November 14, 2017
MEPS P21R5/P22R3/P23R1
NOTE: The MEPS instrument design changed beginning in Spring of 2018, affecting Panel 23 Round 1, Panel 22 Round 3, and Panel 21 Round 5, and affected the 2017 MEPS data files. The MEPS website releases the consolidated CAPI survey instruments each year for the Rounds 1 through 3 for the first year panel and Rounds 3 through 5 for the second year panel to accompany data releases. For the Full-Year 2017 PUFs, the Panel 22 Round 3 and Panel 21 Round 5 data were transformed to the degree possible to conform to the previous year (2016) design. For this reason, we are releasing 2016 CAPI survey instruments, updated to reflect 2017 dates, and users should note that not all changes to the instrument administered in the Spring of 2018 will be reflected in these documents.
BOX_00A
THE CS SECTION IS ASKED IN ROUNDS 2 AND 4 ONLY.
IF IT IS ROUND 1, 3, OR 5, CONTINUE TO THE NEXT
SECTION.
BOX_00
CONTEXT HEADER DISPLAY INSTRUCTIONS:
DISPLAY PERS.FULLNAME.
BOX_01
IF ANY RU MEMBERS < OR = 17 YEARS OF AGE OR IN AGE
CATEGORIES 1 THROUGH 4, CONTINUE WITH LOOP_01
OTHERWISE, GO TO BOX_08
LOOP_01
FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER,
ASK NAV_CS01 - END_LP01
LOOP DEFINITION: LOOP_01 COLLECTS INFORMATION
ABOUT HEALTH NEEDS A CHILD MAY HAVE BECAUSE OF A
HEALTH CONDITION (LWIM), RATINGS ON THE CHILD’S
BEHAVIOR AND RELATIONSHIPS (CIS), HEALTH CARE THE
CHILD RECEIVED IN THE LAST YEAR (CAHPS), AND
INFORMATION ABOUT THE CHILD’S USE OF CLINICAL
PREVENTIVE SERVICES. THIS LOOP CYCLES ON EACH
PERSON IN THE RU-MEMBERS-ROSTER WHO MEETS THE
FOLLOWING CONDITIONS:
- PERSON IS A CURRENT OR INSTITUTIONALIZED RU
MEMBER
AND
- PERSON IS NOT DECEASED
AND
- PERSON IS < OR = 17 YEARS OF AGE OR IN AGE
CATEGORIES 1 THROUGH 4
NAVIGATOR DETAILS: LOOP_01 USES NAV_CS01 TO
CONTROL THE FLOW OF THE LOOP.
NAV_CS01
SERIES: All Child Preventive Health Questions (i.e.,
child’s
health needs, behavioral ratings, etc.)
USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS
WITHIN THIS SERIES.
WHEN ALL LINKS ARE MARKED “DONE,” USE [Continue
Interview] TO GO
PAST THIS SERIES.
IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS
BEFORE THIS
SERIES.
RU Member
[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]
ROSTER DETAILS:
COL # 1 HEADER: RU MEMBER
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH RU MEMBER EACH TIME THE NAVIGATOR
IS PRESENTED
ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.
ROSTER BEHAVIOR:
1. SELECT ALLOWED.
2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.
ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS A CURRENT OR INSTITUTIONALIZED RU
MEMBER
AND
- PERSON IS NOT DECEASED
AND
- PERSON IS < OR = 17 YEARS OF AGE OR IN AGE
CATEGORIES 1 THROUGH 4
CONTINUE WITH BOX_01A FOR SELECTED RU MEMBER
BOX_01A
IF FIRST CYCLE OF LOOP, CONTINUE WITH CS02
OTHERWISE, GO TO CS03
CS02
{PERSON’S FIRST MIDDLE AND LAST NAME}
The next questions are about {your/{PERSON}’s} health
needs and whether
{you/he/she} {have/has} a health condition. A
health condition can be
physical, mental or behavioral. Health conditions
may affect a child’s
development, daily functioning or need for services.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
CS03
{PERSON’S FIRST MIDDLE AND LAST NAME}
{Now I’d like to talk about {you/{PERSON}}.}
{Do/Does} {you/{PERSON}} currently need or use
medicine prescribed by
a doctor, other than vitamins?
