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.
Crosstabulation Table:
 
CDC Core
Section 4: Exercise (Physical Activity)
4.1
Data Results 4.1
During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
Crosstabulation Table:
 
CDC Core
Section 5: Inadequate Sleep
5.1
Data Results 5.1
I would like to ask you about your sleep pattern.

On average, how many hours of sleep do you get in a 24-hour period?

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.
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?
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 incontinence.
Crosstabulation Table:
6.12
Data Results 6.12
(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:
6.13
Data Results 6.13
How old were you when you were told you have diabetes?
 
 
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.

Interviewre 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:
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 Hispanic, Latino/a, or Spanish origin?

INTERVIEWER NOTE: One or more categories may be selected.

If yes, ask: Are you…

  • Mexican, Mexican American, Chicano/a
  • Puerto Rican
  • Cuban
  • Another Hispanic, Latino/a, or Spanish origin
8.3
Data Results 8.3
Which one or more of the following would you say is your race? (Mark all that Apply)
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.

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
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
SA1.1.
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?
 
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]
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?
QUESTIONS 8.15 THROUGH 8.20 ARE ASKED ONLY OF LANDLINE RESPONDENTS
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.
Skip to Q8.19
8.18 NOTE: THIS QUESTION IS NO LONGER TO BE ASKED PER CDC, AND THE QUESTIONNAIRE NUMBERING WAS NOT ALTERED.
8.19
Data Results 8.19
Have you used the internet in the past 30 days?
8.20
Data Results 8.20
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.
8.21
Data Results 8.21
Indicate sex of respondent. (Asked Only if Necessary)
If Q8.21 = 1 (Male) or Q8.21 = 2 (female) and is 45 years old or older, skip to next section.
8.22
Data Results 8.22
To your knowledge, are you now pregnant?
 
The following questions are about health problems or impairments you may have.
Crosstabulation Table:
8.23
Data Results 8.23
Are you limited in any way in any activities because of physical, mental, or emotional problems?
Crosstabulation Table:
8.24
Data Results 8.24
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.

 
8.25
Data Results 8.25
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
 
8.26
Data Results 8.26
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
 
8.27
Data Results 8.27
Do you have serious difficulty walking or climbing stairs?
 
8.28
Data Results 8.28
Do you have difficulty dressing or bathing?
 
8.29
Data Results 8.29
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
 
 
CDC Core
Section 9: Tobacco Use
9.1
Data Results 9.1
Have you smoked at least 100 cigarettes in your entire life? [NOTE: 5 packs = 100 cigarettes]

INTERVIEWER NOTE:
“For cigarettes, do NOT include: electronic cigarettes (e-cigarettes, NJOY, Bluetip), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs), or marijuana.”
If Q9.1 = 1 (Yes); continue. Otherwise, go to Q9.5.
9.2
Data Results 9.2
Do you now smoke cigarettes every day, some days, or not at all?
Crosstabulation Table:
Summary Index Table:
If Q9.2 = 1 (Every day) or 2 (Some days); continue. Otherwise, if Q9.2 = 3 (Not at all); go to Q9.4. Else, go to Q9.5.
9.3
Data Results 9.3
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
Crosstabulation Table:
Go to Q9.5.
9.4
Data Results 9.4
How long has it been since you last smoked a cigarette, even one or two puffs?
9.5
Data Results 9.5
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 10: Alcohol Consumption
10.1
Data Results 10.1
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?
If Q10.1 = 888 “No drinks in past 30 days”, 777 “Don't know/Not sure” or 999 “Refused”; go to next section.
10.2
Data Results 10.2
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:
10.3
Data Results 10.3
Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [X = 5 for men, X = 4 for women] or more drinks on one occasion?
Crosstabulation Table:
Summary Index:
10.4
Data Results 10.4
During the past 30 days, what is the largest number of drinks you had on any occasion?
 
 
CDC Core
Section 11: Immunization
11.1
Data Results 11.1

Now I will ask you questions about the flu vaccine. There are two ways to get the 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 flu shot or a flu vaccine that was sprayed in your nose?

READ IF NECESSARY: A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.

Crosstabulation Table:
If Q11.1 = 1 (Yes); continue. Else, go to Q11.4.
11.2 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?
11.3
Data Results 11.3
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:
If respondent is less than 49 years of age, go to next section.
The next question is about the Shingles vaccine.
11.4
Data Results 11.4
Have you ever had the shingles or zoster vaccine?

