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?
Crosstabulation Table:
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?
Crosstabulation Table:
 
 
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: Hypertension Awareness
4.1
Data Results 4.1
Have you EVER been told by a doctor, nurse, or other health professional that you have high blood pressure?
(If "Yes" and respondent is female, ask: "Was this only when you were pregnant?")
Crosstabulation Table:
4.2
Data Results 4.2
Are you currently taking medicine for your high blood pressure?
 
 
CDC Core
Section 5: Cholesterol Awareness
5.1
Data Results 5.1
Blood cholesterol is a fatty substance found in the blood. Have you EVER had your blood cholesterol checked?
5.2
Data Results 5.2
About how long has it been since you last had your blood cholesterol checked?
Crosstabulation Table:
5.3
Data Results 5.3
Have you EVER been told by a doctor, nurse, or other health professional that your blood cholesterol is high?
Crosstabulation Table:
 
 
 
CDC Core
Section 6: Chronic Health Conditions
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.
6.1
Data Results 6.1
Ever told you had a heart attack, also called a myocardial infarction?
Crosstabulation Table:
6.2
Data Results 6.2
(Ever told) you had angina or coronary heart disease?
Crosstabulation Table:
6.3
Data Results 6.3
(Ever told) you had a stroke?
Crosstabulation Table:
6.4
Data Results 6.4
Have you EVER been told by a doctor, nurse, or other health professional that you had asthma?
6.5
Data Results 6.5
Do you still have asthma?
Crosstabulation Table:
Summary Index:
6.6
Data Results 6.6
(Ever told) you had skin cancer?
Crosstabulation Table:
6.7
Data Results 6.7
(Ever told) you had any other type of cancer?
Crosstabulation Table:
6.8
Data Results 6.8
(Ever told) you have (COPD) chronic obstructive pulmonary disease, emphysema or chronic bronchitis?
Crosstabulation Table:
6.9
Data Results 6.9
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 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:
6.10
Data Results 6.10
(Ever told) you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?
Crosstabulation Table:
6.11
Data Results 6.11
(Ever told) you have kidney disease? DO NOT include kidney stones, bladder infection or incontnence.
Crosstabulation Table:
6.12
Data Results 6.12
Has a doctor, nurse or other health professional ever said you have a vision impairment in one or both eyes, even when wearing glasses?
Crosstabulation Table:
6.13
Data Results 6.13
(Ever told) you have diabetes?

INTERVIEWER INSTRUCTION: 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:
Crosstabulation Table:
 
 
CDC Core
Section 7: Tobacco Use
7.1
Data Results 7.1
Have you smoked at least 100 cigarettes in your entire life?
[Interviewer: 5 packs = 100 cigarettes]
7.2
Data Results 7.2
Do you now smoke cigarettes every day, some days, or not at all?
Crosstabulation Table:
Summary Index Table:
Summary Index Table:
7.3
Data Results 7.3
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
Crosstabulation Table:
CATI NOTE: If Q7.2 = 3 (Not at all); continue. Otherwise, go to Q7.5.
7.4
Data Results 7.4
How long has it been since you last smoked a cigarette, even one or two puffs?
7.5
Data Results 7.5
Do you currently use chewing tobacco, snuff or snus every day, some days or not at all?

INTERVIEWER INSTRUCTION: 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 8: Demographics
8.1
Data Results 8.1
What is your age?
8.2
Data Results 8.2
Are you of Hispanic or Latino?
8.3
Data Results 8.3
Which one or more of the following would you say is your race? (Mark all that Apply)
CATI NOTE: If more than one response to Q8.3, continue. Otherwise, go to Q8.5.
8.4
Data Results 8.4
Which one of these groups would you say BEST represents your race?
8.5
Data Results 8.5

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

  • Yes, now on active duty
  • Yes, on active duty during the last 12 months, but not now
  • Yes, on active duty in the past, but not during the last 12 months
  • No, training for Reserves or National Guard only
  • No, never served in the military
Crosstabulation Table:
8.6
Data Results 8.6
Are you:
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
8.7
Data Results 8.7
How many children less than 18 years of age live in your household ?
8.8
Data Results 8.8
What is the highest grade or year of school you completed?
8.9
Data Results 8.9
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
8.10
Data Results 8.10
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
CATI NOTE: If Q8.9 = 1 (Employed for Wages), 2 (Self-Employed), 5 (A Homemaker), 6 (A Student) or 7 (Retired); skip out of the Demographics Core Section to ask the State-Added Average Hours Worked Module.
 
State-Added
State-Added 1: Average Hours Worked
1.
Data Results SA1.1
Previously, you indicated you were (a) [insert response from core, Question 8.9, reported employment status]. On the average, how many hours per week, if any, do you work at a job or business?
 
