2000
Behavioral Risk Factor Surveillance System Questionnaire

CORE SECTIONS
Section 1:   Health Status	2
Section 2:   Health Care Access	4
Section 3:   Asthma	9
Section 4:   Diabetes	10
Section 5:   Care Giving	11
Section 6:   Exercise	12
Section 7:   Tobacco Use	15
Section 8:   Fruits and Vegetables	17
Section 9:   Weight Control	20
Section 10:  Demographics	22
Section 11:  Women's Health	28
Section 12:  HIV/AIDS	32

OPTIONAL MODULES
Module 1:    Diabetes	39
Module 2:    Sexual Behavior	43
Module 3:    Family Planning	47
Module 4:    Health Care Coverage and Utilization	52
Module 5:    Health Care Satisfaction	56
Module 6:    Oral Health	59
Module 7:    Hypertension Awareness	62
Module 8:    Cholesterol Awareness	63
Module 9:    Colorectal Cancer Screening	64
Module 10:   Immunization	66
Module 11:   Injury Control	67
Module 12:   Alcohol Consumption	69
Module 13:   Cardiovascular Disease	71
Module 14:   Arthritis	75
Module 15:   Quality of Life and Care Giving	77
Module 16:   Folic Acid	83
Module 17:   Skin Cancer	85
Module 18:   Tobacco Use Prevention	88
Module 19:   Smokeless Tobacco	90

HELLO,  I'm                         calling for the                               and the Centers for Disease Control and Prevention.  We're gathering information on the health practices of                       residents to guide state health policies.  Your phone number has been chosen randomly, and we'd like to ask some questions about day-to-day living habits that may affect health.

Is this                          ?	If "no"	Thank you very much, but I seem to have dialed the wrong number,  It's possible that your number may be called at a later time.  Stop

Is this a private residence?	If "no"	Thank you very much, but we are only interviewing private residences.  Stop

We need to randomly select one adult who lives in your household to be interviewed.  How many members of your household, including yourself, are 18 years of age or older?	(62-63)

			Number of adults						         

	If "1"	Are you the adult?

		If "yes"	Then you are the person I need to speak with.
Enter 1 man or 1 women below (Ask gender if necessary).  Go to page 2

		If "no"	Is the adult a man or a woman?  Enter 1 man or 1 women below.
May I speak with [fill in (him/her) from previous question]?  Go to "correct respondent" at bottom of page

How many of these adults are men and how many are women?

			Number of men						    	(64)

			Number of women						    	(65)

Who is the oldest man who presently lives in this household?
Who is the next oldest man who presently lives in this household?
Etc.

Who is the oldest woman who presently lives in this household?
Who is the next oldest woman who presently lives in this household?
Etc.

The person in your household that I need to speak with is                                .
							    If "you," go to page 2

To correct respondent	HELLO,  I'm                         calling for the                               and the Centers for Disease Control and Prevention.  We're gathering information on the health practices of                       residents to guide state health policies.  You have been chosen randomly to be interviewed, and we'd like to ask some questions about day-to-day living habits that may affect health.  

We do not ask for your name, address, or other personal information that identifies you.  The phone number is erased once we finish all interviews at the end of the year.  There are no risks or benefits to you being in this survey.  Taking part is up to you.  You don’t have to answer any question you don’t want to, and you are free to end the interview at any time.  The interview takes                       minutes.  All information you give us will be confidential.  If you have any questions about this survey, I will provide a toll free telephone number for you to call to get more information.

Section 1: Health Status

1.1.	Would you say that in general your health is:	(66)

		Please Read

		a.  Excellent	1

		b.  Very good	2

		c.  Good	3

		d.  Fair	4
			or
		e.  Poor	5

Do not				Don't know/Not Sure	7
read these
responses			Refused	9

1.2.	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?	(67-68)
     
		a.  Number of days	         

		b.  None	8  8

			Don't know/Not sure	7  7

 			Refused	9  9

1.3.	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?
					(69-70)

		a.  Number of days 	         

		b.  None  If Q1.2 also "None," go to Q2.1 (p. 4)	8  8

			Don't know/Not sure	7  7

			Refused	9  9

1.4.	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?	(71-72)

		a.  Number of days	         
	
		b.  None	8  8

			Don't know/Not sure	7  7

			Refused	9  9

Section 2:  Health Care Access

2.1.	Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?	(73)

		a.  Yes	1

		b.  No  Go to Q2.3a (p. 6)	2

			Don't know/Not sure  Go to Q2.6 (p. 7)	7

			Refused  Go to Q2.6 (p. 7)	9

2.2.	Medicare is a coverage plan for people 65 or over and for certain disabled people.  Do you have Medicare?	(74)

		a.	Yes  Go to Q2.6 (p.7)	1

		b.	No	2

			Don’t know/not sure	7

			Refused	9

2.3.	What type of health care coverage do you use to pay for most of your medical care?
					(75-76)

Is it coverage through:         Coverage Code	         

		Please Read 

	a.  Your employer  Go to Q2.4 (p.7)	0 1

		b.  Someone else’s employer  Go to Q2.4 (p.7)	0 2

	c.  A plan that you or someone else buys on your own  Go to Q2.4 (p.7)	0 3

		d.  Medicare  Go to Q2.6 (p.7)	0 4

		e.  Medicaid or Medical Assistance [or substitute state program name]
			 Go to Q2.4 (p.7)	0 5

	f.  The military, CHAMPUS, TriCare, or the VA [or CHAMP-VA]  
			Go to Q2.4 (p.7)	0 6

		g.  The Indian Health Service [or the Alaska Native Health Service]  
			Go to Q2.4 (p.7)	0 7
			or
		h.  Some other source  Go to Q2.4 (p.7)	0 8	

Do not				None  Go to Q2.5 (p.7)	8 8
read these
responses			Don't know/Not sure  Go to Q2.4 (p.7)	7 7

			Refused  Go to Q2.4 (p.7)	9 9

2.3a.	There are some types of coverage you may not have considered. Please tell me if you have any of the following:	(77-78)

	Coverage through:               Coverage Code	         

		Please Read 

If more than		a.  Your employer	0 1
one, ask
"Which type		b.  Someone else’s employer	0 2
do you use to
pay for most		c.  A plan that you or someone else buys on your own	0 3
of your		
medical care?"		d.  Medicare  Go to Q2.6 (p. 7)	0 4

		e.  Medicaid or Medical Assistance [or substitute state program name]	0 5

	f.  The military, CHAMPUS, TriCare, or the VA
			[or CHAMP-VA]	0 6

		g.  The Indian Health Service [or the Alaska Native Health Service]	0 7
			or
		h.  Some other source	0 8	

Do not				None  Go to Q2.5 (p.7)	8 8
read these
responses			Don't know/Not sure Go to Q2.6 (p.7)	7 7

			Refused  Go to Q2.6 (p.7)	9 9

2.4.	During the past 12 months, was there any time that you did not have any health insurance or coverage?	(79)

		a.  Yes  Go to Q2.6	1

		b.  No  Go to Q2.6	2

			Don't know/Not sure  Go to Q2.6	7

			Refused  Go to Q2.6	9

2.5.	About how long has it been since you had health care coverage?	(80)

		Read Only if Necessary

		a.  Within the past 6 months  (1 to 6 months ago)	1

		b.  Within the past year  (6 to 12 months ago)	2	

		c.  Within the past 2 years  (1 to 2 years ago)	3

		d.  Within the past 5 years  (2 to 5 years ago)	4

		e.  5 or more years ago	5

			Don't know/Not sure	7

			Never	8

			Refused	9

2.6.	Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?	(81)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

2.7.	About how long has it been since you last visited a doctor for a routine checkup?	
					(82)

		Read Only if Necessary

A routine		a.  Within the past year  (1 to 12 months ago)	1
checkup is a
general phys-		b.  Within the past 2 years  (1 to 2 years ago)	2
ical exam, not
an exam for		c.  Within the past 5 years  (2 to 5 years ago)	3
a specific
injury, ill-		d.  5 or more years ago	4
ness, or con-
dition				Don't know/Not sure	7

			Never	8

			Refused	9

Section 3: Asthma

3.1	Did a doctor ever tell you that you had asthma?	(83)

		a.  Yes	1

		b.  No Go to Q4.1 (p. 10)	2

			Don’t know/Not sure Go to Q4.1 (p. 10)	7

			Refused Go to Q4.1 (p. 10)	9

3.2	Do you still have asthma?	(84)

		a.  Yes	1

		b.  No	2

			Don’t know/Not sure	7

			Refused	9

Section 4:  Diabetes

4.1.	Have you ever been told by a doctor that you have diabetes?	(85)

If "Yes" and
female, ask		a.  Yes	1
"Was this 
only when		b.  Yes, but female told only during pregnancy	2
you were
pregnant?"		c.  No	3

			Don't know/Not sure	7

			Refused	9

Section 5: Care Giving

5.1.	There are situations where people provide regular care or assistance to a family member or friend who is elderly or has a long-term illness or disability.  During the past month, did you provide any such care or assistance to a family member or friend who is 60 years of age or older?		(86)

		a.  Yes	1

		b.  No	2

			Don’t Know/Not Sure	7

			Refused	9

5.2.	Who would you call to arrange short or long-term care in the home for an elderly relative or friend who was no longer able to care for themselves?	(87-88)

		Read Only if Necessary

		a.	Relative or friend	0 1

		b.  Would provide care myself	0 2

		c.  Nursing home	0 3

		d.  Home health service	0 4

		e.  Personal physician	0 5

		f.	Area Agency on Aging	0 6

		g.  Hospice	0 7

		h.  Hospital nurse	0 8

		i.	Minister/priest/rabbi	0 9

		j.	Other	1 0

		k.	Don’t know who to call	1 1

			Refused	9 9

Section 6:  Exercise

The next few questions are about exercise, recreation, or physical activities other than your regular job duties.

