BRFSS Preliminary Experiment for Sample and Mode

XX State Department of Health Street City, State XXXXX Tel: 1-8XX-XXX-XXXX

Behavioral Risk Factor Surveillance System

This questionnaire is designed to gather information about the health and health practices of adults. The information is kept confidential and is used only to evaluate health programs and to plan future action to improve the health of citizens in the state.

We are asking that an adult in the household complete this health survey. The survey should only take approximately 10-20 minutes to finish. Please return the completed survey in the enclosed pre-paid envelope.

Although answering the health survey is voluntary, participation is important for the results to truly represent your state’s population. The adult who completes the survey will answer questions about their own health and health knowledge. Any question this person does not want to answer can be skipped. The information provided will be kept strictly confidential and your household will never be identified in any reports.

For more information about this study, please call 1-800-XXX-XXXX.

Instructions for Completing the Survey

This survey contains several types of questions. These instructions will show you how to answer each type of question. Each question should be answered only about the selected adult, not anyone else in your household.

• Some questions are answered by checking a choice from a list. You answer the question by checking a box, like this:

 Yes

 No

• Some questions are answered by entering numbers into one or more boxes to the left of the answer. You answer the question by filling in one digit or number per box, like this:

0

9

Number of days

• You will sometimes be instructed to skip one or more questions. In this example, if your choice is ‘No’, you skip to question A16; otherwise, you continue to the next question.

 Yes

 No  Skip to Question A16

What is today’s date?

-

-

2

0

1

7

Month Day Year

Instruction for sampling an adult within a household:

This survey should be completed by one adult living in your household.

1. How many adults, age 18 or older, live in this household? Note: Please include yourself.

Number of adults

Not counting

• college students living away at school

• or anyone in a prison, mental hospital or nursing home.

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

		Number of men
		Number of women

If only one adult lives here, that person should complete the survey.

If more than one adult lives here, the one with the next birthday should complete the survey.

2. Is the adult with the next birthday:

 Male

 Female

3. In what month was the adult with the next birthday born?

Month

Please ask the person with the next birthday to complete the survey, starting with question A1. If you have any questions, please call 1-8XX-XXX-XXXX.

A. Your General Health

A1. Would you say that in general your health is:

 Excellent

 Very Good

 Good

 Fair

 Poor

 Don’t know/Not sure

A2. 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?

Number of days [If none enter “00.”]

A3. 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?

Number of days [If none enter “00.”]

IF THE ANSWER TO EITHER A2 OR A3 IS GREATER THAN ZERO, THEN ANSWER A4.

IF “0” DAYS IS THE ANSWER FOR BOTH A2 AND A3 THEN SKIP TO A5.

A4. 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?

Number of days [If none enter “00.”]

A5. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?

 Yes

 No

 Don’t know/Not sure

A6. Do you have one person you think of as your personal doctor or health care provider?

 Yes - only one person

 Yes - more than one person

 No - no person

 Don’t know/Not sure

A7. Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?

 Yes

 No

 Don’t know/Not sure

A8. About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.

 Within past year (anytime less than 12 months ago)
 Within past 2 years (1 year but less than 2 years ago)
 Within past 5 years (2 years but less than 5 years ago)
 5 or more years ago
 Never

 Don’t know/Not sure

A9. During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?

Number of days [If none enter “00.”]

A10. During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

 Yes

 No

 Don’t know/Not sure

A11. Have you EVER been told by a doctor that you have diabetes?

 Yes

 Only during pregnancy

 No

 Pre-diabetes or borderline diabetes

 Don’t know/Not sure

B. Oral Health

B1. How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists.

 Within the past year (anytime less than 12 months ago)

 Within the past two years (1 year but less than 2 years ago)

 Within the past 5 yeast (2 years but less than 5 years ago)

 5 or more years ago

 Never  Skip to Question C1

 Don’t know/Not sure

B2. How many of your permanent teeth have been removed because of tooth decay or gum disease? Include teeth lost to infection, but do not include teeth lost for other reasons, such as injury or orthodontics. Note: If wisdom teeth are to be removed for tooth decay or gum disease they should be included in the count for lost teeth.

 1 to 5

 6 or more but not all

 All  Skip to Question C1

 None

 Don’t know/Not sure

B3. How long has it been since you had your teeth cleaned by a dentist or dental hygienist?

 Within the past year (anytime less than 12 months ago)

 Within the past two years (1 year but less than 2 years ago)

 Within the past 5 yeast (2 years but less than 5 years ago)

 5 or more years ago

 Never  Skip to Question C1

 Don’t know/Not sure

C. Health Problems

C1. Has a doctor, nurse, or other health professional EVER told you that you had any of the following?