CATI NOTE: Skip back into Demographics Core Section at Q8.11, and continue with the survey.
8.11 About how much do you weigh without shoes?
[Round fractions up]
CATI NOTE: If Q8.11 = 7777 (Don't know/Not sure) or 9999 (Refused), skip Q8.13 and Q8.14.
8.12 About how tall are you without shoes?
[Round fractions down]
Crosstabulation Table:
Summary Index Table:
8.13 What county do you live in?
8.14
 
What is your ZIP Code where you live?
8.15
Data Results 8.15
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.
8.16
Data Results 8.16
How many of these phone numbers are residential numbers?
8.17
Data Results 8.17
Do you have a cell phone for personal use? Please include cell phones used for both business and personal use.
CATI NOTE: If Q8.17 = 1 (Yes), skip to Q8.19
8.18
Data Results 8.18
Do you share a cell phone for personal use (at least one-third of the time) with other adults?
CATI NOTE: If Q8.18 = 1 (Yes), skip to Q8.20. Otherwise, skip to Q8.21.
8.19
Data Results 8.19
Do you usually share this cell phone (at least one-third of the time) with any other adults?
8.20
Data Results 8.20
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?
8.21
Data Results 8.21
Do you own or rent your home?

INTERVIEWER NOTE: "Other arrangement" may include group homes, staying with friends or family without paying rent.

INTERVIEWER NOTE: Home is defined as the place where you live most of the time/the majority of the year.
8.22
Data Results 8.22
Indicate sex of respondent. (Asked Only if Necessary)
CATI NOTE: If Q8.20 = 1 (Male) or Q8.20 = 2 (female) and is 45 years old or older, skip to next section.
8.23
Data Results 8.23
To your knowledge, are you now pregnant?
 
CDC Core
Section 9: Fruits and Vegetables
These next questions are about the fruits and vegetables you ate or drank during the past 30 days. Please think about all forms of fruits and vegetables including cooked or raw, fresh, frozen or canned. Please think about all meals, snacks, and food consumed at home and away from home.
I will be asking how often you ate or drank each one: for example, once a day, twice a week, three times a month, and so forth.
INTERVIEWER NOTE: If respondent responds less than once per month, put "0" times per month. If respondent gives a number without a time frame, ask: "Was that per day, week, or month?"
9.1
Data Results 9.1
During the past month, how many times per day, week or month did you drink 100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. Only include 100% juice.

INTERVIEWER NOTE: Do not include fruit drinks with added sugar or other added sweeteners like Kool-aid, Hi-C, lemonade, cranberry cocktail, Tampico, Sunny Delight, Snapple, Fruitopia, Gatorade, Power-Ade, or yogurt drinks. Do not include fruit juice drinks that provide 100% daily vitamin C but include added sugar.

Do not include vegetable juices such as tomato and V8 if respondent provides but include in "other vegetables" question 9.6.

DO include 100% pure juices including orange, mango, papaya, pineapple, apple, grape (white or red), or grapefruit. Only count cranberry juice if the R perception is that it is 100% juice with no sugar or artificial sweetener added. 100% juice blends such as orange-pineapple, orange-tangerine, cranberry-grape are also acceptable as are fruit-vegetable 100% blends. 100% pure juice from concentrate (i.e., reconstituted) is counted.

9.2
Data Results 9.2
During the past month, not counting juice, how many times per day, week, or month did you eat fruit? Count fresh, frozen, or canned fruit.

Read only if necessary: "Your best guess is fine. Include apples, bananas, applesauce, oranges, grape fruit, fruit salad, watermelon, cantaloupe or musk melon, papaya, lychees, star fruit, pomegranates, mangos, grapes, and berries such as blueberries and strawberries."

INTERVIEWER NOTE: Do not count fruit jam, jelly, or fruit preserves.

Do not include dried fruit in ready-to-eat cereals.

Do include dried raisins, cran-raisins if respondent tells you - but due to their small serving size they are not included in the prompt.

Do include cut up fresh, frozen, or canned fruit added to yogurt, cereal, jello, and other meal items.

Include culturally and geographically appropriate fruits that are not mentioned (e.g. genip, soursop, sugar apple, figs, tamarind, bread fruit, sea grapes, carambola, longans, lychees, akee, rambutan, etc.).

9.3
Data Results 9.3
During the past month, how many times per day, week, or month did you eat cooked or canned beans, such as refried, baked, black, garbanzo beans, beans in soup, soybeans, edamame, tofu or lentils. Do NOT include long green beans.

Read only if necessary: "Include round or oval beans or peas such as navy, pinto, split peas, cow peas, hummus, lentils, soy beans and tofu. Do NOT include long green beans such as string beans, broad or winged beans, or pole beans."

INTERVIEWER NOTE: Include soybeans also called edamame, TOFU (BEAN CURD MADE FROM SOYBEANS), kidney, pinto, hummus, lentils, black, black-eyed peas, cow peas, lima beans and white beans. Include bean burgers including garden burgers and veggie burgers.

Include falafel and tempeh.

9.4
Data Results 9.4
During the past month, how many times per day, week, or month did you eat dark green vegetables for example broccoli or dark leafy greens including romaine, chard, collard greens or spinach?

INTERVIEWER NOTE: Each time a vegetable is eaten it counts as one time.

INTERVIEWER NOTE: Include all raw leafy green salads including spinach, mesclun, romaine lettuce, bok choy, dark green leafy lettuce, dandelions, komatsuna, watercress, and arugula.

Do not include iceberg (head) lettuce if specifically told type of lettuce. Include all cooked greens including kale, collard greens, choys, turnip greens, mustard greens.

9.5
Data Results 9.5
During the past month, how many times per day, week, or month did you eat orange-colored vegetables such as sweet potatoes, pumpkin, winter squash, or carrots?

