Transcription
2020Behavioral Risk Factor Surveillance SystemQuestionnaireDelawareEnglish & Spanish (state-added only)February 10, 2020122 February 2021
Table of ContentsOMB Header and Introductory Text .4Landline Introduction.5Cell Phone Introduction . 10Core Section 1: Health Status . 15Core Section 2: Healthy Days . 16Core Section 3: Health Care Access . 18Core Section 4: Exercise . 20Core Section 5: Inadequate Sleep . 21Core Section 6: Chronic Health Conditions . 21Module 1: Prediabetes . 24Core Section 6: Chronic Health Conditions (continued). 25Module 2: Diabetes. 25Core Section 7: Oral Health . 28Core Section 8: Demographics . 29Core Section 9: Disability . 35Core Section 10: Tobacco Use . 36Core Section 11: Alcohol Consumption . 39Core Section 12: Immunization . 40Core Section 13: Falls . 42Core Section 14: Seat Belt Use and Drinking and Driving . 43Core Section 15: Breast and Cervical Cancer Screening . 44Core Section 16: Prostate Cancer Screening . 46Core Section 17: Colorectal Cancer Screening . 49Core Section 18: H.I.V./AIDS . 54Closing Statement/ Transition to Modules . 56Optional Modules . 57Module 6: Cognitive Decline . 57Module 8: E-Cigarettes . 59Module 9: Marijuana Use . 60Module 10: Lung Cancer Screening . 62Module 11: Cancer Survivorship: Type of Cancer . 64222 February 2021
Module 12: Cancer Survivorship: Course of Treatment . 68Module 13: Cancer Survivorship: Pain Management . 71Delaware State-Added 1: Adult Well Being Assessment (NEW) . 72Delaware State-Added 2: Perception of Equity (NEW) . 74Delaware State-Added 3: The Preconception Health/Family Planning (2018, DE state-added 2) . 81322 February 2021
OMB Header and Introductory TextRead if necessaryReadPublic reporting burden of thiscollection of information isestimated to average 27 minutesper response, including the timefor reviewing instructions,searching existing data sources,gathering and maintaining thedata needed, and completing andreviewing the collection ofinformation. An agency may notconduct or sponsor, and a personis not required to respond to acollection of information unless itdisplays a currently valid OMBcontrol number. Send commentsregarding this burden estimate orany other aspect of this collectionof information, includingsuggestions for reducing thisburden to CDC/ATSDR ReportsClearance Officer; 1600 CliftonRoad NE, MS D-74, Atlanta,Georgia 30333; ATTN: PRA (09201061).Interviewer instructions(not read)Form ApprovedOMB No. 0920-1061Exp. Date 3/31/2021Interviewers do not need toread any part of the burdenestimate nor provide theOMB number unless askedby the respondent forspecific information. If arespondent asks for thelength of time of theinterview provide the mostaccurate information basedon the version of thequestionnaire that will beadministered to thatrespondent. If theinterviewer is not sure,provide the average time asindicated in the burdenstatement. If data collectorshave questions concerningthe BRFSS OMB process,please contact CarolPierannunzi ativk7@cdc.gov.HELLO, I am calling for theDelaware Division of PublicHealth. My name is (name). Weare gathering information aboutthe health of US residents. Thisproject is conducted by the healthdepartment with assistance fromthe Centers for Disease Controland Prevention. Your telephonenumber has been chosenrandomly, and I would like to asksome questions about health andhealth practices.422 February 2021