6.1.	During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?	(89)

		a.  Yes	1

		b.  No  Go to Q7.1 (p. 15)	2

			Don't know/Not sure  Go to Q7.1 (p. 15)	7

			Refused  Go to Q7.1 (p. 15)	9

6.2.	What type of physical activity or exercise did you spend the most time doing during the past month?		(90-91)

			Activity [specify]:                         	         
		                                 See coding list A

			Refused  Go to Q6.6 (p. 13)	9  9

Ask Q6.3 only if answer to Q6.2 is running, jogging, walking, or swimming.  All others, go to Q6.4.

6.3.	How far did you usually walk/run/jog/swim?	(92-94)

See coding			Miles and tenths	         .    
list B if
response is			Don't know/Not sure	7  7  7
not in miles
and tenths			Refused	9  9  9

6.4.	How many times per week or per month did you take part in this activity during the past month?
					(95-97)

		a.  Times per week	1          

		b.  Times per month	2          

			Don't know/Not sure	7  7  7

			Refused	9  9  9

6.5.	And when you took part in this activity, for how many minutes or hours did you usually keep at it?			(98-100)

			Hours and minutes	    :         

			Don't know/Not sure	7  7  7

			Refused	9  9  9 

6.6.	Was there another physical activity or exercise that you participated in during the last month?
					(101)

		a.  Yes	1

		b.  No  Go to Q7.1 (p. 15)	2

			Don't know/Not sure  Go to Q7.1 (p. 15)	7

			Refused  Go to Q7.1 (p. 15)	9

6.7.	What other type of physical activity gave you the next most exercise during the past month?
					(102-103)

			Activity [specify]:                         	         
		                                  See coding list A

			Refused  Go to Q7.1 (p. 15)	9  9

Ask Q6.8 only if answer to Q6.7 is running, jogging, walking, or swimming.  All others go to Q6.9 (p.14).

6.8.	How far did you usually walk/run/jog/swim?	(104-106)

See coding			Miles and tenths	         .    
list B if
response is			Don't know/Not sure	7  7  7
not in miles
and tenths			Refused	9  9  9

6.9.	How many times per week or per month did you take part in this activity?	(107-109)

		a.  Times per week	1           

		b.  Times per month	2           

			Don't know/Not sure	7  7  7

			Refused	9  9  9

6.10.	And when you took part in this activity, for how many minutes or hours did you usually keep at it?			(110-112)

			Hours and minutes	    :         

			Don't know/Not sure	7  7  7

			Refused	9  9  9

Section 7:  Tobacco Use

7.1.	Have you smoked at least 100 cigarettes in your entire life?	(113)

5 packs 		a.  Yes	1
= 100			
cigarettes 		b.  No  Go to Q8.1 (p. 17)	2

			Don't know/Not sure  Go to Q8.1 (p. 17)	7

			Refused  Go to Q8.1 (p. 17)	9

7.2.	Do you now smoke cigarettes everyday, some days, or not at all?	(114)	

		a.  Everyday	1

		b.  Some days Go to Q7.3a	2

		c.  Not at all Go to Q7.5 (p. 16)	3

			Refused  Go to Q8.1 (p. 17)	9

7.3.	On the average, about how many cigarettes a day do you now smoke?	(115-116)

1 pack = 20			Number of cigarettes [76 = 76 or more]  Go to Q7.4 (p. 16)	         
cigarettes			
			Don't know/Not sure  Go to Q7.4 (p. 16)	 7  7

			Refused  Go to Q7.4 (p. 16)	 9  9

7.3a.	On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?	(117-118)

1 pack = 20 			Number of cigarettes [76 = 76 or more]  Go to Q8.1 (p. 17)	         
cigarettes			
				Don't know/Not sure  Go to Q8.1 (p. 17)	 7  7
	
			Refused  Go to Q8.1 (p. 17)	 9  9

7.4.	During the past 12 months, have you quit smoking for 1 day or longer?
					(119)

		a.  Yes  Go to Q8.1 (p. 17)	1

		b.  No  Go to Q8.1 (p. 17)	2

			Don't know/Not sure Go to Q8.1 (p. 17)	7

			Refused  Go to Q8.1 (p. 17)	9

7.5.	About how long has it been since you last smoked cigarettes regularly, that is, daily?
					(120-121)

			Time code	         

		Read Only if Necessary

		a.  Within the past month (0 to 1 month ago)	0 1

		b.  Within the past 3 months (1 to 3 months ago)	0 2

		c.  Within the past 6 months (3 to 6 months ago)	0 3

		d.  Within the past year (6 to 12 months ago)	0 4

		e.  Within the past 5 years (1 to 5 years ago)	0 5

		f.  Within the past 15 years (5 to 15 years ago)	0 6

		g.  15 or more years ago	0 7

			Don't know/Not sure	7 7 

			Never smoked regularly	8 8 

			Refused	9 9

Section 8: Fruits and Vegetables

These next questions are about the foods you usually eat or drink.  Please tell me how often you eat or drink each one, for example, twice a week, three times a month, and so forth.  Remember, I am only interested in the foods you eat.  Include all foods you eat, both at home and away from home.

8.1.	How often do you drink fruit juices such as orange, grapefruit, or tomato?	(122-124)

		a.  Per day	1           

		b.  Per week	2           

		c.  Per month	3           
 
		d.  Per year	4           

		e.  Never	5  5  5

			Don't know/Not sure	7  7  7

			Refused	9  9  9

8.2.	Not counting juice, how often do you eat fruit?	(125-127)

		a.  Per day	1           

		b.  Per week	2           

		c.  Per month	3           
 
		d.  Per year	4           

		e.  Never	5  5  5

			Don't know/Not sure	7  7  7

			Refused	9  9  9

8.3.	How often do you eat green salad?	(128-130)

		a.  Per day	1           

		b.  Per week	2           

		c.  Per month	3           
 
		d.  Per year	4           

		e.  Never	5  5  5

			Don't know/Not sure	7  7  7

			Refused	9  9  9

8.4.	How often do you eat potatoes not including french fries, fried potatoes, or potato chips?
					(131-133)

		a.  Per day	1           

		b.  Per week	2           

		c.  Per month	3           
 
		d.  Per year	4           

		e.  Never	5  5  5

			Don't know/Not sure	7  7  7

			Refused	9  9  9

8.5.	How often do you eat carrots?	(134-136)

		a.  Per day	1           

		b.  Per week	2           

		c.  Per month	3           
 
		d.  Per year	4           

		e.  Never	5  5  5

			Don't know/Not sure	7  7  7

			Refused	9  9  9

8.6.	Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?
					(137-139)

Example:		a.  Per day	1           
A serving of
vegetables at		b.  Per week	2           
both lunch
and dinner		c.  Per month	3           
would be two
servings		d.  Per year	4           

		e.  Never	5  5  5

			Don't know/Not sure	7  7  7

			Refused	9  9  9

Section 9: Weight Control

9.1.	Are you now trying to lose weight?	(140)

		a.  Yes Go to Q. 9.3 	1

		b.  No 	2

			Don't know/Not sure	7

			Refused	9

9.2.	Are you now trying to maintain your current weight, that is to keep from gaining weight?
					(141)

		a.  Yes	1

		b.  No  Go to Q. 9.5  (p. 21) 	2

			Don't know/Not sure  Go to 9.5  (p. 21)	7

			Refused  Go to Q. 9.5  (p. 21)	9

9.3.	Are you eating either fewer calories or less fat to...

	lose weight? [if "Yes" on Q. 9.1]

	keep from gaining weight? [if "Yes" on Q. 9.2]	(142)

Probe			a.  Yes, fewer calories	1
for
which			b.  Yes, less fat	2

		c.  Yes, fewer calories and less fat	3

		d.  No	4

			Don't know/Not sure	7

			Refused	9

9.4.	Are you using physical activity or exercise to... 

	lose weight? [if "Yes" on Q. 9.1]

	keep from gaining weight? [if "Yes" on Q. 9.2]	(143)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

9.5.	In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?	(144)

Probe			a.  Yes, lose weight	1
for
which			b.  Yes, gain weight	2

		c.  Yes, maintain current weight	3

		d.  No	4

			Don't know/Not sure	7

			Refused	9

Section 10: Demographics

10.1.	What is your age?	(145-146)

			Code age in years	         

			Don't know/Not sure	 0  7

			Refused	 0  9

10.2.	What is your race?	(147)

	Would you say:  Please Read

		a.  White	1

		b.  Black	2

		c.  Asian, Pacific Islander	3

		d.  American Indian, Alaska Native	4
			or
		e.  Other: [specify]                             	5

