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:
If Q2.1 & Q2.2 both equal 88 - None, go to next module. Otherwise, continue.
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, government plans such as Medicare, or Indian Health Service?
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: 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:
If Q4.1 equal 1-Yes, continue. Otherwise, go to next module.
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?
If Q5.1 equal 1-Yes, continue. Otherwise, go to next module.
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 general health conditions.
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
(Ever told) you had asthma?
If Q6.4 equal 1-Yes, continue. Otherwise, go to Q6.6.
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 types of cancer?
Crosstabulation Table:
6.8
Data Results 6.8
(Ever told) you have Chronic Obstructive Pulmonary Disease or COPD, emphysema or chronic bronchitis?
Crosstabulation Table:
6.9
Data Results 6.9
(Ever told) 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:
If Q6.12 equal 1-Yes, continue.
If Q6.12 > 1 & Qstver = 11 or 21, go to CDC Diabetes Optional Module 2.
Otherwise, goes to next section.
6.13
Data Results 6.13
How old were you when you were told you have diabetes?
 
 
CDC Core
Section 7: Demographics
7.1
Data Results 7.1
Indicate sex of respondent. (Asked Only if Necessary)
7.2
Data Results 7.2
What is your age?
7.3
Data Results 7.3
Are you Hispanic, Latino/a, or Spanish origin?
7.4
Data Results 7.4
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.
7.5
Data Results 7.5
Which one of these groups would you say BEST represents your race?
7.6
Data Results 7.6
Are you:
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
7.7
Data Results 7.7
What is the highest grade or year of school you completed?
7.8
Data Results 7.8
Do you own or rent your home?
7.9 What county do you live in?
7.10
What is your ZIP Code where you live?
Data Results Table:
If Landline Survey; continue.

If Cell Phone Survey; skip to Q7.14.
7.11 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.
If Q7.11 = 1 (Yes), continue. Otherwise, go to Q7.13.
7.12 How many of these phone numbers are residential numbers?
7.13 Do you have a cell phone for personal use? Please include cell phones used for both business and personal use.
7.14
Data Results 7.14

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?

INTERVIEWER NOTE: 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:
7.15
Data Results 7.15
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
7.16
Data Results 7.16
How many children less than 18 years of age live in your household ?
7.17
Data Results 7.17
Is your annual household income from all sources:
  • Less than $25,000 ($20,000 to less than $25,000)
  • Less than $20,000 ($15,000 to less than $20,000)
  • Less than $15,000 ($10,000 to less than $15,000)
  • Less than $10,000

  • or
  • Less than $35,000 ($25,000 to less than $35,000)
  • Less than $50,000 ($35,000 to less than $50,000)
  • Less than $75,000 ($50,000 to less than $75,000)
  • $75,000 or more
 
State-Added
State-Added 1: Average Hours Worked
If Core Q7.15 = 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.
1.
Data Results SA1.1
Previously, you indicated you were (a) [insert response from core 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 Q7.18, and continue with the survey.
 
7.18
Data Results 7.18
Have you used the internet in the past 30 days?
7.19 About how much do you weigh without shoes?
[Round fractions up]
7.20 About how tall are you without shoes?
[Round fractions down]
Crosstabulation Table:
Summary Index Table:
If Q7.01 = 1 (Male) or Q7.01 = 2 (female) and Q7.02 >= 45 years old or older, skip to next section. Otherwise, continue.
7.21
Data Results 7.21
To your knowledge, are you now pregnant?
 
The following questions are about health problems or impairments you may have.
Crosstabulation Table:
Summary Index:
7.22
Data Results 7.22
Are you limited in any way in any activities because of physical, mental, or emotional problems?
Crosstabulation Table:
7.23
Data Results 7.23
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.