Read only if needed: "Winter squash have hard, thick skins and deep yellow to orange flesh. They include acorn, buttercup, and spaghetti squash."

FOR INTERVIEWER: Include all forms of carrots including long or baby-cut.

Include carrot-slaw (e.g. shredded carrots with or without other vegetables or fruit).

Include all forms of sweet potatoes including baked, mashed, casserole, pie, or sweet potatoes fries.

Include all hard-winter squash varieties including acorn, autumn cup, banana, butternut, buttercup, delicate, hubbard, kabocha (Also known as an Ebisu, Delica, Hoka, Hokkaido, or Japanese Pumpkin; blue kuri), and spaghetti squash. Include all forms including soup.

Include pumpkin, including pumpkin soup and pie. Do not include pumpkin bars, cake, bread or other grain-based desert-type food containing pumpkin (i.e. similar to banana bars, zucchini bars we do not include).

9.6
Data Results 9.6
Not counting what you just told me about, during the past month, about how many times per day, week, or month did you eat OTHER vegetables? Examples of other vegetables include tomatoes, tomato juice or V-8 juice, corn, eggplant, peas, lettuce, cabbage, and white potatoes that are not fried such as baked or mashed potatoes.

Read only if needed: "Do not count vegetables you have already counted and do not include fried potatoes."

INTERVIEWER NOTE: Include corn, peas, tomatoes, okra, beets, cauliflower, bean sprouts, avocado, cucumber, onions, peppers (red, green, yellow, orange); all cabbage including American-style cole-slaw; mushrooms, snow peas, snap peas, broad beans, string, wax-, or pole-beans.

Include any form of the vegetable (raw, cooked, canned, or frozen).

Do not include products consumed usually as condiments including ketchup, catsup, salsa, chutney, relish.

Do include tomato juice if respondent did not count in fruit juice.

Include culturally and geographically appropriate vegetables that are not mentioned (e.g. daikon, jicama, oriental cucumber, etc.).

Do not include rice or other grains.

 
CDC Core
Section 10: Exercise (Physical Activity)
Crosstabulation Table:
Summary Index Table:
Crosstabulation Table:
Summary Index Table:
The next few questions are about exercise, recreation, or physical activities other than your regular job duties.
INTERVIEWER INSTRUCTION: If respondent does not have a "regular job duty" or is retired, they may count the physical activity or exercise they spend the most time doing in a regular month.
10.1
Data Results 10.1
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:
CATI NOTE: If Q10.1 = 1 "Yes" continue, otherwise go to Q10.8.
10.2
What type of physical activity or exercise did you spend the most time doing during the past month? (First Activity)[See Coding List A (Please refer to the .pdf file of 2011 survey.)]

INTERVIEWER INSTRUCTION: If the respondent's activity is not included in the Coding List A, choose the option listed as "Other ".

INTERVIEWER NOTE: Housework may be included as a physical activity or exercise spent and can be coded as "Other".

CATI NOTE: If Q10.2 = 77 "Don't know/Not sure" or 99 "Refused", go to Q10.8.
10.3
Data Results 10.3
How many times per week or per month did you take part in this activity during the past month? (First Activity)
10.4
Data Results 10.4
And when you took part in this activity, for how many minutes or hours did you usually keep at it? (First Activity)
10.5
What other type of physical activity gave you the next most exercise during the past month? (Second Activity) [See Coding List A (Please refer to the .pdf file of 2011 survey.)]

INTERVIEWER INSTRUCTION: If the respondent's activity is not included in the Coding List A, choose the option listed as "Other ".

INTERVIEWER NOTE: Housework may be included as a physical activity or exercise spent and can be coded as "Other".

CATI NOTE: If Q10.5 = 88 "No other activity", 77 "Don't know/Not sure" or 99 "Refused", go to Q10.8.
10.6
Data Results 10.6
How many times per week or per month did you take part in this activity during the past month?(Second Activity)
10.7
Data Results 10.7
And when you took part in this activity, for how many minutes or hours did you usually keep at it? (Second Activity)
10.8
Data Results 10.8
During the past month, how many times per week or per month did you do physical activities or exercises to STRENGTHEN your muscles? Do NOT count aerobic activities like walking, running, or bicycling. Count activities using your own body weight like yoga, sit-ups or push-ups and those using weight machines, free weights, or elastic bands.
 
CDC Core
Section 11: Disability
The following questions are about health problems or impairments you may have.
11.1
Data Results 11.1
Are you limited in any way in any activities because of physical, mental, or emotional problems?
Crosstabulation Table:
11.2
Data Results 11.2
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?

INTERVIEWER NOTE: Include occasional use or use in certain circumstances.

Crosstabulation Table:
 
 
CDC Core
Section 12: Arthritis Burden
CATI NOTE: If Q6.9 = 1 "Yes" then continue, else go to next section.
Next, I will ask you about your arthritis
Arthritis can cause symptoms like pain, aching, or stiffness in or around a joint.
12.1
Data Results 12.1
Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?

INTERVIEWER INSTRUCTION: 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."