Do not				Don't know/Not sure	7
read these
responses			Refused	9

10.3.	Are you of Spanish or Hispanic origin?	(148)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9 

10.4.	Are you:	(149)

		Please Read

		a.  Married	1

		b.  Divorced	2

		c.  Widowed	3

		d.  Separated	4

		e.  Never been married	5
			or
		f.  A member of an unmarried couple	6

			Refused	9

10.5.	How many children live in your household who are...

		Please Read

Code 1-9		a.  less than 5 years old?	      (150)
7 = 7 or more			
8 = None		b.  5 through 12 years old?	      (151)
9 = Refused
		c.  13 through 17 years old?	      (152)

10.6.	What is the highest grade or year of school you completed?
					(153)
		Read Only if Necessary

		a.  Never attended school or only attended kindergarten	1

		b.  Grades 1 through 8 (Elementary)	2

		c.  Grades 9 through 11 (Some high school)	3

		d.  Grade 12 or GED (High school graduate)	4

		e.  College 1 year to 3 years (Some college or technical school)	5

		f.  College 4 years or more (College graduate)	6

			Refused	9

10.7.	Are you currently:	(154)

		Please Read

		a.  Employed for wages	1

		b.  Self-employed	2

		c.  Out of work for more than 1 year	3

		d.  Out of work for less than 1 year	4

		e.  Homemaker	5

		f.  Student	6

		g.  Retired	7
			or
		h.  Unable to work	8

			Refused	9

10.8.	Is your annual household income from all sources: 	(155-156)

			Read as Appropriate

		a.  Less than $25,000  If "no," ask e; if "yes," ask b
If res-				($20,000 to less than $25,000)	0 4
pondent 
refuses		b.  Less than $20,000  If "no," code a; if "yes," ask c
at any				($15,000 to less than $20,000)	0 3 
income
level,			c.  Less than $15,000  If "no," code b; if "yes," ask d
code				($10,000 to less than $15,000)	0 2
refused				
		d.  Less than $10,000  If "no," code c	0 1

		e.  Less than $35,000  If "no," ask f
			($25,000 to less than $35,000)	0 5

		f.  Less than $50,000  If "no," ask g
			($35,000 to less than $50,000)	0 6

		g.  Less than $75,000  If "no," code h
			($50,000 to $75,000)	0 7

		h.  $75,000 or more	0 8

Do not				Don't know/Not sure	7 7
read these
responses			Refused	9 9

10.9.	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?	(157)

		a.  Yes	1

		b.  No Go to Q10.12	2

			Don't know/Not sure Go to Q10.12	7

			Refused Go to Q10.12 	9

10.10.	Which of the following best describes your current military status?	(158)

	Are you: Please Read

		a.  Currently on active duty  Go to Q10.12	1

		b.  Currently in reserves  Go to Q10.12	2

		c.  No longer in military service	3

Do not				Don't know/Not sure  Go to Q10.12	7
read these
responses			Refused  Go to Q10.12	9

10.11.	In the past 12 months have you received some or all of your health care from VA facilities?
					(159)

Probe for		a.  Yes, all of my health care	1
which
		b.  Yes, some of my health care	2

		c.  No, no VA health care received	3

			Don't know/not sure	7

			Refused	9

10.12.	About how much do you weigh without shoes?	(160-162)

Round				Weight	              
fractions					pounds
up
			Don't know/Not sure	 7  7  7

			Refused	 9  9  9

10.13.	How much would you like to weigh?	(163-165)

			Weight	              
					pounds

			Don't know/Not sure	7  7  7

			Refused	9  9  9

10.14.	About how tall are you without shoes?	(166-168)

Round				Height	    /         
fractions					ft/inches
down
			Don't know/Not sure	 7  7  7

			Refused	 9  9  9

10.15.	What county do you live in?	(169-171)

			FIPS county code	              

			Don't know/not sure	 7  7  7

			Refused	 9  9  9

10.16.	Do you have more than one telephone number in your household?
					(172)

		a.  Yes	1

		b.  No  Go to Q10.18 (p. 27)	2

			Refused  Go to Q10.18 (p. 27)	9

10.17.	How many residential telephone numbers do you have?	(173)

Exclude ded-		Total telephone numbers [8 = 8 or more] 	    
icated fax
and computer		Refused	9
lines

10.18.	Indicate sex of respondent.  Ask Only if Necessary	(174)

			Male  Go to Section 12: HIV/AIDS (p. 32)	1

			Female	2

Now I have some questions about other health services you may have received.

Section 11:  Women's Health

11.1.	A mammogram is an x-ray of each breast to look for breast cancer.  Have you ever had a mammogram?	(175)

		a.  Yes	1

		b.  No  Go to Q11.4 (p. 29)	2

			Don't know/Not sure  Go to Q11.4 (p. 29)	7

			Refused  Go to Q11.4 (p. 29)	9

11.2.	How long has it been since you had your last mammogram?	(176)

		Read only if Necessary

		a.  Within the past year  (1 to 12 months ago)	1

		b.  Within the past 2 years  (1 to 2 years ago)	2

		c.  Within the past 3 years  (2 to 3 years ago)	3

		d.  Within the past 5 years  (3 to 5 years ago)	4

		e.  5 or more years ago	5
		
			Don't know/Not sure	7

			Refused	9

11.3.	Was your last mammogram done as part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?	(177)

		a.  Routine checkup	1

		b.  Breast problem other than cancer	2

		c.  Had breast cancer	3

			Don't know/Not sure	7

			Refused	9

11.4.	A clinical breast exam is when a doctor, nurse, or other health professional feels the breast for lumps.  Have you ever had a clinical breast exam?	(178)

		a.  Yes	1

		b.  No  Go to Q11.7 (p. 30)	2

			Don't know/Not sure  Go to Q11.7 (p. 30)	7

			Refused  Go to Q11.7 (p. 30)	9

11.5.	How long has it been since your last breast exam?	(179)

		Read Only if Necessary

		a.  Within the past year  (1 to 12 months ago)	1

		b.  Within the past 2 years  (1 to 2 years ago)	2

		c.  Within the past 3 years  (2 to 3 years ago)	3

		d.  Within the past 5 years  (3 to 5 years ago)	4

		e.  5 or more years ago	5
		
			Don't know/Not sure	7

			Refused	9

11.6.	Was your last breast exam done as part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?	(180)

		a.  Routine Checkup	1

		b.  Breast problem other than cancer	2

		c.  Had breast cancer	3

			Don't know/Not sure	7

			Refused	9

11.7.	A Pap smear is a test for cancer of the cervix.  Have you ever had a Pap smear?	(181)

		a.  Yes	1

		b.  No  Go to Q11.10 (p. 31)	2

			Don't know/Not sure  Go to Q11.10 (p. 31)	7

			Refused  Go to Q11.10 (p. 31)	9

11.8.	How long has it been since you had your last Pap smear?	(182)

		Read Only if Necessary

		a.  Within the past year  (1 to 12 months ago)	1

		b.  Within the past 2 years  (1 to 2 years ago)	2

		c.  Within the past 3 years  (2 to 3 years ago)	3

		d.  Within the past 5 years  (3 to 5 years ago)	4

		e.  5 or more years ago	5
		
			Don't know/Not sure	7

			Refused	9

11.9.	Was your last Pap smear done as part of a routine exam, or to check a current or previous problem?	(183)

		a.  Routine exam	1

		b.  Check current or previous problem	2

			Other	3

			Don't know/Not sure	7

			Refused	9

11.10.	Have you had a hysterectomy?	(184)

		a.  Yes  Go to Section 12: HIV/AIDS (p. 32)	1
A hysterec-
tomy is an		b.  No	2
operation
to remove the			Don't know/Not sure	7
uterus (womb)
			Refused	9

If respondent 45 years old or older, go to Section 12: HIV/AIDS (p. 32)

11.11	To your knowledge, are you now pregnant?	(185)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

Section 12: HIV/AIDS

If respondent is 65 years old or older, go to Closing Statement (p. 37).

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 don't have to answer every question if you don't want to.