YES .................................... 1 {CS03OV1}
NO ..................................... 2 {CS04}
REF ................................... -7 {CS04}
DK .................................... -8 {CS04}
CS03OV1
Is this because of any medical, behavioral or
other health condition?
YES .................................... 1 {CS03OV2}
NO ..................................... 2 {CS04}
REF ................................... -7 {CS04}
DK .................................... -8 {CS04}
CS03OV2
Is this a condition that has lasted or is expected to
last for at
least 12 months?
YES .................................... 1 {CS04}
NO ..................................... 2 {CS04}
REF ................................... -7 {CS04}
DK .................................... -8 {CS04}
DISPLAY ‘Now I’d like to talk about {you/
{PERSON}}.’ IF NOT FIRST CYCLE THROUGH LOOP_01.
OTHERWISE (THAT IS, IF IT IS THE FIRST CYCLE
THROUGH LOOP_01), USE A NULL DISPLAY.
CS04
{PERSON’S FIRST MIDDLE AND LAST NAME}
{Do/Does} {you/{PERSON}} need or use more medical
care, mental health
or educational services than is usual for most
children of the same
age?
YES .................................... 1 {CS04OV1}
NO ..................................... 2 {CS05}
REF ................................... -7 {CS05}
DK .................................... -8 {CS05}
CS04OV1
Is this because of any medical, behavioral or
other health condition?
YES .................................... 1 {CS04OV2}
NO ..................................... 2 {CS05}
REF ................................... -7 {CS05}
DK .................................... -8 {CS05}
CS04OV2
Is this a condition that has lasted or is expected to
last for at least
12 months?
YES .................................... 1 {CS05}
NO ..................................... 2 {CS05}
REF ................................... -7 {CS05}
DK .................................... -8 {CS05}
CS05
{PERSON’S FIRST MIDDLE AND LAST NAME}
{Are/Is} {you/PERSON}} limited or prevented in
any way in
{your/his/her} ability to do the things most children
of the same age
can do?
YES .................................... 1 {CS05OV1}
NO ..................................... 2 {CS06}
REF ................................... -7 {CS06}
DK .................................... -8 {CS06}
CS05OV1
Is this because of any medical, behavioral or
other health condition?
YES .................................... 1 {CS05OV2}
NO ..................................... 2 {CS06}
REF ................................... -7 {CS06}
DK .................................... -8 {CS06}
CS05OV2
Is this a condition that has lasted or is expected to
last for at least
12 months?
YES .................................... 1 {CS06}
NO ..................................... 2 {CS06}
REF ................................... -7 {CS06}
DK .................................... -8 {CS06}
CS06
{PERSON’S FIRST MIDDLE AND LAST NAME}
{Do/Does} {you/{PERSON}} need or get special
therapy such as physical,
occupational or speech therapy?
YES .................................... 1 {CS06OV1}
NO ..................................... 2 {CS07}
REF ................................... -7 {CS07}
DK .................................... -8 {CS07}
CS06OV1
Is this because of any medical, behavioral or
other health condition?
YES .................................... 1 {CS06OV2}
NO ..................................... 2 {CS07}
REF ................................... -7 {CS07}
DK .................................... -8 {CS07}
CS06OV2
Is this a condition that has lasted or is expected to
last for at least
12 months?
YES .................................... 1 {CS07}
NO ..................................... 2 {CS07}
REF ................................... -7 {CS07}
DK .................................... -8 {CS07}
CS07
{PERSON’S FIRST MIDDLE AND LAST NAME}
{Do/Does} {you/{PERSON}} have any kind of emotional,
developmental or
behavioral problem for which {you/he/she} need{s} or
get{s} treatment
or counseling?
YES .................................... 1 {CS07OV}
NO ..................................... 2 {BOX_02}
REF ................................... -7 {BOX_02}
DK .................................... -8 {BOX_02}
CS07OV
Is this a condition that has lasted or is expected to
last for at least
12 months?
