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 = 88 (None) & Q2.2 = 88 (None), go to next section. 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 activites, 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, or Indian Health Service?
Crosstabulation Table:
 
If Q3.1 = 1 (Yes); skip out of the Health Care Access Core Section to ask the State-Added Health Care Access Module.
 
State-Added
State-Added 1: Health Care Access
SA1.1.
Data Results SA1.1

What is the primary source of your health care coverage? Please let me read all the answer choices before giving me your answer.

INTERVIEWER INSTRUCTION:
If the respondent indicates that they purchased health insurance through the Health Insurance Marketplace (Kansas Marketplace), ask:

“Was it a private health insurance plan purchased on your own or by a family member (private) or if they received Medicaid (KanCare)?”

INTERVIEWER NOTE:
If purchased on their own (or by a family member), code as 02.
If Medicaid, code as 04.


Please Read:

  • A plan purchased through an employer or union (includes plans purchased through another person's employer)
  • A plan that you or another family member buys on your own
  • Medicare
  • Medicaid or other state program (KanCare)
  • TRICARE (formerly CHAMPUS), VA, or Military
  • Alaska Native, Indian Health Service, Tribal Health Services
  • Some other source
  • None (no coverage)
Skip back into Health Care Access Core Section at Q3.2, and continue with the survey.
 
3.2
Data Results 3.2
Do you have one person you think of as your personal doctor or health care provider?

INTERVIEWER INSTRUCTION:
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
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
(Ever told) you had asthma?
If Q6.4 = 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 (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 = 1 (Yes), continue. Otherwise, go to next section.
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.

Interviewer 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
Are you...
  • Male
  • Female
8.2
Data Results 8.2
What is your age?
8.3
Data Results 8.3
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
8.4
Data Results 8.4
Which one or more of the following would you say is your race? (Mark all that Apply)
If more than one response to Q8.4, continue. Otherwise, go to Q8.6.
8.5
Data Results 8.5
Which one of these groups would you say BEST represents your race?
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
What is the highest grade or year of school you completed?
8.8
Data Results 8.8
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.

INTERVIEWER NOTE: We ask this question in order to compare health indicators among people with different housing situations.
8.9 What county do you live in?
8.10 What is your ZIP Code where you live?
Data Results Table:
QUESTIONS 8.11 THROUGH 8.13 ARE ASKED ONLY OF LANDLINE RESPONDENTS.
8.11
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.
8.12 How many of these phone numbers are residential numbers?
8.13 Do you have a cell phone for personal use? Please include cell phones used for both business and personal use.
8.14
Data Results 8.14

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:
8.15
Data Results 8.15
Are you currently:
  • Employed for wages
  • Self-employed
  • Out of work for 1 year or more
  • Out of work for less than 1 year
  • Homemaker
  • Student
  • Retired
  • Unable to work
8.16
Data Results 8.16
How many children less than 18 years of age live in your household?
8.17
Data Results 8.17
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

If Employment Q8.15 = 1 (employed), 2 (self-employed), 5 (homemaker), 6 (student) or 7 (Retired); skip out of the Demographics Core Section to ask the State-Added Average Hours Worked Module.

Otherwise, go to Q8.18.

 
State-Added
State-Added 2: Average Hours Worked
SA2.1.
Data Results SA2.1
Previously, you indicated you were (a) [insert response from core, Question 8.15, 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 Q8.18, and continue with the survey.
8.18
Data Results 8.18
Have you used the internet in the past 30 days?
8.19 About how much do you weigh without shoes?
[Round fractions up]
8.20 About how tall are you without shoes?
[Round fractions down]
Crosstabulation Table:
Summary Index Table:
If Q8.1 = 1 (Male) or Q8.1 = 2 (Female) and Q8.2 >= 45 years old or older, skip to Q8.22.
8.21
Data Results 8.21
To your knowledge, are you now pregnant?
 
The following questions are about health problems or impairments you may have.
Crosstabulation Table:
8.22
Data Results 8.22
Some people who are deaf or have serious difficulty hearing may or may not use equipment to communicate by phone.