Crosstabulation Table:
CATI Note: Q2 should be asked of all respondents regardless of employment status.
12.2
Data Results Q12.2
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."
12.3
Data Results Q12.3
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."
12.4
Data Results Q12.4
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.
Summary Index:
 
 
CDC Core
Section 13: Seatbelt Use
13.1
Data Results 13.1
How often do you use seat belts when you drive or ride in a car? Would you say...
  • Always
  • Nearly Always
  • Sometimes
  • Seldom
  • Never
Crosstabulation Table:
 
CDC Core
Section 14: Immunization
14.1
Data Results 14.1
Now I will ask you questions about seasonal flu vaccine. There are two ways to get the seasonal flu vaccine, one is a shot in the arm and the other is a spray, mist, or drop in the nose called FluMist™. During the past 12 months, have you had either a seasonal flu shot or a seasonal flu vaccine that was sprayed in your nose?
Crosstabulation Table:
CATI NOTE: If 14.1 = 1 "Yes"continue, otherwise got to question 14.4.
14.2
During what month and year did you receive your most recent flu shot injected into your arm or flu vaccine that was sprayed in your nose?
14.3
Data Results 14.3
At what kind of place did you get your last flu shot/vaccine?
14.4
Data Results 14.4
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: Alcohol Consumption
15.1
Data Results 15.1
During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?
Summary Index Table:
CATI NOTE: If Q15.1 = 888 "No drinks in past 30 days", 777 "Don't know/Not sure" or 999 "Refused"; go to next section.
15.2
Data Results 15.2
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?

INTERVIEWER NOTE: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.
Crosstabulation Table:
Summary Index:
15.3
Data Results 15.3
Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI NOTE: X = 5 for men, X = 4 for women] or more drinks on one occasion?
Crosstabulation Table:
Summary Index:
15.4
Data Results 15.4
During the past 30 days, what is the largest number of drinks you had on any occasion?
 
CDC Core
NOTE: Asked starting August 1, 2011 thru December 31, 2011
Section 18: Preventive Counseling for Alcohol Use
18.1
Data Results 18.1
The next question is about counseling services related to prevention that you might have received from a doctor, nurse, or other health professional.

Has a doctor or other health professional ever talked with you about alcohol use?
  • Yes, within the past 12 months
  • Yes, within the past 3 years
  • Yes, 3 or more years ago
  • No
 
CDC Core
Section 16: HIV/AIDS
CATI NOTE: If respondent is 65 years old 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.
16.1
Data Results 16.1
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.
CATI NOTE: If Q16.1 = "Yes" continue, otherwise go to Q16.5.
16.2 Not including blood donations, in what month and year was your last HIV test?
INTERVIEWER INSTRUCTION: If response is before January 1985, code “Don’t know.”
16.3
Data Results 16.3
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 intravenous drugs in the past year.
  • You have been treated for a sexually transmitted or venereal 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 Emergency
Section 6: Adult ILI (Influenza Like Illness)
We would like to ask you some questions about recent respiratory illnesses.
ES6.1
Data Results ES6.1
Last month (i.e. [CATI NOTE: insert previous months name] ), were you ill with a fever?
CATI NOTE: If ES6.1 = 1 "Yes" continue, otherwise go to ES6.8.
ES6.2
Data Results ES6.2
Did you also have a cough and/or sore throat?
CATI NOTE: If ES6.2 = 1 "Yes" continue, otherwise go to ES6.8.
ES6.3
Data Results ES6.3
Did you visit a doctor, nurse, or other health professional for this illness?
ES6.4
Data Results ES6.4
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
ES6.5
Data Results ES6.5
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.

INTERVIEWER NOTE: If respondent says they had either H1N1 or seasonal influenza, please code as "1 = You had influenza or the flu".
ES6.6
Data Results ES6.6
Did you have a flu test that was positive for this illness? Usually a swab from your 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.

INTERVIEWER NOTE:If respondent says they had either a positive H1N1 or seasonal influenza test result, please code as "1 = Had flu test and it was positive".
ES6.7
Data Results ES6.7
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 (ES6.1 or ES6.2 = 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 (ES6.1 and ES6.2 = 1 "Yes"), then go to ES6.10.
ES6.8
Data Results ES6.8
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 ES6.8 = 2 "No", ES6.1 = 1 "Yes" and ES6.2 = 1 "Yes", then go to ES6.10.

Otherwise if ES6.8 = 2 "No" go to next section.
ES6.9
Data Results ES6.9
How many household members [CATI NOTE: If ES6.1 = 1 "Yes" and E6.2 = 1 "Yes" then insert ", including you,".] were ill last month (i.e. [CATI NOTE: insert previous month's name] )?
CATI NOTE:

If (ES6.1 = 1 "Yes" and ES6.2 = 1 "Yes") or E6.8 = 1 "Yes" continue to E6.10.

Otherwise skip to next section.
ES6.10
Data Results ES6.10
How many people in your household, including you, were hospitalized for flu last month (i.e. [CATI NOTE: insert previous month's name] )?

INTERVIEWER INSTRUCTION: If needed, "Hospitalized means admitted to a hospital to receive medical treatment."
 
 
State-Added
Module 2: Breast Cancer Screening
If respondent is male, go to the next section.
The next questions are about breast cancer.
1
Data Results SA2.1
A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
2
Data Results SA2.2
How long has it been since you had your last mammogram?
  • Within the past year (anytime less than 12 months ago)
  • Within the past 2 years (1 year but less than 2 years ago)
  • Within the past 3 years (2 years but less than 3 years ago)
  • Within the past 5 years (3 years but less than 5 years ago)
  • 5 or more years ago
Crosstabulation Table:
 
CDC Optional
Module 32: Random Child Selection

If Core Question 8.7 = 88, or 99 (no children under age 18 in the household, or refused), go to next module.