YES .................................... 1 {BOX_02}
NO ..................................... 2 {BOX_02}
REF ................................... -7 {BOX_02}
DK .................................... -8 {BOX_02}
BOX_02
IF RU MEMBER BEING ASKED ABOUT IS AGED 5-17 YEARS,
INCLUSIVE, OR IN AGE CATEGORIES 3 OR 4, CONTINUE
WITH CS08
OTHERWISE, GO TO CS09A
CS08
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-2.
The following questions are about some aspects of
{your/{PERSON}’s}
health.
In this series of questions, please rate
{yourself/him/her} on a scale
of 0 to 4 where 0 indicates no problem and 4 indicates
a very big
problem.
In general, how much of a problem do you think
{you/{PERSON}}
{have/has} {have/has} with:
PROBE: Please rate on a scale of 0 to 4 where 0
indicates no problem
and 4 indicates a very big problem, how much of a
problem you think
{you/he/she} {have/has} with (ACTIVITY).
CS08_01. a. Getting along with
{your/his/her} mother? ( )
CS08_02. b. Getting along with
{your/his/her} father? ( )
CS08_03. c. Feeling unhappy or
sad? ( )
CS08_04. d. {Your/His/Her}
behavior at school? ( )
CS08_05. e. Having fun? ( )
CS08_06. f. Getting along with
other adults? ( )
CS08_07. g. Feeling nervous or
afraid? ( )
CS08_08. h. Getting along with
brothers and sisters? ( )
CS08_09. i. Getting along with
other kids? ( )
CS08_10. j. Getting involved in
activities like sports or
hobbies? ( )
CS08_11. k. {Your/His/Her}
schoolwork? ( )
CS08_12. l. {Your/His/Her)
behavior at home? ( )
CS08_13. m. Staying out of
trouble? ( )
ONLY THE VALUES OF 0 AND 4 WILL BE DEFINED IN THE
TEXT OF THE QUESTION. HOWEVER, THE VALUES OF ALL
THE ANSWER CATEGORIES ARE:
0 = NO PROBLEM
1
2 = SOME PROBLEM
3
4 = VERY BIG PROBLEM
-7 = REF
-8 = DK
NOTE: THIS SCREEN WILL BE SPLIT INTO TWO SCREENS
IN CAPI. THE FIRST SCREEN (CS08A) WILL CONTAIN
THE FOLLOWING PARTS OF THE QUESTION AS SPECIFIED
BELOW:
- THE SHOW CARD LINE
- THE FIRST THREE BLOCKS OF TEXT
- THE INTERVIEWER INSTRUCTION: ‘CODE 99...’
- CS08_01 (a.) THROUGH CS08_08 (h.) DISPLAYED IN
MULTIPLE ROWS, WITH CS08_01 AND CS08_02 IN THE
FIRST ROW, CS08_03 AND CS08_04 IN THE SECOND
ROW, CS08_05 AND CS08_06 IN THE THIRD ROW, AND
CS08_07 AND CS08_08 IN THE LAST ROW.
THE SECOND SCREEN (CS08B) WILL CONTAIN THE
FOLLOWING PARTS OF THE QUESTION AS SPECIFIED
BELOW:
- THE SHOW CARD LINE
- THE PROBE
- THE INTERVIEWER INSTRUCTION:
- CS08_09 (i.) THROUGH CS08_13 (m.) DISPLAYED IN
MULTIPLE ROWS, WITH CS08_09 AND CS08_10 IN THE
FIRST ROW, CS08_11 AND CS08_12 IN THE SECOND
ROW, AND CS08_13 IN THE LAST ROW.
SPECIAL CHECK:
THE VALUES FOR MOTHPROB, FATHPROB, UNHAPSAD,
BEHVSCHL, HAVFUNPR, ADULPROB, NERVAFRD, SIBSPROB,
KIDSPROB, SPORTHOB, SCHLWORK, BEHVHOME AND TROUBLE
SHOULD BE BETWEEN 0 AND 4 AND SHOULD ALSO INCLUDE
99. A CHECK SHOULD BE CONDUCTED TO ENSURE THAT
ANY VALUES OUTSIDE OF THOSE DEFINED PRODUCE AN
ERROR AND PROHIBIT THE INTERVIEWER FROM CONTINUING
UNTIL CORRECTED.