Are you deaf or do you have serious difficulty hearing?
 
8.23
Data Results 8.23
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
 
8.24
Data Results 8.24
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
 
8.25
Data Results 8.25
Do you have serious difficulty walking or climbing stairs?
 
8.26
Data Results 8.26
Do you have difficulty dressing or bathing?
 
8.27
Data Results 8.27
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: E-Cigarettes
READ IF NECESSARY:
Electronic cigarettes (e-cigarettes) and other electronic "vaping" products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy.
10.1
Data Results 10.1
Have you ever used an e-cigarette or other electronic “vaping” product, even just one time, in your entire life?
If Q10.1 = 1(Yes) or 7(Don't know/Not sure); continue. Otherwise, go to next module.
10.2
Data Results 10.2
Do you now use e-cigarettes or other electronic "vaping" products every day, some days, or not at all?
Crosstabulation Table:
Summary Index Table:
 
 
CDC Core
Section 11: Alcohol Consumption
11.1
Data Results 11.1
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 Q11.1 = 888 “No drinks in past 30 days”, 777 “Don't know/Not sure” or 999 “Refused”; go to next section.
11.2
Data Results 11.2
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:
11.3
Data Results 11.3
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:
11.4
Data Results 11.4
During the past 30 days, what is the largest number of drinks you had on any occasion?
 
 
CDC Core
Section 12: Immunization
12.1
Data Results 12.1

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 Q12.1 = 1 (Yes); continue. Else, go to Q12.3.
12.2 During what month and year did you receive your most recent flu shot?
12.3
Data Results 12.3
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:
12.4
Data Results 12.4
Since 2005, have you had a tetanus shot?

INTERVIEWER INSTRUCTION:
If yes, ask:
“Was this Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?”
 
 
CDC Core
Section 13: 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.
13.1
Data Results 13.1
In the past 12 months, how many times have you fallen?
13.2
Data Results 13.2
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 14: Seatbelt Use
14.1
Data Results 14.1
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 Q14.1 = 8 (Never drive or ride in a car), go to Section 16; otherwise continue.
 
CDC Core
Section 15: Drinking and Driving
If Q11.1 = 888 (No drinks in the past 30 days); go to next section.
The next question is about drinking and driving.
15.1
Data Results 15.1
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 16: Breast and Cervical Cancer Screening
If response to Core Q8.1 = 1(Male); go to the next section.
The next questions are about breast and cervical cancer.
16.1
Data Results 16.1
A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
If response to Core Q16.1 = 1(Yes); conintue. Otherwise, go to Q16.3.
16.2
Data Results 16.2
How long has it been since you had your last mammogram?
Crosstabulation Table:
16.3
Data Results 16.3
A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?
If response to Core Q16.3 = 1(Yes); conintue. Otherwise, go to Q16.5.
16.4
Data Results 16.4
How long has it been since you had your last Pap test?
Crosstabulation Table:
Now, I would like to ask you about the Human Papillomavirus (Pap·uh·loh·muh virus) or HPV test.
16.5
Data Results 16.5
An HPV test is sometimes given with the Pap test for cervical cancer screening.
Have you ever had an HPV test?
If response to Core Q16.5 = 1(Yes); conintue. Otherwise, go to Q16.7.
16.6
Data Results 16.6
How long has it been since you had your last HPV test?
If response to Core Q8.21 = 1 (is pregnant); then go to next section. Otherwise, continue.
16.7
Data Results 16.7
Have you had a hysterectomy?

Read only if necessary:
A hysterectomy is an operation to remove the uterus (womb).
 
