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:
SKIP INSTRUCTION:
If Q2.1 & Q2.2 both equal "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:
 
 
State-Added
State-Added 1: Health Care Access
SKIP INSTRUCTION:
If Core Q3.1 = "Yes"; go to State-Added Module 1: Health Care Access.
Otherwise, continue.
1.1
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. Is it…

  • 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)

(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 did you receive Medicaid (KanCare)?")

SKIP INSTRUCTION:
Go back into Health Care Access 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?

(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
A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition. About how long has it been since you last visited a doctor for a routine checkup?
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:
SKIP INSTRUCTION:
If Q4.1 = "Yes", continue.
Otherwise, go to next section.
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. About how long has it been since you last had your blood cholesterol checked?
Crosstabulation Table:
SKIP INSTRUCTION:
If Q5.1 = "Never" or "Refused", go to next section.
Otherwise, continue.
5.2
Data Results 5.2
Have you EVER been told by a doctor, nurse, or other health professional that your blood cholesterol is high?
Crosstabulation Table:
SKIP INSTRUCTION:
If Q5.2 = "Yes", continue.
Otherwise, go to next section.
5.3
Data Results 5.3
Are you currently taking medicine prescribed by a doctor or other health professional for your blood cholesterol?
 
CDC Core
Section 6: Chronic 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?
SKIP INSTRUCTION:
If Q6.4 = "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 NOTE: 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.

INTERVIEWER INSTRUCTION:
If "Yes" and respondent is female, ask:
"
Was this only when you were pregnant?"
Crosstabulation Table:
SKIP INSTRUCTION:
If Q6.12 = "Yes", continue.
If Q6.12 = "Yes, but femlae told only during pregnancy", "No", "No, pre-diabetes or borderline diabetes", "Don't know/Not sure" or "Refused" AND assigned to Part A (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: Arthritis Burden
SKIP INSTRUCTION:
If Q6.9 = "Yes", continue.
Otherwise, 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.
7.1
Data Results 7.1
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:
INTERVIEWER INSTRUCTION:
Next question should be asked of all respondents regardless of employment status.
7.2
Data Results Q7.2
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."
7.3
Data Results Q7.3
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."
7.4
Data Results Q7.4
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. 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. DURING THE PAST 30 DAYS, how bad was your joint pain ON AVERAGE?
 
 
CDC Core
Section 8: Demographics
8.1
Data Results 8.1

For the accuracy of this survey, it is important that we verify your sex.

Are you male or 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? (Mark all that Apply)

INTERVIEWER INSTRUCTION:
If yes, ask:

“Are you: Mexican, Mexican American, Chicano/a; Puerto Rican; Cuban OR 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)
SKIP INSTRUCTION:
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?
8.9 In what county do you currently live?
8.10
What is the ZIP Code where you currently live?
Data Results Table:
SKIP INSTRUCTION:
If Landline Survey (QSTVER = 11 or 12), continue.
If Cell Phone Survey (QSTVER = 21 or 22); go to Q8.14.
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.
SKIP INSTRUCTION:
If Q8.11 = "Yes", continue.
Otherwise, go to Q8.13.
8.12 How many of these telephone numbers are residential numbers?
8.13 Including phones for business and personal use, do you have a cell phone for 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 more than 1 year
  • Out of work for less than 1 year
  • Homemaker
  • Student
  • Retired
  • Unable to work?

INTERVIEWER INSTRUCTION:
If more than one response given; read:

“Select the category which best describes you.”

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
 
State-Added
State-Added 2: Average Hours Worked
SKIP INSTRUCTION:
If Q8.15 = "Employed for Wages", "Self-Employed", "A Homemaker", "A Student" or "Retired", go to State-Added Module 2: Average Hours Worked.
Otherwise, continue with Q8.18.
SA2.1.
Data Results SA2.1
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 INSTRUCTION:
Go 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:

SKIP INSTRUCTION:
If Sex (Q8.1) = "Male", go to next section.
If Sex (Q8.1) = "Female" AND Age (Q8.2) >= 45 years old or older, go to next section.
Otherwise, continue.

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:
Summary Index:
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]
SKIP INSTRUCTION:
If Q9.1 = "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:
SKIP INSTRUCTION:
If Q9.2 = "Every day" or "Some days", continue.
If Q9.2 = "Not at all", go to Q9.4.
Otherwise, 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:
SKIP INSTRUCTION:
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? (Snus rhymes with "goose")

INTERVIEWER NOTE:
Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.
Crosstabulation Table:
 
 
CDC Core
Section 10: E-Cigarettes

The next questions are about electronic cigarettes and other electronic "vaping" products. These products typically contain nicotine, flavors, and other ingredients. Do not include products used only for marijuana.

INTERVIEWER NOTE:
These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.

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?

INTERVIEWER INSTRUCTION:
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."

SKIP INSTRUCTION:
If Q10.1 = "Yes", continue.
Otherwise, go to next section.
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:
SKIP INSTRUCTION:
If Q10.1 ="Yes" AND Respondent is assigned to Part B (QSTVER = 12 or 22), go to State-Added Module 14: Electronic Cigarettes (E-Cigarettes) Reason for Initiating.
Otherwise, go to next section.
 
 
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?
SKIP INSTRUCTION:
If Q11.1 = "No drinks in past 30 days", "Don't know/Not sure" or "Refused", go to next section.
Otherwise, continue.
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 [Fill: 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: Fruits and Vegetables
Crosstabulation Table:
Summary Index:
INTERVIEWER INSTRUCTIONS:
Do not enter "Times Per Day" unless the respondent reports that he/she consumed a food item each day during the past month.
If a respondent indicates that they consumed a food item everyday; then enter the number of "Times Per Day".
If a respondent indicates that they consumed a food less than daily; then enter the number of "Times Per Week" or "Times Per Month".
Now think about the foods you ate or drank during the past month, that is, the past 30 days, including meals and snacks.
12.1
Data Results 12.1

Not including juices, how often did you eat fruit? You can tell me times per day, times per week or times per month.

