Transcription
2021 IllinoisBRFSS QuestionnaireDRAFT130 March 2021
Table of ContentsOMB Header and Introductory Text .3Landline Introduction.4Cell Phone Introduction .9Core Section 1: Health Status . 15Core Section 2: Healthy Days . 15Core Section 3: Health Care Access . 18Core Section 4: Exercise . 21Core Section 5: Hypertension Awareness . 22Core Section 6: Cholesterol Awareness . 23Core Section 7: Chronic Health Conditions . 25Core Section 8: Arthritis . 28Core Section 9: Demographics . 30Optional Module 28: Sexual Orientation and Gender Identity (SOGI) . 32Optional Module 24: Industry and Occupation . 38Core Section 10: Disability . 41Core Section 11: Tobacco Use . 42Optional Module 22: Tobacco Cessation. 43State Added E-Cigarettes. 44Core Section 12: Alcohol Consumption. 48Core Section 13: Immunization . 50Core Section 14: H.I.V./AIDS . 52Core Section 15: Fruits and Vegetables . 53Optional Module 2: Diabetes . 56Optional Module 8: COVID Vaccination . 59Optional Module 16: Home/ Self-measured Blood Pressure . 62Optional Module 19: Caregiver . 64Optional Module 21: Marijuana Use . 68State Added: Marijuana Use . 69Optional Module 25: Random Child Selection . 72Optional Module 26: Childhood Asthma Prevalence . 76Asthma Call-Back Permission Script . 77State Added Opioid . 79State Added COVID . 84State Added Social Determinants of Health . 87State Added Reactions to Race . 91230 March 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).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.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.States may opt not tomention the state name toavoid refusals by out ofstate residents in the cellphone sample.If cell phone respondentobjects to being contactedby state where they havenever lived, say:“This survey is conducted byall states and yourinformation will beforwarded to the correctstate of residence”330 March 2021
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 whichare also used for430 March 2021
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 phoneTERMINATEpersonalcommunicationare 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 inprivateresidences or530 March 2021
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 Refusedcollege 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 for630 March 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?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].730 March 2021
If the number ofadult males andadult femalesdoes not add tothe total numberof adults due tosome membersof thehousehold’sgender identity,the interviewmay continue.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 theinterviewIf 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 to830 March 2021
at any time.Anyinformationyou giveme will notbeconnectedto anypersonalinformationIf you haveanyquestionsabout thesurvey,please call(giveappropriatestatetelephonenumber).identify you.” Ifthe statecoordinatorapproves thechange.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 NoGo to CP03TERMINATEGo toCADULT1TERMINATEInterviewerNote (s)Column(s)Thank youvery much.We will callyou back at amoreconvenienttime.If "no”: thankyou verymuch, but weare onlyinterviewingpersons oncell930 March 2021
telephones atthis timeCP04.CP05.CP06.Are you 18 yearsof age or older?Are you male orfemale?Do you live in aprivateresidence?CADULT1CELLSEXPVTRESD31 Yes2 NoTERMINATERead: Thankyou very muchbut we areonlyinterviewingpersons aged18 or older atthis time.1 Male2 Female7 Don’t Know/Not sure9 RefusedTERMINATE1 YesGo to CP08Thank you foryour time,your numbermay beselected foranothersurvey in thefuture.Read ifnecessary: Byprivateresidence wemeansomeplacelike a house orapartmentDo not read:Privateresidenceincludes anyhome wheretherespondentspends atleast 30 daysincludingvacationhomes, RVs orotherlocations inwhich therespondentlives forportions ofthe year.1030 March 2021