 
CDC Core
Section 17: 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.
17.1
Data Results 17.1
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?
17.2
Data Results 17.2
Has a doctor, nurse, or other health professional EVER talked with you about the disadvantages of the PSA test?
17.3
Data Results 17.3
Has a doctor, nurse, or other health professional EVER recommended that you have a PSA test?
17.4
Data Results 17.4
Have you EVER HAD a PSA test?
If Q17.4 = 1 (Yes); continue. Else, go to next section.
17.5
Data Results 17.5

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

Crosstabulation Table:
17.6
Data Results 17.6

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 18: Colorectal Cancer Screening
If respondent is < 50 years of age, go to next section.
The next questions are about colorectal cancer screening.
18.1
Data Results 18.1
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?
18.2
Data Results 18.2
How long has it been since you had your last blood stool test using a home kit?
18.3
Data Results 18.3
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?
18.4
Data Results 18.4
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?
18.5
Data Results 18.5
How long has it been since you had your last sigmoidoscopy or colonoscopy?
Crosstabulation Table:
 
 
CDC Core
Section 19: HIV/AIDS
The next few questions are about the national health problem of HIV, the virus that causes AIDS. Please remember that your answers are strictly confidential and that you do not have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.
19.1
Data Results 19.1
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 Q19.1 = 1 (Yes); continue. Otherwise, go to Q19.3.
19.2 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.
19.3
Data Results 19.3
I am going to read you a list. When I am 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.
  • You had four or more sex partners in the past year.
Do any of these situations apply to you?
 
Modules Asked of All Respondents (before split into Parts A & B)
CDC Optional
Module 22: Random Child Selection

If Core Question 8.16 = 88, or 99 (no children under age 18 in the household, or refused), go to next module.

If Core Question 8.16 = 1, Interviewer 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 8.16 is > 1 and Core Question 8.16 does not equal to 88 or 99, Interviewer 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.

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.
M22.1
Data Results M22.1
What is the birth month and year of the “X"th 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?

INTERVIEWER NOTE:
Select all that apply.

If yes, ask: Are they...

  • Mexican, Mexican American, Chicano/a
  • Puerto Rican
  • Cuban
  • Another 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
If response to Core Q8.16 = 88 "No children under age 18" or 99 "Refused", go to next module.
The next two questions are about the "X"th 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 Q6.4 = ‘yes” or Childhood Asthma Prevalence Module Q23.1 = ‘Yes’ and Random Child Selection Module Q22.6 = “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?
 
State-Added
Module 22: Preconception Health/Family Planning
If Core Q8.1 = 1(Male); go to next module.
If Core Q8.1 = 2(Female) and Core Q8.2 > 49 years old; go to next module.
If Core Q8.21 = 1(is pregnant); go to next module.
If Core Q16.7 = 1(had hysterectomy); go to next module.
Otherwise, continue.
The next set of questions asks you about your thoughts and experiences with family planning. Please remember that all of your answers will be kept confidential.
SA22.1
Data Results SA22.1
Did you or your partner do anything the last time you had vaginal sex to keep you from getting pregnant?
If Core SA22.1 = 2(No), 7(Don't know/Not sure) or 9(Refused); go to SA22.3.
If Core SA22.1 = 3(No partner/not sexually active) or 4(Same sex partner); go to next module.
SA22.2
Data Results SA22.2
What did you or your partner do the last time you had sex to keep you from getting pregnant?

INTERVIEWER NOTE: If respondent reports using more than one method, please code the method that occurs first on the list.

INTERVIEWER NOTE: If respondent reports using "condom"; probe to determine if "female condoms" or "male condoms".

INTERVIEWER NOTE: If respondent reports using an "IUD"; probe to determine if "Levonorgestrel IUD" or "Copper-Bearing IUD".

INTERVIEWER INSTRUCTIONS: If respondent reports "other method"; ask respondent: "Please specify." Ensure that their response does not fit into any of the categories listed. If response does not fit into another category, please code 18. Other method.
Go to next module.
SA22.3
Data Results SA22.3
Some reasons for not doing anything to keep you from getting pregnant the last time you had sex might include wanting a pregnancy, not being able to pay for birth control, or not thinking that you can get pregnant.

What was your main reason for not doing anything the last time you had sex to keep you from getting pregnant?

INTERVIEWER INSTRUCTIONS:If respondent reports "other method"; ask respondent: "Please specify." Ensure that their response does not fit into any of the categories listed. If response does not fit into another category, please code 18. Other reasons.
 