CS09A
{PERSON’S FIRST MIDDLE AND LAST NAME}
In the last 12 months, did {you/{PERSON}} have an
illness, injury or
condition that needed care right away in a
clinic, emergency room, or
doctor’s office?
YES .................................... 1 {CS10A}
NO ..................................... 2 {CS11A}
REF ................................... -7 {CS11A}
DK .................................... -8 {CS11A}
CS10A
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, when {you/{PERSON}} needed
care right away, how
often did {you/he/she} get care as soon as you thought
{you/he/she}
needed?
NEVER .................................. 1 {CS11A}
SOMETIMES .............................. 2 {CS11A}
USUALLY ................................ 3 {CS11A}
ALWAYS ................................. 4 {CS11A}
REF ................................... -7 {CS11A}
DK .................................... -8 {CS11A}
[Code One]
IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE
QUESTION WORDING AT CS10A WAS UPDATED TO BE MORE
CONSISTENT WITH CAHPS VERSION 4.0 QUESTION
WORDING.
CS11A
{PERSON’S FIRST MIDDLE AND LAST NAME}
In the last 12 months, not counting the times
{you/{PERSON}} needed
health care right away, did you make any appointments
for
{your/his/her} health care at a doctor’s office or
clinic?
YES .................................... 1 {CS12A}
NO ..................................... 2 {CS13}
REF ................................... -7 {CS13}
DK .................................... -8 {CS13}
IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE
QUESTION WORDING AT CS11A WAS UPDATED TO BE MORE
CONSISTENT WITH CAHPS VERSION 4.0 QUESTION
WORDING.
CS12A
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, not counting times
{you/{PERSON}} needed health
care right away, how often did {you/he/she} get an
appointment for
health care at a doctor’s office or clinic as soon as
you thought
{you/he/she} needed?
NEVER .................................. 1 {CS13}
SOMETIMES .............................. 2 {CS13}
USUALLY ................................ 3 {CS13}
ALWAYS ................................. 4 {CS13}
REF ................................... -7 {CS13}
DK .................................... -8 {CS13}
[Code One]
IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE
QUESTION WORDING AT CS12A WAS UPDATED TO BE MORE
CONSISTENT WITH CAHPS VERSION 4.0 QUESTION
WORDING.
CS13
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-4.
In the last 12 months, not counting times
{you/{PERSON}} went to an
emergency room, how many times did {you/he/she} go to
a doctor’s
office or clinic to get health care?
NONE ................................... 0 {CS20}
1 TIME ................................. 1 {CS14A}
2 TIMES ................................ 2 {CS14A}
3 TIMES ................................ 3 {CS14A}
4 TIMES ................................ 4 {CS14A}
5 TO 9 TIMES............................ 5 {CS14A}
10 OR MORE TIMES ....................... 6 {CS14A}
REF ................................... -7 {CS20}
DK .................................... -8 {CS20}
[Code One]
IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE
QUESTION WORDING AT CS13 WAS UPDATED TO BE MORE
CONSISTENT WITH CAHPS VERSION 4.0 QUESTION
WORDING.
CS14A
{PERSON’S FIRST MIDDLE AND LAST NAME}
In the last 12 months, did you or a doctor believe
{you/{PERSON}}
needed any care, tests, or treatment?
YES .................................... 1 {CS14}
NO ..................................... 2 {CS15}
REF ................................... -7 {CS15}
DK .................................... -8 {CS15}
CS14
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, how often was it easy to get
the care, tests,
or treatments you or a doctor believed necessary?
NEVER .................................. 1 {CS15}
SOMETIMES .............................. 2 {CS15}
USUALLY ................................ 3 {CS15}
ALWAYS ................................. 4 {CS15}
REF ................................... -7 {CS15}
DK .................................... -8 {CS15}
[Code One]
IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE
QUESTION WORDING AND RESPONSE CATEGORIES AT CS14
WERE CHANGED TO BE MORE CONSISTENT WITH CAHPS
VERSION 4.0 QUESTION WORDING AND RESPONSE
CATEGORIES. THE RESPONSE SCALE CHANGED FROM A
PROBLEM SCALE TO A TIME FRAME SCALE
CS15
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, how often did {your/{PERSON}’s}
doctors or other
health providers listen carefully to you?