CP07.CP08.Do you live incollege housing?CCLGHOUSDo you currentlyCSTATE1livein (state) ?2 No1 YesGo to CP07Go to CP082 NoTERMINATE1 Yes2 NoGo to CP10Go to CP09Read ifnecessary: Bycollegehousing wemeandormitory,graduatestudent orvisiting facultyhousing, orother housingarrangementprovided by acollege oruniversity.Read: Thankyou verymuch, but weare onlyinterviewingpersons wholive in privateresidences orcollegehousing at thistime.1130 March 2021
CP09.In what state doyou currentlylive?RSPSTAT11 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 Oregon42 Pennsylvania44 Rhode Island45 SouthCarolina46 SouthDakota47 Tennessee1230 March 2021
48 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 11330 March 2021
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).1430 March 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)1530 March 2021
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 physicalor mentalPOORHLTHNumberof days (0130)88 None88 may be coded ifrespondent says“never” or “none”It is not necessaryto askrespondents to1630 March 2021
health keepyou from doingyour usualactivities, suchas self-care,work, orrecreation?77 Don’tknow/notsure99 Refusedprovide a numberif they indicatethat this neveroccurs.1730 March 2021
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.1830 March 2021
77 Don’tKnow/Not Sure99 RefusedCHCA.02CHCA.03CHCA.04Do you haveone personor a group ofdoctors thatyou think ofas yourpersonalhealth careprovider?***NEW***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?NOTE: if therespondent hadmultiple doctorgroups then itwould be morethan one—but ifthey had morethan one doctor inthe same group itwould be one.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 yearsagoRead if necessary:A routine checkupis a generalphysical exam, notan exam for aspecific injury,illness, orcondition.1930 March 2021
Do not read:7 Don’t know /Not sure8 Never9 Refused2030 March 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 do2130 March 2021
Core Section 5: Hypertension AwarenessQuestionNumberQuestion textC05.01Have you everBPHIGH4been 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.2230 March 2021
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 ago7 Don’tknow/ NotsureGo to nextsection9 Refused2330 March 2021
C06.02C06.03Have 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.Doctors mightprescribe statin forthose without highcholesterol butwith highatheroscleroticcardiovasculardisease risk2430 March 2021
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?ASTHMA3CCHC.05Do you stillhave asthma?ASTHNOWCCHC.06(Ever told) (youhad) skincancer?CHCSCNCR2 No7 Don’t know/ Not sure9 Refused1 Yes2 No7 Don’t know/ Not sure9 Refused1 Yes2 NoSKIP INFO/CATI NoteInterviewer Note(s)Column(s)Go toCCHC.062530 March 2021
CCHC.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.117 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 code4.2 Yes, butfemale toldGo to PreDiabetesOptional2630 March 2021
CCHC.12How old wereyou when youwere told youhad diabetes?DIABAGE3only duringpregnancy3 No4 No, prediabetes orborderlinediabetes7 Don’t know/ Not sure9 RefusedCode agein years [97 97 and older]98 Don‘tknow / Notsure99 RefusedModule (ifused).Otherwise,go to nextsection.Go toDiabetesModule ifused,otherwise goto nextsection.2730 March 2021
Core Section 8: ArthritisQuestionNumberQuestion textVariablenamesC08.01Has a doctor,nurse or otherhealthprofessionalever told youthat you hadsome form ofarthritis,rheumatoidarthritis, gout,lupus, orfibromyalgia?HAVARTH5Has a doctor orother healthprofessionalever suggestedphysical activityor exercise tohelp yourarthritis or jointsymptoms?Have you evertaken aneducationalcourse or classto teach youARTHEXER1 Yes2 No7 Don’t know/ Not sure9 RefusedARTHEDU1 Yes2 No7 Don’t know/ Not sure9 RefusedC08.02C08.03Responses(DO NOTREADUNLESSOTHERWISENOTED)1 YesSKIP INFO/CATI Note2 No7 Don’t know/ Not sure9 RefusedGo to nextsectionInterviewer Note (s)Column(s)Arthritis diagnosesinclude: rheumatism,polymyalgiarheumatic,osteoarthritis (notosteoporosis),tendonitis, bursitis,bunion, tenniselbow, carpal tunnelsyndrome, tarsaltunnel syndrome,joint infection,Reiter’s syndrome,ankylosingspondylitis;spondylosis, rotatorcuff syndrome,connective tissuedisease,scleroderma,polymyositis,Raynaud’s syndrome,vasculitis, giant cellarteritis, HenochSchonlein purpura,Wegener’sgranulomatosis,polyarteritis nodosa)If the respondent isunclear aboutwhether this meansincrease or decreasein physical activity,this means increase.2830 March 2021