	Check one box for each item…
	YES	NO	NOT SURE
a. A heart attack, also called a myocardial infarction?			
b. Angina or coronary heart disease?			
c. A stroke?			

C2. Have you EVER been told by a doctor, nurse, or other health professional that you had asthma? 39/

 Yes

 No Skip to D1

 Don’t know/Not sure Skip to D1

C2a. Do you still have asthma?

 Yes

 No

 Don’t know/Not sure

D. Disability

D1. Are you limited in any way in any activities because of physical, mental, or emotional problems?

 Yes

 No

 Don’t know/Not sure

D2. Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone? Include occasional use or use in certain circumstances.

 Yes

 No

 Don’t know/Not sure

E. Tobacco Use

E1. Have you smoked at least 100 cigarettes in your entire life? Note: 5 packs = 100 cigarettes

 Yes

 No Skip to E2

 Don’t know/Not sure Skip to E2

E1a. Do you now smoke cigarettes every day, some days, or not at all?

 Every day

 Some days

 Not at all Skip to E1c

 Don’t know/Not sure Skip to E2

E1b. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

 Yes Skip to E2

 No Skip to E2

 Don’t know/Not sure Skip to E2

E1c. How long has it been since you last smoked cigarettes regularly?

 Within the past month (less than 1 month ago)

 Within the past 3 months (1 month but less than 3 months ago)

 Within the past 6 months (3 months but less than 6 months ago)

 Within the past year (6 months but less than 1 year ago)

 Within the past 5 years (1 year but less than 5 years ago)

 Within the past 10 years (5 years but less than 10 years ago)

 10 years or more

 Never smoked regularly

 Don’t know/Not sure

E2. Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?

 Every day

 Some days

 Not at all

 Don’t know/Not sure

F. General Information

F1. What is your age?

Age in years

F2. Are you Hispanic or Latino?

 Yes

 No Skip to F4

 Don’t know/Not sure Skip to F4

F3. Are you (select as many as apply)…

 Mexican, Mexican American, Chicano/a

 Puerto Rican

 Cuban

 Another Hispanic, Latino/a, or Spanish origin

F4. Which one or more of the following would you say is your race? [Check all that apply]

 White

 Black or African American

 Asian

 Asian Indian

 Chinese

 Filipino

 Japanese

 Korean

 Vietnamese

 Other Asian

 Pacific Islander

 Native Hawaiian

 Guamanian or Chamorro

 Samoan

 Other Pacific Islander

 American Indian, Alaska Native

 Other [Specify:] ____________________

 Don’t know/Not sure

If you chose only one race in F4, please Skip to F6. Otherwise, please continue.

F5. If you chose more than one race in F3, please tell us which one of these groups would you say BEST represents your race?

 White

 Black or African American

 Asian

 Native Hawaiian or Other Pacific Islander

 American Indian or Alaska Native

 Other [Specify:] ____________________

F6. 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? Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.

 Yes, now on active duty  Yes, on active duty during the last 12 months, but not now 51/

 Yes, on active duty in the past, but not during the last 12 months 52/

 No, training for Reserves or National Guard only

 No, never served in the military

 Don’t know/Not sure

F6. Are you…? [Check only one]

 Married

 Divorced

 Widowed

 Separated

 Never married

 A member of an unmarried couple

F7. How many children less than 18 years of age live in your household?

Number of Children [If none enter “00.”]

F7. What is the highest grade or year of school you completed?

 Never attended school or only attended kindergarten

 Grades 1 through 8 (Elementary)

 Grades 9 through 11 (Some high school)

 Grade 12 or GED (High school graduate)

 College 1 year to 3 years (Some college or technical school)

 College 4 years or more (College graduate)

F8. Are you currently . . . ? [Check only one]

 Employed for wages

 Self-employed

 Out of work for more than 1 year

 Out of work for less than 1 year

 A homemaker

 A student

 Retired

 Unable to work

F9. Is your annual household income from all sources…?

 Less than $10,000

 $10,000 to less than $15,000

 $15,000 to less than $20,000

 $20,000 to less than $25,000

 $25,000 to less than $35,000

 $35,000 to less than $50,000

 $50,000 to less than $75,000

 $75,000 or more

 Don’t know/Not sure

F10. About how much do you weigh without shoes?

Weight (in pounds) OR

Weight (in kilograms)

F11. About how tall are you without shoes?

Feet

Inches OR

Centimeters

F12. What county do you live in?

County Name ________________________, USA

F13. What is your ZIP Code where you live?