12.1.	If you had a child in school, at what grade do you think he or she should begin receiving education in school about HIV infection and AIDS?	(186-187)

Code 01		a.  Grade 	         
through 12
		b.  Kindergarten	5  5

		c.  Never	8  8

			Don't know/Not sure	7  7

			Refused	9  9

12.2.	If you had a teenager who was sexually active, would you encourage him or her to use a condom?	(188)

		a.  Yes	1

		b.  No	2

			Would give other advice	3

			Don't know/Not sure	7

			Refused	9

12.3.	What are your chances of getting infected with HIV, the virus that causes AIDS?
					(189)

		Would you say:  Please Read

		a.  High	1

		b.  Medium	2

		c.  Low	3
			or
		d.  None	4

			Not applicable Go to Q12.7a (p. 34)	5
Do not
read these			Don't know/Not sure	7
responses
			Refused	9

12.4.	Have you donated blood since March 1985?	(190)

			a.  Yes	1

			b.  No  Go to Q12.6a (p. 34)	2

			Don't know/Not sure  Go to Q12.6a (p. 34)	7

			Refused  Go to Q12.6a (p. 34)	9

12.5.	Have you donated blood in the past 12 months?	(191)

		a.  Yes	1

		b.  No	2

			Don’t know/Not sure	7

			Refused	9

12.6.	Except for tests you may have had as part of blood donations, have you ever been tested for HIV?		(192)

Include		a.  Yes  Go to Q12.7 (p. 34)	1
saliva
tests			b.  No  Go to Closing Statement (p. 37)	2

Don’t know/Not sure  Go to Closing Statement (p. 37)	7

			Refused  Go to Closing Statement (p. 37)	9

12.6a.	Have you ever been tested for HIV?	(193)

Include		a.  Yes  Go to Q12.7a	1
saliva
tests			b.  No  Go to Closing Statement (p. 37)	2

			Don’t know/Not sure  Go to Closing Statement (p. 37)	7

			Refused  Go to Closing Statement (p. 37)	9

12.7.	Not including your blood donations, have you been tested for HIV in the past 12 months?
					(194)

Include		a.  Yes  Go to Q12.8 (p. 35)	1
saliva
tests			b.  No  Go to Closing Statement (p. 37)	2

			Don’t know/Not sure  Go to Closing Statement (p. 37)	7

			Refused  Go to Closing Statement (p. 37)	9

12.7a.	Have you been tested for HIV in the past 12 months?	(195)

Include		a.  Yes	1
saliva
tests			b.  No  Go to Closing Statement (p. 37)	2

			Don’t know/Not sure  Go to Closing Statement (p. 37)	7

			Refused  Go to Closing Statement (p. 37)	9

12.8.	What was the main reason you had your last test for HIV?
					(196-197)

			Reason code	         

		Read Only if Necessary

		a.  For hospitalization or surgical procedure	0 1

		b.  To apply for health insurance	0 2

		c.  To apply for life insurance	0 3

		d.  For employment	0 4

		e.  To apply for a marriage license	0 5

		f.  For military induction or military service	0 6

		g.  For immigration	0 7

		h.  Just to find out if you were infected	0 8

		i.  Because of referral by a doctor	0 9

		j.  Because of pregnancy	1 0

		k.  Referred by your sex partner	1 1

		l.  Because it was part of a blood donation process
			Go to Closing Statement (p. 37)	1 2

		m.  For routine check-up	1 3

		n.  Because of occupational exposure	1 4

		o.  Because of illness	1 5

		p.  Because I am at risk for HIV	1 6

		q.  Other	8 7

			Don't know/Not sure	7 7

			Refused	9 9

12.9.	Where did you have your last test for HIV?	(198-199)

			Facility Code	         

		Read Only if Necessary

		a.  Private doctor, HMO	0 1

		b.  Blood bank, plasma center, Red Cross	0 2

		c.  Health department	0 3

		d.  AIDS clinic, counseling, testing site	0 4

		e.  Hospital, emergency room, outpatient clinic	0 5

		f.  Family planning clinic	0 6

		g.  Prenatal clinic, obstetrician’s office	0 7

		h.  Tuberculosis clinic	0 8

		i.  STD clinic	0 9

		j.  Community health clinic	1 0

		k.  Clinic run by employer	1 1

		l.  Insurance company clinic	1 2

		m.  Other public clinic	1 3

		n.  Drug treatment facility	1 4

		o.  Military induction or military service site	1 5

		p.  Immigration site	1 6

		q.  At home, home visit by nurse or health worker	1 7

		r.  At home using self-sampling kit	1 8

		s.  In jail or prison	1 9

		t.  Other	8 7

			Don't know/Not sure	7 7

			Refused	9 9

12.10.	Did you receive the results of your last test?	(200)

		a.  Yes 	1

		b.  No  Go to Closing Statement	2

			Don't know/Not sure  Go to Closing Statement	7

			Refused  Go to Closing Statement  	9

12.11.	Did you receive counseling or talk with a health care professional about the results of your test?	
					(201)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

Closing Statement

That's my last question.  Everyone's answers will be combined to give us information about the health practices of people in this state.  Thank you very much for your time and cooperation.

OR

Transition to Modules and/or State-added Questions

Finally, I have just a few questions left about some other health topics.

Activity List for Common Leisure Activities
Coding List A

Code Description

01. Aerobics class
02. Backpacking
03. Badminton
04. Basketball
05. Bicycling for pleasure
06. Boating (canoeing, rowing, sailing for                   pleasure or camping)
07. Bowling
08. Boxing
09. Calisthenics
10. Canoeing/rowing - in competition
11. Carpentry
12. Dancing-aerobics/ballet
13. Fishing from river bank or boat
14. Gardening (spading, weeding,
     digging, filling)
15. Golf
16. Handball
17. Health club exercise
18. Hiking - cross-country
19. Home exercise
20. Horseback riding
21. Hunting large game - deer, elk
22. Jogging
23. Judo/karate
24. Mountain climbing
25. Mowing lawn
26. Paddleball
27. Painting/papering house

28. Racketball
29. Raking lawn
30. Running
31. Rope skipping
32. Scuba diving
33. Skating - ice or roller
34. Sledding, tobogganing
35. Snorkeling
36. Snowshoeing
37. Snow shoveling by hand
38. Snow blowing
39. Snow skiing
40. Soccer
41. Softball
42. Squash
43. Stair climbing
44. Stream fishing in waders
45. Surfing
46. Swimming laps
47. Table tennis
48. Tennis
49. Touch football
50. Volleyball
51. Walking
52. Waterskiing
53. Weight lifting
54. Other______________
55. Bicycling machine exercise 
56. Rowing machine exercise

Coding List B

Lap Swimming

Size pool/Laps
(1 lap = 2 lengths) 

50 ft. pool
5 laps (10 lengths) = .1 mile
100 ft. pool
2½ laps (5 lengths) = .1 mile
50 meter pool
1½ laps (3 lengths) = .1 mile

Running/Jogging/Walking

1/2 mile = .5 mile
1/4 mile = .3 mile
1/8 mile = .1 mile
 1 block = .1 mile

Module 1:  Diabetes

1.	How old were you when you were told you have diabetes?	(202-203)

			Code age in years  [97 = 97 and older]	         

			Don't know/Not sure	9  8

			Refused	9  9

2.	Are you now taking insulin?	(204)

		a.  Yes	1

		b.  No	2

			Refused	9

3.	Are you now taking diabetes pills?	(205)

	a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused 	9

4.	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.
					(206-208)

		a.  Times per day	1           

		b.  Times per week	2           

		c.  Times per month	3           

		d.  Times per year	4           

		e.  Never	8  8  8

			Don't know/Not sure	7  7  7

			Refused	9  9  9

5.	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.	(209-211)

		a.  Times per day	1           

		b.  Times per week	2           

		c.  Times per month	3           

		d.  Times per year	4           

		e.  Never	8  8  8

		f.  No feet	5  5  5

			Don't know/Not sure	7  7  7

			Refused	9  9  9

6.	Have you ever had any sores or irritations on your feet that took more than four weeks to heal?
					(212)

	a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused 	9

7.	About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?	(213-214)

		a.  Number of times	         

		b.  None	8  8

			Don't know/Not sure	7  7

			Refused	9  9

8.	A test for hemoglobin "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 hemoglobin "A one C"?	(215-216)

		a.  Number of times [76 = 76 or more]	         

		b.  None	8 8

		c.  Never heard of hemoglobin "A one C" test	9 8

			Don't know/Not sure	7 7

			Refused	9 9

If "no feet" to Q5, go to Q10

9.	About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?	(217-218)

		a.  Number of times	         

		b.  None	8 8

			Don't know/Not sure	7 7

			Refused	9 9

10.	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.	(219)

		Read Only if Necessary

		a.  Within the past month (0 to 1 month ago)	1

		b.  Within the past year (1 to 12 months ago)	2

		c.  Within the past 2 years (1 to 2 years ago)	3

		d.  2 or more years ago	4

		e.  Never	8

			Don't know/Not sure	7

			Refused	9

11.	Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
					(220)

	a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused 	9

12.	Have you ever taken a course or class in how to manage your diabetes yourself?	(221)

	a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

Module 2: Sexual Behavior

If respondent 50 years old or older, go to next module.

These next few questions are about your personal sexual behavior, and I want to remind you that your answers are confidential.