NEVER .................................. 1 {CS16}
SOMETIMES .............................. 2 {CS16}
USUALLY ................................ 3 {CS16}
ALWAYS ................................. 4 {CS16}
REF ................................... -7 {CS16}
DK .................................... -8 {CS16}
[Code One]
CS16
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, how often did {your/{PERSON}’s}
doctors or other
health providers explain things in a way that was easy
to understand?
NEVER .................................. 1 {CS17}
SOMETIMES .............................. 2 {CS17}
USUALLY ................................ 3 {CS17}
ALWAYS ................................. 4 {CS17}
REF ................................... -7 {CS17}
DK .................................... -8 {CS17}
[Code One]
IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE
QUESTION WORDING AT CS16 WAS UPDATED TO BE MORE
CONSISTENT WITH CAHPS VERSION 4.0 QUESTION
WORDING
CS17
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, how often did {your/{PERSON}’s}
doctors or other
health providers show respect for what you had to say?
NEVER .................................. 1 {CS18}
SOMETIMES .............................. 2 {CS18}
USUALLY ................................ 3 {CS18}
ALWAYS ................................. 4 {CS18}
REF ................................... -7 {CS18}
DK .................................... -8 {CS18}
[Code One]
CS18
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, how often did doctors or other
health providers
spend enough time with {you/{PERSON}}?
NEVER .................................. 1 {CS19}
SOMETIMES .............................. 2 {CS19}
USUALLY ................................ 3 {CS19}
ALWAYS ................................. 4 {CS19}
REF ................................... -7 {CS19}
DK .................................... -8 {CS19}
[Code One]
CS19
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-5.
Using any number from 0 to 10 where 0 is the worst
health care
possible, and 10 is the best health care possible,
what number would
you use to rate all {your/{PERSON}’s} health care in
the last 12
months?
RATING FROM 0-10:
[Enter Number] ........................
REF ................................... -7 {CS20}
DK .................................... -8 {CS20}
HARD CHECK: 0-10
CS20
{PERSON’S FIRST MIDDLE AND LAST NAME}
When you answer the next questions, do not include
dental visits.
Specialists are doctors like surgeons, heart doctors,
allergy doctors,
skin doctors, and others who specialize in one area of
health care.
In the last 12 months, did you or a doctor think
{you/{PERSON}} needed
to see a specialist?
YES .................................... 1 {CS21}
NO ..................................... 2 {CS22}
REF ................................... -7 {CS22}
DK .................................... -8 {CS22}
CS21
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, how often was it easy to see a
specialist that
{you/{PERSON}} needed to see?
NEVER .................................. 1 {CS22}
SOMETIMES .............................. 2 {CS22}
USUALLY ................................ 3 {CS22}
ALWAYS ................................. 4 {CS22}
REF ................................... -7 {CS22}
DK .................................... -8 {CS22}
[Code One]
IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE
QUESTION WORDING AND RESPONSE CATEGORIES AT CS21
WERE CHANGED TO BE MORE CONSISTENT WITH CAHPS
VERSION 4.0 QUESTION WORDING AND RESPONSE
CATEGORIES. THE RESPONSE SCALE CHANGED FROM A
PROBLEM SCALE TO A TIME FRAME SCALE.
CS22
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever measured
{your/{PERSON}’s}
height?
YES .................................... 1 {CS22OV}
NO ..................................... 2 {CS23_01}
REF ................................... -7 {CS23_01}
DK .................................... -8 {CS23_01}
CS22OV
When was that?
WITHIN PAST YEAR....................... 1 {CS23_01}
WITHIN PAST 2 YEARS .................... 2 {CS23_01}
MORE THAN 2 YEARS ...................... 3 {CS23_01}
REF ................................... -7 {CS23_01}
DK .................................... -8 {CS23_01}
[Code One]
CS23_01
{PERSON’S FIRST MIDDLE AND LAST NAME}
About how tall {are/is} {you/{PERSON}} without shoes?
PROBE FOR INCHES IF NOT REPORTED.
FEET:
[Enter Feet] .......................... {CS23_02}
REF ................................... -7 {CS24}
DK .................................... -8 {CS24}
SOFT CHECK:
SOFT RANGE CHECK: 0 TO 7
CS23_02
INCHES:
[Enter Inches] ........................