7.24
Data Results 7.24
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
7.25
Data Results 7.25
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
7.26
Data Results 7.26
Do you have serious difficulty walking or climbing stairs?
7.27
Data Results 7.27
Do you have difficulty dressing or bathing?
7.28
Data Results 7.28
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 8: Tobacco Use
8.1
Data Results 8.1
Have you smoked at least 100 cigarettes in your entire life?
[NOTE: 5 packs = 100 cigarettes]
If Q8.1 = 1 (Yes); continue. Otherwise, go to Q8.5.
8.2
Data Results 8.2
Do you now smoke cigarettes every day, some days, or not at all?
Crosstabulation Table:
Summary Index Table:
If Q8.2 = 1 (Every day) or 2 (Some days); continue. Otherwise, if Q8.2 = 3 (Not at all); go to Q8.4. Else, go to Q8.5.
8.3
Data Results 8.3
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 Q8.5.
8.4
Data Results 8.4
How long has it been since you last smoked a cigarette, even one or two puffs?
8.5
Data Results 8.5
Do you currently use chewing tobacco, snuff or snus every day, some days or not at all? (Snus rhymes with "goose")

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 9: Alcohol Consumption
9.1
Data Results 9.1
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 Q9.1 = 888 "No drinks in past 30 days", 777 "Don't know/Not sure" or 999 "Refused"; go to next section.
9.2
Data Results 9.2
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:
9.3
Data Results 9.3
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:
9.4
Data Results 9.4
During the past 30 days, what is the largest number of drinks you had on any occasion?
 
CDC Core
Section 10: Fruits and Vegetables
Crosstabulation Table:
Summary Index:
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?"
10.1
Data Results 10.1
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" Q11.6.

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.

10.2
Data Results 10.2
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 INCLUDE fruit jam, jelly, or fruit preserves.

DO NOT INCLUDE dried fruit in ready-to-eat cereals.

INCLUDE dried raisins, cran-raisins if respondent tells you (but due to their small serving size they are not included In the prompt).

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.).

10.3
Data Results 10.3
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.

10.4
Data Results 10.4
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.

DO NOT INCLUDE iceberg (head) lettuce if specifically told type of lettuce.

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

INCLUDE all cooked greens including kale, collard greens, choys, turnip greens, mustard greens.

10.5
Data Results 10.5
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."

INTERVIEWER NOTE:

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 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).

10.6
Data Results 10.6
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:

DO NOT INCLUDE products consumed usually as condiments including ketchup, catsup, salsa, chutney, relish.

DO NOT INCLUDE rice or other grains.

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).

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.).

 
 
CDC Core
Section 11: Exercise (Physical Activity)
Crosstabulation Table:
Summary Index::
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.
11.1
Data Results 11.1
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 Q11.1 = 1 "Yes"; continue, otherwise go to Q11.8.
11.2
What type of physical activity or exercise did you spend the most time doing during the past month? (First Activity)
See Physical Activity Coding List (Please refer to the .pdf of the Questionnaire for the 2015 survey.)

INTERVIEWER INSTRUCTION: If the respondent's activity is not included in the Physical Activity Coding List, 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 Q11.2 = 77 "Don't know/Not sure" or 99 "Refused", go to Q11.8.
11.3
Data Results 11.3
How many times per week or per month did you take part in this activity during the past month? (First Activity)
11.4
Data Results 11.4
And when you took part in this activity, for how many minutes or hours did you usually keep at it? (First Activity)
11.5
What other type of physical activity gave you the next most exercise during the past month? (Second Activity)
See Physical Activity Coding List (Please refer to the .pdf of the Questionnaire for the 2015 survey.)

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

CATI NOTE: If Q11.5 = 88 "No other activity", 77 "Don't know/Not sure" or 99 "Refused", go to Q11.8.
11.6
Data Results 11.6
How many times per week or per month did you take part in this activity during the past month?(Second Activity)
11.7
Data Results 11.7
And when you took part in this activity, for how many minutes or hours did you usually keep at it? (Second Activity)
11.8
Data Results 11.8
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 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: Next question, Q12.2, 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 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.
 
 
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 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 Q14.1 = 1 (Yes); continue. Else, go to Q14.4.
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: HIV/AIDS
The next few questions are about the national health problem of HIV, the virus that causes AIDS. Please remember that your answers are strictly confidential and that you do not have to answer every question if you don't want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.
15.1
Data Results 15.1
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.
Crosstabulation Table:
Summary Index Table:
If Q15.1 = 1 (Yes); continue. Otherwise, go to NEXT MODULE.
15.2 Not including blood donations, in what month and year was your last HIV test?

INTERVIEWER NOTE:

If response is before January 1985, code "Don't know."