1.	During the past twelve months, with how many people have you had sexual intercourse?
					(222-223)

		a.	Number [76 = 76 or more]	         

		b.	None Go to Next Module	8  8

			Don't know/Not sure	7  7

			Refused	9  9

2.	Was a condom used the last time you had sexual intercourse?
					(224)

		a.	Yes	1

		b.	No Go to Q4	2

			Don't know/Not sure  Go to Q4	7

			Refused  Go to Q4	9

3.	The last time you had sexual intercourse, was the condom  used ...  	(225)

		Please Read

		a.  To prevent pregnancy	1

		b.  To prevent diseases like syphilis, gonorrhea, and AIDS	2

		c.  For both of these reasons	3
			or
		d.  For some other reason	4

Do not				Don't know/Not sure	7	
read these
responses			Refused	9

4.	Some people use condoms to keep from getting infected with HIV through sexual activity.  How effective do you think a properly used condom is for this purpose?	(226)

	Would you say:  Please Read

		a.  Very effective	1

		b.  Somewhat effective	2
			or
		c.  Not at all effective	3

			Don't know how effective	4
Do not
read these			Don't know method	5
responses
			Refused	9

5.	How many new sex partners did you have during the past twelve months?	(227-228)
A new sex
partner is		a.	Number [76 = 76 or more]	         
someone
the respon-		b.	None	8  8
dent had sex
with for the			Don't know/Not sure	7  7
first time in
the past 12			Refused	9  9
months

6.	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 intravenous drugs in the past year

You have been treated for a sexually transmitted or venereal disease 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?	(229) 

		a.  Yes	1

		b.  No	2

			Don't know/Not sure 	7

			Refused	9

7.	In the past five years, have you been treated for a sexually transmitted or venereal disease?
					(230)

		a.  Yes	1

		b.  No  Go to Q9	2

			Don't know/Not sure  Go to Q9	7

			Refused  Go to Q9	9

8.	Were you treated at a health department STD clinic?	(231)
	
		a.  Yes	1

		b.  No	2

			Don't know/Not sure 	7

			Refused	9

9.	Due to what you know about HIV, have you changed your sexual behavior in the past 12 months?		(232)

		a.  Yes	1

		b.  No  Go to Next Module	2

			Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

10.	Did you make any of the following changes in the past 12 months?

		Please Read	Yes	No	Dk/Ns	NA	Ref
If respon-
dent says		a.	Did you decrease the number your
"abstinent,"			sexual partners or become abstinent?	1	 2	7		 9	(233)
ask "Are			
you abstinent
now?"  If "no,"	
read b and c.		
If "yes," do	
not read b and
c and code b	
and c 8	

		b.	Do you now have sexual intercourse
			with only the same partner?	1	 2	7	8	 9	(234)

		c.	Do you now always use condoms
			for protection?	1	 2	7	8	 9	(235)

Module 3: Family Planning

If respondent is male or age 45 years old or older, go to next module.

The next few questions ask about pregnancy and ways to prevent pregnancy.

If pregnant now ("Yes" to core Q10.11), go to Q2a.

1.  Have you been pregnant in the last 5 years?	(236)

		a.  Yes	1

		b.  No Go to Q3	2

			Don’t know/Not sure Go to Q3	7

			Refused Go to Q3	9

2.	Thinking back to your last pregnancy, just before you got pregnant, how did you feel about becoming pregnant?	(237)

	Would you say: Please Read

		a.  You wanted to be pregnant sooner  Go to Q3	1

		b.  You wanted to be pregnant later  Go to Q3	2

		c.  You wanted to be pregnant then  Go to Q3	3

		d.  You didn’t want to be pregnant then or at anytime in the future
			Go to Q3	4
			or
		e.  You don’t know  Go to Q3	7

Do not read			Refused  Go to Q3	9

2a.	Thinking back to just before you got pregnant with your current pregnancy, how did you feel about becoming pregnant?	(238)

	Would you say: Please Read

		a.  You wanted to be pregnant sooner	1

		b.  You wanted to be pregnant later	2

		c.  You wanted to be pregnant then	3

		d.  You didn’t want to be pregnant then or at any time in the future	4
			or
		e.	You don’t know	7

Do not read			Refused	9

If respondent had hysterectomy ("Yes" to core Q11.10) or is pregnant now ("Yes" to core Q11.11), go to Q6.
If respondent has no sex partners ("None" to Q1 in Sexual Behavior module), go to Q6.

3.	Are you or your [fill in (husband/partner) from core Q10.4] 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.
					(239)

		a.  Yes	1

		b.  No  Go to Q5	2

		c.  Not sexually active  Go to Q6	3

			Don't know/Not sure  Go to Q6	7

			Refused  Go to Q6	9

4.	What kinds of birth control are you or your [fill in (husband/partner) from core Q10.4] using now?				(240-241)

			Kind Code	         

		Read Only if Necessary

		a.  Tubes tied (sterilization)  Go to Q6	0 1

		b.  Vasectomy (sterilization)  Go to Q6	0 2

If more than		c.  Pill  Go to Q6	0 3
one, code
other and		d.  Condoms  Go to Q6	0 4
specify each
method code	e.  Foam, jelly, cream  Go to Q6	0 5

				f.  Diaphragm  Go to Q6	0 6

				g.  Norplant  Go to Q6	0 7

		h.  Shots (Depo-Provera)  Go to Q6	0 8

		i.  Withdrawal  Go to Q6	0 9

		j.  Other [specify]                   Go to Q6	8 7  

			Don't know/Not sure  Go to Q6	7 7

			Refused  Go to Q6	9 9

5.  What are your reasons for not using any birth control now?
					(242-243)

			Reason Code	         

		Read Only if Necessary

If more than		a.  I am not having sex	0 1
one, code
other and		b.  I want to get pregnant	0 2
specify each
method code	c.  I don’t want to use birth control	0 3

		d.  My husband or partner doesn’t want to use birth control	0 4

		e.  I don’t think I can get pregnant	0 5

		f.  I can’t pay for birth control	0 6

		g.  Other [specify]                      	8 7

			Don't know/Not sure	7 7

			Refused	9 9

6.	Where is your usual source of services for female health concerns, such as family planning, annual exams, breast exams, tests for sexually transmitted diseases, and other female health concerns?
					(244)

	Would you say: Please Read

		a.  A family planning clinic [Example: a Planned Parenthood clinic] 
			Go to Q8	1

		b.  A health department clinic	2
	
		c.  A community health center	3

		d.  A private gynecologist	4

		e.  A general or family physician	5
			or
		f.  Some other kind of place	8

Do not				Don’t know/not sure	7
read these
responses			Refused	9

7.	Have you ever used the services at a family planning clinic?	(245)

Example:		a.  Yes	1
a Planned
Parenthood		b.  No Go to Next Module	2
clinic
			Don’t know/not sure Go to Next Module	7

			Refused Go to Next Module	9

8.	How long has it been since you used the services at a family planning clinic?	(246)

		Read Only if Necessary

		a.	Within the past year (1 to 12 months ago)	1

		b.	Within the past 2 years (1 to 2 years ago)	2

		c.	Within the past 3 years (2 to 3 years ago)	3

		d.	Within the past 5 years (3 to 5 years ago)	4

		e.	5 or more years ago	5

			Don’t know/Not sure	7

			Refused	9

Module 4: Health Care Coverage and Utilization

To be asked following core Q2.3a if response is "none"

1.	What is the main reason you are without health care coverage? 	(247-248)   

			Reason Code	         

		Read Only if Necessary

		a.  Lost job or changed employers  Go to core Q2.5	0 1

		b.  Spouse or parent lost job or changed employers [includes any 
			 person who had been providing insurance prior to job loss
			 or change] Go to core Q2.5	0 2

		c.  Became divorced or separated  Go to core Q2.5	0 3

		d.  Spouse or parent died  Go to core Q2.5	0 4

		e.  Became ineligible because of age or because left school  Go to core Q2.5	0 5

	f.  Employer doesn’t offer or stopped offering coverage  Go to core Q2.5	0 6

	g.  Cut back to part time or became temporary employee  Go to core Q2.5	0 7

		h.  Benefits from employer or former employer ran out  Go to core Q2.5	0 8

		i.  Couldn't afford to pay the premiums  Go to core Q2.5	0 9

		j.  Insurance company refused coverage  Go to core Q2.5	1 0

		k.  Lost Medicaid or Medical Assistance eligibility  Go to core Q2.5	1 1
	
		l.  Other  Go to core Q2.5	8 7

	Don't know/Not sure  Go to core Q2.5	7 7

			Refused  Go to core Q2.5	9 9

To be asked following core Q2.4 if response is "yes."

1a.	What was the main reason you were without health care coverage during the past 12 months?
				 	(249-250)

			Reason Code	         

		Read Only if Necessary

		a.  Lost job or changed employers  Go to core Q2.6	0 1

		b.  Spouse or parent lost job or changed employers [includes any person 
			who had been providing insurance prior to job loss or change]
			Go to core Q2.6	0 2

		c.  Became divorced or separated  Go to core Q2.6	0 3

		d.  Spouse or parent died  Go to core Q2.6	0 4

		e.  Became ineligible because of age or because left school  Go to core Q2.6	0 5

	f.  Employer doesn’t offer or stopped offering coverage  Go to core Q2.6	0 6

	g.  Cut back to part time or became temporary employee  Go to core Q2.6	0 7

		h.  Benefits from employer or former employer ran out  Go to core Q2.6	0 8

		i.  Couldn't afford to pay the premiums Go to core Q2.6	0 9

		j.  Insurance company refused coverage  Go to core Q2.6	1 0

		k.  Lost Medicaid or Medical Assistance eligibility Go to core Q2.6	1 1

		l.  Other  Go to core Q2.6	8 7

	Don't know/Not sure  Go to core Q2.6	7 7

			Refused  Go to core Q2.6	9 9

2.	Is there one particular clinic, health center, doctor's office, or other place that you usually go to if you are sick or need advice about your health?	(251)

If "no," ask		a.  Yes  Go to Q4	1
"Is there more
than one or is	b.  More than one place	2
there no place
you usually		c.  No Go to Next Module	3
go to?"
			Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