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: At Risk for Diabetes
If C6Q12 = 2 (Yes, but female told only during pregnancy), 3 (No), 7 (Don't know/Not sure) or 9 Refused) OR M1Q2 = 2 (Yes, during pregnancy), 3 (No), 7 (Don't know/Not sure), 9 (Refused); continue.
If C6Q12 = 1 (Yes) or 4 (No, pre-diabetes or borderline diabetes) OR M1Q2 = 1 (Yes); go to next module.
SA4.1
Data Results SA4.1

Have you ever been told by a doctor or other health professional that you are at risk for diabetes?

SA4.2
Data Results SA4.2
Do you think you are at risk for diabetes?
 
 
State-Added
Module 5: Lifestyle Change Behaviors to Prevent/Control Diabetes
CATI Note: If C6Q12 = 1, ask:
“Earlier you stated that you had been diagnosed with diabetes.
Are you now doing any of the following to help manage your diabetes?”
CATI Note: If C6Q12 = 4 or M1Q2 = 1, ask:
“Earlier you stated that you had been diagnosed with pre-diabetes or borderline diabetes.
Are you now doing any of the following to help prevent diabetes?”
CATI Note: If SA4Q1 = 1, ask:
“Earlier you stated that you had been told you were at risk for diabetes.
Are you now doing any of the following to help prevent diabetes?”
CATI Note: If SA4Q1 > 1 & SA04Q02 = 1, ask:
“Earlier you stated that you think you are at risk for diabetes.
Are you now doing any of the following to help prevent diabetes?”
SA5.1
Data Results SA5.1
(Are you) changing your eating habits (to help [Fill: prevent/manage your] diabetes)?
SA5.2
Data Results SA5.2
(Are you) exercising (to help [Fill: prevent/manage your] diabetes)?
Has a doctor or other health professional ever advised you to do any of the following to help [Fill: prevent/manage your] diabetes?
SA5.3
Data Results SA5.3
(Ever advised you to) change your eating habits (to help [Fill: prevent/manage your] diabetes)?
SA5.4
Data Results SA5.4
(Ever advised you to) exercise (to help [Fill: prevent/manage your] diabetes)?
SA5.5
Data Results SA5.5
Have you ever taken a course or class in how to help [Fill: prevent/manage your] diabetes yourself?
 
 
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.

  • Mother
  • Father
  • Brothers [include half brother]
  • Sisters [include half sister]
  • No one
If response to Core Q8.1 = 2(Female); 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: Hypertension Medication Adherence
SA7.1
Data Results for SA7.1
Have you EVER been told by a doctor, nurse, or other health professional that you have high blood pressure?

Read only if necessary:
“By “other health professional” we mean a nurse practitioner, a physician’s assistant,
or some other licensed health professional.”

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

INTERVIEWER NOTE:
If respondent says borderline high or pre-hypertensive, use response code 4.
Crosstabulation Table:
If SA7.1 = 1(Yes); continue. Otherwise, go to next module.
SA7.2
Data Results for SA7.2
Are you currently taking medicine for your high blood pressure?
SA7.3
Data Results for SA5.3
Has a doctor, nurse, or other health professional EVER talked with you about the advantages of taking your high blood pressure medication as prescribed?
SA7.4
Data Results for SA7.4
Has a doctor, nurse, or other health professional EVER talked with you about the disadvantages of not taking your high blood pressure medication as prescribed?
SA7.5
Data Results for SA7.5
Have you EVER received instructions from a doctor, nurse, or other health professional about how to correctly take your high blood pressure medication?
If SA7.5 = 1(Yes); continue. Otherwise, go to next module.
SA7.6
Data Results for SA7.6
Were these instructions written down or printed on paper for you?
 
State-Added
Module 8: Multi-Unit Dwelling Secondhand Smoke
SA8.1
Data Results SA8.1
What type of residence do you reside in? Please let me read all the answer choices
before giving me you answer. Is it a…?

Read:
Single family home/Mobile home/Trailer
Duplex
Double or other multi-family home
Apartment building
Condominium
Townhouse
If SA8.1 = 1(Single family home/Mobile home/Trailer), 7(Don't know/Not sure) or 9(Refused); go to next module. Otherwise, continue.
SA8.2
Data Results SA8.2
During the last 12 months of living in your unit, how often has second-hand smoke
entered into your personal living space from somewhere else in or around the building?
Would you say…?