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.

15.3
Data Results 15.3
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
 
State-Added
Module 2: Lung Cancer Screening Questions
If Q6.7 = 1 (Yes); continue. Otherwise, go to NEXT MODULE.
SA2.1
Data Results SA2.1
Have you ever been told by a doctor or other health professional that you have lung cancer?
If SA2.1 = 1 (Yes); go to next module. Otherwise, continue.
If Q7.2 >= 50 years old
AND
([If Q8.2 = 1,2] OR [If Q8.2 = 3 & Q8.4 = 01-07])
AND
([If Q6.7 = 2,7,9] OR [If Q2.1 = 2,7.9]), continue.

Otherwise, go to next module.
SA2.2
Data Results SA2.2
Have you discussed with your health care provider whether or not to be screened for lung cancer?

INTERVIEWER NOTE:

X-rays and CT scans of the chest area are tests sometimes used to screen for lung cancer.

 
 
CDC Optional
Module 22: Random Child Selection

CATI NOTE: If Core Question 7.16 = 88, or 99 (no children under age 18 in the household or refused); go to NEXT MODULE.

INTERVIEWER INSTRUCTION:

If Core Section Q7.16 = 1 Child, interviewer please read:
"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 Section Q7.16 > 1 Child, interviewer please read:
"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."

I have some additional questions about one specific child. The child I will be referring to is the "Xth" child in your household. All following questions about children will be about the "Xth" child.
M22.1
Data Results M22.1
What is the birth month and year of the "Xth" child?
M22.2
Data Results M22.2
Is the child a boy or a girl?
M22.3
Data Results M22.3
Is the child Hispanic, Latino/a, or Spanish origin?
M22.4
Data Results M22.4
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 M22.4, continue. Otherwise, go to M22.6.
M22.5
Data Results M22.5
Which one of these groups would you say best represents the child's race?
M22.6
Data Results M22.6
How are you related to the child?
 
CDC Optional
Module 23: Childhood Asthma Prevalence
CATI NOTE: If response to Core Q7.16 = 88 "No children under age 18" or 99 "Refused", go to NEXT MODULE.
The next two questions are about the "Xth" child.
M23.1
Data Results M23.1
Has a doctor, nurse, or other health professional EVER said that the child has asthma?
If M23.1 = 1 "Yes"; continue. Otherwise, go to NEXT MODULE.
M23.2
Data Results M23.2
Does the child still have asthma?
Crosstabulation Table:
 
 
State-Added
Module 3: Asthma Call Back Survey Information
If Adult Asthma Q6.4 = 1 (Yes) or Childhood Asthma Prevalence CDC Module Q23.1 = 1 (Yes) and Random Child Selection CDC Module Q22.6 = 1 (Parent) or 3 (Foster parent or guardian) 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 your experiences with asthma. The information will be used to help develop programs 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 all right if we call back at a later time to ask additional questions about your asthma?
 
 
Part A
Summary Index Table:
 
CDC Optional
Module 2: Diabetes
CATI NOTE:
If Core Section 7 Q6.12 = 1, continue. Otherwise, go to Core Section 7.

Only asked of those responding "Yes" (code = 1) to Core Section Q6.12 (Diabetes awareness question).
M2.1
Data Results M2.1
Are you now taking insulin?
M2.2
Data Results M2.2
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.
M2.3
Data Results M2.3
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.
M2.4
Data Results M2.4
About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
M2.5
Data Results M2.5
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"?
If M2.3 = 555 (No feet), go to M2.7.
M2.6
Data Results M2.6
About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
M2.7
Data Results M2.7
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.
M2.8
Data Results M2.8
Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
M2.9
Data Results M2.9
Have you ever taken a course or class in how to manage your diabetes yourself?
CATI NOTE: Go Back to Core Q7.18.
 
 
State-Added
Module 6: Diabetes Risk Assessment
SA6.1
Data Results SA6.1

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

  • Mother
  • Father
  • Brothers [INTERVIEWER INSTRUCTION: include half brother]
  • Sisters [INTERVIEWER INSTRUCTION: include half sister]
  • No one
CATI NOTE: If respondent is female (Q8.1 = 2), continue. Otherwise, go to NEXT MODULE.
SA6.2
Data Results SA6.2
Have you had a baby weighing more then 9 pounds at birth?
 