Landline IntroductionQuestionNumberQuestion textVariablenamesLL01.Is this [PHONENUMBER]?CTELENM1Responses(DO NOTREADUNLESSOTHERWISE NOTED)1 Yes2 NoLL02.Is this a privateresidence?PVTRESD1SKIP INFO/CATI NoteGo toPVTRESD1TERMINATE1 YesGo toSTATERE12 NoGo toCOLGHOUSInterviewer Note(s)Column(s)63Thank you verymuch, but I seemto have dialedthe wrongnumber. It’spossible thatyour number maybe called at alater time.Read if64necessary: Byprivate residencewe meansomeplace like ahouse orapartment.Do not read:Private residenceincludes anyhome where therespondentspends at least30 days includingvacation homes,RVs or otherlocations inwhich therespondent livesfor portions ofthe year.If no, businessphone only:thank you verymuch but we are522 February 2021
3 No, this isa businessLL03.LL04.Do you live incollege housing?Do you currentlylivein Delware?COLGHOUSSTATERE11 YesGo toSTATERE12 NoTERMINATE1 YesGo toCELPHONETERMINATE2 Noonly interviewingpersons onresidentialphones lines atthis time.NOTE: Businessnumbers whichare also used forpersonalcommunicationare eligible.Read: Thank youvery much butwe are onlyinterviewingpersons onresidentialphones at thistime.TERMINATERead ifnecessary: Bycollege housingwe meandormitory,graduate studentor visiting facultyhousing, or otherhousingarrangementprovided by acollege oruniversity.Read: Thank youvery much, butwe are onlyinterviewingpersons who livein privateresidences orcollege housingat this time.6566Thank you verymuch but we areonly interviewingpersons who livein Delware at thistime.622 February 2021
LL05.LL06.Is this a cellphone?Are you 18 yearsof age or older?CELPHONELADULT11 Yes, it is acell phoneTERMINATE2 Not a cellphoneGo toLADULT11 YesIF COLLEGEHOUSING “YES,”CONTINUE;OTHERWISEGO TO ADULTRANDOMSELECTION]IF COLLEGEHOUSING “YES,”Terminate;OTHERWISEGO TO ADULTRANDOMSELECTION]ONLY forrespondentswho are LLandCOLGHOUS 1.2 NoLL07.Are you male orfemale?COLGSEX1 Male2 FemaleRead: Thank youvery much butwe are onlyinterviewing bylandlinetelephones inprivateresidences orcollege housingat this time.Read ifnecessary: By cellphone we meana telephone thatis mobile andusable outsideyourneighborhood.Do not read:Telephoneservice over theinternet countsas landlineservice (includesVonage, MagicJack and otherhome-basedphone services).6768Read: Thank youvery much butwe are onlyinterviewingpersons aged 18or older at thistime.69722 February 2021
LL08.LL09.I need torandomly selectone adult wholives in yourhousehold to beinterviewed.Excluding adultsliving away fromhome, such asstudents away atcollege, howmany membersof yourhousehold,includingyourself, are 18years of age orolder?Are you male orfemale?NUMADULTLANDSEX7 Don’tknow/Notsure9 RefusedTERMINATE1Go toLANDSEX2-6 or moreGo toNUMMEN1 Male2 FemaleGO toTransitionSection 1.TERMINATE7 Don’tknow/Notsure9 RefusedLL10.How many ofthese adults aremen?NUMMENLL11.So the number ofwomen in thehousehold is [X].Is that correct?NUMWOMENThank you foryour time, yournumber may beselected foranother survey inthe future.Read: Are youthat adult?If yes: Then youare the person Ineed to speakwith.If no: May I speakwith the adult inthe household?70-7172Thank you foryour time, yournumber may beselected foranother survey inthe future.Number77 Don’tknow/ Notsure99 Refused73-74Do not read:Confirm thenumber of adultwomen or clarifythe total numberof adults in thehousehold.Read: Thepersons in yourhousehold that I75-76822 February 2021