If Core Question 8.7 = 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 8.7 is >1 and Core Question 8.7 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 "X"th child."

INTERVIEWER INSTRUCTION: If there are two children with the same birth date, randomly select one.
1
Data Results M32.1
What is the birth month and year of the “X"th child?
2
Data Results M32.2
Is the child a boy or a girl?
3
Data Results M32.3
Is the child Hispanic or Latino?
4
Data Results M32.4
Which one or more of the following would you say is the race of the child?
[Check all that apply]
CATI NOTE: If more than one response to M32.4, continue. Otherwise, go to M32.6.
5
Data Results M32.5
Which one of these groups would you say best represents the child's race?
6
Data Results M32.6
How are you related to the child?
 
CDC Emergency Section
Emergency Section 7: Childhood ILI - Influenza Like Illness [Asked January - April]
CATI NOTE: If Q8.7 = 88 "No children under age 18" or 99 "Refused", go to next module.
The next questions are about the "X"th child.
ES7.1
Data Results ES7.1
Has the child had a fever with cough and/or sore throat during the past month?
CATI NOTE: If ES7.1 = 1 "Yes" continue, otherwise go to next module.
ES7.2
Data Results ES7.2
Did the child visit a doctor, nurse, or other health professional for this illness?
 
State-Added
Module 3: Childhood Diabetes
CATI NOTE: If Core Q8.7 = 88, or 99 (No children under age 18 in the household, or Refused); go to next module.
Now, I would like to ask you about the "Xth" [CATI: Fill in correct number] child.
1
Data Results SA3.1
Has a doctor, nurse or other health professional EVER said the child has diabetes?
 
 
 
CDC Optional
Module 33: Childhood Asthma Prevalence
CATI NOTE: If response to Core Q8.7 = 88 "No children under age 18" or 99 "Refused", go to next module.
The next two questions are about the "X"th child.
M33.1
Data Results M33.1
Has a doctor, nurse, or other health professional EVER said that the child has asthma?
CATI NOTE: If M33.1 = 1 "Yes" continue, otherwise go to next module.
M33.2
Data Results M33.2
Does the child still have asthma?
Crosstabulation Table:
 
 
State-Added
Module 2: Asthma Call Back Survey Information
If Q10.1 = ‘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 and the one state-added module is asked of every respondent. However, the additional CDC Optionals and state-added modules that follow are separated 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
CATI NOTE: Only asked of those not responding "Yes" (code = 1) to Core Q6.1 (if assigned qstpath=1).
1
Data Results M1.1
Have you had a test for high blood sugar or diabetes within the past three years?
CATI 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
CATI NOTE: To be asked following Core Q6.13 (if assigned qstpath = 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" ?
CATI NOTE: If M2.4 = 555 “No feet”, go to M2.8.
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 5: Diabetes Assessment
1
Data Results SA5.1

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 INSTRUCTION: include half brother]
  • Sisters [INTERVIEWER INSTRUCTION: include half sister]
  • No one

CATI NOTE: If respondent is female, continue. Otherwise, go to next Module.
2
Data Results SA5.2
Have you had a baby weighing more then 9 pounds at birth?
 
 
CDC Optional
Module 10: Actions to Control High Blood Pressure
CATI NOTE: If Core Q6.1 = 1 (Yes); continue. Otherwise, go to next module.
Are you now doing any of the following to help lower or control your high blood pressure?
1
Data Results M10.1
(Are you) changing your eating habits (to help lower or control your high blood pressure)?
2
Data Results M10.2
(Are you) cutting down on salt (to help lower or control your high blood pressure)?
3
Data Results M10.3
(Are you) reducing alcohol use (to help lower or control your high blood pressure)?
4
Data Results M10.4
(Are you) exercising (to help lower or control your high blood pressure)?
Has a doctor or other health professional ever advised you to do any of the following to help lower or control your high blood pressure?
5
Data Results M10.5
(Ever advised you to) change your eating habits (to help lower or control your high blood pressure)?
6
Data Results M10.6
(Ever advised you to) cut down on salt (to help lower or control your high blood pressure)?
7
Data Results M10.7
(Ever advised you to) reduce alcohol use (to help lower or control your high blood pressure)?
8
Data Results M10.8
(Ever advised you to) exercise (to help lower or control your high blood pressure)?
9
Data Results M10.9
(Ever advised you to) take medication (to help lower or control your high blood pressure)?
10
Data Results M10.10
Were you told on two or more different visits to a doctor or other health professional that you had high blood pressure?
If "Yes" and respondent is female, ask: "Was this only when you were pregnant?"
Crosstabulation Table:
 