Read:
Daily
A few times a week
Once a week
Once every couple of weeks
Once a month or less
Never
SA8.3
Data Results SA8.3
Would you be in favor of a policy in your residential building that prohibits smoking in all
personal living spaces as apartments, private balconies and patios? Would you say…?

Read:
Definitely in favor
Probably in favor
Probably NOT in favor
Definitely NOT in favor
 
 
State-Added
Module 9: In-Home Smoking Policy
The next question is about smoking inside the home.
SA9.1
Data Results SA9.1
Not counting decks, porches, or garages, inside your home, is smoking always allowed,
allowed only at some time in some places or never allowed?
 
 
State-Added
Module 10: Palliative Care
SA10.1
Data Results SA10.1
A health care directive or living will is a formal document in which a person gives
instructions regarding his or her own health care should they become unable to make
decisions for themselves such as during general anesthesia, coma, or mental illness. Do
you have a health care directive or living will?
SA10.2
Data Results SA10.2
Palliative care is medical care provided by a team of doctors, nurses, social workers and
other health care providers to help relieve pain, stress and other symptoms due to a
serious and chronic illness. Palliative care can be provided at any stage of illness and
along with treatment meant to cure you. Have you ever received palliative care for a
serious and chronic illness?

Interviewer Note:
Pronunciation Key for Palliative is pal-lee-uh-tiv.
SA10.3
Data Results SA10.3
What type of illness was it?

Interviewer Note: If respondent indicates more than one illness; please read:
“If you have had more than one serious and chronic illness, please answer these
questions about your most recent illness.”

Interviewer Note:
If respondent states they have Leukemia, lymphoma or multiple myeloma; please code as 3. Cancer.
SA10.4
Data Results SA10.4
Did you experience any physical pain caused by your illness or its treatment?
If SA10.4 = 1(Yes); continue. Otherwise, go to SA10.7.
SA10.5
Data Results SA10.5
How would you rate the information given to you by your palliative care team about how
to manage your pain? Would you say…?

Interviewer Note:
Palliative care team includes doctors, nurses, social workers and other health care providers.

Excellent
Very good
Good
Fair
Poor
SA10.6
Data Results SA10.6
Did a health care provider on your palliative care team prescribe any medications to help
control the pain?

Interviewer Note:
Palliative care team includes doctors, nurses, social workers and other health care providers.
SA10.7
Data Results SA10.7
Did you experience any stress, depression, or problems with emotions caused by your
illness or its treatment?
If SA10.7 = 1(Yes); continue. Otherwise, go to SA10.9.
SA10.8
Data Results SA10.8
How would you rate the information given to you by your palliative care team about how
to manage your stress, depression, or problems with emotions? Would you say…?

Interviewer Note:
Palliative care team includes doctors, nurses, social workers and other health care providers.

Excellent
Very good
Good
Fair
Poor
SA10.9
Data Results SA10.9
How would you rate the emotional support provided to you by the palliative care team?
Would you say…?

Interviewer Note:
Palliative care team includes doctors, nurses, social workers and other health care
providers.

Excellent
Very good
Good
Fair
Poor
 
CDC Optional
Module 17: Cancer Survivorship
If Core Q6.6 = 1(Yes), Q6.7 = 1(Yes) or Core Q17.6 = 4(Because you were told you had prostate cancer); continue.
Otherwise, go to closing.
You’ve told us that you have had cancer. I would like to ask you a few more questions about your cancer.
M17.1
Data Results M17.1
How many different types of cancer have you had?
If M17.1 = 7 (Don't know/Not sure) or 9(Refused); go to closing. Otherwise, continue.
M17.2
Data Results M17.2
If M17.1 = 1(Only one), ask:
“At what age were you told that you had cancer?”
or
If M17.1 = 2 (Two) or 3 (Three or more), ask:

“At what age were you first diagnosed with cancer?”