need to speakwith is[Oldest/Youngest/ Middle//Male/Female].LL12The person inyour householdthat I need tospeak with is[Oldest/Youngest/ Middle//Male/Female]. Are youthe[Oldest/Youngest/ Middle//Male/Female] in thishousehold?RESPSLCT1 Male2 Female7 Don’tknow/Notsure9 RefusedTransition toSection 1.I will notask for yourlast name,address, orotherpersonalinformationthat canidentifyyou. Youdo not haveto answeranyquestionyou do notwant to,and you canend theinterview atany time.Anyinformationyou give mewill not beconnectedto anyIf personindicates thatthey are notthe selectedrespondent,ask forcorrectrespondentand re-askLL12. (SeeCATIprogramming)TERMINATE77Thank you foryour time, yournumber may beselected foranother survey inthe future.Do not read:Introductory textmay be rereadwhen selectedrespondent isreached.Do not read: Thesentence “Anyinformation yougive me will notbe connected toany personalinformation” maybe replaced by“Any personalinformation thatyou provide willnot be used toidentify you.” Ifthe statecoordinatorapproves thechange.922 February 2021
personalinformation. If youhave anyquestionsabout thesurvey,please call877-5516138.Cell Phone IntroductionQuestionNumberQuestion textVariablenamesResponses(DO NOT READUNLESSOTHERWISENOTED)SKIP INFO/CATI NoteCP01.Is this a safe timeto talk with you?SAFETIME1 YesGo toCTELNUM1([setappointmentif possible])TERMINATE]2 NoCP02.Is this [PHONENUMBER]?CTELNUM1 1 YesCP03.Is this a cell phone?CELLFON52 No1 Yes2 NoCP04.Are you 18 years ofage or older?CADULT1Go toCELLSEXTERMINATEGo toCADULT1TERMINATEInterviewerNote (s)78Thank youvery much.We will callyou back at amoreconvenienttime.7980If "no”: thankyou verymuch, but weare onlyinterviewingpersons oncelltelephones atthis time1 Yes2 NoColumn(s)81TERMINATERead: Thankyou verymuch but weare onlyinterviewing1022 February 2021
persons aged18 or older atthis time.CP05.CP06.CP07.Are you male orfemale?Do you live in aprivate residence?Do you live incollege housing?CELLSEXPVTRESD3CCLGHOUS1 Male2 Female7 Don’t Know/Not sure9 Refused82TERMINATE1 YesGo toCSTATE12 NoGo toCCLGHOUSGo toCSTATE11 YesThank you foryour time,your numbermay beselected foranothersurvey in thefuture.Read ifnecessary: Byprivateresidence wemeansomeplacelike a houseor apartmentDo not read:Privateresidenceincludes anyhome wheretherespondentspends atleast 30 daysincludingvacationhomes, RVsor otherlocations inwhich therespondentlives forportions ofthe year.Read ifnecessary:By collegehousing wemeandormitory,graduatestudent or83841122 February 2021
CP08.CP09.2 NoTERMINATEDo you currentlyCSTATE1livein Delware ?1 YesGo toLANDLINEGo toRSPSTAT1In what state doyou currently live?1 Alabama2 Alaska4 Arizona5 Arkansas6 California8 Colorado9 Connecticut10 Delaware11 District ofColumbia12 Florida13 Georgia15 Hawaii16 Idaho17 Illinois18 Indiana19 Iowa20 Kansas21 Kentucky22 Louisiana23 Maine24 Maryland25Massachusetts26 Michigan27 Minnesota28 MississippiRSPSTAT12 Novisitingfacultyhousing, orother housingarrangementprovided by acollege oruniversity.Read: Thankyou verymuch, but weare onlyinterviewingpersons wholive in privateresidences orcollegehousing atthis time.8586-871222 February 2021
29 Missouri30 Montana31 Nebraska32 Nevada33 NewHampshire34 New Jersey35 New Mexico36 New York37 NorthCarolina38 NorthDakota39 Ohio40 Oklahoma41 Oregon42Pennsylvania44 RhodeIsland45 SouthCarolina46 SouthDakota47 Tennessee48 Texas49 Utah50 Vermont51 Virginia53 Washington54 WestVirginia55 Wisconsin56 Wyoming66 Guam72 Puerto Rico78 VirginIslands77 Live outsideUS andparticipatingterritories99 RefusedCP10.Do you also have a LANDLINElandline telephonein your home thatis used to make andreceive calls?1 Yes2 No7 Don’t know/Not sure9 RefusedTERMINATERead: Thankyou verymuch, but weare onlyinterviewingpersons wholive in the US.Read ifnecessary: Bylandlinetelephone,we mean a881322 February 2021