 
CDC Optional
Module 11: 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 M11.1
(Do you think) pain or discomfort in the jaw, neck, or back (are symptoms of a heart attack?)
2
Data Results M11.2
(Do you think) feeling weak, lightheaded, or faint (are symptoms of a heart attack?)
3
Data Results M11.3
(Do you think) chest pain or discomfort (are symptoms of a heart attack?)
4
Data Results M11.4
(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a heart attack?)
5
Data Results M11.5
(Do you think) pain or discomfort in the arms or shoulder (are symptoms of a heart attack?)
6
Data Results M11.6
(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 M11.7
(Do you think) sudden confusion or trouble speaking (are symptoms of a stroke?)
8
Data Results M11.8
(Do you think) sudden numbness or weakness of face, arm, or leg, especially on one side, (are symptoms of a stroke?)
9
Data Results M11.9
(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a stroke?)
10
Data Results M11.10
(Do you think) sudden chest pain or discomfort (are symptoms of a stroke?)
11
Data Results M11.11
(Do you think) sudden trouble walking, dizziness, or loss of balance (are symptoms of a stroke?)
12
Data Results M11.12
(Do you think) severe headache with no known cause (is a symptom of a stroke?)
13
Data Results M11.13
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 6: Tobacco Related Issues
The next questions refer to tobacco issues.
1.
Data Results for SA6.1
How much additional tax on a pack of cigarettes would you be willing to support? Would you say...
  • More than two dollars a pack
  • Two dollars a pack
  • One dollar a pack
  • Fifty to ninety-nine cents a pack
  • Less than fifty cents a pack
  • No tax increase
2.
Data Results for SA6.2
Would you support or oppose increasing the tax on smokeless tobacco? Smokeless tobacco products include chewing tobacco, snuf and snus.
INTERVIEWER NOTE: Snus (Swedish for snuff) is moist smokeless tobacco, usually sold in small pouches, that is placed under the lip against the gum.
3.
Data Results for SA6.3
In general, do you support statewide laws that ban smoking in indoor public places such as stores, restaurants, bars, casinos, clubs, and sport arenas? Would you say…
  • Yes, all indoor public places
  • Yes, some indoor public places
  • No, I do not support any smoking ban for indoor public places
4.
Data Results for SA6.4
Kansas state legislature passed a statewide smoking ban in 2010 that prohibits smoking in indoor public places. Has this new law prompted you to eat out more often, less often or was there no difference?

INTERVIEWER NOTE: Examples of indoor public places are the indoor areas of stores, restaurants, bars, casinos, clubs, and sports arenas.
CATI NOTE: If respondent is a current smoker who has tried to quit in the last 12 months (Q7.3 = 1 (Yes)) or respondent is a former smoker who quit smoking in the last 12 months (Q7.4 = 1 (less than 1 month), 2 (1 month to less than 3 months), 3 (3 months to less than 6 months) or 4 (6 months to less than 1 year ago)); continue. Otherwise, go to Q6.
5.
Data Results for SA6.5
Did this statewide smoking ban passed by the Kansas state legislature in 2010 prompt you to quit smoking or try to quit smoking?
6.
Data Results for SA6.6
During the past 30 days, have you heard or seen any advertisement for the Kansas Tobacco Quitline 1-800-QUIT-NOW?

Interviewer Probe: If respondent answers "No" or "Don't know/Not Sure"; Say: "The advertisements may show or mention a Superman kid or burning money."
 
 
CDC Optional
Module 22: Chronic Obstructive Pulmonary Disease (COPD)
CATI NOTE: If core Q6.8 = 1 (Yes) then continue, else go to next module.
Earlier you said that you had been diagnosed with Chronic Obstructive Pulmonary Disease (COPD).
M22.1
Data Results for M22.1
Have you ever been given a breathing test to diagnose your COPD, chronic bronchitis, or emphysema?
M22.2
Data Results for M22.2
Would you say that shortness of breath affects the quality of your life?
M22.3
Data Results for M22.3
Other than a routine visit, have you had to see a doctor in the past 12 months for symptoms related to shortness of breath, bronchitis, or other COPD, or emphysema flare?
M22.4
Data Results for M22.4
Did you have to visit an emergency room or be admitted to the hospital in the past 12 months because of your COPD, chronic bronchitis, or emphysema?
M22.5
Data Results for M22.5
How many different medications do you currently take each day to help with your COPD, chronic bronchitis, or emphysema?
 
 
State-Added
Module 7: Doctor Advised Smoking Cessation
CATI NOTE: If Q7.2 = 1 (Everyday) or 2 (Some days), current smoker, continue. Otherwise go to next module.
Previously, you indicated that you smoke everyday or some days.
1.
Data Results for SA7.1
During any visit to a doctor or health care provider in the past 12 months, were you advised to quit smoking cigarettes?
 
 
State-Added
Module 8: Fruits & Vegetables Tax
The next question refers to tax on fresh fruits and vegetables.
1.
Data Results for SA8.1
Would you support or oppose removing the sales tax on fresh fruits and vegetables?
 
Part B
Summary Index Table:
 
CDC Optional
Module 18: Arthritis Management
CATI NOTE: If Core Q6.9 = 1 (Yes), continue. Otherwise, go to next module.
M18.1
Data Results M18.1
Earlier you indicated that you had arthritis or joint symptoms. Thinking about your arthritis or joint symptoms, which of the following best describes you today?
  • I can do everything I would like to do
  • I can do most things I would like to do
  • I can do some things I would like to do
  • I can hardly do anything I would like to do
M18.2
Data Results M18.2
Has a doctor or other health professional EVER suggested losing weight to help your arthritis or joint symptoms?
M18.3
Data Results M18.3
Has a doctor or other health professional ever suggested physical activity or exercise to help your arthritis or joint symptoms?
INTERVIEWER NOTE: If the respondent is unclear about whether this means an increase or decrease in physical activity, this means increase.
M18.4
Data Results M18.4
Have you EVER taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?
 
