Transcription
2021 BRFSSQuestionnaire11 October 2021 Missouri
Table of ContentsOMB Header and Introductory Text .3Landline Introduction.4Cell 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: Hypertension Awareness . 21Core Section 6: Cholesterol Awareness . 22Core Section 7: Chronic Health Conditions . 24Core Section 8: Arthritis . 27Core Section 9: Demographics . 29Core Section 10: Disability . 35Core Section 11: Tobacco Use . 37Core Section 12: Alcohol Consumption. 38Core Section 13: Immunization . 40Core Section 14: H.I.V./AIDS . 42Core Section 15: Fruits and Vegetables . 43Closing Statement/ Transition to Modules . 46Optional Modules . 47Module 16: Home/ Self-measured Blood Pressure . 47Module 17: Sodium or Salt-Related Behavior . 49Module 19: Caregiver . 50Module 22: Tobacco Cessation . 54Module 24: Industry and Occupation . 56Module 25: Random Child Selection . 57Module 26: Childhood Asthma Prevalence . 61Module 28: Sexual Orientation and Gender Identity (SOGI) . 63State-Added: Smoke Free Laws . 67State-Added: Suicide Prevention . 68State-added Module: Coronavirus Infection – COVID 19 . 70State-added Module: Coronavirus Infection . 70Closing Statement . 83Asthma Call-Back Permission Script . 8321 October 2021 Missouri
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 the [STATEOF xxx] Department of Health. Myname is (name). We are gatheringinformation about the health ofUS residents. This project isconducted 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.31 October 2021 Missouri
Landline IntroductionQuestionNumberQuestion textVariablenamesLL01.Is this [PHONENUMBER]?CTELENM1Is this a privateresidence?PVTRESD1LL02.Responses(DO NOTREADUNLESSOTHERWISE NOTED)1 Yes2 NoSKIP INFO/CATI Note1 YesGo to LL042 NoGo to LL03Go to LL02TERMINATEInterviewer Note(s)Column(s)Thank you verymuch, but I seemto have dialedthe wrongnumber. It’spossible thatyour number maybe called at alater time.Read ifnecessary: Byprivate residencewe meansomeplace like ahouse orapartment.Do not read:Private residenceincludes anyhome where therespondentspends at least 30days includingvacation homes,RVs or otherlocations in whichthe respondentlives for portionsof the year.If no, businessphone only:thank you verymuch but we areonly interviewingpersons onresidentialphones lines atthis time.NOTE: Businessnumbers which41 October 2021 Missouri
3 No, this isa businessLL03.LL04.LL05.Do you live incollege housing?COLGHOUSDo you currentlylivein (state) ?STATERE1Is this a cellphone?CELPHONE1 YesGo to LL042 NoTERMINATE1 Yes2 NoGo to LL05TERMINATE1 Yes, it is acell phoneTERMINATEare 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.Thank you verymuch but we areonly interviewingpersons who livein [STATE] at thistime.Read: Thank youvery much butwe are onlyinterviewing bylandlinetelephones inprivate51 October 2021 Missouri
LL06.Are you 18 yearsof age or older?LADULT12 Not a cellphoneGo to LL061 YesIF COLLEGEHOUSING “YES,”CONTINUE;OTHERWISEGO TO ADULTRANDOMSELECTION]IF COLLEGEHOUSING “YES,”Terminate;OTHERWISEGO TO ADULTRANDOMSELECTION]ONLY forrespondentswho are LLandCOLGHOUS 1.Go toTransitionSection 1.TERMINATE2 NoLL07.Are you male orfemale?COLGSEX1 Male2 Female7 Don’tknow/Notsure9 Refusedresidences orcollege housingat this time.Read ifnecessary: By cellphone we mean atelephone that ismobile andusable outsideyourneighborhood.Do not read:Telephoneservice over theinternet countsas landlineservice (includesVonage, MagicJack and otherhome-basedphone services).Read: Thank youvery much butwe are onlyinterviewingpersons aged 18or older at thistime.Thank you foryour time, yournumber may beselected for61 October 2021 Missouri