 
State-Added
Module 7: Self-Monitoring Blood Pressure Monitoring
If CDC Core Section Q4.1 = 1 (Yes) or 4 (Told borderline high or pre-hypertensive), continue. Otherwise, got to next module.
SA7.1
Data Results SA7.1
Do you measure your blood pressure at home?
Crosstabulation Table:
If SA7.1 = 1 (Yes), continue. Otherwise, got to next module.
SA7.2
Data Results SA7.2
How often do you measure your blood pressure at home?
SA7.3
Data Results SA7.3
What type of blood pressure monitor do you use?

INTERVIEWER NOTE: A manual blood pressure monitor uses a stethoscope, an arm cuff, a squeeze bulb, and a gauge, while an automated one has a self-inflating cuff and digital read-out. A hybrid monitor includes a manually inflated cuff and digital read-out.
SA7.4
Data Results SA7.4
Do you regularly transmit, via e-mail, Internet, phone or fax, blood pressure readings to a health care provider for feedback?
 
 
State-Added
Module 8: Farmers´ Market
SA8.1
Data Results for SA8.1
How often in the past 12 months did you buy fruits or vegetables from a farmers´ market?
Crosstabulation Table:
If SA8.1 = 555 (Never); continue. Otherwise, go to next module.
SA8.2
Data Results for SA8.2
What is the main reason you do not purchase your fruits and vegetables from a farmers´ market?
 
 
State-Added
Module 9: Tobacco Indicators
Now I would like to ask you some questions about your use of other tobacco products.
SA9.1
Data Results SA9.1
Have you ever used or tried Electronic Cigarettes or E-cigarettes, such as Ruyan or NJOY?

INTERVIEWER NOTE: The act of using electronic cigarettes is sometimes called "vaping."
Crosstabulation Table:
If SA9.1 = 1 (Yes); continue. Otherwise, go to SA9.3.
SA9.2
Data Results SA9.2
During the past 30 days, that is, since [CATI NOTE: FILL IN DATE], on how many days did you use Electronic Cigarettes or E-cigarettes?
Crosstabulation Table:
SA9.3
Data Results SA9.3
The next question asks you about smoking tobacco in a water pipe. A water pipe is also called a hookah. Have you ever tried smoking tobacco in a water pipe, even one or two puffs?
Crosstabulation Table:
If SA9.3 = 1 (Yes); continue. Otherwise, go to SA9.5.
SA9.4
Data Results SA9.4
During the past 30 days, that is, since [CATI NOTE: FILL IN DATE], on how many days did you smoke tobacco in a water pipe?
Crosstabulation Table:
Next I would like to ask you about stores that sell tobacco products near schools.
SA9.5
Data Results SA9.5
Do you support or oppose displaying tobacco products, such as cigarettes, cigars and smokeless tobacco, in stores located near schools?
Crosstabulation Table:
 
State-Added
Module 10: Sunburn
The next question is about sunburns, including any time that even a small part of your skin was red for more than 12 hours.
SA10.1
Data Results SA10.1
Have you had a sunburn within the past 12 months?
Crosstabulation Table:
 
 
State-Added
Module 11: Clinical Trials
SA11.1
Data Results SA11.1
A clinical trial is a type of research study that involves people to test new methods of screening, prevention, diagnosis, or treatment of a disease. Has your health care provider ever talked to you about participating in a clinical trial?
CATI NOTE: If CDC Core Section Q6.6 = 1 (Yes) OR CDC Core Section Q6.7 = 1 (Yes), continue. Otherwise, go to next module.
SA11.2
Data Results SA11.2
Have you ever been enrolled in a cancer clinical trial managed by your Kansas health care provider?
 
 
State-Added
Module 12: Family History of Cancer, Genetic Counseling/Testing
SA12.1
Data Results SA12.1
Do you have a family history of [CATI NOTE: Fill; if female, "breast, ovarian, or colorectal" or if male, "breast or colorectal"] cancer? Include only blood relatives. Do not include adoptive or those related only by marriage.
Crosstabulation Table:
SA12.2
Data Results SA12.2
Have you ever received genetic counseling for cancer? This would include a conversation with an expert, a suitably trained health care provider, about your hereditary risk of cancer.
SA12.3
Data Results SA12.3
Have you ever had a blood or saliva test to determine your hereditary risk for cancer? A doctor or other health professional would have ordered this test and you would have received the results.
 