ZIP Code

F14. Do you have more than one telephone number in your household? Note: Do not include cell phones or numbers that are only used by a computer or fax machine.

 Yes

 No Skip to D19

 Don’t know/Not sure Skip to D19

F16. How many of these telephone numbers are residential numbers? 105/

Residential telephone numbers

F17. Do you have a cell phone for personal use? Please include cell phones used for both business and personal use.

 YesSkip to F20

 No

 Don’t know/Not sure

F18. Have you used the internet in the past 30 days?

 Yes

 No

 Don’t know/Not sure

F19. Are you deaf or do you have serious difficulty hearing?

 Yes

 No

 Don’t know/Not sure

F20. Are you blind or do you have serious difficulty seeing, even when wearing glasses?

 Yes

 No

 Don’t know/Not sure

F21. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating,r emembering, or making decisions?

 Yes

 No

 Don’t know/Not sure

F22. Do you have serious difficulty walking or climbing stairs?

 Yes

 No

 Don’t know/Not sure

F23. Do you have difficulty dressing or bathing?

 Yes

 No

 Don’t know/Not sure

F24. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

 Yes

 No

 Don’t know/Not sure

F25. Please indicate your sex:

 Male Skip to G1

 Female

F25a. To your knowledge, are you now pregnant? 110/

 Yes

 No

 Don’t know/Not sure

G. Alcohol Use

G1. During the past 30 days, have you had at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?

 Yes

 No Skip to H1

 Don’t know/Not sure Skip to H1

G1a. During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage?

Days per week OR

Days in the past 30 days

G1b. One drink is equivalent to a 12 ounce beer, a 5 ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average? Note: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.

Number of drinks

G1c. Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 (for men) /4 (for women) or more drinks on one occasion?

Number of times

G1d. During the past 30 days, what is the largest number of drinks you had on any occasion?

Number of drinks

H. Immunization

A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.

H1.During the past 12 months, have you had either a flu shot or a flu vaccine that was sprayed in your nose?

 Yes

 No Skip to H3

 Don’t know/Not sure Skip to H3

H2. During what month and year did you receive your most recent seasonal flu shot? 131/

/

Month and year

H3. A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person’s lifetime and is different from the flu shot. Have you ever had a pneumonia shot?

 Yes

 No Skip to H5

 Don’t know/Not sure Skip to H5

H4. During what month and year did you receive your most recent seasonal flu vaccine that was sprayed in your nose?

/

Month and year

H5. Since 2005, have you had a tetanus shot? (201)

 Yes, received Tdap

 Yes, received tetanus shot, but not Tdap

 Yes, received tetanus shot but not sure what type

 No, did not receive any tetanus since 2005

 Don’t know/Not sure

I. Falls

If you are 45 years or older complete this section, otherwise go to section J: Seat Belt Use.

The next questions ask about recent falls. By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.

I1. In the past 3 months, how many times have you fallen?

		None (Skip to J1)
		Number of times (if 0 Skip to J1)
		Don’t know/ Not Sure

I2. How many of these falls caused an injury? By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor.

		None
		Number of times
		Don’t know/ Not Sure

J. Seat Belt Use

J1. How often do you use seat belts when you drive or ride in a car? Would you say—

 Always

 Nearly always

 Sometimes

 Seldom

 Never

 Don’t know/Not sure

 Never drive or ride in a car Skip to L1

K. Drinking and Driving

The next question is about drinking and driving.

K1. During the past 30 days, how many times have you driven when you’ve had perhaps too much to drink?

		None
		Number of times
		Don’t know/ Not Sure

L. Women’s Health

If you are male, skip to Section M: Prostate Cancer Screening.

The next questions are about breast and cervical cancer.

L1. A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?

 Yes

 No Skip to L3

 Don’t know/Not sure Skip to L3

L2. How long has it been since you had your last mammogram?

 Within the past year (anytime less than 12 months ago)

 Within the past two years (1 year but less than 2 years ago)

 Within the past 5 yeast (2 years but less than 5 years ago)

 5 or more years ago

 Don’t know/ Not sure

L3. A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you ever had a clinical breast exam?

 Yes

 No Skip to L5

 Don’t know/Not sure Skip to L5

L4. How long has it been since your last breast exam?

 Within the past year (anytime less than 12 months ago)

 Within the past two years (1 year but less than 2 years ago)

 Within the past 5 yeast (2 years but less than 5 years ago)

 5 or more years ago

 Don’t know/ Not sure

L5. A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?

 Yes

 No Skip to L7

 Don’t know/Not sure Skip to L7

L6. How long has it been since your last Pap test?