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?NUMADULTLANDSEX1Go to LL092-6 or moreGo to LL10.1 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?NUMWOMENanother 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?Thank you foryour time, yournumber may beselected foranother survey inthe future.Number77 Don’tknow/ Notsure99 RefusedDo not read:Confirm thenumber of adultwomen or clarifythe total numberof adults in thehousehold.Read: Thepersons in yourhousehold that Ineed to speakwith is[Oldest/Youngest/ Middle//Male/Female].71 October 2021 Missouri
LL12The person inRESPSLCTyour householdthat I need tospeak with is[Oldest/Youngest/ Middle//Male/Female]. Are youthe[Oldest/Youngest/ Middle//Male/Female] in thishousehold?1 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 youcan end theinterviewat any time.Anyinformationyou giveme will notbeconnectedto anypersonalinformationIf you haveanyIf personindicates thatthey are notthe selectedrespondent,ask forcorrectrespondentand re-askLL12. (SeeCATIprogramming)TERMINATEThank 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.81 October 2021 Missouri
questionsabout thesurvey,please call(giveappropriatestatetelephonenumber).91 October 2021 Missouri
Cell Phone IntroductionQuestionNumberQuestion textVariablenamesResponses(DO NOT READUNLESSOTHERWISENOTED)SKIP INFO/CATI NoteCP01.Is this a safe timeto talk with you?SAFETIME1 Yes2 NoGo to CP02([setappointmentif possible])TERMINATE]Is this [PHONENUMBER]?Is this a cellphone?CTELNUM1 1 Yes2 NoCELLFON5 1 YesCP02.CP03.2 NoCP04.CP05.Are you 18 yearsof age or older?Are you male orfemale?CADULT1CELLSEXGo to CP03TERMINATEGo toCADULT1TERMINATEInterviewerNote (s)Column(s)Thank youvery much.We will callyou back at amoreconvenienttime.If "no”: thankyou verymuch, but weare onlyinterviewingpersons oncelltelephones atthis time1 Yes2 NoTERMINATERead: Thankyou very muchbut we areonlyinterviewingpersons aged18 or older atthis time.1 Male2 Female7 Don’t Know/Not sure9 RefusedTERMINATEThank you foryour time,your numbermay beselected foranothersurvey in thefuture.101 October 2021 Missouri
CP06.CP07.Do you live in aprivateresidence?Do you live incollege housing?PVTRESD31 YesGo to CP08CCLGHOUS2 No1 YesGo to CP07Go to CP082 NoTERMINATERead ifnecessary: Byprivateresidence wemeansomeplacelike a house orapartmentDo not read:Privateresidenceincludes anyhome wheretherespondentspends atleast 30 daysincludingvacationhomes, RVs orotherlocations inwhich therespondentlives forportions ofthe year.Read ifnecessary: Bycollegehousing wemeandormitory,graduatestudent orvisiting facultyhousing, orother housingarrangementprovided by acollege oruniversity.Read: Thankyou verymuch, but weare onlyinterviewingpersons wholive in private111 October 2021 Missouri
residences orcollegehousing at thistime.CP08.CP09.Do you currentlylivein (state) ?In what state doyou currentlylive?CSTATE11 Yes2 NoRSPSTAT11 Alabama2 Alaska4 Arizona5 Arkansas6 California8 Colorado9 Connecticut10 Delaware11 District ofColumbia12 Florida13 Georgia15 Hawaii16 Idaho17 Illinois18 Indiana19 Iowa20 Kansas21 Kentucky22 Louisiana23 Maine24 Maryland25Massachusetts26 Michigan27 Minnesota28 Mississippi29 Missouri30 Montana31 Nebraska32 Nevada33 NewHampshire34 New Jersey35 New Mexico36 New York37 NorthCarolina38 NorthDakota39 Ohio40 Oklahoma41 OregonGo to CP10Go to CP09121 October 2021 Missouri