INTERVIEWER NOTE (Read if necessary):Shingles is caused by the chicken pox virus. It is an outbreak of rash or blisters on the skin that may be associated with severe pain. A vaccine for shingles has been available since May 2006; it is called Zostavax®, the zoster vaccine, or the shingles vaccine.
 
 
CDC Core
Section 12: Falls
If respondent is 45 years or older continue, otherwise go to next section.
Next, I will ask about recent falls. By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.
12.1
Data Results 12.1
In the past 12 months, how many times have you fallen?
12.2
Data Results 12.2
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 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:
If Q13.1 = 8 (Never drive or ride in a car), go to Section 15; otherwise continue.
 
CDC Core
Section 14: Drinking and Driving
If Q10.1 = 888 (No drinks in the past 30 days); go to next section.
The next question is about drinking and driving.
14.1
Data Results 14.1
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 15: Breast and Cervical Cancer Screening
If respondent is MALE, go to the next section.
The next questions are about breast and cervical cancer.
15.1
Data Results 15.1
A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
15.2
Data Results 15.2
How long has it been since you had your last mammogram?
Crosstabulation Table:
15.3
Data Results 15.3
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?
15.4
Data Results 15.4
How long has it been since your last breast exam?
15.5
Data Results 15.5
A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?
15.6
Data Results 15.6
How long has it been since you had your last Pap test?
Crosstabulation Table:
If response to Core Q7.23 = 1 (is pregnant); then go to next section.
15.7
Data Results 15.7
Have you had a hysterectomy?
Read only if necessary:A hysterectomy is an operation to remove the uterus (womb).
 
 
CDC Core
Section 16: 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.
16.1
Data Results 16.1
A Prostate-Specific Antigen test, also called a PSA test, is a blood test used to check men for prostate cancer. Has a doctor, nurse, or other health professional EVER talked with you about the advantages of the PSA test?
16.2
Data Results 16.2
Has a doctor, nurse, or other health professional EVER talked with you about the disadvantages of the PSA test?
16.3
Data Results 16.3
Has a doctor, nurse, or other health professional EVER recommended that you have a PSA test?
16.4
Data Results 16.4
Have you EVER HAD a PSA test?
If Q16.4 = 1 (Yes); continue. Else, go to next section.
16.5
Data Results 16.5

How long has it been since you had your last PSA test?

Crosstabulation Table:
16.6
Data Results 16.6

What was the MAIN reason you had this PSA test ? was it ...?

  • Part of a routine exam
  • Because of a prostate problem
  • Because of a family history of prostate cancer
  • Because you were told you had prostate cancer
  • Some other reason
 
 
CDC Core
Section 17: Colorectal Cancer Screening
If respondent is < 50 years of age, go to next section.
The next questions are about colorectal cancer screening.
17.1
Data Results 17.1
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?
17.2
Data Results 17.2
How long has it been since you had your last blood stool test using a home kit?
Crosstabulation Table:
17.3
Data Results 17.3
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:
17.4
Data Results 17.4
For a SIGMOIDOSCOPY, a flexible tube is inserted into the rectum 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?
17.5
Data Results 17.5
How long has it been since you had your last sigmoidoscopy or colonoscopy?
Crosstabulation Table:
 
 
CDC Core
Section 18: HIV/AIDS
The next few questions are about the national health problem of HIV, the virus that causes AIDS. Please remember that your answers are sSA5ctly 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.
18.1
Data Results 18.1
Have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation. Include testing fluid from your mouth.
If Q18.1 = 1 (Yes); continue. Otherwise, go to Q18.3.
18.2 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.”

NOTE: If the respondent remembers the year but cannot remember the month, code the first two digits 77 and the last four digits for the year.
18.3
Data Results 18.3
Where did you have your last HIV test — at a private doctor or HMO office, at a counseling and testing site, at an emergency room, as an inpatient in a hospital, at a clinic, in a jail or prison, at a drug treatment facility, at home, or somewhere else?
  • Private doctor or HMO office
  • Counseling and testing site
  • Emergency room
  • Hospital inpatient
  • Clinic
  • Jail or prison (or other correctional facility)
  • Drug treatment facility
  • At home
  • Somewhere else
 
Modules Asked of All Respondents (before split into Parts A & B)
CDC Optional
Module 17: 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.
M17.1
Data Results M17.1
What is the birth month and year of the “X"th child?
M17.2
Data Results M17.2
Is the child a boy or a girl?
M17.3
Data Results M17.3
Is the child Hispanic, Latino/a, or Spanish origin?