 
CDC MODULE 21: Sexual Orientation and Gender Identity, STATE-ADDED MODULE 4: Adverse Childhood Experiences & STATE-ADDED MODULE 5: Sexual Violence
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 13: Oral Health
SA13.1
Data Results SA13.1
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:
SA13.2
Data Results SA13.2
During the past 12 months, was there any time when you needed dental care but did not get it?
Crosstabulation Table:
CATI NOTE: If SA13.2 = 1(Yes), continue. Otherwise, go to SA13.4.
SA13.3
Data Results SA13.3
What was the main reason you did not receive the dental care you needed?
SA13.4
Data Results SA13.4
In the past 12 months, have you visited a hospital emergency room for relief of dental pain in your mouth not related to injury?

INTERVIEWER NOTE: Dental pain or pain in your mouth include toothache, swelling, abscess, bleeding, or sores in your gums, cheek, tongue, or lips.
 
CDC Module
Module 10: Arthritis Management
CATI NOTE: If CDC Core Section Q6.9 = 1 (Yes), continue. Otherwise, go to next module.
M10.1
Data Results M10.1
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?
M10.2
Data Results M10.2
Has a doctor or other health professional EVER suggested losing weight to help your arthritis or joint symptoms?
M10.3
Data Results M10.3

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.

M10.4
Data Results M10.4
Have you EVER taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?
 
 
State-Module
Module 14: Hepatitis C Virus Testing
SA14.1
Data Results SA14.1
Has your doctor ever recommended that you be tested for hepatitis C virus?
SA14.2
Data Results SA14.2
When was the last time you were tested for hepatitis C? Do not count tests you may have had as part of a blood donation. Include testing fluid from your mouth.
 
 
State-Module
Module 15: Adolescent Immunization - Meningococcal Vaccination
CATI NOTE: If Childís age is between 11 and 17 years (CHLDAGE2 => 11), continue. Otherwise, go to next module.
SA15.1
Data Results SA15.1
A vaccine to prevent some types of meningitis caused by bacteria is available. Has this child ever had the Meningococcal vaccination?
 
 
State-Module
Module 16: Child Immunization (Influenza)
CATI NOTE: If CDC Core Section Q8.7 = 88 or 99 (No children under age 18 in the household or Refused), go to next module.
CATI NOTE: If selected childís age is 6 months or greater (CHLDAGE1 = 6), continue. Otherwise, go to next module.
SA16.1
Data Results SA16.1
During the past 12 months, has [CATI NOTE: 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 SA16.1 = 1(Yes), continue. If SA16.1 = 2(No), go to SA16.3. Otherwise, go to next module.
SA16.2
 
During what month and year did [CATI NOTE: 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?
CATI NOTE: If SA16.2 = 777777 OR 999999, continue. Otherwise, go to next module.
SA16.3
Data Results SA16.3

What is the MAIN reason [CATI NOTE: Fill: he/she] has not received a flu vaccination for this current flu season?

INTERVIEWER NOTE:
Do not read answer choices below. Select category that best matches response.

 
 
State-Added
Module 17: Tick Borne Disease
SA17.1
Data Results SA17.1

In the past 12 months have you been told by your doctor or healthcare provider that you have a tick-borne diseases?

INTERVIEWER NOTE:
A tick-borne disease is a disease passed by the bite of an infected tick to a human. The following are a list of tick-borne diseases found in the United States; Lyme disease, ehrlichiosis, anaplasmosis, Rocky Mountain Spotted Fever, tularemia, babesiosis, and tick-associated rash illness (STARI).

CATI NOTE: If SA17.1 = 1(Yes), continue. Otherwise, go to SA17.3.
SA17.2
Data Results SA17.2
Which tick-borne disease have you been told by your doctor or healthcare provider that you had in the past 12 months?
SA17.3
Data Results SA17.3
How many dogs do you have?
CATI NOTE: If SA17.3 = 2-6, continue. Otherwise, go to next module.
SA17.4
Data Results SA17.4
In the past 12 months, how many of your dog(s) has a veterinarian told you had ehrilichiosis (er-lick-e-osis)?
 