3.	Is there one of these places that you go to most often when you are sick or need advice about your health?			(252)

		a.  Yes	1

		b.  No  Go to Q5	2

			Don't know/Not sure  Go to Q5	7

			Refused  Go to Q5	9

4.	What kind of place is it?	(253)

	Would you say:  Please Read

		a.  A doctor's office or HMO	1
					
		b.  A clinic or health center	2

		c.  A hospital outpatient department	3

		d.  A hospital emergency room	4

		e.  An urgent care center	5
			or
		f.  Some other kind of place	8

Do not				Don't know/Not sure	7
read these 
responses			Refused	9

5.	Do you have one person you think of as your personal doctor or health care provider?
					(254)

If "no," ask		a.  Yes, only one	1
"Is there more
than one or is	b.  More than one	2
there no usual
doctor who you	c.  No	3
go to?"  			
				 	Don't know/Not sure 	7

			Refused 	9

Module 5: Health Care Satisfaction

If Health Care Coverage and Utilization Module used, go to Q2

1.	Do you have one person you think of as your personal doctor or health care provider?
					(254)

If "no," ask		a.  Yes, only one	1
"Is there more
than one or is	b.  More than one	2
there no usual
doctor who you	c.  No	3
go to?"  			
				 	Don't know/Not sure 	7

			Refused 	9

2.	In the last 12 months, how many times did you go to an emergency room to get care for yourself?
					(255-256)

Do not include	a.  Number of times	         
stand-alone
urgent care		b.  None	8  8
centers
			Don't know/Not sure	7  7

 			Refused	9  9

3.	In the last 12 months, [fill in "not counting times you went to an emergency room" if Q2=1-76], how many times did you go to a doctor’s office or clinic to get care for yourself?
					(257)

Would you say: Please Read

		a.  None Go to Next Module	8

		b.  Once	1

		c.  Twice	2

		d.  3 times	3

		e.  4 times	4

		f.  5 to 9 times	5
			or
		g.  10 or more times	6

			Don't know/Not Sure	7

			Refused	9

4.	In the last 12 months, how often did doctors or other health providers listen carefully to you?
					(258)

Would you say: Please Read

		a.  Never	1

		b.  Sometimes	2

 		c.  Usually	3
			or	
		d.  Always	4

Do not				Don't know/Not Sure	7
read these
responses			Refused	9

5.	In the last 12 months, how often did doctors or other health providers explain things in a way you could understand?	 (259)

Would you say: Please Read

		a.  Never	1

		b.  Sometimes	2

 		c.  Usually	3
			or	
		d.  Always	4

Do not				Don't know/Not Sure	7
read these
responses			Refused	9

6.	In the last 12 months, how often did doctors or other health providers show respect for what you had to say?		(260)

Would you say: Please Read

		a.  Never	1

		b.  Sometimes	2

 		c.  Usually	3
			or	
		d.  Always	4

Do not				Don't know/Not Sure	7
read these
responses			Refused	9

7.	In the last 12 months, how often did doctors or other health providers spend enough time with you?				(261)

Would you say: Please Read

		a.  Never	1

		b.  Sometimes	2

 		c.  Usually	3
			or	
		d.  Always	4

Do not				Don't know/Not Sure	7
read these
responses			Refused	9

8.	We want to know your rating of all your health care in the last 12 months from all doctors and other health providers.  Use any number from 1 to 5 where 1 is the worst health care possible, and 5 the best health care possible.  How would you rate all your health care?	(262)	

		a.  1 Worst health care possible	1

		b.  2		2

		c.  3		3

		d.  4		4

		e.  5 Best health care possible	5

			Don't know/Not Sure	7

			Refused	9

Module 6: Oral Health

1.	How long has it been since you last visited a dentist or a dental clinic for any reason?
					(263)

		Read only if necessary

Include		a.  Within the past year (1 to 12 months ago)	1
visits to	
dental spec-		b.  Within the past 2 years (1 to 2 years ago)	2
ialists, such
as ortho-		c.  Within the past 5 years (2 to 5 years ago)	3
dontists
				d.  5 or more years ago	4

	   		Don’t know/Not sure	7

			Never	8

			Refused	9

2.	How many of your permanent teeth have been removed because of tooth decay or gum disease?  Do not include teeth lost for other reasons, such as injury or orthodontics.	(264)

Include teeth	a.  1 to 5	1
lost due to
"infection"		b.  6 or more but not all	2

		c.  All	3

		d.  None	8

			Don’t know/Not sure	7

			Refused 	9

If "never" to Q1 or "all" to Q2, go to 4. 

3.	How long has it been since you had your teeth cleaned by a dentist or dental hygienist?
					(265)

		Read only if necessary

		a.  Within the past year (1 to 12 months ago)	1
 
		b.  Within the past 2 years (1 to 2 years ago)	2

		c.  Within the past 5 years (2 to 5 years ago)	3

		d.  5 or more years ago	4

			Don’t know/Not sure	7

	     		Never	8

			Refused	9

If "within the past year," to Q1 or Q3, go to Q5.

4.	What is the main reason you have not visited the dentist in the last year?	(266-267)

			Reason code	         

		Read Only if Necessary

		a.  Fear, apprehension, nervousness, pain, dislike going	0 1	

		b.  Cost	0 2

		c.  Do not have/know a dentist	0 3

		d.  Cannot get to the office/clinic (too far away, no transportation,
			no appointments available)	0 4

		e.  No reason to go (no problems, no teeth)	0 5

		f.  Other priorities	0 6

		g.  Have not thought of it	0 7

		h.  Other	0 8

			Don't know/Not sure	7 7

			Refused	9 9

5.	Do you have any kind of insurance coverage that pays for some or all of your routine dental care, including dental insurance, prepaid plans such as HMOs, or government plans such as Medicaid?
					(268) 

		a.	Yes	1

		b.	No	2

			Don't know/Not sure	7

			Refused	9

Module 7:  Hypertension Awareness

1.	About how long has it been since you last had your blood pressure taken by a doctor, nurse, or other health professional?	(269)

		Read Only if Necessary

		a.  Within the past 6 months  (1 to 6 months ago)	1

		b.  Within the past year  (6 to 12 months ago)	2	

		c.  Within the past 2 years  (1 to 2 years ago)	3

		d.  Within the past 5 years  (2 to 5 years ago)	4

		e.  5 or more years ago	5
		
			Don't know/Not sure	7

			Never  Go to Next Module	8

			Refused	9

2.	Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?		(270)

		a.  Yes	1

		b.  No  Go to Next Module	2

			Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

3.	Have you been told on more than one occasion that your blood pressure was high, or have you been told this only once?	(271)

		a.  More than once	1

		b.  Only once	2

			Don't know/Not sure	7

			Refused	9

Module 8:  Cholesterol Awareness

1.	Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?		(272)

		a.  Yes	1

		b.  No  Go to Next Module	2

			Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

2.	About how long has it been since you last had your blood cholesterol checked?	(273)

		Read Only if Necessary

		a.  Within the past year  (1 to 12 months ago)	1	

		b.  Within the past 2 years  (1 to 2 years ago)	2

		c.  Within the past 5 years  (2 to 5 years ago)	3

		d.  5 or more years ago	4
		
			Don't know/Not sure	7

			Refused	9

3.	Have you ever been told by a doctor or other health professional that your blood cholesterol is high?				(274)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

Module 9: Colorectal Cancer Screening

If respondent 40 years or older, continue with this module.  Otherwise, go to next module.

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?	(275)

		a.  Yes	1

		b.  No  Go to Q3	2

			Don't know/Not sure  Go to Q3	7

			Refused  Go to Q3	9

2.	When did you have your last blood stool test using a home kit?	(276)

		Read Only if Necessary

		a.  Within the past year  (1 to 12 months ago)	1	

		b.  Within the past 2 years  (1 to 2 years ago)	2

		c.  Within the past 5 years  (2 to 5 years ago)	3

		d.  5 or more years ago	4
		
			Don't know/Not sure	7

			Refused	9

3.	A sigmoidoscopy or colonoscopy is when a tube is inserted in the rectum to view the bowel for signs of cancer and other health problems.  Have you ever had this exam?	(277)

			a.  Yes	1

			b.  No  Go to Next Module	2

			Don't know/Not sure Go to Next Module	7

			Refused  Go to Next Module	9

4.	When did you have your last sigmoidoscopy or colonoscopy?	(278)

		Read Only if Necessary

		a.  Within the past year  (1 to 12 months ago)	1	

		b.  Within the past 2 years  (1 to 2 years ago)	2

		c.  Within the past 5 years  (2 to 5 years ago)	3

		d.  5 or more years ago	4
		
			Don't know/Not sure	7

			Refused	9

Module 10:  Immunization

1.	During the past 12 months, have you had a flu shot?	(279)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

2.	Have you ever had a pneumonia vaccination?	(280)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

Module 11:  Injury Control

If core Q10.5a, b, and c are all "None," go to Q3

1.	What is the age of the oldest child in your household under the age of 16?	(281-282)
Code
<1 yr.			a.  Code age in years	             
as "01"
		b.  No children under age 16  Go to Q3	8  8

			Don't know/Not sure  Go to Q3 	7  7

			Refused  Go to Q3	9  9

If oldest child 5 years or older, continue with Q2.  Otherwise, go to Q3.