INTERVIEWER NOTE: One or more categories may be selected.

If yes, ask: Are they…

  • Mexican, Mexican American, Chicano/a
  • Puerto Rican
  • Cuban
  • Another Hispanic, Latino/a, or Spanish origin
M17.4
Data Results M17.4
Which one or more of the following would you say is the race of the child?
[Check all that apply]
If more than one response to M17.4, continue. Otherwise, go to M17.6.
M17.5
Data Results M17.5
Which one of these groups would you say best represents the child's race?
M17.6
Data Results M17.6
How are you related to the child?
 
CDC Optional
Module 18: Childhood Asthma Prevalence
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.
M18.1
Data Results M18.1
Has a doctor, nurse, or other health professional EVER said that the child has asthma?
If M18.1 = 1 “Yes”; continue. Otherwise, go to next module.
M18.2
Data Results M18.2
Does the child still have asthma?
Crosstabulation Table:
 
 
State-Added
Module 2: Childhood Diabetes
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” [Fill in correct number] child.
SA2.1
Data Results SA2.1
Has a doctor, nurse or other health professional EVER said the child has diabetes?
 
 
State-Added
Module 3: Asthma Call Back Survey Information
If Q6.4 = ‘yes” or Childhood Asthma Prevalence Module Q18.1 = ‘Yes’ and Random Child Selection Module Q17.6 = “Parent” (1) or “Foster parent or guardian” (3) then continue. Otherwise, go to next module.
SA3.1
We would like to call you again within the next 2 weeks to talk in more detail about [Fill: 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 section questions and the module is asked of every respondent. However, the additional CDC Optional 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
Only asked of those not responding “Yes” (code = 1) to Core Q6.12 (if assigned qstver=11 (Part A)).
M1.1
Data Results M1.1
Have you had a test for high blood sugar or diabetes within the past three years?
If Core Q6.12 = 4 (No, pre-diabetes or borderline diabetes); answer Q2 “Yes” (code = 1).
M1.2
Data Results M1.2

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

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

Crosstabulation Table:
 
 
State-Added
Module 4: Diabetes Risk Assessment
SA4.1
Data Results SA4.1

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

  • Mother
  • Father
  • Brothers [INTERVIEWER INSTRUCTION: include half brother]
  • Sisters [INTERVIEWER INSTRUCTION: include half sister]
  • No one
If respondent is FEMALE; continue. Otherwise, go to next module.
SA4.2
Data Results SA4.2
Have you had a baby weighing more then 9 pounds at birth?
 
 
State-Added
Module 5: Tobacco Indicators
Now I’m going to ask you some questions about smoking inside the home.
SA5.1
Data Results for SA5.1
Not counting decks, porches, or garages, during the past 7 days, that is, since last [Fill with TODAY’S DAY OF WEEK], on how many days did someone other than you smoke tobacco inside your home while you were at home?
SA5.2
Data Results for SA5.2
Not counting decks, porches, or garages, inside your home, is smoking …?
  • Always allowed
  • Allowed only at some times or in some places
  • Never allowed
Now we have two questions about smoking in vehicles.
SA5.3
Data Results for SA5.3
During the past 7 days, that is, since last [Fill with TODAY’S DAY OF WEEK], on how many days did you ride in a vehicle where someone other than you was smoking tobacco?
SA5.4
Data Results for SA5.4
Not counting motorcycles, in the vehicles that you or family members who live with you own or lease, is smoking…?

  • Always allowed in all vehicles
  • Sometimes allowed in at least one vehicle
  • Never allowed in any vehicle
 
 
State-Added
Module 6: Oral Health
SA6.1
Data Results SA6.1
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:
SA6.2
Data Results SA6.2
During the past 12 months, was there any time when you needed dental care but did not get it?
Crosstabulation Table:
If SA6.2 = 1 (Yes); continue. Otherwise, go to SA6.4.
SA6.3
Data Results SA6.3
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
  • No Dental Insurance
  • Did not need/want to go
  • Did not like/was not satisfied with dentist
SA6.4
Data Results SA6.4
In the past 12 months, have you had a dentist, hygienist, or other oral health professional check for oral cancer by pulling on your tongue, sometimes with gauze wrapped around it, and feeling under the tongue and inside the cheeks?
 