42 Pennsylvania44 Rhode Island45 SouthCarolina46 SouthDakota47 Tennessee48 Texas49 Utah50 Vermont51 Virginia53 Washington54 WestVirginia55 Wisconsin56 Wyoming66 Guam72 Puerto Rico78 VirginIslands77 Live outsideUS andparticipatingterritories99 RefusedCP10.Do you also havea landlinetelephone in yourhome that is usedto make andreceive calls?LANDLINE1 Yes2 No7 Don’t know/Not sure9 RefusedCP11.How manymembers of yourhousehold,includingyourself, are 18HHADULTNumber77 Don’t know/Not sure99 RefusedTERMINATERead: Thankyou verymuch, but weare onlyinterviewingpersons wholive in the US.Read ifnecessary: Bylandlinetelephone, wemean aregulartelephone inyour homethat is usedfor making orreceiving calls.Please includelandlinephones usedfor bothbusiness andpersonal use.If CP07 yesthen numberof adults isautomaticallyset to 1131 October 2021 Missouri
years of age orolder?Transitionto section1.I will not ask foryour last name,address, orother personalinformationthat canidentify you.You do nothave to answerany questionyou do notwant to, andyou can end theinterview at anytime. Anyinformation yougive me will notbe connectedto any personalinformation. Ifyou have anyquestionsabout thesurvey, pleasecall (giveappropriatestate telephonenumber).141 October 2021 Missouri
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)151 October 2021 Missouri
Core Section 2: Healthy DaysQuestionNumberQuestion textVariablenamesCHD.01Now thinkingabout yourphysicalhealth, whichincludesphysical illnessand injury, forhow manydays during thepast 30 dayswas yourphysical healthnot good?PHYSHLTHCHD.02Now thinkingabout yourmental health,which includesstress,depression,and problemswith emotions,for how manydays during thepast 30 dayswas yourmental healthnot good?MENTHLTHResponses(DO NOTREADUNLESSOTHERWISENOTED)Numberof days (0130)88 None77 Don’tknow/notsure99 RefusedSKIP INFO/CATI NoteInterviewer Note(s)Column(s)88 may be coded ifrespondent says“never” or “none”It is not necessaryto askrespondents toprovide a numberif they indicatethat this neveroccurs.Numberof days (0130)88 None77 Don’tknow/notsure99 Refused88 may be coded ifrespondent says“never” or “none”It is not necessaryto askrespondents toprovide a numberif they indicatethat this neveroccurs.Skip CHD.03 ifCHD.01,PHYSHLTH, is88 andCHD.02,MENTHLTH, is88CHD.03During the past30 days, forabout howmany days didpoor physicalPOORHLTHNumberof days (0130)88 None88 may be coded ifrespondent says“never” or “none”It is not necessaryto ask161 October 2021 Missouri
or mentalhealth keepyou from doingyour usualactivities, suchas self-care,work, orrecreation?77 Don’tknow/notsure99 Refusedrespondents toprovide a numberif they indicatethat this neveroccurs.171 October 2021 Missouri
Core Section 3: Health Care 01What is thecurrentprimarysource ofyour healthinsurance?***NEW***Responses(DO NOT READUNLESSOTHERWISENOTED)Read ifnecessary:01 A planpurchasedthrough anemployer orunion (includingplans purchasedthrough anotherperson'semployer)02 A privatenongovernmentalplan that you oranother familymember buys onyour own03 Medicare04 Medigap05 Medicaid06 Children'sHealth InsuranceProgram (CHIP)07 Militaryrelated healthcare: TRICARE(CHAMPUS) / VAhealth care /CHAMP- VA08IndianHealth Service09Statesponsored healthplan10 Othergovernmentprogram88 No coverageof any typeSKIP INFO/CATI NoteInterviewer Note(s)Column(s)If respondent hasmultiple sources ofinsurance, ask forthe one used mostoften.If respondents givethe name of ahealth plan ratherthan the type ofcoverageask whether this isinsurancepurchasedindependently,through theiremployer, orwhether it isthrough Medicaidor CHIP.181 October 2021 Missouri