INTERVIEWER INSTRUCTION:
Enter quantity in times per day, week, or month.

INTERVIEWER INSTRUCTION:
If Respondent asks what to include or says "I don’t know"; read:

"Include fresh, frozen or canned fruit. Do not included dried fruit."

12.2
Data Results 12.2

Not including fruit-flavored drinks or fruit juices with added sugar, how often did you drink 100% fruit juice such as apple or orange juice?

INTERVIEWER INSTRUCTION:
Enter quantity in times per day, week, or month.

INTERVIEWER INSTRUCTION:
If Respondent asks about examples of fruit-flavored drinks; read:
"Do not include fruit-flavored drinks with added sugar like cranberry cocktail, HI-C, lemonade, Kool-Aid, Gatorade, Tampico and Sunny Delight. Include only 100% pure juices or 100% juice blends."

12.3
Data Results 12.3

How often did you eat a green leafy or lettuce salad, with or without other vegetables?

INTERVIEWER INSTRUCTION:
Enter quantity in times per day, week, or month.

INTERVIEWER INSTRUCTION:
If Respondent asks about spinach; read:
"Include spinach salads."

12.4
Data Results 12.4

How often did you eat any kind of fried potatoes, including French fries, home fries, or hash browns?

INTERVIEWER INSTRUCTION:
Enter quantity in times per day, week, or month.

INTERVIEWER INSTRUCTION:
If Respondent asks about potato chips; read:
"Do not include potato chips."

12.5
Data Results 12.5

How often did you eat any other kind of potatoes, or sweet potatoes, such as baked, boiled, mashed potatoes, or potato salad?

INTERVIEWER INSTRUCTION:
Enter quantity in times per day, week, or month.

INTERVIEWER INSTRUCTION:
If Respondent asks about what types of potatoes; read:
"Include all types of potatoes except fried. Include potatoes au gratin and scalloped potatoes."

12.6
Data Results 12.6

Not including lettuce salads and potatoes, how often did you eat other vegetables?

INTERVIEWER INSTRUCTION:
Enter quantity in times per day, week, or month.

INTERVIEWER INSTRUCTION:
If Respondent asks what to include; read:
"Include tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens and broccoli. Include raw, cooked, canned or frozen vegetables. Do not include rice."

 
 
CDC Core
Section 13: Exercise (Physical Activity)
Crosstabulation Table:
Summary Index:
The next few questions are about exercise, recreation, or physical activities other than your regular job duties.
13.1
Data Results 13.1
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?

INTERVIEWER NOTE:
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.

Crosstabulation Table:
SKIP INSTRUCTION:
If Q13.1 = "Yes", continue.
Otherwise go to Q13.8.
13.2 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 2017 survey.)

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

SKIP INSTRUCTION:
If Q13.2 = "Don't know/Not sure" or "Refused", go to Q13.8.
Otherwise, continue.
13.3
Data Results 13.3
How many times per week or per month did you take part in this activity during the past month? (First Activity)
13.4
Data Results 13.4
And when you took part in this activity, for how many minutes or hours did you usually keep at it? (First Activity)
13.5 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 2017 survey.]

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

SKIP INSTRUCTION:
If Q13.5 = "No other activity", "Don't know/Not sure" or "Refused", go to Q13.8.
Otherwise, continue.
13.6
Data Results 13.6
How many times per week or per month did you take part in this activity during the past month? (Second Activity)
13.7
Data Results 13.7
And when you took part in this activity, for how many minutes or hours did you usually keep at it? (Second Activity)
13.8
Data Results 13.8
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 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:
 
CDC Core
Section 15: Immunization
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™.
15.1
Data Results 15.1

During the past 12 months, have you had either a flu shot or a flu vaccine that was sprayed in your nose?

INTERVIEWER INSTRUCTION:
Read only 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:
SKIP INSTRUCTION:
If Q15.1 = "Yes", continue.
Otherwise, go to Q15.3.
15.2 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?
15.3
Data Results 15.3
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:
SKIP INSTRUCTION:
If Age (Q8.2) < 50 years old; go to next section.
Otherwise, continue.
15.4
Data Results 15.4

Have you ever had the shingles or zoster vaccine?

INTERVIEWER INSTRUCTION:
Read if necessary:

"Shingles is caused by the chicken pox virus. It is an outbreak of rash or blisters on the skin that may be associated with severe pain. A vaccine for shingles has been available since May 2006; it is called Zostavax®, the zoster vaccine, or the shingles vaccine."

Crosstabulation Table:
 
 
CDC Core
Section 16: 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.
16.1
Data Results 16.1
Have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation. Include testing fluid from your mouth.
SKIP INSTRUCTION:
If Q16.1 = "Yes", continue.
Otherwise, go to Q16.3.
16.2 Not including blood donations, in what month and year was your last HIV test?

INTERVIEWER INSTRUCTIONS:
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.

16.3
Data Results 16.3
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 injected any drug other than those prescribed for you in the past year.
  • You have been treated for a sexually transmitted disease or STD 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?
 
CDC Optional
Module 28: Random Child Selection
SKIP INSTRUCTION:
If Children (Q8.16) = "No Children under 18" or "Refused", go to next module.
INTERVIEWER INSTRUCTIONS:
If Children (Q8.16) is equal to one 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 M22.1]

If Children (Q8.16) is equal to more then one child, interviewer please read:
"Previously, you indicated there were [Fill: number of chilren] children age 17 or younger in your household. Think about those [Fill: number of chilren] 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" (Number of Selected Child) child in your household. All following questions about children will be about the "Xth" (Number of Selected Child) child.
M28.1
Data Results M28.1
What is the birth month and year of the "Xth" (Number of Selected Child) child?
M28.2
Data Results M28.2
Is the child a boy or a girl?
M28.3
Data Results M28.3

Is the child Hispanic, Latino/a, or Spanish origin? [Mark all that apply]

INTERVIEWER INSTRUCTION:
If yes, ask:

“Is the child: Mexican, Mexican American, Chicano/a; Puerto Rican; Cuban OR another Hispanic; Latino/a or Spanish origin?”)

M28.4
Data Results M28.4
Which one or more of the following would you say is the race of the child? [Mark all that apply]
SKIP INSTRUCTION:
If more than one response to M28.4, continue.
Otherwise, go to M28.6.
M28.5
Data Results M28.5
Which one of these groups would you say best represents the child's race?
M28.6
Data Results M28.6
How are you related to the child?
 
 
CDC Optional
Module 29: Childhood Asthma Prevalence
SKIP INSTRUCTION:
If response to Children (Q8.16) = "No children under age 18" or "Refused", go to next module.
The next two questions are about the"Xth" (Number of Selected Child) child.
M29.1
Data Results M29.1
Has a doctor, nurse, or other health professional EVER said that the child has asthma?
SKIP INSTRUCTION:
If M29.1 = "Yes", continue.
Otherwise, go to next module.
M29.2
Data Results M29.2
Does the child still have asthma?
Crosstabulation Table:
 
 
State-Added
Module 3: Asthma Call Back Survey Information
SKIP INSTRUCTION:
If Adult Asthma Q6.4 = "Yes" or
Childhood Asthma Prevalence CDC Module Q23.1 = "Yes" AND Random Child Selection CDC Module Q22.6 = "Parent" or "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?
 
 
CDC Optional
Module 16: Preconception Health/Family Planning
SKIP INSTRUCTION:
If Sex (Q8.1) = "Female" & Age (Q8.2) is 18-49 years old, continue.
Otherwise, go to next module.
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.
M16.1
Data Results M16.1
Did you or your partner do anything the last time you had sex to keep you from getting pregnant?
SKIP INSTRUCTION:
If M16.1 = "Yes", continue.
If M16.1 = "No", "Don't know/Not sure" or "Refused", go to M16.3.
Otherwise, go to next module.
M16.2
Data Results M16.2
What did you or your partner do the last time you had sex to keep you from getting pregnant?
SKIP INSTRUCTION:
If M16.2 = "Don't know/Not sure" or "Refused", go to M16.3.
Otherwise, go to next module.
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.
M16.3
Data Results M16.3
What was your main reason for not doing anything the last time you had sex to keep you from getting pregnant?
 
Part A
Summary Index Table:
 
CDC Optional
Module 9: Sleep Disorder
M9.1
Data Results M9.1

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

INTERVIEWER INSTRUCTION:
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.

M9.2
Data Results M9.2
Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?
Crosstabulation Table:
M9.3
Data Results M9.3
Over the last 2 weeks, how many days did you unintentionally fall asleep during the day?
M9.4
Data Results M9.4

Have you ever been told that you snore loudly?

M9.5
Data Results M9.5

Has anyone ever observed that you stop breathing during your sleep?

INTRODUCTION INSTRUCTION:
If respondent mentions having a machine or CPAP that records that breathing sometimes stops during the night; enter 1 "Yes".

 
CDC Optional
Module 3: Respiratory Health (COPD Symptoms)
The next few questions are about breathing problems you may have.
M3.1
Data Results M3.1

During the past 3 months, did you have a cough on most days?

M3.2
Data Results M3.2
During the past 3 months, did you cough up phlegm [FLEM] or mucus on most days?
M3.3
Data Results M3.3
Do you have shortness of breath either when hurrying on level ground or when walking up a slight hill or stairs?
M3.4
Data Results M3.4

Have you ever been given a breathing test to diagnose breathing problems?

M3.5
Data Results M3.5

Over your lifetime, how many years have you smoked tobacco products?

 
 
CDC Optional
Module 11: Alcohol Screening & Brief Intervention (ASBI)
SKIP INSTRUCTION:
If C3.4 = "Within the past year" or "Within the past 2 years", continue.
Otherwise, go to next module.
Healthcare providers may ask during routine checkups about behaviors like alcohol use, whether you drink or not. We want to know about their questions.
M11.1
Data Results M11.1

You told me earlier that your last routine checkup was [Fill: If C3.4 = "within the past year" or C3.4 = "within the past 2 years"]. At that checkup, were you asked in person or on a form if you drink alcohol?

M11.2
Data Results M11.2
Did the health care provider ask you in person or on a form how much you drink?
M11.3
Data Results M11.3
Did the healthcare provider specifically ask whether you drank X [Fill: X = 5 for men, X = 4 for women] or more alcoholic drinks on an occasion?
M11.4
Data Results M11.4

Were you offered advice about what level of drinking is harmful or risky for your health?

SKIP INSTRUCTION:
If M11.1 = "Yes", M11.2 = "Yes" or M11.3 = "Yes", continue.
Otherwise, go to next module.
M11.5
Data Results M11.5
Healthcare providers may also advise patients to drink less for various reasons. At your last routine checkup, were you advised to reduce or quit your drinking?
 
 
State-Added
Module 4: Oral Health (CDC Even Years Rotating Core Section Oral Health Q1)
SA4.1
Data Results SA4.1
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.
 
State-Added
Module 5: Oral Health
SA5.1
Data Results SA5.1
During the past 12 months, was there any time when you needed dental care but did not get it?
SKIP INSTRUCTION:
If SA5.1 = "Yes", continue.
Otherwise, go to SA5.3.
SA5.2
Data Results SA5.2
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
SA5.3
Data Results SA5.3
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 the mouth includes toothache, swelling, abscess, bleeding, or sores in your gums, cheek, tongue or lips.
 