 
CDC Optional
Module 26: 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.
M26.1
Data Results M26.1
Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?
M26.2
Data Results M26.2
Over the last 2 weeks, how many days have you felt down, depressed or hopless?
M26.3
Data Results M26.3
Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?
M26.4
Data Results M26.4
Over the last 2 weeks, how many days have you felt tired or had little energy?
M26.5
Data Results M26.5
Over the last 2 weeks, how many days have you had a poor appetite or eaten too much?
M26.6
Data Results M26.6
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?
M26.7
Data Results M26.7
Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching the TV?
M26.8
Data Results M26.8
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?
M26.9
Data Results M26.9
Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?
M26.10
Data Results M26.10
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)?
 
 
State-Added
Module 9: Depression Treatment
If CDC Core Chronic Health Conditions Section 6Q10 = 1 (Yes) for ever diagnosed with a depressive disorder; continue. Otherwise, go to Q2.
SA9.1
Data Results SA9.1
About how long has it been since you were diagnosed with depression?
  • During the past twelve months (one year or less)
  • During the past two years (more than 1 year to 2 years)
  • During the past five years (more than 2 years to 5 years)
  • More than five years
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.
SA9.2
Data Results SA9.2
During the past 12 months, have you had a period of two weeks or longer when you felt sad, discouraged or uninterested?
Crosstabulation Table:
SA9.3
Data Results SA9.3
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.)
SA9.4
Data Results SA9.4
During the past 12 months, did you get a precscription medicine for your sadness, discouragement or lack of interest?
SA9.5
Data Results SA9.5
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.
SA9.6
Data Results SA9.6
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?
SA9.7
Data Results SA9.7
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 7: Inadequate Sleep
I would like to ask you a few questions about your sleep patterns.
M7.1
Data Results M7.1
During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?
Summary Index:
M7.2
Data Results M7.2
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.
7.3
Data Results M7.3
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.
M7.4
Data Results M7.4
During the past 30 days, for about how many days did you find yourself unintentionally falling asleep during the day?
7.5
Data Results M7.5
During the past 30 days, have you ever nodded off or fallen asleep, even just for a brief moment, while driving?
Crosstabulation Table:
 
CDC
Module 19: Tetanus Diphtheria (Adults)
Next, I will ask you about the tetanus diphtheria vaccination.
19.1
Data Results M19.1
Have you received a tetanus shot in the past 10 years?
19.2
Data Results M19.2
Was your most recent tetanus shot given in 2005 or later?
19.3
Data Results M19.3
There are currently two types of tetanus shots available for adults. One contains the tetanus diphtheria vaccine. The other type contains tetanus diphtheria and pertussis or whooping cough vaccine. Did your doctor say your recent tetanus shot included the pertussis or whooping cough vaccine?
 
 
CDC Optional
Module 10: Tetanus Diphtheria (Adolescents)
CATI NOTE: If selected child is aged 10 to 17, continue. Otherwise, go to next module.
I would like to ask you about the tetanus diphtheria vaccine for your child.
SA10.1
Data Results SA10.1
Has he/she received a tetanus shot in the past 10 years?
SA10.2
Data Results SA10.2
Was his/her most recent tetanus shot given in 2005 or later?
SA10.3
Data Results SA10.3
There are currently two types of tetanus shots available today for older children and teenagers. One contains the tetanus diphtheria vaccine. The other type contains tetanus diphtheria and pertussis or whooping cough vaccine. Did the doctor say his/her most recent tetanus shot included the pertussis or whooping cough vaccine?
 
 
CDC Optional
Module 34: Childhood Immunization (Influenza)
CATI NOTE: If response to Core Q8.7 = 88 (No children under age 18) or 99 (Refused), go to next module.
CATI NOTE: If selected child's age is greater than or equal 6 months, continue. Otherwise, go to next module.
M34.1
Data Results M34.1
During the past 12 months, has [Fill: he/she] had a seasonal flu vaccination? There are two types of flu vaccinations. One is a shot and the other is a spray in the nose.
CATI NOTE: If M34.1 = 1 "Yes" continue, otherwise go to next module.
M34.2
During what month and year did [Fill: he/she] receive his/her most recent seasonal flu vaccination? The seasonal flu vaccination may have been either the flu shot or the flu spray. The flu spray is the flu vaccination that is sprayed the nose?
M34.3
Data Results M34.3
At what kind of place did [he/she] get [his/her] last seasonal flu vaccine?
 
 
State-Added
Module 11: Oral Health
SA11.1
Data Results SA11.1
During the past 12 months, was there any time when you needed dental care but did not get it?
SA11.2
Data Results SA11.2
What was the main reason you did not receive the dental care you needed?
  • Fear, apprehension, nervousness, pain, dislike going
  • Could not afford / cost / too expensive
  • Dentist would not accept my insurance, including Medicaid
  • Do not have/know a dentist
  • Lack transportation / too far away
  • Hours aren’t convenient
  • Do not have time
  • Other ailments prevent dental care
  • Could not get into dentist/clinic
  • Outside issues preventing obtaining treatment
  • Appointment has been or is being scheduled
  • Dentist refused/unable to provide treatment
  • Other (specify :______________)
SA11.3
Data Results SA11.3
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:
 
State-Added
Module 12: Disability Barrier to Attend Work or School
CATI NOTE: If Core Q11.1 = 1 (Yes), limited in any way or Q11.2 = 1 (Yes), use special equipment, continue. Otherwise go to next module.
Previously, you indicated you were limited in your activities or use special equipment due to an impairment or health problem.
SA12.1
Data Results SA12.1
Does your impairment or health problem affect your ability to go to school or work?