CDC
Module 20: Social Context
Now, I am going to ask you about several factors that can affect a person's health.
If Core Section Q7.8 = 1 (own) or 2 (rent); continue. Else, go to M20.2.
M20.1
Data Results M20.1
How often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage? Would you say you were worried or stressed---
  • Always
  • Usually
  • Sometimes
  • Rarely
  • Never
Crosstabulation Table:
M20.2
Data Results M20.2
How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or stressed---
  • Always
  • Usually
  • Sometimes
  • Rarely
  • Never
Crosstabulation Table:
If Core Section Q7.15 = 1 (Employed for wages), 2 (Self-employed) or 9 (Refused); continue to Q3 and Q4.
If Core Section Q7.15 = 3 (Out of work for 1 year or more), 4 (Out of work for less than 1 year), or 7 (Retired); go to Q5 and Q6.
If Core Section Q7.15 = 5 (A homemaker), 6 (A student), or 8 (Unable to work); go to next module.
M20.3
Data Results M20.3
At your main job or business, how are you generally paid for the work you do. Are you:
  • Paid by salary
  • Paid by the hour
  • Paid by the job/task (e.g. commission, piecework)
  • Paid some other way

INTERVIEWER NOTE: If paid in multiple ways at their main job, select option 4 (Paid some other way).
M20.4
Data Results M20.4
About how many hours do you work per week at all of your jobs and businesses combined?
CATI Interviewer Instruction: Go to next module.
M20.5
Data Results M20.5
Thinking about the last time you worked, at your main job or business, how were you generally paid for the work you do? Were you:
  • Paid by salary
  • Paid by the hour
  • Paid by the job/task (e.g. commission, piecework)
  • Paid some other way

INTERVIEWER NOTE: If paid in multiple ways at their main job, select option 4 (Paid some other way).
M20.6
Data Results M20.6
Thinking about the last time you worked, about how many hours did you work per week at all of your jobs and businesses combined?
 
State-Added
Module 18: Prescription Drug Overdose
SA18.1
Data Results SA18.1
In the past year, did you use prescription pain medication that was NOT prescribed specifically to you by a doctor?
We only want to know about prescription medication NOT medication that is available over the counter.
CATI NOTE: If SA18.1 = 1(Yes), continue. Otherwise, go to next module.
SA18.2
Data Results SA18.2
We want to understand why people use prescription medication that was not prescribed specifically to them.
The last time you used prescription pain medication that was not prescribed to you, what were the reasons?
CHECK ALL THAT APPLY
 
Modules Asked of All Respondents at end of Parts A & B.
CDC Optional
Module 21: Sexual Orientation and Gender Identity
The next two questions are about sexual orientation and gender identity.
M21.1
Data Results M21.1
Do you consider yourself to be:

Please read (include number before the text):
  • 1 - Straight
  • 2 - Lesbian or gay
  • 3 - Bisexual
M21.2
Data Results M21.2
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 Ė 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 4: Adverse Childhood Experiences
Iíd 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-
SA4.1
Data Results SA4.1
Did you live with anyone who was depressed, mentally ill, or suicidal?
SA4.2
Data Results SA4.2
Did you live with anyone who was a problem drinker or alcoholic?
SA4.3
Data Results SA4.3
Did you live with anyone who used illegal street drugs or who abused prescription medications?
SA4.4
Data Results SA4.4
Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
SA4.5
Data Results SA4.5
Were your parents separated or divorced?
SA4.6
Data Results SA4.6
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
SA4.7
Data Results SA4.7
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
SA4.8
Data Results SA4.8
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
SA4.9
Data Results SA4.9
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
SA4.10
Data Results SA4.10
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
SA4.11
Data Results SA4.11
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 5: Sexual Violence
Now Iíd 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.
SA5.1
Data Results for SA5.1
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 didnít 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.
SA5.2
Data Results for SA5.2
Has anyone EVER had sex with you after you said or showed that you didnít want them to or without your consent?
Now we have two questions about smoking in vehicles.
SA5.3
Data Results for SA5.3
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 didnít want to or without your consent. What was that personís 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.