
M17.9
Data Results M17.9
Has a doctor or other healthcare provider EVER told you that you had an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder)?
M17.10
Data Results M17.10
Has a doctor or other healthcare provider EVER told you that you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?
Crosstabulation Table:
 
 
State-Added
Module 6: Depression Treatment
If CDC Module 17 Q10 = 1 (Yes) for ever diagnosed with a depressive disorder; continue. Otherwise, go to Q2.
SA6.1
Data Results SA6.1
About how long has it been since you were diagnosed with depression?
Now, I am going to ask a few questions about your feelings of being sad, discouraged or uninterested in the past 12 months and the treatment received for these feelings.
SA6.2
Data Results SA6.2
During the past 12 months, have you had a period of two weeks or longer when you felt sad, discouraged or uninterested?
Crosstabulation Table:
SA6.3
Data Results SA6.3
Did you receive any treatment for your sadness, discouragement or lack of interest at any time in the past 12 months by a medical doctor or other health professionals? (By health professional we mean psychologists, counseolors, spiritual advisors, herbalists, acupuncturists, and other healing professionals.)
SA6.4
Data Results SA6.4
During the past 12 months, did you get a precscription medicine for your sadness, discouragement or lack of interest?
SA6.5
Data Results SA6.5
During the past 12 months, did you receive counseling or therapy from a medical doctor or other health professional for your sadness, discouragement or lack of interest? (By health professional we mean psychologists, counseolors, spiritual advisors, herbalists, acupuncturists, and other healing professionals.)
If Q3 = 2 (No); continue. Otherwise, go to Q7.
SA6.6
Data Results SA6.6
What was the main reason you did not receive treatment that you needed for your sadness, discouragement or lack of interest in the past 12 months?
SA6.7
Data Results SA6.7
During the past 12 months, how many different times have you stayed overnight or longer in a hospital to receive treatment for your sadness, discouragement or lack of interest?
 
 
CDC Optional
Module 9: Arthritis Burden
Next I will ask you about arthritis.
M9.1
Data Results 9.1M9.1
Have you EVER been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?

INTERVIEWER INTERVIEWER INSTRUCTION: Arthritis diagnoses includes:
  • rheumatism, polymyalgia rheumatica
  • 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)
Crosstabulation Table:
Summary Index Table:
 
 
State-Added
Module 7: Arthritis Burden
Arthritis can cause symptoms like pain, aching, or stiffness in or around the joint.
1
Data Results SA7.1
Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?

INTERVIEWER INSTRUCTION: If a respondent question arises about medication, then the interviewer should reply: "Please answer the question based on how you are when you are taking any of the medications or treatments you might use."
Crosstabulation Table:
Note: Q2 should be asked of all respondents regardless of employment status.
2
Data Results SA7.2
In this next question, we are referring to work for pay. Do arthritis or joint symptoms now affect whether you work, the type of work you do, or the amount of work you do?

INTERVIEWER INSTRUCTION: If respondent gives an answer to each issue (whether works, type work, or amount of work), then if any issue is "yes" mark the overall response as "yes." If a question arises about medications or treatment, then the interviewer should say: "Please answer the question based on your current experience, regardless of whether you are taking any medication or treatment."
3
Data Results SA7.3
During the past 30 days, to what extent has your arthritis or joint symptoms interfered with your normal social activities, such as going shopping, to the movies, or to religious or social gatherings? Would you say…
  • A lot
  • A little
  • Not at all

INTERVIEWER INSTRUCTION: If a question arises about medications or treatments, then the interviewer should say: "Please answer the question based on your current experiences, regardless of whether you are taking any medication or treatment."
4
Data Results SA7.4
Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. DURING THE PAST 30 DAYS, how bad was your joint pain ON AVERAGE? Please answer on a scale of 0 to 10 where 0 is no pain or aching and 10 is pain or aching as bad as it can be.
 
 
State-Added
Module 8: Disability
The following questions refer to your physical health that includes physical illness or injury.
SA8.1
Data Results SA8.1
During the past 12 months, was there any time when you needed health care services such as a physician's visit or hospital inpatient care but did not receive it?
Note: If Q1 = 1, continue. Otherwise, skip to Q4.
SA8.2
Data Results SA8.2
What was the MAIN reason you did not receive health care services?
SA8.3
Data Results SA8.3
How big of a problem was it for you?
The following questions refer to physical activity.
SA8.4
Data Results SA8.4
Are you currently physically active or exercising as much as you WANT?
Note: If Q4 = 3 (Physically unable), then code Q6 = 04 (Permanent physical illness or injury) and go to next section. Otherwise, continue.
SA8.5
Data Results SA8.5
Are you currently physically active or exercising as much as you think you SHOULD?
Note: If Q4 = 2 (no) OR Q5 = 2 (no) then continue. Otherwise, go to next section.
SA8.6
Data Results SA8.6
What is the main personal reason that you do not exercise more or be more physically active?
SA8.7
Data Results SA8.7
What one thing would it take to get you to exercise more or be more physically active?
 
 
CDC Optional
Module 6: Inadequate Sleep
I would like to ask you a few questions about your sleep patterns.
1.
Data Results M6.1 for M6.1
On average, how many hours of sleep do you get in a 24-hour period? Think about the time you actually spend sleeping or napping, not just the amount of sleep you think you should get.
Interviewer Note: Enter hours of sleep in whole numbers, rounding 30 minutes (1/2 hour) or more up to the next whole hour and dropping 29 or fewer minutes.
2.
Data Results M6.2 for M6.2
Do you snore?
Interviewer Note: If the respondent indicates that their spouse or someone told him/her that they snore, then the answer to the question is "Yes", the respondent snores.
3.
Data Results M6.3 for M6.3
During the past 30 days, for about how many days did you find yourself unintentionally falling asleep during the day?
4.
Data Results M6.4 for M6.4
During the past 30 days, have you ever nodded off or fallen asleep, even just for a brief moment, while driving?
Crosstabulation Table: