During the past 30 days, how often did the [randomly selected child] ride in the back seat?

During the past 30 days, how often did the [randomly selected child] use a child safety seat, booster seat, or seat belt when riding in a car, van, sports utility vehicle, or truck?

During that time, did the [randomly selected child] use: a child safety seat?

(During that time, did the [randomly selected child] use): a booster seat?

(During that time, did the [randomly selected child] use): a seat belt only?

(Has a doctor or other health professional ever talked with you) about drug abuse?

How often do you use seat belts when you drive or ride in a car?

How often does the [fill in age]-year-old child in your household use a... car safety seat [for child under 5] or seatbelt [for child 5 or older] ...when they ride in a car?

How often does the oldest child (of children under age 15) in your household use a... car safety seat [for child under 5] or seatbelt [for child 5 or older] ...when they ride in a car?

Are you or your [fill in (husband/partner)] using any kind of birth control now? Birth control means having your tubes tied, vasectomy, the pill, condoms, diaphragm, foam, rhythm, Norplant, shots (Depo-provera) or any other way to keep from getting pregnant.

Are you or your [fill in (wife/partner)] using any kind of birth control now? Birth control means having your tubes tied, vasectomy, the pill, condoms, diaphragm, foam, rhythm, Norplant, shots (Depo-provera) or any other way to keep from getting pregnant.

Are you or your [husband/wife/partner] doing anything now to keep [you/her] from getting pregnant? Some things people do to keep from getting pregnant include not having sex at certain times, using birth control methods such as the pill, Norplant, shots or Depo-provera, condoms, diaphragm, foam, IUD, having their tubes tied, or having a vasectomy.

During the past 12 months, with how many different people have you had sexual intercourse?

[Females] What is your main reason for not doing anything to keep from getting pregnant?
[Males]What is your main reason for not doing anything to keep your partner from getting pregnant? 

(Has a doctor or other health professional) ever talked with you about your sexual practices, including family planning, sexually transmitted diseases, AIDS, or the use of condoms?

How many new sex partners did you have during the past 12 months?

I’m going to read you a list. When I’m done, please tell me if any of the situations apply to you. You don't need to tell me which one.

• You have used injectable drugs in the past year.
• You tested positive for having HIV, the virus that causes AIDS.
• You had anal sex without a condom in the past year.

Do any of these situations apply to you?

In the past five years, have you been treated for a sexually transmitted or venereal disease?

Some things people do to keep from getting pregnant include not having sex at certain times, using birth control methods such as the pill, Norplant, shots or Depo-provera, condoms, diaphragm, foam, IUD, having their tubes tied, or having a vasectomy. Are you or your [husband/wife/partner] doing anything now to keep [you/her] from getting pregnant?

The last time you had sexual intercourse, was the condom used ..

• To prevent pregnancy
• To prevent diseases like syphilis, gonorrhea, and AIDS
• For both of these reasons
• For some other reason

Was a condom used the last time you had sexual intercourse?

Were you treated at a local health department?

What are you or your [if female husband/partner; if male, insert wife/partner] doing now to keep [if female, insert "you"; insert "her" if male] from getting pregnant?

What are your reasons for not using any birth control now?

What kinds of birth control are you or your [fill in (husband/partner)] using now?

What kinds of birth control are you or your [fill in (wife/partner)] using now?

What is the main reason for not doing anything to keep [if female husband/partner; if male, insert wife/partner] from getting pregnant?

What other method are you also using to prevent pregnancy?

These next questions may be hard for you to answer but the information is very important. These questions are about different types of physical and/or sexual violence or other unwanted sexual experiences that might or might not have happened to you since you were 18 years old. We recognize this is a sensitive topic. Some people may feel uncomfortable with these questions. The information you provide us will be kept strictly confidential. At the end of this section, I will give you a phone number for organizations that can provide information and referral for these issues. Please keep in mind that if you are not in a safe place you can ask me to skip any question you do not want to answer.

Are you in a safe place to answer these questions?

Now, I am going to ask you questions about unwanted sex.

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

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

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

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

Has this happened in the past 12 months?

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?

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. Have you had this vaccine?

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.”
(Ever told) you had skin cancer?

Have you ever been told by a doctor that you have skin cancer?

Have you had any of the following skin cancers?

• Melanoma
• Basal cell
• Squamous cell
• Some other type of skin cancer (specify: _____)

How long ago was your melanoma skin cancer diagnosed?

Including times when even a small part of your skin was red for more than 12 hours, how many sunburns have you had within the past 12 months?

The next question is about sunburns, including any time that even a small part of your skin was red for more than 12 hours. Have you had a sunburn within the past 12 months?

Have you ever had all of your skin from head to toe checked for cancer either by a dermatologist or some other kind of doctor?
[Interviewer note: If asked, 'A dermatologist is a doctor who specializes in skin diseases'.]
If 'Yes' probe for how long ago

When you go outside on a very sunny day, for more than one hour, how often do you stay in the shade?

When you go outside on a very sunny day, for more than one hour, how often do you wear a hat that shades your face, ears, and neck?
[READ IF NECESSARY] Do not include visors, baseball caps, or hats that do not shade the ears and neck.

When you go outside on a very sunny day, for more than one hour, how often do you wear a long sleeved shirt?

When you go outside on a very sunny day, for more than one hour, how often do you use sunscreen?

Have you used a sun lamp or tanning bed in the past 12 months?

Has a doctor, nurse, or other health professional ever advised or discussed with you about taking protective measures against skin cancer. Protective measures include use of sunscreen, protective clothing and avoiding exposure to sunlamps or tanning beds.
If 'Yes', probe for how long ago

The next question is about getting enough rest or sleep

During the past 30 days, for about how many days have you felt you did not get enought rest or sleep?

I would like to ask you a few questions about your sleep patterns.

During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?

On average, how many hours of sleep do you get in a 24-hour period? Think about the time you actually spend sleeping or napping, not just the amount of sleep you think you should get.
Interviewer Note: Enter hours of sleep in whole numbers, rounding 30 minutes (1/2 hour) or more up to the next whole hour and dropping 29 or fewer minutes.

I would like to ask you a few questions about your sleep patterns.

During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?

Do you snore?
Interviewer Note: If the respondent indicates that their spouse or someone told him/her that they snore, then the answer to the question is "Yes", the respondent snores.

During the past 30 days, for about how many days did you find yourself unintentionally falling asleep during the day?

During the past 30 days, have you ever nodded off or fallen asleep, even just for a brief moment, while driving?

Do you have a functioning smoke detector on every level of your home and outside each sleeping area?

Do you have a specific plan for how you would escape from your house or apartment in case of fire?

Does your family have an escape plan in case of fire in the home?

(Has a doctor or other health professional ever talked with you) about injury prevention, such as safety belt use, helmet use, or smoke detectors?

Has your family practiced an escape plan in case of fire in the home?

Has your family practiced or discussed an escape plan in case of a fire at home?

Is there a working smoke detector in your household?

When was the last time you or someone else deliberately tested all of the smoke detectors in your home?

When was the last time you or someone else deliberately tested all of the smoke detectors in your home, either by pressing the test buttons or holding a source of smoke near them?

Which of the following best describes whether you have a smoke detector in your home? Is it:

• I don't have a smoke detector.
• I have an installed and working smoke detector.
• I have a smoke detector, but it is not installed.
• I have a smoke detector, but it is broken or the battery is missing.
• I have a smoke detector, but don't know if it works.

About how many hours do you work per week at all of your jobs and businesses combined?

At your main job or business, how are you generally paid for the work you do. Are you:

• Paid by salary
• Paid by the hour
• Paid by the job/task (e.g. commission, piecework)
• Paid some other way

INTERVIEWER NOTE: If paid in multiple ways at their main job, select option 4 (Paid some other way).

Do you rent or own your home?

Did you vote in the last presidential election? The November 2008 election between Barack Obama and John McCain?

Do you rent or own your home?
INTERVIEWER NOTE: "Other arrangement" may include group home or staying with friends or family without paying rent.

How long have you lived at your current address?

How many close friends or relatives would help you with your emotional problems or feelings if you needed it?

How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or stressed---

• Always
• Usually
• Sometimes
• Rarely
• Never

How often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage? Would you say you were worried or stressed---

• Always
• Usually
• Sometimes
• Rarely
• Never

How safe from crime do you consider your neighborhood to be?

In the past 30 days, have you been concerned about having enough food for you or your family?

Thinking about the last time you worked, about how many hours did you work per week at all of your jobs and businesses combined?

Thinking about the last time you worked, at your main job or business, how were you generally paid for the work you do? Were you:

• Paid by salary
• Paid by the hour
• Paid by the job/task (e.g. commission, piecework)
• Paid some other way

INTERVIEWER NOTE: If paid in multiple ways at their main job, select option 4 (Paid some other way).

What is the source of water you usually drink at home? Is it:

• City/town water supple
• Private well
• Bottled water
• Other

The following questions deal with suicide. Many people feel that this subject is personal, but we would appreciate you trying to answer these questions. Remember that you don't have to answer any questions that you don't want to.

Has there been a time in the past 12 months when you thought of taking your own life?

If CDC Module Q24.6 = 1 (Yes, but did not require treatment), 2 (Yes, was treated at a VA facility) or 3 (Yes, was treated at a non-VA facility), read:
During the past 12 months, before you attempted suicide, did you make a plan about how you would attempt suicide?

Else, read:
During the past 12 months, did you make a plan about how you would attempt suicide?

The next question is about sunburns, including any time that even a small part of your skin was red for more than 12 hours. Have you had a sunburn within the past 12 months?

Including times when even a small part of your skin was red for more than 12 hours, how many sunburns have you had within the past 12 months?