CDC Module
Module 6: Arthritis Management
SKIP INSTRUCTION:
If Q6.9 = "Yes", continue.
Otherwise, go to next module.
M6.1
Data Results M6.1
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?
M6.2
Data Results M6.2
Has a doctor or other health professional EVER suggested losing weight to help your arthritis or joint symptoms?
M6.3
Data Results M6.3

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.

M6.4
Data Results M6.4
Have you EVER taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?
 
 
CDC Module
Module 21: Caregiving
People may provide regular care or assistance to a friend or family member who has a health problem or disability.
M21.1
Data Results M21.1

During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?

INTERVIEWER INSTRUCTIONS:
If caregiving recipient has died in the past 30 days, please say:

"I’m so sorry to hear of your loss." Code 8 - Caregiving recipient died in past 30 days and go to next module.

SKIP INSTRUCTION:
If M21.1 = "Yes", continue.
If M21.1 = "Caregiving recipient died in past 30 days", go to next module.
Otherwise, go to M21.9.
M21.2
Data Results M21.2

What is his or her relationship to you? For example is he or she your (mother or daughter or father or son)?

INTERVIEWER INSTRUCTIONS:
If more than one person, ask:

"Please refer to the person to whom you are giving the most care."

M21.3
Data Results M21.3

For how long have you provided care for that person? Would you say…

  • Less than 30 days
  • 1 month to less than 6 months
  • 6 months to less than 2 years
  • 2 years to less than 5 years
  • 5 years or more?
M21.4
Data Results M21.4

In an average week, how many hours do you provide care or assistance? Would you say…

  • Up to 8 hours per week
  • 09 to 19 hours per week
  • 20 to 39 hours per week
  • 40 hours or more?
M21.5
Data Results M21.5

What is the main health problem, long-term illness, or disability that the person you care for has?

INTERVIEWER INSTRUCTIONS:
If necessary, read:

"Please tell me which one of these conditions would you say is the major problem?"

M21.6
Data Results M21.6

In the past 30 days, did you provide care for this person by…

...Managing personal care such as giving medications, feeding, dressing, or bathing?

M21.7
Data Results M21.7

In the past 30 days, did you provide care for this person by…

...Managing household tasks such as cleaning, managing money, or preparing meals?

M21.8
Data Results M21.8

Of the following support services, which one do you most need, that you are not currently getting?

  • Classes about giving care, such as giving medications
  • Help in getting access to services
  • Support groups
  • Individual counseling to help cope with giving care
  • Respite care
  • You don’t need any of these support services

INTERVIEWER INSTRUCTIONS:
If respondent asks what respite care is; read:

"Respite care means short-term breaks for people who provide care."

SKIP INSTRUCTION:
If M21.1 = "Yes" or "Caregiving recipient died in past 30 days", go to next module.
Otherwise, continue.
M21.9
Data Results M21.9
In the next 2 years, do you expect to provide care or assistance to a friend or family member who has a health problem or disability?
 
State-Added
Module 6: Farmers´ Market
SA6.1
Data Results for SA6.1
How often in the past 12 months did you buy fruits or vegetables from a farmers´ market?
Crosstabulation Table:
 
 
State-Added
Module 7: Adult Active Transportation
SA7.1
Data Results SA7.1
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 8: Child Active Transportation
SKIP INSTRUCTION:
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.
If selected child's age is not given (don't know/not sure or refused), go to next module.
Otherwise, go to next module.
I have some additional questions about the "Xth" [FILL: Number of Selected Child] child. All the following questions about children will be about the
"Xth" [FILL: Number of Selected Child] child.
SA8.1
Data Results SA8.1
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?
SA8.2
Data Results SA8.2
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 9: Childhood Influenza (Flu) Immunization
SKIP INSTRUCTION:
If response to Core Q8.16 = "None" or"Refused", go to next module.
If selected child's age is greater than or equal 6 months, continue.
Otherwise, go to next module.
SA9.1
Data Results SA9.1
Now I will ask you questions about seasonal flu. There are two types of seasonal flu vaccinations. One is a shot and the other is a spray in the nose. During the past 12 months, has [FILL: he/she] had a seasonal flu vaccination?
SKIP INSTRUCTION:
If SA9.1 = "Yes", continue.
If SA9.1 = "No", go to SA9.3.
Otherwise, go to next module.
SA9.2 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.
SKIP INSTRUCTION:
Go to Next Module.
SA9.3
Data Results SA9.3

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

INTERVIEWER NOTE:
Select ONE category that “best” matches.

Do not read answer choices below.
  • 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
  • Age is too young
  • Decision left to child who refused
 
 
State-Module
Module 10: Adolescent Meningococcal Vaccination
SKIP INSTRUCTION:
If response to Core Q8.16 = "None" or "Refused", go to next module.
If Child’s age is between 11 and 17 years (CHLDAGE2 => 11), continue.
Otherwise, go to next module.
SA10.1
Data Results SA10.1
A vaccine to prevent some types of meningitis caused by bacteria is available. Has this child ever had the meningococcal vaccination?
SKIP INSTRUCTION:
If SA10.1 = "Yes", continue.
If SA10.1 = "No", go to SA10.3.
Otherwise, go to next module.
SA10.2
Data Results SA10.2
How many meningococcal shots [FILL: his/her] receive? 
SKIP INSTRUCTION:
Go to Next Module.
SA10.3
Data Results SA10.3
What is the MAIN reason [FILL: he/she] has not received the meningococcal vaccination?

INTERVIEWER NOTE:
Select ONE category that “best” matches.