Interviewer Note:
This question refers to the first time they were told about their first cancer.
M17.3
Data Results M17.3

If M17.1 = 1(Only one), ask:
“What type of cancer was it?”
or
If M17.1 = 2 (Two) or 3 (Three or more), ask:

“With your most recent diagnoses of cancer, what type of cancer was it?”

Interviewer Note:
If Core Q6.6 = 1 (Yes) and M17.1 = 1 (Only one), ask:
“Was it “Melanoma” or “other skin cancer"?”

Interviewer Instruction:
If “Melanoma”, code 21 or if “other skin cancer”, code 22.

Interviewer Instruction:
If Core Q17.6 = 4 (Because you were told you had Prostate Cancer) and M17.1 = 1
(Only one), code 19.

Interviewer Note:
Please read list only if respondent needs prompting for cancer type (i.e., name of cancer).

M17.4
Data Results M17.4
Are you currently receiving treatment for cancer? By treatment, we mean surgery,
radiation therapy, chemotherapy, or chemotherapy pills.
If M17.4 = 2 (No, I've completed treatment); continue. Otherwise, go to closing.
M17.5
Data Results M17.5
What type of doctor provides the majority of your health care?

Interviewer Note:
If the respondent requests clarification of this question, say:

“We want to know which type of doctor you see most often for illness or regular health
care (Examples: annual exams and/or physicals, treatment of colds, etc.).”

Please read:
Cancer Surgeon
Family Practitioner
General Surgeon
Gynecologic Oncologist
General Practitioner, Internist
Plastic Surgeon, Reconstructive Surgeon
Medical Oncologist
Radiation Oncologist
Urologist
M17.6
Data Results M17.6
Did any doctor, nurse, or other health professional EVER give you a written summary of all the cancer treatments that you received?

Read only if necessary:
“By ‘other healthcare professional’, we mean a nurse practitioner, a physician’s assistant,social worker, or some other licensed professional.”
M17.7
Data Results M17.7
Have you EVER received instructions from a doctor, nurse, or other health
professional about where you should return or who you should see for routine cancer
check-ups after completing your treatment for cancer?
If M17.7 = 1(Yes); continue. Otherwise, go to M17.9.
M17.8
Data Results M17.8
Were these instructions written down or printed on paper for you?
M17.9
Data Results M17.9
With your most recent diagnosis of cancer, did you have health insurance that paid for all
or part of your cancer treatment?

Interviewer Note:
"Health insurance" also includes Medicare, Medicaid, or other types of state health programs.
M17.10
Data Results M17.10
Were you EVER denied health insurance or life insurance coverage because of your
cancer?
M17.11
Data Results M17.11
Did you participate in a clinical trial as part of your cancer treatment?
M17.12
Data Results M17.12
Do you currently have physical pain caused by your cancer or cancer treatment?
If M17.12 = 1(Yes); continue. Otherwise, go to closing.
M17.13
Data Results M17.13
Is your pain currently under control?
 
 
Part B
Summary Index Table:
 
CDC Optional
Module 7: Cognitive Decline
If Core Q8.2 >= 45 years of age older; continue. Otherwise, go to next module.
The next few questions ask about difficulties in thinking or remembering that can make a big difference in
everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you
recently met, which is normal. This refers to confusion or memory loss that is happening more often or
getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would
normally know. We want to know how these difficulties impact you.
M7.1
Data Results M7.1
During the past 12 months, have you experienced confusion or memory loss that is
happening more often or is getting worse?
If M7.1 = 1(Yes) or 7(Don't know/Not sure); continue. Otherwise, go to next module.
M7.2
Data Results M7.2
During the past 12 months, as a result of confusion or memory loss, how often have you
given up day-to-day household activities or chores you used to do, such as cooking,
cleaning, taking medications, driving, or paying bills?
M7.3
Data Results M7.3
As a result of confusion or memory loss, how often do you need assistance with these
day-to-day activities?
If M7.3 = 1(Always), 2(Usually) or 3(Sometimes); continue. Otherwise, go to M7.5 .
M7.4
Data Results M7.4
When you need help with these day-to-day activities, how often are you able to get the
help that you need?
M7.5
Data Results M7.5
During the past 12 months, how often has confusion or memory loss interfered with your
ability to work, volunteer, or engage in social activities outside the home?
M7.6
Data Results M7.6
Have you or anyone else discussed your confusion or memory loss with a health care
professional?
 