{CS24}
REF ................................... –7
{CS24}
DK .................................... –8 {CS24}
SOFT CHECK:
SOFT RANGE CHECK: 0-12
EDIT: IF FEET (CS23_01) = 0, INCHES (CS23_02)
MUST BE 1-30. IF FEET (CS23_01) > 0, INCHES
(CS23_02) MUST BE 0-11.
CS24
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever measured
{your/{PERSON}’s}
weight?
YES .................................... 1 {CS24OV}
NO ..................................... 2 {CS25_01}
REF ................................... -7 {CS25_01}
DK .................................... -8 {CS25_01}
CS24OV
When was that?
WITHIN PAST YEAR ....................... 1 {CS25_01}
WITHIN PAST 2 YEARS .................... 2 {CS25_01}
MORE THAN 2 YEARS ...................... 3 {CS25_01}
REF ................................... -7 {CS25_01}
DK .................................... -8 {CS25_01}
[Code One]
CS25_01
{PERSON’S FIRST MIDDLE AND LAST NAME}
About how much {do/does} {you/{PERSON}} weigh without
shoes?
POUNDS:
[Enter Pounds] ........................
REF
................................... -7 {BOX_03}
DK .................................... -8 {BOX_03}
IF CS25_01 IS < OR = 20 POUNDS, CONTINUE WITH
CS25_02
IF CS25_01 IS > 20 POUNDS, GO TO BOX_03
SOFT CHECK:
SOFT RANGE CHECK: 1 TO 300
NOTE THAT CS25_02 IS AN OVERLAY ON CS25_01.
CS25_02
{PROBE FOR OUNCES IF NOT REPORTED.}
OUNCES:
[Enter Ounces] ........................ {BOX_03}
REF ................................... –7 {BOX_03}
DK .................................... –8 {BOX_03}
DISPLAY ‘PROBE FOR OUNCES IF NOT REPORTED.’ IF
CS25_01 IS < OR = 20 POUNDS.
SOFT CHECK:
SOFT RANGE CHECK: 0-15
EDIT: IF POUNDS (CS25_01) = 0, THEN OUNCES MUST
BE 1-16.
BOX_03
IF RU MEMBER BEING ASKED ABOUT IS AGED 3-6 YEARS,
INCLUSIVE, OR IN AGE CATEGORIES 2 OR 3, CONTINUE
WITH CS26
OTHERWISE, GO TO BOX_04
CS26
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever checked
{your/{PERSON}’s}
vision?
YES .................................... 1 {BOX_04}
NO ..................................... 2 {BOX_04}
TRIED, BUT {YOU/HE/SHE} {WERE/WAS}
UNCOOPERATIVE ........................ 3 {BOX_04}
REF ................................... -7 {BOX_04}
DK .................................... -8 {BOX_04}
[Code One]
BOX_04
IF RU MEMBER BEING ASKED ABOUT IS > OR = 2 YEARS
OF AGE OR IN AGE CATEGORIES 2 THROUGH 4, CONTINUE
WITH CS27
OTHERWISE, GO TO BOX_05
CS27
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever measured
{your/{PERSON}’s}
blood pressure?
YES .................................... 1 {CS27OV}
NO ..................................... 2 {CS28}
TRIED, BUT {YOU/HE/SHE} {WERE/WAS}
UNCOOPERATIVE ........................ 3 {CS27OV}
REF ................................... -7 {CS28}
DK .................................... -8 {CS28}
[Code One]
CS27OV
When was that?
WITHIN PAST YEAR ....................... 1 {CS28}
WITHIN PAST 2 YEARS .................... 2 {CS28}
MORE THAN 2 YEARS ...................... 3 {CS28}
REF ................................... -7 {CS28}
DK .................................... -8 {CS28}
[Code One]
CS28
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you
{or {PERSON}}
advice about {{him/her}} having regular dental
check-ups?
YES .................................... 1 {CS28OV}
NO ..................................... 2 {CS29}
REF ................................... -7 {CS29}
DK .................................... -8 {CS29}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
DISPLAY ‘or {PERSON}’ AND ‘{him/her}’ IF PERSON
BEING ASKED ABOUT IS NOT SELECTED AS THE
RESPONDENT. OTHERWISE, (PERSON BEING ASKED ABOUT
IS SELECTED AS THE RESPONDENT), USE A NULL
DISPLAY.