Do not read answer choices below.
  • Child does not need it
  • Doctor did not recommend it
  • Did not know that child should be vaccinated
  • Side effects
  • Does not work
  • Plan to get child 7676vaccinated later
  • 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
  • Not required for school
  • Other
  • Have no got around to it/didn't get it
  • Parent does not believe/approve or is against Meningococcal shots
  • Age is too young
  • Decision left to child who refused
 
 
State-Added
Module 11: Adolescent Tetanus-Diphtheria-Pertussis (TDap) Immunization
SKIP INSTRUCTION:
If Core Q8.16 = "None" or "Refused", go to next module.
If selected child's age is 11 through 17 years old, continue.
If selected child's age is not given (don't know/not sure or refused), go to next module.
Otherwise, go to next module.
The tetanus booster shot we’re asking about is different from the Dtap, DT or DTP shots, which children usually receive for the age of six. This tetanus booster is required for school entry for 7th & 8th grade students and is called Tdap.
SA11.1
Data Results SA11.1
In the last 10 years has your child received a tetanus shot?
SKIP INSTRUCTION:
If SA11.1 = "Yes", continue.
If SA11.1 = "No", go to SA11.3.
Otherwise, go to the next module.
SA11.2
Data Results SA11.2
Was this tetanus shot Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?
SKIP INSTRUCTION:
Go to Next Module.
SA11.3
Data Results SA11.3
What is the MAIN reason [FILL: he/she] has not received the tetanus, diphtheria, pertussis vaccination?

INTERVIEWER NOTE:
Select ONE category that “best” matches.



Do not read answer choices below.
  • Child does not need it
  • Doctor did not recommend it
  • Did not know that child should be vaccinated
  • Side effects
  • Does not work
  • Plan to get child vaccinated later
  • 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
  • Parent does not believe/approve or is against TDap shots
  • Age is too young
 
 
State-Added
Module 12: Childhood Human Papilloma Virus (HPV)
SKIP INSTRUCTION:
If Core Q8.16 = "None" or "Refused", go to next module.
If selected child's age is 9 through 17 years old, continue.
If selected child's age is not given (don't know/not sure or refused), go to next module.
Otherwise, go to next module.
SA12.1
Data Results SA12.1
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?
SKIP INSTRUCTION:
If SA12.1 = "Yes", continue.
If SA12.1 = "No", go to SA12.3.
Otherwise, go to the next module.
SA12.2
Data Results SA12.2
How many HPV shots did [FILL: he/she] receive?
SKIP INSTRUCTION:
Go to Next Module.
SA12.3
Data Results SA12.3
What is the MAIN reason [FILL: he/she] has not received the HPV vaccination?

INTERVIEWER NOTE:
Select ONE category that “best” matches.



Do not read answer choices below.
  • 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
  • Not required for school
  • Other
  • Parent does not believe/approve or is against HPV shots
  • Age is too young
  • Do not trust vaccine
  • Needs more information about vaccine
  • Decision left to child who refused
 
 
State-Added
Module 13: Opioid Use Disorder
The following questions concern information about your possible involvement with prescription narcotics during the past 12 months. We only want to know about prescription narcotics NOT medication that is available over the counter, such as aspirin, Tylenol, Ibuprofen, Advil, or Aleve. Examples of prescription narcotics that we ARE interested in include Vicodin, Hydrocodone, Lortab, Percocet, OxyContin, Oxycodone, Ultram, Tramadol, Tylenol with Codeine, Opana, and Dilaudid.
SA13.1
Data Results SA13.1
In the past year, has your doctor prescribed to you any prescription narcotics?
SKIP INSTRUCTION:
If SA13.1 = "Yes", continue.
If SA13.1 = "Yes, I'm taking prescription pain medication as part of a treatment program for opioid dependency", go to next module.
Otherwise, go to SA13.3.
SA13.2
Data Results SA13.2
The last time you filled a prescription narcotic did you use any of your medication more frequently or in higher doses than directed by a doctor?
SA13.3
Data Results SA13.3
In the past year, did you use any prescription narcotics that were NOT prescribed specifically to you by a doctor? We only want to know about prescription narcotics NOT medication that is available over the counter.
SKIP INSTRUCTION:
If SA13.3 = "Yes, I took it to relieve my pain" or "Yes, I took it for the feeling or experience it caused", continue.
If SA13.1 = "No", "Don't know/Not sure" or "Refused" and SA13.2 = "Yes", continue.
Otherwise, go to the next module.
SA13.4
Data Results SA13.4

I am going to read you a list of situations about your use of prescription narcotics in the past 12 months. When I am done, please tell me how many of the situations apply to you. You do not need to tell me which ones.

In the past 12 months have you ever…?

  • Wanted to cut down or quit taking prescription narcotics.
  • Felt sick after you stopped taking it.
  • Continued using in spite of physical, emotional, or social problems caused by your use of prescription narcotics.
SKIP INSTRUCTION:
If SA13.4 = "Two or more", go to next module.
Otherwise, continue.
SA13.5
Data Results SA13.5

(I am going t read you a list. When I am done, please tell me how many of the situations apply to you. You do not need to tell me which ones. )

In the past 12 months have you ever…?

  • Had to increase the amount of prescription narcotics used to get the same effect
  • Taken more than intended
  • Experienced a strong urge to take it
SKIP INSTRUCTION:
If SA13.5 = "Two or more", go to next module.
If SA13.5 = "One" and SA13.4 = "One", go to next module.
Otherwise, continue.
SA13.6
Data Results SA13.6

(I am going to read you a list. When I am done, please tell me how many of the situations apply to you. You do not need to tell me which ones.)

In the past 12 months have you ever…?