Interviewer Probe: If respondent indicates they don't go/or don't need to go to school or work, probe with:
"Is this due to your impairment or health problem?"

If yes, then code as 1. If no, then code as 8.
 
CDC Optional
Module 24: Veteran's Health
CATI NOTE: If Core Q8.5 = 1 (Yes) continue, else go to next module.
The next questions relate to veteran's health.
M24.1
Data Results M24.1
Did you ever serve in a combat or war zone?
M24.2
Data Results M24.2
Has a doctor or other health professional ever told you that you have depression, anxiety, or post traumatic stress disorder (PTSD)?
M24.3
Data Results M24.3
A traumatic brain injury may result from a violent blow to the head or when an object pierces the skull and enters the brain tissue. Has a doctor or other health professional ever told you that you have suffered a traumatic brain injury (TBI)?
M24.4
Data Results M24.4
In the past 12 months, did you receive any psychological or psychiatric counseling or treatment?
The next few questions are a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer.
M24.5
Data Results M24.5
Has there been a time in the past 12 months when you thought of taking your own life?
M24.6
Data Results M24.6
During the past 12 months, did you attempt to commit suicide? Would you say...
  • Yes, but did not require treatment
  • Yes, was treated at a VA facility
  • Yes, was treated at a non-VA facility
  • No
As I mentioned, I would give you a phone number for an organization that can provide information and referral for these issues. You can dial the National Crisis line at 1-800-273-TALK (8255). You can also speak directly to your doctor or health provider.
 
State-Added
Module 13: Suicide
CATI Note:
If CDC Optional Module Q24.5 = 2 (No), then go to next module.
If CDC Optional Module Q24.5 = 1 (Yes), 7 (Don't know/Not sure) or 9 (Refused), go to Q2.
Else, continue.
The following questions deal with suicide. Many people feel that this subject is personal, but we would appreciate you trying to answer these questions. Remember that you don't have to answer any questions that you don't want to.
SA13.1
Data Results SA13.1
Has there been a time in the past 12 months when you thought of taking your own life?
SA13.2
Data Results SA13.2
If CDC Optional Module Q24.6 = 1 (Yes, but did not require treatment), 2 (Yes, was treated at a VA facility) or 3 (Yes, was treated at a non-VA facility), read:
During the past 12 months, before you attempted suicide, did you make a plan about how you would attempt suicide?

Else, read:
During the past 12 months, did you make a plan about how you would attempt suicide?
If CDC Optional Module Q24.5 = 1 (Yes), 7 (Don't know/Not sure) or 9 (Refused), read:
As I mentioned, I would give you a phone number for an organization that can provide information and referral for these issues. You can dial the National Crisis line at 1-800-273-TALK (8255). You can also speak directly to your doctor or health provider.

Else, read:
We realize that some people may wish to talk about this topic. If you or someone you know would like to talk to a trained counselor, please call 1-800-273-TALK (8255). Would you like me to repeat this number? Do you want me to transfer you to this number?
 
 
State-Added
Module 14: Sexual Violence
These next questions may be hard for you to answer but the information is very important. These questions are about different types of physical and/or sexual violence or other unwanted sexual experiences that might or might not have happened to you since you were 18 years old. We recognize this is a sensitive topic. Some people may feel uncomfortable with these questions. The information you provide us will be kept strictly confidential. At the end of this section, I will give you a phone number for organizations that can provide information and referral for these issues. Please keep in mind that if you are not in a safe place you can ask me to skip any question you do not want to answer.
SA14.1
Data Results SA14.1
Are you in a safe place to answer these questions?
SA14.2
Data Results SA14.2
Now, I am going to ask you questions about unwanted sex.

CATI NOTE: If respondent is female read:
Unwanted sex includes things like putting anything into your vagina, anus, or mouth or making you do these things to them after you said or showed that you didn't want to.

CATI NOTE: If respondent is male read:
Unwanted sex includes things like putting anything into your anus, or mouth or making you do these things to them after you said or showed that you didn't want to.

It includes times when you were unable to consent, for example, you were drunk or asleep, or you thought you would be hurt or punished if you refused.

Has anyone EVER had sex with you after you said or showed that you didn't want them to or without your consent?

SA14.3
Data Results SA14.3
Has this happened in the past 12 months?
SA14.4
Data Results SA14.4
Think about the time of the most recent incident involving a person who had sex with you, or attempted to have sex with you, after you said or showed that you didn't want to or without your consent. What was that person's relationship to you?
We realize that this topic may bring up past experiences that some people may wish to talk about. If you or someone you know would like to talk to a trained counselor, please call 1-800-656-HOPE(4673). Would you like me to repeat this number? Do you want me to me to transfer you to this number?