77 Don’tKnow/Not Sure99 RefusedCHCA.02CHCA.03CHCA.04Do you have***NEW***one personor a group ofdoctors thatyou think ofas yourpersonalhealth careprovider?Was there a***NEW***time in thepast 12months whenyou neededto see adoctor butcould notbecause youcould notafford it?About howCHECKUP1long has itbeen sinceyou lastvisited adoctor for aroutinecheckup?1 Yes, only one2 More than one3 No7 Don’t know /Not sure9 RefusedIf no, read: Is theremore than one, oris there no personwho you think ofas your personaldoctor or healthcare provider?1 Yes2 No7 Don’t know /Not sure9 RefusedRead ifnecessary:1 Within the pastyear (anytimeless than 12months ago)2 Within the past2 years (1 yearbut less than 2years ago)3 Within the past5 years (2 yearsbut less than 5years ago)4 5 or more yearsagoDo not read:7 Don’t know /Not sure8 Never9 RefusedRead if necessary:A routine checkupis a generalphysical exam, notan exam for aspecific injury,illness, orcondition.191 October 2021 Missouri
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 do201 October 2021 Missouri
Core Section 5: Hypertension AwarenessQuestionNumberQuestion textC05.01BPHIGH4Have you everbeen told by adoctor, nurse, orother healthprofessionalthat you havehigh bloodpressure?C05.02Are youcurrently takingprescriptionmedicine foryour high bloodpressure?VariablenamesBPMEDSResponses(DO NOTREAD UNLESSOTHERWISENOTED)SKIP INFO/CATI Note1 Yes2 Yes, butfemale toldonly duringpregnancy3 No4 Toldborderlinehigh or prehypertensiveor elevatedbloodpressure7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 RefusedGo to nextsectionInterviewer Note (s)Column(s)If “Yes” andrespondent isfemale, ask: “Wasthis only when youwere pregnant?”By other healthprofessional wemean nursepractitioner, aphysician assistant,or some otherlicensed healthprofessional.211 October 2021 Missouri
Core Section 6: Cholesterol AwarenessQuestionNumberQuestion textC06.01Cholesterol isa fattysubstancefound in theblood. Abouthow long hasit been sinceyou last hadyour CHK21 Never(DO NOTREAD UNLESSOTHERWISENOTED)SKIP INFO/CATI NoteInterviewer Note(s)Column(s)Go to nextsection.2 Within thepast year(anytime lessthan oneyear ago)3 Within thepast 2 years(1 year butless than 2years ago)4 Within thepast 3 years(2 years butless than 3years ago)5 Within thepast 4 years(3 years butless than 4years ago)6 Within thepast 5 years(4 years butless than 5years ago)8 5 or moreyears ago221 October 2021 Missouri
7 Don’tknow/ NotsureGo to nextsection9 RefusedC06.02C06.03Have you everbeen told by adoctor, nurseor otherhealthprofessionalthat yourbloodcholesterol ishigh?TOLDHI2Are youcurrentlytakingmedicineprescribed byyour doctor orother healthprofessionalfor your bloodcholesterol?CHOLMED21 Yes2 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 RefusedGo to nextsection.By other healthprofessional wemean nursepractitioner, aphysician assistant,or some otherlicensed healthprofessional.If respondentquestions why theymight take drugswithout havinghigh cholesterolread: ‘High’cholesterol is justone grouprecommendedstatin therapy forcholesterolmanagement in the2013 and 2018CholesterolGuidelines.231 October 2021 Missouri
Core Section 7: Chronic Health ConditionsQuestionNumberQuestion textPrologueHas 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 DO NOTREADUNLESSOTHERWISENOTED)CVDINFR41 Yes2 No7 Don’t know/ Not sure9 RefusedCVDCRHD41 Yes2 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 Refused1 YesCCHC.03(Ever told) (youhad) a stroke?CVDSTRK3CCHC.04(Ever told) (youhad) asthma?ASTHMA3Do you stillhave asthma?ASTHNOWCCHC.052 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 RefusedSKIP INFO/CATI NoteInterviewer Note(s)Column(s)Go toCCHC.06241 October 2021 Missouri