  • Spent lots of time taking, obtaining, or recovering from taking prescription narcotics
  • Given up important activities due to continued use
  • Recurrently used prescription narcotics in physically hazardous situations
  • Failed to fulfill major role obligations due to prescription narcotic use
 
CDC Optional
Module 27: Firearm Safety
The next questions are about safety and firearms. Some people keep guns for recreational purposes such as hunting or sport shooting. People also keep guns in the home for protection. Please include firearms such as pistols, revolvers, shotguns, and rifles; but not BB guns or guns that cannot fire. Include those kept in a garage, outdoor storage area, or motor vehicle.

INTERVIEWER INSTRUCTION:
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.”

M27.1
Data Results M27.1
Are any firearms now kept in or around your home?
SKIP INSTRUCTION:
If M27.1 = "Yes", continue.
Otherwise, go to next module.
M27.2
Data Results M27.2
Are any of these firearms now loaded?
SKIP INSTRUCTION:
If M27.2 = "Yes", continue.
Otherwise, go to next module.
M27.3
Data Results M27.3
Are any of these loaded firearms also unlocked? By 'unlocked' we mean you do not need a key or a combination or a hand/fingerprint to get the gun or to fire it. We don't count a safety as a lock.
 
Part B
Summary Index Table:
 
CDC Optional
Module 2: Diabetes (Asked in Core)
SKIP INSTRUCTION:
If Core Section 6: Chronic Health Conditions DIABETE3 (C6.12) = "Yes" and QSTVER = 12 or 22 (Part B), continue.
[To be asked after C6.13 in the core.]
Otherwise, go to Core Section 7: Arthritis Burden.
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.

INTERVIEWER INSTRUCTIONS:
Enter quantity per day, week, or month.
If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously); fill in “98” time per day (198).

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.

INTERVIEWER INSTRUCTION:
Enter quantity per day, week, or month.

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"?

SKIP INSTRUCTION:
If M2.3 = "no feet", go to M2.7.
Otherwise, continue.
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?

SKIP INSTRUCTION:
Return to Core Section 7: Arthritis Burden.
 
 
State-Added
Module 14: Electronic Cigarettes (E-Cigarette) Reason for Initiating (Asked in Core)
SKIP INSTRUCTION:
If Core Section 10: E-Cigarettes ECIGARET (C10.1) = "Yes" and QSTVER = 12 or 22 (Part B), continue.
[To be asked after Section 10: E-Cigarettes in the core.]
Otherwise, continue to Core Section 11: Alcohol Consumption.
SA14.1
Data Results SA14.1

I am going to read you a list. Please let me read all the answer choices before giving me your answer. When I am done, please tell me what was the main reason you tried e-cigarettes?

CATI INSTRUCTON:
If Core Section 9: Tobacco Use SMOKE100 (C9.1) = "Yes" or USENOW3 (C9.5) = "Yes", and the respondent indicates they thought it would be safer than trying cigarettes or other tobacco products; ask:
"Were you trying to CUT BACK on smoking cigarettes or other tobacco products?”

If “yes”, code as 04 (I wanted to cut back on cigarettes and/or other tobacco products).
If “no”, ask:

“Were you trying to QUIT smoking cigarettes or other tobacco products?”

If “yes”, code as 05 (I watned to quit cigarettes or other tobacco products).
If “no”, ask:
“Which choice is the MAIN reason you tried e-cigarettes?”

INTERVIEWER INSTRUCTION: 
If respondent selects more than one reason; ask:
“Which is the MAIN reason you tried e-cigarettes?” 

Please read:
  • Because I was curious to try something new
  • I thought it would be safer than trying cigarettes or other tobacco products
  • As part of a social activity, for fun or someone invited me to try
  • I wanted to cut back on cigarettes or other tobacco products
  • I wanted to quit cigarettes and/or other tobacco products
  • To use indoors or in other places where smoking is not allowed
  • It's cheaper (less expensive) than cigarettes or other tobacco products
  • Other (specify :_________)
SKIP INSTRUCTION:
Return to Core Section 11: Alcohol Consumption.
 
 
State-Added
Module 15: Diabetes Risk Assessment
SA15.1
Data Results SA15.1

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
SKIP INSTRUCTION:
If Sex (Q8.1) = "Female", continue.
Otherwise, go to next module.
SA15.2
Data Results SA15.2
Have you had a baby weighing more then 9 pounds at birth?
 
 
State-Added
Module 16: Self-Monitoring Blood Pressure Monitoring

SKIP INSTRUCTION:
If Core Section 4: Hypertension Awareness BPHIGH4 (C4.1) = "Yes" or "Told borderline high or pre-hypertensive", continue.
Otherwise, got to next module.

SA16.1
Data Results SA16.1
Do you measure your blood pressure at home?
Crosstabulation Table:
SKIP INSTRUCTION:
If SA16.1 = "Yes" continue.
Otherwise, go to next module.
SA16.2
Data Results SA16.2
How often do you measure your blood pressure at home?
SA16.3
Data Results SA16.3

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.

  • Manual
  • Automated
  • Hybird
  • Other (specify: _______)
SA16.4
Data Results SA16.4
Do you regularly transmit, via e-mail, Internet, phone or fax, blood pressure readings to a health care provider for feedback?
 
 
State-Added
Module 17: Sun Safety Behavior
SA17.1
Data Results SA17.1
When you go outside on a sunny day for more than one hour, how often do you use sunscreen or sun-block? Would you say…?
  • Always
  • Nearly always
  • Sometimes
  • Seldom
  • Never
 
 
State-Added
Module 18: Tanning Bed/Sun Lamp Use - Adults
SA18.1
Data Results SA18.1
Thinking about the last 12 months; on how many days did you use a tanning bed or sun lamp?
 
 
State-Added
Module 19: Tanning Bed/Sun Lamp Use - Child
SKIP INSTRUCTION:
If Core Q8.16 = "None" or "Refused", go to next module.
If selected child's age is 5 through 17 years old, continue.
If selected child's age is not given (don't know/not sure or refused), go to next module.
Otherwise, go to next module.