C08.04how to manageproblemsrelated to yourarthritis or jointsymptoms?Are you nowlimited in anyway in any ofyour usualactivitiesbecause ofarthritis or jointsymptoms?LMTJOIN31 Yes2 No7 Don’t know/ Not sure9 RefusedC08.05In the nextquestion, we arereferring towork for pay.Do arthritis orjoint symptomsnow affectwhether youwork, the typeof work you door the amountof work you do?ARTHDIS21 Yes2 No7 Don’t know/ Not sure9 RefusedC08.06Please thinkabout the past30 days, keepingin mind all ofyour joint painor aching andwhether or notyou have takenmedication.During the pastJOINPAI2Enternumber [0010]77 Don’tknow/ Notsure99 RefusedIf a respondentquestion arises aboutmedication, then theinterviewer shouldreply: "Please answerthe question basedon your currentexperience,regardless ofwhether you aretaking anymedication ortreatment”If respondent givesan answer to eachissue (whetherworks, type of work,or amount of work),then if any issue is"yes" mark theoverall response as"yes." If a questionarises aboutmedications ortreatment, then theinterviewer shouldsay: "Please answerthe question basedon your currentexperience,regardless ofwhether you aretaking anymedication ortreatment."2930 March 2021
30 days, howbad was yourjoint pain onaverage on ascale of 0 to 10where 0 is nopain and 10 ispain or aching asbad as it can be?Core Section 9: DemographicsQuestion QuestionNumber textVariablenamesCDEM.01 What isyour age?AGECDEM.02 Are youHispanic,Latino/a,or Spanishorigin?HISPANC3CDEM.03 Which 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 Guamanianor ChamorroSKIP INFO/CATI NoteInterviewerNote (s)Column(s)One or morecategoriesmay beselected.If 40 (Asian)or 50 (PacificIslander) isselected readand codesubcategoriesunderneathmajorheading.One or morecategoriesmay beselected.3030 March 2021
53 Samoan54 Other PacificIslanderDo not read:60 Other88 No additional choices77 Don’t know / Notsure99 RefusedIf more thanone responseto CDEM.03;continue.Otherwise, goto CDEM.05CDEM.04 Which 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 Guamanianor Chamorro53 Samoan54 Other PacificIslanderDo not read:60 Other77 Don’t know / Notsure99 RefusedIf 40 (Asian)or 50 (PacificIslander) isselected readand codesubcategoriesunderneathmajorheading.If respondenthas selectedmultipleraces inprevious andrefuses toselect asingle race,code refusedIf using Sex atBirth Module,insert hereIf using SOGImodule, inserthere.3130 March 2021
INSERT: Optional Module 28: Sexual Orientation and Gender Identity (SOGI)QuestionNumberQuestion textPrologueThe next twoquestions areabout sexualorientationand genderidentityVariablenamesResponses(DO NOT READUNLESSOTHERWISENOTED)SKIP INFO/CATI NoteInterviewerNote (s)Column(s)Read ifnecessary: Weask thisquestion inorder to betterunderstand thehealth andhealth careneeds of peoplewith differentsexualorientations.551If sex male(usingBIRTHSEX,CELLSEX,LANDSEX )continue,otherwise gotoMSOGI.01b.MSOGI.01aWhich of thefollowing bestrepresentshow you thinkof yourself?SOMALE1 Gay2 Straight,that is, not gay3 Bisexual4 Somethingelse7 I don't knowthe answer9 RefusedPlease say thenumber beforethe textresponse.Respondent cananswer witheither thenumber or thetext/word.3230 March 2021
MSOGI.01b Which of thefollowing bestrepresentshow you thinkof yourself?MSOGI.02Do youconsideryourself to betransgender?SOFEMALETRNSGNDR1 Lesbian orGay2 Straight,that is, not gay3 Bisexual4 Somethingelse7 I don't knowthe answer9 Refused1 Yes,Transgender,male-to-female2 Yes,Transgender,female to male3 Yes,Transgender,gendernonconforming4 No
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