CS28OV
When was that?
WITHIN PAST YEAR ....................... 1 {CS29}
WITHIN PAST 2 YEARS .................... 2 {CS29}
MORE THAN 2 YEARS ...................... 3 {CS29}
REF ................................... -7 {CS29}
DK .................................... -8 {CS29}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS29
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you
{or {PERSON}}
advice about {{him/her}} eating healthy?
YES .................................... 1 {CS29OV}
NO ..................................... 2 {CS30}
REF ................................... -7 {CS30}
DK .................................... -8 {CS30}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
DISPLAY ‘or {PERSON}’ AND ‘{him/her}’ IF PERSON
BEING ASKED ABOUT IS NOT SELECTED AS THE
RESPONDENT. OTHERWISE, (PERSON BEING ASKED ABOUT
IS SELECTED AS THE RESPONDENT), USE A NULL
DISPLAY.
CS29OV
When was that?
WITHIN PAST YEAR ....................... 1 {CS30}
WITHIN PAST 2 YEARS .................... 2 {CS30}
MORE THAN 2 YEARS ...................... 3 {CS30}
REF ................................... -7 {CS30}
DK .................................... -8 {CS30}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS30
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you
{or {PERSON}}
advice about the amount and kind of exercise, sports,
or physically
active hobbies {you/he/she} should have?
YES .................................... 1 {CS30OV}
NO ..................................... 2 {BOX_05}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS30OV
When was that?
WITHIN PAST YEAR ....................... 1 {BOX_05}
WITHIN PAST 2 YEARS .................... 2 {BOX_05}
MORE THAN 2 YEARS ...................... 3 {BOX_05}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
BOX_05
IF RU MEMBER BEING ASKED ABOUT:
- HAS A WEIGHT AT CS25_01 < OR = 40 POUNDS,
OR
- IF CS25_01 IS CODED ‘REF’ OR ‘DK’
AND
- PERSON < OR = 4 YEARS OF AGE (OR IN AGE
CATEGORIES 1 OR 2),
CONTINUE WITH CS31
IF RU MEMBER BEING ASKED ABOUT:
- HAS A WEIGHT AT CS25_01 > 40 AND < OR = 80
POUNDS
OR
- IF CS25_01 IS CODED ‘REF’ OR ‘DK’
AND
- PERSON > 4 AND < OR = 9 YEARS OF AGE (OR IN AGE
CATEGORY 3),
GO TO CS32
IF RU MEMBER BEING ASKED ABOUT:
- HAS A WEIGHT AT CS25_01 > 80 POUNDS,
OR
- IF CS25_01 IS CODED ‘REF’ OR ‘DK’
AND
- PERSON > 9 YEARS OF AGE (OR IN AGE CATEGORY 4),
GO TO CS33
CS31
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you
{or {PERSON}}
advice about {{him/her}} using a child safety seat
while riding in
the car?
YES .................................... 1 {CS31OV}
NO ..................................... 2 {BOX_06}
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
DISPLAY ‘or {PERSON}’ AND ‘{him/her}’ IF PERSON
BEING ASKED ABOUT IS NOT SELECTED AS THE
RESPONDENT. OTHERWISE, (PERSON BEING ASKED ABOUT
IS SELECTED AS THE RESPONDENT), USE A NULL
DISPLAY.
CS31OV
When was that?
WITHIN PAST YEAR ....................... 1 {BOX_06}
WITHIN PAST 2 YEARS .................... 2 {BOX_06}
MORE THAN 2 YEARS ...................... 3 {BOX_06}
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS32
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you
{or {PERSON}}
advice about {{him/her}} using a booster seat when
riding in the car?
YES .................................... 1 {CS32OV}
NO ..................................... 2 {BOX_05A}
REF ................................... -7 {BOX_05A}
DK .................................... -8 {BOX_05A}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
DISPLAY ‘or {PERSON}’ AND ‘{him/her}’ IF PERSON
BEING ASKED ABOUT IS NOT SELECTED AS THE
RESPONDENT. OTHERWISE, (PERSON BEING ASKED ABOUT
IS SELECTED AS THE RESPONDENT), USE A NULL
DISPLAY.