CDC Optional
Module 5:Health Literacy
M5.1
Data Results M5.1

How difficult is it for you to get advice or information about health or medical topics if you
need it? Would you say it is…?

Interviewer Note:
Respondent can answer based on any source of health or medical advice or
information. If the respondent asks what is meant by advice or information,
interviewer re-reads the question to the respondent. If the respondent still doesn’t
understand, interviewer can say:
“You can think about any source of health or medical advice or information.”

Very easy
Somewhat easy
Somewhat difficult
Very difficult

M5.2
Data Results M5.2
How difficult is it for you to understand information that doctors, nurses and other health professionals tell you?? Would you say it is…?

Very easy
Somewhat easy
Somewhat difficult
Very difficult
M5.3
Data Results M5.3
You can find written information about health on the Internet, in newspapers and
magazines, and in brochures in the doctor’s office and clinic. In general, how difficult is it
for you to understand written health information? Would you say it is…?

Very easy
Somewhat easy
Somewhat difficult
Very difficult
I don’t pay attention to written health information
 
CDC Optional
Module 11:Sleep Disorder
Asked only from June through December of 2016.
I would like to ask you a few questions about your sleep patterns.
M11.1
Data Results M11.1
Over the last 2 weeks, how many days have you had trouble falling asleep or staying
asleep or sleeping too much??
M11.2
Data Results M11.2
Over the last 2 weeks, how many days did you unintentionally fall asleep during the day?
M11.3
Data Results M11.3
Have you ever been told that you snore loudly?
M11.4
Data Results M11.4
Has anyone ever observed that you stop breathing during your sleep?

Interviewer Note:
If respondent mentions having a machine or CPAP that records that breathing sometimes
stops during the night, code 1 (Yes).
 
 
State-Added
Module 11: Chronic Fatigue Syndrome (CFS)
SA11.1
Data Results for SA11.1
Have you ever been told by a doctor or other health professional that you had Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME)?
If SA11.1 = 1(Yes); continue. Otherwise, go to next module.
SA11.2
Data Results for SA11.2
Do you still have Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME)?
 
 
State-Added
Module 12: Oral Health
SA12.1
Data Results SA12.1
During the past 12 months, was there any time when you needed dental care but did not get it?
If SA12.1 = 1 (Yes); continue. Otherwise, go to SA12.3.
SA12.2
Data Results SA12.2
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
  • No Dental Insurance
  • Did not need/want to go
SA12.3
Data Results SA12.3
In the last 12 months, have you been to a hospital emergency department for relief of
dental pain or 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.?
 
 
State-Added
Module 13: Adult Active Transportation
SA13.1
Data Results SA13.1
During the past 30 days, for about how many days did you walk or bike to get some place
such as work, school, church, a store, the bus stop or a restaurant?
 
 
State-Added
Module 14: Child Active Transportation
If Core Q8.16 = 88(None) or 99(Refused), go to next module.
If selected child's age is 5 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.
The next questions is about the "Xth" [CATI: please fill in correct number] child.
SA14.1
Data Results SA14.1
In an average school-week, on how many days does the child walk or ride a bike TO school when weather allows [Fill: him/her] to do so?
SA14.2
Data Results SA14.2
In an average school-week, on how many days does the child walk or ride a bike FROM school when weather allows [Fill: him/her] to do so?
 