I have one additional question about the “Xth” [FILL: Number of selected child] child.

SA19.1
Data Results SA19.1
Thinking about the last 12 months; on how many days did [FILL: he/she] use a tanning bed or sun lamp?
 
 
CDC Optional
Module 20: Lung Cancer Screening
SKIP INSTRUCTION:
If Core Section 9: Tobacco Use SMOKE100 (C9.1) = "Yes" and SMOKDAY2 (C9.2) = "Every day", "Some days" or "Not at all", continue.
Otherwise, go to M20.4.
You’ve told us that you have smoked in the past or are currently smoking. The next questions are about screening for lung cancer.
M20.1
Data Results M20.1

How old were you when you first started to smoke cigarettes regularly?

INTERVIEWER NOTE:
“Regularly” is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all).

SKIP INSTRUCTION:
If M20.1 = "Never smoked cigarettes regularly", go to M20.4.
Otherwise, continue.
M20.2
Data Results M20.2

How old were you when you last smoked cigarettes regularly?

INTERVIEWER NOTE:
“Regularly” is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all).

M20.3
Data Results M20.3

On average, when you [Fill: “smoke” or “smoked”] regularly, about how many cigarettes [Fill: “do” or “did”] you usually smoke each day?

INTERVIEWER NOTE:
“Regularly” is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all).

INTERVIEWER NOTE:
Respondents may answer in packs instead of number of cigarettes. Below is a conversion table:

0.5 PACK; = 10 CIGARETTES                   1.75 PACKS = 35 CIGARETTES
0.75 PACK   = 15 CIGARETTES                 2.00 PACKS = 40 CIGARETTES
1.00 PACK   = 20 CIGARETTES                 2.50 PACKS= 50 CIGARETTES
1.25 PACKS = 25 CIGARETTES                 3.00 PACKS= 60 CIGARETTES

M20.4
Data Results M20.4
The next question is about CT or CAT scans. During this test, you lie flat on your back on a table. While you hold your breath, the table moves through a donut shaped x-ray machine while the scan is done. In the last 12 months, did you have a CT or CAT scan?
 
 
State-Added
Module 20: Lung Cancer Screening
SKIP INSTRUCTION:
If CDC Optional Module 20: Lung Cancer Screening LCSCTSCN (M20.4) = "No", "Yes, had a CT scan, but for some other reason", "Don't know/Not sure" or "Refused", continue.
Otherwise, go to next module.
You’ve told us that you have smoked in the past or are currently smoking. The next questions are about screening for lung cancer.
SA20.1
Data Results SA20.1
In the last 12 months, has a doctor, nurse or other health professional recommended that you have a CT or CAT scan?
 
 
CDC Optional
Module 12: Cancer Survivorship
SKIP INSTRUCTION:
If Core Section 6: Chronic Health Conditions CHCSCNCR (Q6.6) = "Yes" or CHCOCNCR (Q6.7) = "Yes", continue.
Otherwise, go to next module.
You’ve told us that you have had cancer. I would like to ask you a few more questions about your cancer.
M12.1
Data Results M12.1
How many different types of cancer have you had?
SKIP INSTRUCTION:
If M12.1 = "Don't know/Not sure" or "Refused", go to next module.
Otherwise, continue.
M12.2
Data Results M12.2
If M12.1 = "Only one", ask:
“At what age were you told that you had cancer?”
or
If M12.1 = "Two" or "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.
M12.3
Data Results M12.3

INTERVIEWER INSTRUCTIONS:
If M12.1 = "Only one" and Core Q6.6 = "Yes", ask:
Was it “Melanoma” or “other skin cancer"?”
Code 21 for melanoma or Code 22 for other skin cancer.
or
If M12.1 = "Only one" and Core Q6.6 = "No", "Don't know/Not sure" or "Refused", ask:
“What type of cancer was it?”
or
If M12.1 ="Two" or "Three or more", ask:

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

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

M12.4
Data Results M12.4
Are you currently receiving treatment for cancer? By treatment, we mean surgery, radiation therapy, chemotherapy, or chemotherapy pills.
SKIP INSTRUCTION:
If M12.4 = "No, I've completed treatment", continue.
Otherwise, go to next module.
M12.5
Data Results M12.5
What type of doctor provides the majority of your health care?

INTERVIEWER INSTRUCTION:
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
  • Other
M12.6
Data Results M12.6
Did any doctor, nurse, or other health professional EVER give you a written summary of all the cancer treatments that you received?

INTERVIEWER INSTRUCTION:
Read only if necessary:

“By ‘other healthcare professional’, we mean a nurse practitioner, a physician’s assistant,social worker, or some other licensed professional.”
M12.7
Data Results M12.7
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?
SKIP INSTRUCTION:
If M12.7 = "Yes", continue.
Otherwise, go to M12.9.
M12.8
Data Results M12.8
Were these instructions written down or printed on paper for you?
M12.9
Data Results M12.9
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.
M12.10
Data Results M12.10
Were you EVER denied health insurance or life insurance coverage because of your cancer?
M12.11
Data Results M12.11
Did you participate in a clinical trial as part of your cancer treatment?
M12.12
Data Results M12.12
Do you currently have physical pain caused by your cancer or cancer treatment?
SKIP INSTRUCTION:
If M12.12 = "Yes", continue.
Otherwise, go to next module.
M12.13
Data Results M12.13

Is your pain currently under control?