CCHC.06(Ever told) (youhad) skincancer?CHCSCNCRCCHC.07(Ever told) (youhad) any othertypes ofcancer?CHCOCNCRCCHC.08(Ever told) (youhad) sema orchronicbronchitis?(Ever told) (youhad) ssion,dysthymia, orminordepression)?Not includingkidney stones,bladderinfection orincontinence,were you evertold you hadkidney disease?(Ever told) (youhad) diabetes?CHCCOPD3CCHC.09CCHC.10CCHC.111 Yes2 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 RefusedADDEPEV31 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.DIABETE41 YesIf yes andrespondent isfemale, ask: wasthis only when youwere pregnant? Ifrespondent sayspre-diabetes orborderline diabetes,use response code4.251 October 2021 Missouri
CCHC.12How old wereyou when youwere told youhad diabetes?DIABAGE32 Yes, butfemale toldonly duringpregnancy3 No4 No, prediabetes orborderlinediabetes7 Don’t know/ Not sure9 RefusedCode agein years [97 97 and older]98 Don‘tknow / Notsure99 RefusedGo to PreDiabetesOptionalModule (ifused).Otherwise,go to nextsection.Go toDiabetesModule ifused,otherwise goto nextsection.261 October 2021 Missouri
Core Section 8: ArthritisQuestionNumberQuestion textVariablenamesC08.01Has a doctor,nurse or otherhealthprofessional evertold you that youhad some formof arthritis,rheumatoidarthritis, gout,lupus, orfibromyalgia?Has a doctor orother healthprofessional eversuggestedphysical activityor exercise tohelp yourarthritis or jointsymptoms?Have you evertaken aneducationalcourse or class toteach you how tomanageproblems relatedto your arthritisor jointsymptoms?Are you nowlimited in anyway in any ofyour usualactivitiesbecause ofarthritis or DO NOTREAD UNLESSOTHERWISENOTED)1 YesSKIP INFO/CATI Note2 No7 Don’t know/ Not sure9 RefusedGo to nextsectionARTHEXER1 Yes2 No7 Don’t know/ Not sure9 RefusedARTHEDU1 Yes2 No7 Don’t know/ Not sure9 RefusedLMTJOIN31 Yes2 No7 Don’t know/ Not sure9 RefusedInterviewer Note(s)Column(s)If the respondent isunclear aboutwhether this meansincrease ordecrease inphysical activity,this meansincrease.If a respondentquestion arisesabout medication,then theinterviewer shouldreply: "Pleaseanswer thequestion based onyour currentexperience,regardless of271 October 2021 Missouri
C08.05In the nextquestion, we arereferring to workfor pay. Doarthritis or jointsymptoms nowaffect whetheryou work, thetype of work youdo or theamount of workyou do?ARTHDIS21 Yes2 No7 Don’t know/ Not sure9 RefusedC08.06Please thinkabout the past30 days, keepingin mind all ofyour joint pain oraching andwhether or notyou have takenmedication.During the past30 days, how badwas your jointpain on averageon a scale of 0 to10 where 0 is nopain and 10 ispain or aching asbad as it can be?JOINPAI2Enternumber [0010]77 Don’tknow/ Notsure99 Refusedwhether you aretaking anymedication ortreatment”If respondent givesan answer to eachissue (whetherworks, type ofwork, or amount ofwork), then if anyissue is "yes" markthe overallresponse as "yes."If a question arisesabout medicationsor treatment, thenthe interviewershould say: "Pleaseanswer thequestion based onyour currentexperience,regardless ofwhether you aretaking anymedication ortreatment."281 October 2021 Missouri