 
CDC Optional
Module 5: Alcohol Screening & Brief Intervention (ASBI)
If Q3.4 = 1 OR 2 (had a checkup within the past 2 years); continue. Otherwise, go to next module.
Healthcare providers may ask during routine checkups about behaviors like alcohol use, whether you drink or not. We want to know about their questions.
M5.1
Data Results M5.1
You told me earlier that your last routine checkup was [If Q3.4 = 1 fill “within the past year” or Q3.4 = 2 fill “within the past 2 years”]. At that checkup, were you asked in person or on a form if you drink alcohol?
M5.2
Data Results M5.2
Did the health care provider ask you in person or on a form how much you drink?
M5.3
Data Results M5.3
Did the healthcare provider specifically ask whether you drank [If Sex = 1 then fill “5” for men or Sex = 2 then fill “4” for women] or more alcoholic drinks on an occasion?
M5.4
Data Results M5.4
Were you offered advice about what level of drinking is harmful or risky for your health?
If M5.1, M5.2 OR M5.3 = 1 (Yes); continue. Otherwise, go to next module.
M5.5
Data Results M5.5
Healthcare providers may also advise patients to drink less for various reasons. At your last routine checkup, were you advised to reduce or quit your drinking?
 
 
SKIP THE THREE LAST MODULES AT THIS POINT: CDC MODULE 16: Sexual Orientation and Gender Identity, STATE-ADDED MODULE 7: Adverse Childhood Experiences & STATE-ADDED MODULE 8: Sexual Violence, THESE WERE ASKED OF ALL RESPONDENTS AT THE END OF THE SURVEY (END OF EACH SPLIT (PART A & B).
 
Part B
Summary Index Table:
 
State-Added
Module 9: Childhood Immunization (Influenza)
NOTE: Question 3 was inadvertenly not added to the Original Survey Programming. So, in January and February in both Landline & Cell Phone and in Landline for August, data for these months are missing.
 
If response to Core Q8.7 = 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.
 
The next two questions are about the “Xth” [fill in correct number] child.
SA9.1
Data Results SA9.1
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?
If SA9.1 = 1 (Yes); continue. If SA9.1 = 2 (No); go to SA9.3. Otherwise, go to next module.
SA9.2 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.
If SA9.2 = 77/7777 (Don't know/Not sure) or 99/9999 (Refused); continue. Otherwise, go to next module.
SA9.3
Data Results SA9.3
What is the MAIN reason [Fill: he/she] has not received a flu vaccination for this current flu season?

Do not read answer choices below. Select category that best matches response.
  • Child does not need it
  • Doctor did not recommend it
  • Did not know that child should be vaccinated
  • Flu is not that serious
  • Child had the flu already this flu season
  • Side effects/can cause flu
  • Does not work
  • Plan to get child vaccinated later this flu season
  • Flu vaccination costs too much
  • Inconvenient to get vaccinated
  • Saving vaccine for people who need it more
  • Tried to find vaccine, but could not get it
  • Not eligible to receive vaccine
  • Other
  • Have no got around to it/didn’t get it
  • Parent does not believe/approve, or is against, flu shots
 
 
State-Added
Module 10: Adolescent Tetanus-Diphtheria-Pertussis Immunization
If Core Q8.7 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module.
If selected child's age is 11 through 17 years old, continue. Otherwise, go to next module.
If selected child's age is not given (don't know/not sure or refused), 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 [FILL: he/she] received a tetanus shot in the past 10 years?
If Core SA10.1 = 1 (Yes), continue. Otherwise, go to next module.
SA10.2
Data Results SA10.2
Was [Fill: he/she] most recent tetanus given in 2005 or after that?
If Core SA10.1 = 2 (No), go to next module. Otherwise, continue.
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?
 
 
State-Added
Module 11: Health Literacy
Now I would like to ask you some questions about medical forms or medical information.
SA11.1
Data Results for SA11.1
How confident are you in filling out medical forms by yourself? For example insurance forms, questionnaires, and doctor?s office forms. Would you say...?
  • Not at all
  • A little
  • Somewhat
  • Quite a bit
  • Extremely
Crosstabulation Table:
SA11.2
Data Results for SA11.2
How often do you have problems learning about your health condition because of difficulty in understanding written information? Would you say...?