Please read:
  • Yes, with medication (or treatment)
  • Yes, without medication (or treatment)
  • No, with medication (or treatment)
  • No, without medication (or treatment)

 
 
State-Added
Module 21: Hookah Use
The next question asks you about smoking tobacco in a water pipe. A water pipe is also called a hookah.
SA21.1
Data Results SA21.1
Have you ever tried smoking tobacco in a water pipe, even one or two puffs?
Crosstabulation Table:
SKIP INSTRUCTION:
If SA21.1 = "Yes" continue.
Otherwise, go to next module.
SA21.2
Data Results SA21.2

During the past 30 days, that is, since [FILL: the “date” 30 days ago], on how many days did you smoke tobacco in a water pipe?

Crosstabulation Table:
 
 
State-Added
Module 22: Telephone Tobacco Quitline Knowledge
A telephone quitline is a free telephone-based service that connects people who use tobacco with someone who can help them quit.
SA22.1
Data Results SA22.1
Are you aware of any telephone quitline services that are available to help [FILL: if current tobacco user, “you” or if not curren tobacco user, “people”] quit using tobacco?
 
 
State-Added
Module 23: In-Home Smoking Policy
The next question is about smoking inside the home.
SA23.1
Data Results SA23.1

Not counting decks, porches, or garages, during the past 7 days, that is, since last [FILL: with today’s text of day of the week], on how many days did someone other than you smoke tobacco inside your home while you were at home?

SA23.2
Data Results SA23.2

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 24: Multi-Unit Dwelling Secondhand Smoke
SA24.1
Data Results SA24.1
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
SKIP INSTRUCTION:
If SA24.1 = "Single family home/Mobile home/Trailer", "Don't know/Not sure" or "Refused", go to next module.
Otherwise, continue.
SA24.2
Data Results SA24.2
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
 
 
State-Added
Module 25: Work Place Secondhand Smoke
SKIP INSTRUCTION:
If Core Section 8: Demographics EMPLOY1 (C8.15) = "Employed" or "Self-Employed", continue.
Otherwise, go to next module.
Now I‘m going to ask you about smoke you might have breathed at work because someone else was smoking, either indoors or outdoors.
SA25.1
Data Results SA25.1

During the past 7 days, that is, since last [FILL: text of day of the week], on how many days did you breathe the smoke at your workplace from someone other than you who was smoking tobacco?

 
 
State-Added
Module 26: Mental Health - Kessler 6
Crosstabulation Table:
Summary Index:
Now, I am going to ask you some questions about how you have been feeling lately.
SA26.1
Data Results SA26.1
About how often during the past 30 days did you feel nervous? Would you say…?

Read:
  • All of the time
  • Most of the time
  • Some of the time
  • A little of the time
  • None of the time
SA26.2
Data Results SA26.2
During the past 30 days, about how often did you feel hopeless? Would you say…?

Read:
  • All of the time
  • Most of the time
  • Some of the time
  • A little of the time
  • None of the time
SA26.3
Data Results SA26.3
During the past 30 days, about how often did you feel restless or fidgety? Would you say…?

Read:
  • All of the time
  • Most of the time
  • Some of the time
  • A little of the time
  • None of the time
SA26.4
Data Results SA26.4
During the past 30 days, about how often did you feel so depressed that nothing could cheer you up? Would you say…?

Read:
  • All of the time
  • Most of the time
  • Some of the time
  • A little of the time
  • None of the time
SA26.5
Data Results SA26.5
During the past 30 days, about how often did you feel that everything was an effort? Would you say…?

INTERVIEWER INSTRUCTION:
If respondent asks what does “everything was an effort” means; say:
“Whatever it means to you?”

Read:
  • All of the time
  • Most of the time
  • Some of the time
  • A little of the time
  • None of the time
SA26.6
Data Results SA26.6
During the past 30 days, about how often did you feel worthless? Would you say…?

Read:
  • All of the time
  • Most of the time
  • Some of the time
  • A little of the time
  • None of the time
 
 
State-Added
Module 27: Sexual Violence
Now I’d like to ask you some questions about different types of physical and/or sexual violence or other unwanted sexual experiences. This information will allow us to better understand the problem of violence and unwanted sexual contact and may help others in the future. This is a sensitive topic. Some people may feel uncomfortable with these questions. At the end of this section, I will give you phone numbers for organizations that can provide information and referral for these issues. Please keep in mind that if you are not in a safe place you can ask me to skip any question you do not want to answer.
SA27.1
Data Results for SA27.1
Are you in a safe place to answer these questions?
Now, I am going to ask you questions about unwanted sex. Unwanted sex includes things like putting anything into your vagina [If female], anus, or mouth or making you do these things to them after you said or showed that you didn’t want to. It includes times when you were unable to consent, for example, you were drunk or asleep, or you thought you would be hurt or punished if you refused.
SA27.2
Data Results for SA27.2
Has anyone EVER had sex with you after you said or showed that you didn’t want them to or without your consent?
SA27.3
Data Results for SA27.3
Think about the time of the most recent incident involving a person who had sex with you, or attempted to have sex with you, after you said or showed that you didn’t want to or without your consent. What was that person’s relationship to you?
  • Personal attendant/caregiver
  • Someone you were dating
  • Boyfriend/Girlfriend
  • Stranger
  • Spouse or live-in partner
  • Relative
  • Friend
  • Acquaintance
Closing Statement of Sexual Violence Module: We realize that this topic may bring up past experiences that some people may wish to talk about. If you or someone you know would like to talk to a trained counselor, please call the Kansas Crisis Hotline at 1-888-END-ABUSE, that is 1-888-363-2287. Again, that number 1-888-END-ABUSE, that is 1-888-363-2287.
 
State-Added
Module 28: 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.
SA28.1
Data Results for SA28.1
Has there been a time, in the past 12 months, when you thought of taking your own life?
SKIP INSTRUCTION:
If SA28.1 = "Yes", continue.
Otherwise, go to closing.
SA28.2
Data Results for SA28.2
During the past 12 months, did you attempt suicide?
Closing Statement of Suicide Module: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.