 
State-Added
Module 15: Childhood Immunization (Influenza)
If response to Core Q8.16 = 88 (None) 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.
SA15.1
Data Results SA15.1
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 SA15.1 = 1 (Yes); continue. If SA15.1 = 2 (No); go to SA15.3. Otherwise, go to next module.
SA15.2 During what month and year did [Fill: he/she] receive [Fill: 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.
Go to Next Module.
SA15.3
Data Results SA15.3
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 16: Childhood Human Papilloma Virus (HPV)
If Core Q8.16 = 88(None) or 99(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.
SA16.1
Data Results SA16.1
A vaccine to prevent the human papilloma virus or HPV infection is available and is called
the cervical cancer or genital warts vaccine, HPV shot, [Fill: if female, “GARDASIL or CERVARIX”; if male “or GARDASIL”]. Has the child EVER had a HPV vaccination?
If SA16.1 = 1(Yes); continue. If SA16.1 = 2(No); go to SA16.3. Otherwise, go to the next module.
SA16.2
Data Results SA16.2
How many HPV shots did [Fill: he/she] receive?
Go to Next Module.
SA16.3
Data Results SA16.3
What is the MAIN reason [Fill: he/she] has not received a HPV vaccination?

Do not read answer choices below. Select category that best matches response.
  • Child does not need it
  • Doctor did not recommend it
  • Child not sexually active
  • Did not know that child should be vaccinated
  • HPV is not that serious
  • Side effects
  • Does not work
  • Plan to get child vaccinated later
  • HPV 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 not got around to it/didn't get it
  • Parent does not believe/approve or is against HPV shots
  • Age is too young
  • Do not trust vaccine
  • Needs more information about vaccine
 
 
State-Added
Module 17: Fire Alarm
SA17.1
Data Results for SA17.1

Do you have a functioning smoke alarm on every level of your home?

Interviewer Note: If respondent asks if a smoke detector, fire alarm, or fire detector is the same as smoke alarm, say:
"Yes".

SA17.2
Data Results for SA17.2
Do you have a functioning smoke alarm outside each sleeping area?
 
 
State-Added
Module 18: Storage of Firearms
The next questions are about the storage of firearms. Please include weapons such as pistols, shotguns,
and rifles; but not BB guns, starter pistols, or guns that cannot fire. Include those kept in a garage,
outdoor storage area, or motor vehicle.
READ ONLY IF NECESSARY:
If the respondent asks, "Why we need to know?", "What does this have to do to with health?", "That's nobody's business." or anything similar; please read:

"We ask these questions to understand the need for public health education for the safe storage of firearms and prevention of accidental injuries in Kansas."
SA18.1
Data Results SA18.1
Are any firearms kept in or around your home?
If SA18.1 = 1(Yes), continue. Otherwise, got to next module.
SA18.2
Data Results SA18.2
Are any of these firearms now loaded?
If SA18.2 = 1(Yes), continue. Otherwise, got to next module.
SA18.3
Data Results SA18.3
Are any of these loaded firearms also unlocked? By “unlocked”, we mean you do not
need a key or combination to get the gun or to fire it. We don’t count a safety as a lock.
 
State-Added
Module 19: Carbon Monoxide
The following questions are about carbon monoxide. Carbon monoxide is a colorless, odorless gas that
is poisonous.
SA19.1
Data Results SA19.1
A carbon monoxide detector is a device that detects the presence of carbon monoxide gas. It may, or may not be, combined with a smoke alarm. Do you have one or more carbon monoxide detectors installed in your home?
If SA19.1 = 1(Yes), continue. Otherwise, got to SA19.3.
SA19.2
Data Results SA19.2
In the past 12 months, did you, or someone else, on purpose test all of the carbon monoxide detectors in your home, either by pressing the test button or by using a commercial carbon monoxide detector test kit? Would you say…?

Yes, all
Yes, some
or
None
SA19.3
Data Results SA19.3
Has a doctor or other health professional ever talked with you about the dangers of carbon monoxide?
SA19.4
Data Results SA19.4
Has a doctor or other health professional ever talked with you how to reduce your risk of
accidental exposure to carbon monoxide?
 
 
State-Added
Module 20: Suicide
The next questions are about a sensitive topic and some people may feel uncomfortable with these
questions. At the end of the 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.
SA20.1
Data Results SA20.1
Has there been a time, in the past 12 months, when you thought of taking your own life?
If SA20.1 = 1(Yes), continue. Otherwise, go to Suicide Module Closing.
SA20.2
Data Results SA20.2
During the past 12 months, did you attempt suicide?
Sucicide Module Closing: 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.