2.	During the past year, how often has the [fill in age from Q1]-year-old child worn a bicycle helmet when riding a bicycle?	(283)

	Would you say:  Please Read

		a.	Always	1

		b.	Nearly Always	2

		c.	Sometimes	3

		d.	Seldom	4
			or
		e.	Never	5

			Don't know/Not sure	7
Do not
read these			Never rides a bicycle	8
responses
			Refused	9

3.	When was the last time you or someone else deliberately tested all of the smoke detectors in your home?			(284)

		Read Only if Necessary

		a.  Within the past month (0 to 1 month ago)	1

		b.  Within the past 6 months (1 to 6 months ago)	2

		c.  Within the past year (6 to 12 months ago)	3

		d.  One or more years ago 	4

		e.	Never	5

		f.	No smoke detectors in home	6

			Don't know/Not sure	7

			Refused	9

Module 12:  Alcohol Consumption

1.	During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine coolers, or liquor?	(285)

		a.  Yes	1

		b.  No  Go to Next Module	2

			Don't know/Not sure  Go to Next Module	7

			Refused Go to Next Module	9

2.	During the past month, how many days per week or per month did you drink any alcoholic beverages, on the average?	(286-288)

		a.  Days per week	1          

		b.  Days per month	2          

			Don't know/Not sure  Go to Q4	7  7  7

			Refused  Go to Q4	9  9  9

3.	A drink is 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail, or 1 shot of liquor.  On the days when you drank, about how many drinks did you drink on the average?
					(289-290)

			Number of drinks	         

			Don't know/Not sure	7  7

			Refused	9  9

4.	Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?	(291-292)

		a.  Number of times	         

		b.  None	8  8

			Don't know/Not sure	7  7

			Refused	9  9

5.	During the past month, how many times have you driven when you've had perhaps too much to drink?			(293-294)

		a.  Number of times	         

		b.  None	8  8

			Don't know/Not sure	7  7

			Refused	9  9

Module 13:  Cardiovascular Disease

1.	To lower your risk of developing heart disease or stroke, has a doctor advised you to...

		Please Read			Yes	No	Dk/Ns	Ref	
			  		
		a.  Eat fewer high fat or high cholesterol foods		1	2	7	9	(295)

		b.  Exercise more			1	2	7	9	(296)

2.	To lower your risk of developing heart disease or stroke, are you?

		Please Read			Yes	No	Dk/Ns	Ref
			  		
		a.  Eating fewer high fat or high cholesterol foods?	1	2	7	9	(297)

		b.  Exercising more?		1	2	7	9	(298)

3.	Has a doctor ever told you that you had any of the following?

		Please Read			Yes	No	Dk/Ns	Ref

		a.  Heart attack or myocardial infarction		1	2	7	9	(299)

		b.  Angina or coronary heart disease		1	2	7	9	(300)
 
		c.  Stroke			1	2	7	9	(301)

If respondent 35 years old or older continue with Q4.  Otherwise, go to next module.

4.	Do you take aspirin daily or every other day?	(302)

		a.  Yes  Go to Q6	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

5.	Do you have a health problem or condition that makes taking aspirin unsafe for you?
					(303)

If yes, ask		a.  Yes, not stomach related  Go to Q7	1
"Is this a
stomach con-	b.  Yes, stomach problems  Go to Q7	2
dition?"
Code upset		c.  No  Go to Q7	3
stomachs as
stomach			Don't know/Not sure  Go to Q7	7
problems
			Refused  Go to Q7	9

6.	Why do you take aspirin?

		Please Read			Yes	No	Dk/Ns	Ref	

		a.  To relieve pain		1	2	7	9	(304)

		b.  To reduce the chance of a heart attack		1	2	7	9	(305)

		c.  To reduce the chance of a stroke		1	2	7	9	(306)

If respondent is male or is pregnant ("Yes" to core Q11.11), go to next module.

The next few questions are about menopause, or what some women refer to as the "change of life."

If respondent had hysterectomy ("Yes" to core Q11.10) or if respondent is age 65 or older, go to Q8. 

7.	Have you gone through or are you now going through menopause?	(307)

Probe			a.  Yes, have gone through menopause	1
for
which			b.  Yes, now going through menopause 	2

		c.  No Go to Next Module	3

			Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

8.	Estrogens such as Premarin and progestins such as Provera are female hormones that may be prescribed around the time of menopause, after menopause, or after a hysterectomy.  Has your doctor discussed the benefits and risks of estrogen with you?	(308)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

9.	Other than birth control pills, has your doctor ever prescribed estrogen pills for you?
					(309)

Do not			a.  Yes	1
include
estrogen		b.  No  Go to Next Module	2
patches
			Don't know/Not sure Go to Next Module	7

			Refused  Go to Next Module	9

10.	Are you currently taking estrogen pills?          	(310)

Do not			a.  Yes	1
include
estrogen		b.  No	2
patches
	Don't know/Not sure Go to Next Module	7
 
	Refused Go to Next Module	9

11.	Why...

		are you taking...[if "Yes" to Q10]

		did you take...[if "No" to Q10]

 		...estrogen pills?
								Never
	Please Read		Yes	No	Dk/Ns	took	Ref

	a.  To prevent a heart attack	1	2	7	8	9	(311)

	b.  To treat or prevent bone thinning, bone loss,
	     or osteoporosis		1	2	7	8	9	(312)

	c.  To treat symptoms of menopause
	     such as hot flashes	 	1	2	7	8	9	(313)

Module 14: Arthritis

1.	During the past 12 months, have you had pain, aching, stiffness or swelling in or around a joint?
					(314)

		a.  Yes	1
 
		b.  No  Go to Q4	2

			Don't know/Not sure  Go to Q4	7

			Refused  Go to Q4	9

2.	Were these symptoms present on most days for at least one month?	(315)

		a.  Yes	1
 
		b.  No	2

			Don't know/Not sure	7

			Refused	9

3.	Are you now limited in any way in any activities because of joint symptoms?	(316)

		a.  Yes	1
 
		b.  No	2

			Don't know/Not sure	7

			Refused	9

4.	Have you ever been told by a doctor that you have arthritis?	(317)

		a.  Yes	1
 
		b.  No   Go to Next Module	2

			Don't know/Not sure  Go to Next Module	7

			Refused    Go to Next Module	9

5.	What type of arthritis did the doctor say you have?	(318-319)

			Type Code	         

		Read Only if Necessary

		a.  Osteoarthritis/degenerative arthritis	0 1

		b.  Rheumatism	0 2
	
		c.  Rheumatoid Arthritis	0 3

		d.  Lyme disease	0 4

		e.  Other [specify]                            	0 7

		f.	Never saw a doctor	8 8

	  		Don't know/Not sure	7 7
		
			Refused	9 9

6.	Are you currently being treated by a doctor for arthritis?	(320)

		a.  Yes	1
 
		b.  No	2

			Don't know/Not sure 	7

			Refused	9

Module 15: Quality of Life and Care Giving

These next questions are about physical, mental, or emotional problems or limitations you may have in your daily life.

1.	Are you limited in any way in any activities because of any impairment or health problem?
					(321 )

		a.  Yes	1
	
		b.  No  Go to Q6	2

			Don't know/Not sure  Go to Q6   	7

			Refused  Go to Q6	9

2.	What is the major impairment or health problem that limits your activities?	(322-323)

			Reason Code	         

		Read Only if Necessary

		a.  Arthritis/rheumatism	0 1

		b.  Back or neck problem	0 2

		c.  Fractures, bone/joint injury	0 3

		d.  Walking problem	0 4

		e.  Lung/breathing problem	0 5

		f.  Hearing problem	0 6

		g.  Eye/vision problem	0 7

		h.  Heart problem	0 8

		i.  Stroke problem	0 9

		j.  Hypertension/high blood pressure	1 0

		k.  Diabetes	1 1

		l.  Cancer	1 2

		m.  Depression/anxiety/emotional problem	1 3

		n.  Other impairment/problem	1 4

			Don't know/Not sure	7 7

			Refused	9 9

3.	For how long have your activities been limited because of your major impairment or health problem?		(324-326)

		a.  Days	1          

		b.  Weeks	2          

		c.  Months	3          

		d.  Years	4          

			Don't know/Not Sure	7  7  7

			Refused	9  9  9

4.	Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house?
					(327 )	

		a.  Yes	1	

		b.  No	2

			Don't know/Not sure  	7

			Refused	9

5.	Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?	(328)

		a.  Yes  	1	

		b.  No  	2

			Don't know/Not sure  	7

			Refused  	9

6.	During the past 30 days, for about how many days did pain make it hard for you to do your usual activities, such as self-care, work, or recreation?	(329-330)

		a.  Number of days	         

		b.  None	8  8

			Don't know/Not sure	7  7

 			Refused	9  9

7.	During the past 30 days, for about how many days have you felt sad, blue, or depressed?
					(331-332)

		a.  Number of days	         
	
		b.  None	8  8

			Don't know/Not sure	7  7

 			Refused	9  9

8.	During the past 30 days, for about how many days have you felt worried, tense, or anxious?
					(333-334)
 	
		a.  Number of days	         
	
		b.  None	8  8

			Don't know/Not sure	7  7

 			Refused	9  9

9.	During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?			(335-336)

	a.  Number of days	         	

		b.  None	8  8

			Don't know/Not sure	7  7

 			Refused	9  9

10.	During the past 30 days, for about how many days have you felt very healthy and full of energy?
					(337-338)	

		a.  Number of days	         
	
		b.  None	8  8

			Don't know/Not sure	7  7

 			Refused	9  9

If "yes" to Q4, continue.  Otherwise, go to Q13.