CS32OV
When was that?
WITHIN PAST YEAR ....................... 1 {BOX_05A}
WITHIN PAST 2 YEARS .................... 2 {BOX_05A}
MORE THAN 2 YEARS ...................... 3 {BOX_05A}
REF ................................... -7 {BOX_05A}
DK .................................... -8 {BOX_05A}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
BOX_05A
IF CS25_01 IS CODED ‘REF’ OR ‘DK’ FOR RU MEMBER
BEING ASKED ABOUT AND PERSON IS IN AGE CATEGORY 3
(AGE IS UNKNOWN), CONTINUE WITH CS33
OTHERWISE, GO TO BOX_06
CS33
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you
{or {PERSON}}
advice about {{him/her}} using lap and shoulder belts
when driving
or riding in a car?
YES .................................... 1 {CS33OV}
NO ..................................... 2 {BOX_06}
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
DISPLAY ‘or {PERSON}’ AND ‘{him/her}’ IF PERSON
BEING ASKED ABOUT IS NOT SELECTED AS THE
RESPONDENT. OTHERWISE, (PERSON BEING ASKED ABOUT
IS SELECTED AS THE RESPONDENT), USE A NULL
DISPLAY.
CS33OV
When was that?
WITHIN PAST YEAR ....................... 1 {BOX_06}
WITHIN PAST 2 YEARS .................... 2 {BOX_06}
MORE THAN 2 YEARS ...................... 3 {BOX_06}
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
BOX_06
IF RU MEMBER BEING ASKED ABOUT IS > OR = 2 YEARS
OF AGE OR IN AGE CATEGORIES 2 THROUGH 4, CONTINUE
WITH CS34
OTHERWISE, GO TO CS35
CS34
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you
{or {PERSON}}
advice about {{him/her}} using a helmet when riding a
bicycle or
motorcycle?
YES .................................... 1 {CS34OV}
NO ..................................... 2 {CS35}
REF ................................... -7 {CS35}
DK .................................... -8 {CS35}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU (ABOUT
HELMETS).”
DISPLAY ‘or {PERSON}’ AND ‘{him/her}’ IF PERSON
BEING ASKED ABOUT IS NOT SELECTED AS THE
RESPONDENT. OTHERWISE, (PERSON BEING ASKED ABOUT
IS SELECTED AS THE RESPONDENT), USE A NULL
DISPLAY.
CS34OV
When was that?
WITHIN PAST YEAR ....................... 1 {CS35}
WITHIN PAST 2 YEARS .................... 2 {CS35}
MORE THAN 2 YEARS ...................... 3 {CS35}
REF ................................... -7 {CS35}
DK .................................... -8 {CS35}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU (ABOUT
HELMETS).”
CS35
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you
advice about
how smoking in the house can be bad for
{your/{PERSON}’s} health?
YES .................................... 1 {CS35OV}
NO ..................................... 2 {BOX_07}
REF ................................... -7 {BOX_07}
DK .................................... -8 {BOX_07}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS35OV
When was that?
WITHIN PAST YEAR ....................... 1 {BOX_07}
WITHIN PAST 2 YEARS .................... 2 {BOX_07}
MORE THAN 2 YEARS ...................... 3 {BOX_07}
REF ................................... -7 {BOX_07}
DK .................................... -8 {BOX_07}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
BOX_07
IF RU MEMBER BEING ASKED ABOUT IS > OR = 12 YEARS
OF AGE OR IN AGE CATEGORY 4, CONTINUE WITH CS36
OTHERWISE, GO TO END_LP01
CS36
{PERSON’S FIRST MIDDLE AND LAST NAME}
The last time {you/{PERSON}} had a health care visit,
did a doctor
or other health provider spend any time alone with
{you/him/her}
without a parent, relative or guardian in the room?
YES .................................... 1 {END_LP01}
NO ..................................... 2 {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}
END_LP01
CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION
IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_01 AND CONTINUE WITH BOX_08
BOX_08
GO TO NEXT QUESTIONNAIRE SECTION
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