regulartelephone inyour homethat is usedfor making orreceivingcalls. Pleaseincludelandlinephones usedfor bothbusiness andpersonal use.CP11.How manymembers of yourhousehold,including yourself,are 18 years of ageor older?Transitionto section1.HHADULTNumber77 Don’t know/Not sure99 RefusedIf CCLGHOUS yes thennumber ofadults isautomaticallyset to 189-90I will not askfor your lastname, address,or otherpersonalinformationthat canidentify you.You do nothave to answerany questionyou do notwant to, andyou can endthe interviewat any time.Anyinformationyou give mewill not beconnected toany personalinformation. Ifyou have anyquestionsabout thesurvey, pleasecall 877-5516138.1422 February 2021
Core Section 1: Health StatusQuestionNumberQuestion textVariablenamesCHS.01Would you saythat in generalyour healthis—GENHLTHResponses(DO NOTREAD UNLESSOTHERWISENOTED)Read:1 Excellent2 Very Good3 Good4 Fair5 PoorDo not read:7 Don’tknow/Notsure9 RefusedSKIP INFO/CATI NoteInterviewer Note (s)Column(s)1011522 February 2021
Core Section 2: Healthy DaysQuestionNumberQuestion textCHD.01Now thinkingabout yourphysical health,which includesphysical illnessand injury, forhow many daysduring the past30 days wasyour physicalhealth notgood?Now thinkingabout yourmental health,which includesstress,depression,and problemswith emotions,for how manydays during thepast 30 dayswas yourmental healthnot DO NOTREADUNLESSOTHERWISENOTED)Numberof days (0130)88 None77 Don’tknow/notsure99 RefusedSKIP INFO/CATI NoteInterviewer Note(s)Column(s)102-103Numberof days (0130)88 None77 Don’tknow/notsure99 Refused104-105SkipPOORHLTH if,PHYSHLTH is88 andMENTHLTH, is88CHD.03During the past30 days, forabout howmany days didpoor physicalor mentalhealth keepyou from doingPOORHLTHNumberof days (0130)88 None77 Don’tknow/notsure99 Refused106-1071622 February 2021
your usualactivities, suchas self-care,work, orrecreation?1722 February 2021
Core Section 3: Health Care AccessQuestionNumberQuestion textVariablenamesCHCA.01Do you have anykind of healthcare coverage,including healthinsurance,prepaid planssuch as HMOs,or governmentplans such asMedicare, orIndian HealthService?Do you have oneperson you thinkof as yourpersonal doctoror health careprovider?HLTHPLN1Was there atime in the past12 months whenyou needed tosee a doctor butcould notbecause of cost?About how longhas it been sinceyou last visited adoctor for C2CHECKUP1Responses(DO NOTREAD UNLESSOTHERWISENOTED)1 Yes2 No7 Don’tknow/NotSure9 RefusedSKIP INFO/CATI NoteInterviewer Note(s)Column(s)1081 Yes, onlyone2 More thanone3 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 RefusedIf No, read: Is there 109more than one, or isthere no personwho you think of asyour personaldoctor or healthcare provider?Read ifnecessary:1 Within thepast year(anytime lessthan 12months ago)2 Within thepast 2 years(1 year butless than 2years ago)3 Within thepast 5 yearsRead if necessary: Aroutine checkup is ageneral physicalexam, not an examfor a specific injury,illness, or condition.1101111822 February 2021
(2 years butless than 5years ago)4 5 or moreyears agoDo not read:7 Don’t know/ Not sure8 Never9 Refused1922 February 2021
Core Section 4: ExerciseQuestionNumberQuestion textVariablenamesCEX.01During the pastmonth, otherthan yourregular job, didyou participatein any physicalactivities orexercises such asrunning,calisthenics,golf, gardening,or walking forexercise?EXERANY2Responses(DO NOTREAD UNLESSOTHERWISENOTED)1 Yes2 No7 Don’t know/ Not sure9 RefusedSKIP INFO/CATI NoteInterviewer Note(s)Column(s)Do not read: Ifrespondent doesnot have a regularjob or is retired,they may count anyphysical activity orexercise they do1122022 February 2021