Interviewer Probe: If respondent states they do not have a health condition, say: "This would include any routine visit to a doctor?s office for a physical exam, women?s health exam or men?s health exam."
  • Always
  • Often
  • Sometimes
  • Rarely
  • Never
Crosstabulation Table:
SA11.3
Data Results for SA11.3
How often do you have someone help you read medical materials? For example: family member, friend, caregiver, doctor, nurse or other health professional. Would you say...?
  • Always
  • Often
  • Sometimes
  • Rarely
  • Never
Crosstabulation Table:
 
State-Added
Module 12: Chronic Fatigue Syndrome
SA12.1
Data Results for SA12.1
Have you ever been told by a doctor or other health professional that you had Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME)?
If SA12.1 = 1; continue. Otherwise, go to next module.
SA12.2
Data Results for SA12.2
Do you still have Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME)?
 
Modules Asked of All Respondents (at end of Parts A & B)
CDC Optional
Module 16: Sexual Orientation and Gender Identity
The next two questions are about sexual orientation and gender identity.
M16.1
Data Results M16.1
Do you consider yourself to be:

Please read (include number before the text):
  • 1 - Straight
  • 2 - Lesbian or gay
  • 3 - Bisexual
M16.2
Data Results M16.2
Do you consider yourself to be transgender?

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

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

INTERVIEWER NOTE: If asked about definition of gender non-conforming, read:
“Some people think of themselves as gender non-conforming when they do not identify only as a man or only as a woman.”
 
State-Added
Module 7: Adverse Childhood Experiences
I’d like to ask you some questions about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life, and may help others in the future. This is 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.

All questions refer to the time period before you were 18 years of age. Now, looking back before you were 18 years of age-
SA7.1
Data Results SA7.1
Did you live with anyone who was depressed, mentally ill, or suicidal?
SA7.2
Data Results SA7.2
Did you live with anyone who was a problem drinker or alcoholic?
SA7.3
Data Results SA7.3
Did you live with anyone who used illegal street drugs or who abused prescription medications?
SA7.4
Data Results SA7.4
Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
SA7.5
Data Results SA7.5
Were your parents separated or divorced?
SA7.6
Data Results SA7.6
How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up? Would you say...
  • Never
  • Once
  • More than once
SA7.7
Data Results SA7.7
Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking. Would you say...
  • Never
  • Once
  • More than once
SA7.8
Data Results SA7.8
How often did a parent or adult in your home ever swear at you, insult you, or put you down? Would you say...
  • Never
  • Once
  • More than once
SA7.9
Data Results SA7.9
How often did anyone at least 5 years older than you or an adult, ever touch you sexually? Would you say...
  • Never
  • Once
  • More than once
SA7.10
Data Results SA7.10
How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually? Would you say...
  • Never
  • Once
  • More than once
SA7.11
Data Results SA7.11
How often did anyone at least 5 years older than you or an adult, force you to have sex? Would you say...
  • Never
  • Once
  • More than once
As I mentioned when we started this section, I will give you a phone number for an organization that can provide information and referral for these issues.
Please contact The National Hotline for Child Abuse at 1-800-422-4453. Again that number is 1-800-422-4453.
 
State-Added
Module 8: Sexual Violence
Now I’d like to ask you some questions about different types of physical and/or sexual violence or other unwanted sexual experiences. This information will allow us to better understand the problem of violence and unwanted sexual contact and may help others in the future. This is a sensitive topic. Some people may feel uncomfortable with these questions. At the end of this section, I will give you phone numbers 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.
SA8.1
Data Results for SA8.1
Are you in a safe place to answer these questions?
Now, I am going to ask you questions about unwanted sex. Unwanted sex includes things like putting anything into your vagina [If female], 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.
SA8.2
Data Results for SA8.2
Has anyone EVER had sex with you after you said or showed that you didn’t want them to or without your consent?
Now we have two questions about smoking in vehicles.
SA8.3
Data Results for SA8.3
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?
  • Personal attendant/caregiver
  • Someone you were dating
  • Boyfriend/Girlfriend
  • Stranger
  • Spouse or live-in partner
  • Relative
  • Friend
  • Acquaintance
Closing Statement of Sexual Violence Module: 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 the Kansas Crisis Hotline at 1-888-END-ABUSE, that is 1-888-363-2287. Again, that number 1-888-END-ABUSE, that is 1-888-363-2287.