11.	Earlier you reported that due to your impairment you need some assistance from another person with your PERSONAL CARE needs. Who usually helps you with your personal care needs, such as eating, bathing, dressing, or getting around the house?	(339-340)

		Read Only if Necessary

If a rela-		a.  Husband/wife/partner	0 1
tive that is
paid, code 		b.  Parent/son/son-in-law/daughter/daughter-in-law	0 2
as appropri-
ate relative		c.  Other relative	0 3

		d.  Unpaid volunteer	0 4

		e.  Paid employee or home health service	0 5

		f.  Friend or neighbor	0 6

		g.  Combination of family and/or friends	0 7

		h.  Other	0 8

		i.  No one helps me Go to Q13	0 9

			Don’t Know/Not Sure	7 7

			Refused	9 9

12.	Is the assistance you receive to meet your personal care needs:	(341)

		Please Read

		a.  Usually adequate	1

		b.  Sometimes adequate	2
			or
		c.  Rarely adequate 	3

Do not				Don't know/Not sure	7
read these
responses			Refused	9

If "yes" to Q5, continue.  Otherwise, go to Next Module

13.	Earlier you reported that due to your impairment you need some assistance from another person with your ROUTINE needs.  Who usually helps you with handling your routine needs, such as everyday household chores, shopping, or getting around for other purposes?	(342-343)

		Read Only if Necessary	

If a rela-		a.  Husband/wife/partner	0 1
tive that is
paid, code 		b.  Parent/son/son-in-law/daughter/daughter-in-law	0 2
as appropri-
ate relative		c.  Other relative	0 3

		d.  Unpaid volunteer	0 4

		e.  Paid employee or home health service	0 5

		f.  Friend or neighbor	0 6

		g.  Combination of family and/or friends	0 7

		h.  Other	0 8

		i.  No one helps me Go to Next Module	0 9

			Don’t Know/Not Sure	7 7

			Refused	9 9

14.	Is the assistance you receive to meet your routine needs:	(344)

		Please Read

		a.  Usually adequate	1

		b.  Sometimes adequate	2
			or
		c.  Rarely adequate 	3

Do not				Don't know/Not sure	7
read these
responses			Refused	9

Module 16: Folic Acid

1.	Do you currently take any vitamin pills or supplements?	(345)

Include   		a.  Yes	1
liquid
supplements	b.  No  Go to Q5	2

			Don't know/Not sure  Go to Q5 	7

			Refused  Go to Q5	9

2.	Are any of these a multivitamin?	(346)

		a.  Yes  Go to Q4	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

3.	Do any of the vitamin pills or supplements you take contain folic acid?	(347)

		a.  Yes	1

		b.  No Go to Q5	2

			Don't know/Not sure Go to Q5	7

			Refused Go to Q5	9

4.	How often do you take this vitamin pill or supplement?	(348-350)

		a.  Times per day	1          

		b.  Times per week	2          

		c.  Times per month	3          

			Don't know/Not sure	7  7  7

			Refused	9  9  9

If respondent 45 years old or older, go to next module.

5.	Some health experts recommend that women take 400 micrograms of the B vitamin folic acid, for which one of the following reasons... 	(351)

		Please Read

		a.  To make strong bones	1

		b.  To prevent birth defects	2

		c.  To prevent high blood pressure	3
			or
		d.  Some other reason	4

Do not				Don't know/Not sure	7
read these
responses			Refused	9

Module 17: Skin Cancer

The next questions are about what you do to protect your skin when you go outside.

1.	When you go outside on a sunny summer day for more than one hour, how often do you use sunscreen or sunblock?	(352)

	Would you say: Please Read

Summer means	a.  Always	1
June, July,
and August.		b.  Nearly always	2
Sunny is what
respondent		c.  Sometimes	3
considers
sunny			d.  Seldom	4
			or
		e.  Never Go to Q3	5
	
Do not	     			Don't stay out more than an hour  Go to Q6	8
read these    
responses	 		Don’t know/Not sure  Go to Q3	7

			Refused  Go to Q3	9

2.	What is the Sun Protection Factor or SPF of the sunscreen you use most often?	(353-354)

			Number	         

			Don’t know/Not sure	7 7

			Refused	9 9

3.	When you go outside on a sunny summer day for more than an hour, how often do you stay in the shade?			(355)

Would you say: Please Read

		a.  Always	1

		b.  Nearly always	2

		c.  Sometimes	3

		d.  Seldom	4
			or
		e.  Never	5

Do not				Don’t know/Not sure	7
read these
responses			Refused	9

4.	When you go outside on a sunny summer day for more than an hour, how often do you wear a wide-brimmed hat or any other hat that shades your face, ears, and neck from the sun?
					(356)
	
Would you say: Please Read

		a.  Always	1

		b.  Nearly always	2

		c.  Sometimes	3

		d.  Seldom	4
			or
		e.  Never	5

Do not				Don’t know/Not sure	7
read these
responses			Refused	9

5.	When you go outside on a sunny summer day for more than an hour, how often do you wear long-sleeved shirts?	(357)

Would you say: Please Read

		a.  Always	1

		b.  Nearly always	2

		c.  Sometimes	3

		d.  Seldom	4
			or
		e.  Never	5

Do not				Don’t know/Not sure	7
read these
responses			Refused	9

6.	Suppose that after several months of not being out in the sun, you then went out in the sun without a hat, sunscreen, or protective clothing for an hour. 	(358)

Would you: Please Read

		a.  Sunburn	1

		b.  Darken without sunburn Go to Next Module	2
			or
		c.  Not have anything happen Go to Next Module	3

Do not				Don’t know/Not sure Go to Next Module	7
read these
responses			Refused Go to Next Module	9

7.	Would you: Please Read	(359)

		a.  Burn severely with blisters	1

		b.  Burn severely with peeling for a few days	2
			or
		c.  Burn mildly without peeling	3

	Do not				Don’t know/Not sure	7
	read
	responses			Refused	9

Module 18:  Tobacco Use Prevention

1.	In the past 30 days has anyone, including yourself, smoked cigarettes, cigars, or pipes anywhere inside your home?	(360)

		a.	Yes	1

		b.	No	2

			Don’t know/Not sure	7

			Refused	9

If "Employed," or "Self-employed" to core Q10.7 continue.  Otherwise, go to Q5.

2.	While working at your job, are you indoors most of the time?	(361)

		a.  Yes	1

		b.	No  Go to Q5	2
		
			Don’t know/Not sure Go to Q5	7

			Refused  Go to Q5	9

3.	Which of the following best describes your place of work’s official smoking policy for indoor public or common areas, such as lobbies, rest rooms, and lunch rooms?	(362)

		Please Read

For workers		a.	Not allowed in any public areas	1
who visit
clients,		b.	Allowed in some public areas	2
"place
of work"		c.	Allowed in all public areas	3
means their			or
base location	d.	No official policy	4

Do not				Don’t know/Not sure	7
read these
responses			Refused	9

4.	Which of the following best describes your place of work’s official smoking policy for work areas?	
					(363)

		Please Read
 
For workers		a.	Not allowed in any work areas	1
who visit
clients,		b.	Allowed in some work areas, or	2
"place
of work"		c.	Allowed in all work areas	3
means their			or
base location	d.	No official policy	4

Do not				Don’t know/Not sure	7
read these
responses			Refused	9

5.	In the following locations, do you think that smoking should be allowed in all areas, some areas, or not allowed at all?

					All	Some	Not	
					Areas	Areas	Allowed	Dk/Ns	Ref
	Please Read
		 
	a. Restaurants		1	2	3	7	9	(364)

	b. Schools			1	2	3	7	9	(365)

	c. Day care centers		1	2	3	7	9	(366)

	d. Indoor work areas		1	2	3	7	9	(367)

If "No" to core Q7.1 or "Not at all" to core Q7.2, go to Next Module

6.	Has a doctor or other health professional ever advised you to quit smoking?	(368) 
	
If yes,			a.  Yes, within the past 12 months (1 to 12 months ago)	1
ask "About
how long ago	b.  Yes, within the past 3 years (1 to 3 years ago)	2
was it?"
		c.  Yes, 3 or more years ago	3

		d.  No	4

			Don't know/Not sure	7

			Refused	9

Module 19:  Smokeless Tobacco Use

1.	Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff?
					(369)

Probe for		a.  Yes, chewing tobacco	1
chewing
tobacco,		b.  Yes, snuff	2
snuff,
or both		c.  Yes, both	3

		d.  No, neither  Go to Closing Statement	4

			Don't know/Not sure  Go to Closing Statement	7

			Refused  Go to Closing Statement	9  

2.	Do you currently use any smokeless tobacco products such as chewing tobacco or snuff?
					(370)

"Yes"			a.  Yes, chewing tobacco	1
includes
occa-			b.  Yes, snuff	2
sional
use			c.  Yes, both	3

		d.  No, neither	4

			Don't know/Not sure	7

			Refused	9