Core Section 5: Inadequate SleepQuestionNumberQuestion textVariablenamesCIS.01On average,how manyhours of sleepdo you get in a24-hourperiod?SLEPTIM1Responses(DO NOTREAD UNLESSOTHERWISENOTED)Number ofhours [01-24]77 Don’tknow / Notsure99 RefusedSKIP INFO/CATI NoteInterviewer Note (s)Column(s)Do not read: Enterhours of sleep inwhole numbers,rounding 30 minutes(1/2 hour) or moreup to the next wholehour and dropping29 or fewer minutes.113-114Core Section 6: Chronic Health ConditionsQuestionNumberQuestion textVariablenamesCCHC.01Has a doctor,nurse, or otherhealthprofessionalever told youthat you hadany of thefollowing? Foreach, tell meYes, No, OrYou’re NotSure.Ever told) youthat you had aheart attackalso called amyocardialinfarction?(Ever told) (youhad) angina orcoronary heartdisease?CVDINFR4CCHC.02CVDCRHD4Responses(DO NOTREADUNLESSOTHERWISENOTED)1 Yes2 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sureSKIP INFO/CATI NoteInterviewer Note(s)Column(s)1151162122 February 2021
CCHC.03(Ever told) (youhad) a stroke?CVDSTRK3CCHC.04(Ever told) (youhad) asthma?ASTHMA3CCHC.05Do you stillhave asthma?ASTHNOWCCHC.06(Ever told) (youhad) skincancer?CHCSCNCRCCHC.07(Ever told) (youhad) any othertypes ofcancer?CHCOCNCRCCHC.08(Ever told) (youhad) ema orchronicbronchitis?(Ever told) (youhad) some formof arthritis,rheumatoidarthritis, gout,lupus, orfibromyalgia?CHCCOPD2CCHC.09HAVARTH49 Refused1 Yes2 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 Refused117118Go toASTHNOW119120121122Do not read:Arthritis steoarthritis (notosteoporosis),tendonitis, bursitis,bunion, tenniselbow, carpaltunnel syndrome,tarsal tunnelsyndrome, joint1232222 February 2021
infection, is, rotatorcuff syndrome,connective syndrome,vasculitis, giant cellarteritis, HenochSchonlein osa)CCHC.10CCHC.11CCHC.12(Ever told) (youhad) ssion,dysthymia, orminordepression)?Not includingkidney stones,bladderinfection orincontinence,were you evertold you havekidney disease?(Ever told) (youhad) diabetes?ADDEPEV31 Yes2 No7 Don’t know/ Not sure9 RefusedCHCKDNY21 Yes2 No7 Don’t know/ Not sure9 RefusedRead if necessary:Incontinence is notbeing able tocontrol urine flow.125DIABETE41 YesIf yes andrespondent isfemale, ask: wasthis only when youwere pregnant? Ifrespondent sayspre-diabetes orborderline diabetes,use response code4.1262 Yes, butfemale told124Go to PreDiabetes2322 February 2021
only duringpregnancy3 No4 No, prediabetes orborderlinediabetes7 Don’t know/ Not sureOptionalModule (ifused).Otherwise,go to nextsection.9 RefusedModule 1: PrediabetesQuestionNumberQuestion textVariablenamesResponses(DO NOTREADUNLESSOTHERWISENOTED)SKIP INFO/CATI NoteInterviewer Note(s)Column(s)Skip ifDIABETE4 iscoded 1MPDB.01Have you had atest for highblood sugar ordiabetes withinthe past threeyears?PDIABTST1 Yes2 No7 Don’tknow/ notsure9 Refused264Skip PREDIAB1if DIABETE4 iscoded 1; IfDIABETE4 iscoded 4automaticallycode PREDIAB1,equal to 1 (yes);MPDB.02Have you everbeen told by adoctor or otherhealthprofessionalthat you havepre-diabetes orborderlinediabetes?PREDIAB11 Yes2 Yes, duringpregnancy3 No7 Don’t know/ Not sure9 RefusedIf Yes andrespondent isfemale, ask: Wasthis only whenyou werepregnant?2652422 February 2021
Core Section 6: Chronic Health Conditions (continued)QuestionNumberQuestion textVariablenamesCCHC.13How old wereyou when youwere told youhave diabetes?DIABAGE3Responses(DO NOTREADUNLESSOTHERWISENOTED)Code agein years [97 97 and older]98 Don‘tknow / Notsure99 RefusedSKIP INFO/CATI NoteResponses(DO NOTREADUNLESSOTHERWISENOTED)SKIP INFO/CATI NoteInterviewer Note (s)Go toDiabetesModule ifused,otherwise goto nextsection.Column(s)127-128Module 2: DiabetesQuestionNumberQuestion textVariablenamesInterviewer Note(s)Column(s)To be askedfollowing CoreDIABAGE3 ifresponse toDIABETE3 isYes (code 1)andSTATERES 1MDIA.01Are you nowtaking insulin?INSULIN11 Yes2 No7 Don’tknow/ notsure9 Refused2662522 February 2021