Core Section 9: blenamesWhat isyour age?AGECDEM.02Are youHispanic,Latino/a,or Spanishorigin?HISPANC3CDEM.03Which oneor more ofthefollowingwould yousay is yourrace?MRACE1Responses(DO NOT READ UNLESSOTHERWISE NOTED)Code age in years07 Don’t know / Notsure09 RefusedIf yes, read: Are you 1 Mexican, MexicanAmerican, Chicano/a2 Puerto Rican3 Cuban4 Another Hispanic,Latino/a, or SpanishoriginDo not read:5 No7 Don’t know / Not sure9 RefusedPlease read:10 White20 Black or AfricanAmerican30 American Indian orAlaska Native40 Asian41 Asian Indian42 Chinese43 Filipino44 Japanese45 Korean46 Vietnamese47 Other Asian50 Pacific Islander51 NativeHawaiian52 Guamanian orChamorro53 Samoan54 Other PacificIslanderDo not read:60 Other88 No additional choices77 Don’t know / Not sure99 RefusedSKIP INFO/ CATI InterviewerNoteNote (s)Column(s)One or morecategoriesmay beselected.If 40 (Asian)or 50(PacificIslander) isselectedread andcodesubcategoriesunderneathmajorheading.One or morecategoriesmay beselected.291 October 2021 Missouri
If more thanone response toCDEM.03;continue.Otherwise, goto CDEM.05CDEM.04Which oneof thesegroupswould yousay bestrepresentsyour race?ORACE3Please read:10 White20 Black or AfricanAmerican30 American Indian orAlaska Native40 Asian41 Asian Indian42 Chinese43 Filipino44 Japanese45 Korean46 Vietnamese47 Other Asian50 Pacific Islander51 NativeHawaiian52 Guamanian orChamorro53 Samoan54 Other PacificIslanderDo not read:60 Other77 Don’t know / Not sure99 RefusedIf 40 (Asian)or 50(PacificIslander) isselectedread ndenthas selectedmultipleraces inpreviousand refusesto select asingle race,coderefusedIf using Sex atBirth Module,insert hereCDEM.05Are you MARITALCDEM.06What isthehighestgrade orEDUCAPlease read:1 Married2 Divorced3 Widowed4 Separated5 Never marriedOr6 A member of anunmarried coupleDo not read:9 RefusedRead if necessary:1 Never attended schoolor only attendedkindergarten301 October 2021 Missouri
year ofschool youcompleted?CDEM.07Do youown orrent yourhome?RENTHOM1CDEM.08In whatcounty doyoucurrentlylive?CTYCODE22 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 3years (Some college ortechnical school)6 College 4 years or more(College graduate)Do not read:9 Refused1 Own2 Rent3 Other arrangement7 Don’t know / Not sure9 RefusedOtherarrangement mayincludegrouphome,staying withfriends orfamilywithoutpaying rent.Home isdefined asthe placewhere youlive most ofthe time/themajority ofthe year.Read ifnecessary:We ask thisquestion inorder tocomparehealthindicatorsamongpeople withdifferenthousingsituations.ANSI County Code777 Don’t know / Notsure999 Refused311 October 2021 Missouri
CDEM.09What isthe ZIPCodewhere youcurrentlylive?ZIPCODE1888 County from anotherstate77777 Do not know99999 RefusedIf cell interviewgo to phones ornumbersused forcomputers, faxmachinesor securitysystems,do youhave morethan onetelephonenumber inyourhousehold?How manyof thesetelephonenumbersareresidentialnumbers?How manycellphones doyou haveforpersonaluse?NUMHHOL3Have youeverserved onactive1 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 RefusedVETERAN31 Yes2 No7 Don’t know / Not sure9 RefusedGo to CDEM.12Last questionneeded forpartialcomplete.Read ifnecessary:Include cellphones usedfor bothbusinessandpersonaluse.Read ifnecessary:Active dutydoes not321 October 2021 Missouri
CDEM.14CDEM.15CDEM.16duty in theUnitedStatesArmedForces,either intheregularmilitary orin aNationalGuard ormilitaryreserveunit?Are youcurrently ?How manychildrenless than18 yearsof age livein yourhousehold?Is yourannualhouseholdincomefrom allsources—includetraining fortheReserves orNat
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