 Within the past year (anytime less than 12 months ago)

 Within the past two years (1 year but less than 2 years ago)

 Within the past 5 yeast (2 years but less than 5 years ago)

 5 or more years ago

 Don’t know/ Not sure

L7. A hysterectomy is an operation to remove the uterus (womb). Have you had a hysterectomy?

 Yes

 No

 Don’t know/Not sure

M. Prostate Cancer Screening

If you are under 40 years of age or female, skip to Section N: Colorectal Cancer Screening. The next questions are about prostate cancer screening.

M1. A Prostate-Specific Antigen test, also called a PSA test, is a blood test used to check men for prostate cancer. Have you ever had a PSA test?

 Yes

 No Skip to M3

 Don’t know/Not sure Skip to M3

M2. How long has it been since you had your last PSA test?

 Within the past year (anytime less than 12 months ago)

 Within the past two years (1 year but less than 2 years ago)

 Within the past 5 yeast (2 years but less than 5 years ago)

 5 or more years ago

 Don’t know/ Not sure

M3. A digital rectal exam is an exam in which a doctor, nurse, or other health professional places a gloved finger into the rectum to feel the size, shape, and hardness of the prostate gland. Have you ever had a digital rectal exam?

 Yes

 No Skip to M5

 Don’t know/Not sure Skip to M5

M4. How long has it been since your last digital rectal exam?

 Within the past year (anytime less than 12 months ago)

 Within the past two years (1 year but less than 2 years ago)

 Within the past 5 yeast (2 years but less than 5 years ago)

 5 or more years ago

 Don’t know/ Not sure

M5. Have you ever been told by a doctor, nurse or other health professional that you had prostate cancer?

 Yes

 No

 Don’t know/Not sure

N. Colorectal Cancer Screening

The next questions are about colorectal cancer screening.

N1. 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?

 Yes

 No Skip to N3

• Don’t know/Not sure Skip to N3

N2. How long has it been since you had your last blood stool test using a home kit?

 Within the past year (anytime less than 12 months ago)

 Within the past two years (1 year but less than 2 years ago)

 Within the past 5 yeast (2 years but less than 5 years ago)

 5 or more years ago

 Don’t know/ Not sure

N3. Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. Have you ever had either of these exams?

 Yes

 NoSkip to Section O

 Don’t know/Not sureSkip to Section O

N4. For a SIGMOIDOSCOPY, a flexible tube is inserted into the rectum to look for problems. A COLONOSCOPY is similar, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. Was your MOST RECENT exam a sigmoidoscopy or a colonoscopy?

	Sigmoidoscopy
	Colonoscopy
	Don’t know/ Not sure

N5. How long has it been since you had your last sigmoidoscopy or colonoscopy?

 Within the past year (anytime less than 12 months ago)

 Within the past two years (1 year but less than 2 years ago)

 Within the past 5 yeast (2 years but less than 5 years ago)

 5 or more years ago

 Don’t know/ Not sure

O. HIV/AIDS

IF AGE 64 OR YOUNGER ANSWER O1. IF 65 YEARS OLD OR OLDER SKIP TO SECTION P: Emotional Support and Life Satisfaction.

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 do not have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.

O1. Have you EVER been tested for HIV? Do not count tests you may have had as part of a blood donation. Include tests using fluid from your mouth.

 Yes

 No Skip to O2

 Don’t know/Not sure Skip to O2

O1a. Not including blood donations, in what month and year was your last HIV test?

/

Month and year

O1b. Where did you have your last HIV test: at a private doctor or HMO office, at a counseling and testing site, at a hospital, at a clinic, in a jail or prison, at drug treatment facility, at home, or somewhere else?

 Private doctor or HMO office

 Counseling and testing site

 Hospital

 Clinic

 In a jail or prison (or other correctional facility)

 Drug treatment facility

 Home

 Somewhere else

 Don’t know/Not sure

If you did get your last HIV test within last 12 months, please continue. Otherwise Skip to O2

O1c. Was it a rapid test where you could get your results within a couple of hours?

 Yes

 No

 Don’t know/Not sure

O2. After reading the list below, please tell us if any of the situations apply to you. You do not need to tell us 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 have given or received money or drugs in exchange for sex in the past year.

• You had anal sex without a condom in the past year.

Do any of these situations apply to you?

 Yes

 No

 Don’t know/Not sure

That is the last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state.

Thank you very much for your time and cooperation. Please place the completed survey in the pre-paid return envelope and mail back to:

XX State Dept. of Health

Street

City, State XXXXX

If you have misplaced the return envelope, please call 1-8XX-XXX-XXXX for a replacement.

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