MDIA.02About howoften do youcheck yourblood forglucose orsugar?BLDSUGAR1 Timesper day2 Timesper week3 Timesper month4 Timesper year888 Never777 Don’tknow / Notsure999 RefusedMDIA.03Including timeswhen checkedby a familymember orfriend, abouthow often doyou check yourfeet for anysores orirritations?FEETCHK31 Timesper day2 Timesper week3 Timesper monthRead if necessary:Include timeswhen checked by afamily member orfriend, but do notinclude timeswhen checked by ahealthprofessional.267-269Do not read: If therespondent uses acontinuous glucosemonitoring system(a sensor insertedunder the skin tocheck glucoselevelscontinuously), fillin ‘98 times perday.’270-2724 Timesper year555 No feet888 NeverMDIA.04About howmany times inthe past 12months haveyou seen adoctor, nurse,or other healthprofessional foryour diabetes?DOCTDIAB777 Don’tknow / Notsure999 RefusedNumberof times [76 76 ormore]88 None77 Don’tknow / Notsure99 Refused273-2742622 February 2021
MDIA.05About howCHKHEMO3many times inthe past 12months has adoctor, nurse,or otherhealthprofessionalchecked you forA-one-C?Numberof times [76 76 ormore]88 None98 Neverheard of Aone-C test77 Don’tknow / Notsure99 RefusedRead if necessary:A test for A-one-Cmeasures theaverage level ofblood sugar overthe past threemonths.275-276If FEETCHK3 555 (No feet),go toEYEEXAM1MDIA.06About howmany times inthe past 12months has ahealthprofessionalchecked yourfeet for anysores orirritations?FEETCHKMDIA.07When was theEYEEXAM1last time youhad an eyeexam in whichthe pupils weredilated, makingyou temporarilysensitive tobright light?Numberof times [76 76 ormore]88 None77 Don’tknow / Notsure99 Refused277-278Read ifnecessary:1 Within thepast month(anytime lessthan 1month ago)2 Within thepast year (1month butless than 12months ago)3 Within thepast 2 years(1 year butless than 2years ago)4 2 or moreyears agoDo not read:2792722 February 2021
7 Don’t know/ Not sure8 Never9 RefusedMDIA.08MDIA.09Has a doctorever told youthat diabeteshas affectedyour eyes orthat you hadretinopathy?Have you evertaken a courseor class in howto manage yourdiabetesyourself?DIABEYE1 Yes2 No7 Don’tknow/ notsure9 Refused280DIABEDU1 Yes2 No7 Don’tknow/ notsure9 Refused281Core Section 7: Oral HealthQuestionNumberQuestion textVariablenamesCOH.01Including all typesof dentists, suchas orthodontists,oral surgeons,and all otherdental specialists,as well as dentalhygienists, howlong has it beensince you lastvisited a dentistor a dental clinicfor any reason?LASTDEN4Responses(DO NOTREAD UNLESSOTHERWISENOTED)Read ifnecessary:1 Within thepast year(anytime lessthan 12months ago)2 Within thepast 2 years(1 year butless than 2years ago)3 Within thepast 5 years(2 years butless than 5years ago)SKIPINFO/CATI NoteInterviewer Note(s)Column(s)1292822 February 2021
4 5 or moreyears agoDo not read:7 Don’t know/ Not sure8 Never9 RefusedCOH.02Not includingteeth lost forinjury ororthodontics,how many ofyour permanentteeth have beenremoved becauseof tooth decay orgum disease?RMVTETH4Read ifnecessary:1 1 to 52 6 or morebut not all3 All8 NoneDo not read:7 Don’t know/ Not sure9 RefusedRead if necessary:130If wisdom teeth areremoved becauseof tooth decay orgum disease, theyshould be includedin the count for lostteeth.Core Section 8: blenamesWhat isyour age?AGECDEM.02Are youHISPANC3Hispanic,Latino/a, orSpanishorigin?CDEM.03Which oneor more ofthefollowingwould yousay is yourrace?MRACE1Responses(DO NOT READ UNLESSOTHERWISE NOTED)Code age in years07 Don’t know / Not sure09 RefusedIf yes, read: Are you 1 Mexican, MexicanAmerican, Chicano/a2 Puerto Rican3 Cuban4 Another Hispanic,Latino/a, or Spanish originDo not read:5 No7 Don’t know / Not sure9 RefusedPlease read:10 White20 Black or AfricanAmerican30 American Indian orAlaska Native40 Asian41 Asian IndianSKIP INFO/CATI NoteInterviewerNote (s)Column(s)131-132If morethan oneresponsetoCDEM.03;continue.Otherwise,One or morecategoriesmay beselected.133-136If 40 (Asian)or 50 (PacificIslander) isselected readand codesubcategories underneath137-1642922 February 2021
CDEM.04Which oneof thesegroupswould yousay bestrepresentsyour race?ORACE342 Chinese43 Filipino44 Japanese45 Korean46 Vietnamese47 Other Asian50 Pacific Islander51 Native Hawaiian52 Guamanian orChamorro53 Samoan54 Other PacificIslanderDo not read:60 Other88 No additional choices77 Don’t know / Not sure99 RefusedPlease read:10 White20 Black or AfricanAmerican30 American Indian orAlaska Native40 Asian41 Asian Indian42 Chinese43 Filipino44 Japanese45 Korean46 Vietnamese47 Other Asian50 Pacific Islander51 Native Hawaiian52 Guamanian orChamorro53 Samoan54 Other PacificIslanderDo not read:60 Othergo toCDEM.05.majorheading.One or morecategoriesmay beselected.If 40 (Asian)or 50 (PacificIslander) isselected readand codesubcategories underneathmajorheading.165-166If respondenthas selectedmultipleraces inprevious andrefuses toselect asingle race,code refused77 Don’t know / Not sure99 RefusedIf using Sexat BirthModule,insert hereCDEM.05Are you MARITALPlease read:1 Married1673022 February 2021
CDEM.06What is thehighestgrade oryear ofschool youcompleted?EDUCACDEM.07Do youown orrent yourhome?RENTHOM12 Divorced3 Widowed4 Separated5 Never marriedOr6 A member of anunmarried coupleDo not read:9 RefusedRead if necessary:1 Never attended school oronly attended kindergarten2 Grades 1 through 8(Elementary)3 Grades 9 through 11(Some high school)4 Grade 12 or GED (Highschool graduate)5 College 1 year to 3 years(Some college or technicalschool)6 College 4 years or more(College graduate)Do not read:9 Refused1 Own2 Rent3 Other arrangement7 Don’t know / Not sure9 Refused168Otherarrangementmay includegroup home,staying withfriends orfamilywithoutpaying rent.Home isdefined asthe placewhere youlive most ofthe time/themajority ofthe year.Read ifnecessary:We ask thisquestion inorder tocomparehealthindicators1693122 February 2021
amongpeople withdifferenthousingsituations.CDEM.08CDEM.09In whatcounty doyoucurrentlylive?What is theZIP Codewhere youcurrentlylive?CTYCODE2ANSI County Code777 Don’t know / Not sure999 Refused170-172ZIPCODE177777 Do not know99999 Refused173-177If cellinterviewgo toCDEM12CDEM.10CDEM.11CDEM.12Notincludingcell phonesor numbersused forcomputers,faxmachinesor securitysystems,do youhave morethan onetelephonenumber inyourhousehold?How manyof thesetelephonenumbersareresidentialnumbers?How manycell phonesdo youhave forpersonaluse?NUMHHOL3 1 Yes2 No7 Don’t know / Not sure9 RefusedNUMPHON3Enter number (1-5)6 Six or more7 Don’t know / Not sure8 None9 RefusedCPDEMO1BEnter number (1-5)6 Six or more7 Don’t know / Not sure8 None9 Refused178Go toCDEM.12179Lastquestionneeded forpartialcomplete.Read ifnecessary:Include cellphones usedfor both1803222 Febru
Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061). Form Approved OMB No. 0920-1061 Exp. Date 3/31/2021 Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most
