vital and health statistics; series 10, no. 189 (1/94) · gatting oral cancar, that is cancer of...
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I
ITEM.
I❑ Available (N2)I
NISP Statua 2 ❑ Callback required (Household page)
3 ❑ Noninterview (Section Z)
ITEM~
Refer to Hispanic origin in 4e and f on page 2 and 3 of ~I ❑ Hispanic/English Supp. interview ( ?a)
N2 HIS- 1 and expected language for this supplement.2 n Hispanic/Spaniah Supp. intewiew (lb)
Is ❑ Other (Section 0)
I I
Read to respondant:~
I’m going to be asking questions that ara ralatad to haalth concarna, such as smoking, sating practices, vitamin use and so forth.Bafore I ask thasa quastions I would Iika to ask a faw quastions about tha Ianguaga you usa most oftan.
I
1a. Do you spaak any Spanish?I
1•l Yea (2)I 2 ❑ No (4)
--- —-——--—-—————————-———------—-— ————--- L————————————————-—---- ————_______ ———-—Read to respondent: m
I’m going to ba asking quastions that ara ralatad to haalth concams, such as smoking, sating practicas, vitamin usa and so forth.Bafora I ask thasa quastions I would Iika to ask a faw quastions about tha Ianguaga you usa most oftan.
b. Do you spaak any English?
I1•l Yes (2)
I2 ❑ No (4)
I
z. Would you say that you spaak mostly Spanish, mostly English, ~ , ❑ ~05tly Spanish ~
or do you spaak Spanish and English about the sama? I2 ❑ Mostly English
I 3 ❑ Both about the same
a. What Ianguaga do you prafar: Spanish only, mostly Spanish, ; , ❑ Speni5h only ~
mostly English, English only, or Spanish and English aboutsqually? 2 ❑ Mostly Spanish
Mark only one.3 ❑ Mostly English4 ❑ English only
I5 ❑ Spanish and English equally
I
a. Can you raad Spanish? I ~I El Yes
I 20No1
s. Can you raad English? [ ~1❑ Yes
I 20No
Ask if “Yes” to both 4 and 5; otherwise skip to 7. I ~
6. In which Ianguaga do you raad battar?I ❑ Spenish
I2❑ English
I 3❑ Both the same
T. Can you writa in Spanish?tI ~
I ❑ Yesi 20No
8. Can you writa in English?I ~
1 ❑ YesI 20No
Ask if “Yes” to both 7 and 8; otherwise skip to 10.I ~
I ❑ Soanish
!3. In which Ianguaga do you writa battar? : 2❑ English3 ❑ Both the same
I1
HAND CARD B. Read categories if telephone interview. I01 ❑ Puerto Rican 07 ❑ Hismano
~
10. Which of thasa groups bast dascribas your national origin?i 02 ❑ Cuban 08❑ Other Latin American
Mark only one,03❑ Cuban American 09 ❑ Other Spanish or Hispanic
~ 04 ❑ Mexican/Mexicano 10❑ American05❑ Mexican American 11❑ Anglo American
I 06❑ Chicano se ❑ Other (Spacify)
11. Which of thasa groups bast dascribas your mothar’s Inational origin?
01 II Puerto Rican~
07❑ HispanoI 02❑ Cuban 08❑ Other Latin American
Mark only one. 03❑ Cuban American 09❑ Other Spaniah or HispanicI
04❑ Mexican/Mexicano 10❑ AmericanI 05❑ Mexican American 1I ❑ Anglo American
013❑ Chicano 1313❑ Other LSpacify)1
1 z. Which of thasa groups best dascribas your fathar’snational origin?
01•l Puerto Rican21-2:
07❑ Hispano02❑ Cuban os❑ Other Latin American
Mark only one. 03❑ Cuban Amarican 09 ❑ Other Spanish or Hispanic04 ❑ Mexican/Mexicano 10❑ American05 ❑ Mexican Americen 11 ❑ Anglo American
I 06 ❑ Chicano SE❑ Other (Specify)
age 4FORM HIS.2B [3+0
198
Section N – ACCULTURATION – Continued
13a. In what country ware you born?1I I ❑ U. S., except Puerto Rico (74) ~
2 ❑ Puerto RicoI3 ❑ Cuba
I
I}
(13b)4 ❑ Mexico
8 ❑ Other (Specify) ~
II
--------------------------------------------------------------------------------
b. Altogether, how many years hava you iivad inI
I ❑ Less than 1 yr. EEtimUnited States? I 2 ❑ 1 yr., less thsn 5
I3 ❑ 5 yrs., less thsn 10
I 4 ❑ 10 yrs., less then 15I
5 ❑ 15 yrs. or more; 9nDK
I a. In what country was your fathar born?I
I ❑ U. S., except Puerto Rico @I 2 ❑ Puerto Rico1
I 3 ❑ Cuba4 ❑ MexicoIs ❑ Other (Specify) ~
I
I9nDKI
I 5. k what country was your mother born? I 1❑ U. S., except Puerto Rico &
2 ❑ Puerto RicoI3 ❑ Cuba
I4 ❑ Mexico
I s ❑ Other (Specify) ~I
I
1 9CIDK
Uotes
MH13.2B[34921 Pege !
1a. Is there one particular clinic, haalth centar, doctor’s offica, or I
othar placa that YOUusually go to if you ate sick or naad advicaI ❑ Yes (3) +
about your haalth?I 20 No (2)
anThere is more then one (jb)(—--- ———-—————--- ———--—-- .--- ———-—————––––+––––––––––––––––-–--–––––––----–––––--
b. lstharaonaofthosaplaoasyougoto MOSTOFTENwhanyou ~m
arasickornaad advicaaboutyour haalth?tClYes(3)
I 20No (2)
HAND CARD 01. Read all categories if telephone interview. II ❑ I have two or more ueual doctore or places
za. Which ofthasaiatha MAINraasonyou donothavea patiicular \depending onwhatiswrong(2b)
placa or parson you usually go to? I 201 haven’t needed a doctor/Don’t heve e doctors❑ My previous doctor is no longer available
Mark only one.I
40 No care is available/Care is too far awayI SD I haven’t been able to find the right doctor
}
(Item 0?)
6❑ I don’t have insurance/Can’t afford it
s❑ Other reason
9nDK
______________ —————_--____ ——————____ +---------------------------------------b. lsthereonaofthosaplacesyougotomost&anwhenyouare ~
sick or naad advica about your haalth?lCiYes (3)
I 20No (Item 01)I
3. Whattypaofplace iait - a doctor’s offlca, a hospital, aI 9
clinic or some other place?I ❑ Doctor’s officeI2❑ Hoapitel emergency room
IF HOSPITAL: Do you usually go to an outpatient clinic or an I 3❑ Hospital outpatient clinicamargancy room? I An Health center
IF CLINIC: Isthisa public haalthcfirdc orsomaotharkind ~ 5❑ HMO (Health Maintenance Organization)of clinic? I 6DPublicheaIth clinic
IF NAME GIVEN, RECORD NAME: 8nOtherIIs this an HMO, a clinic, a doctor’s offica or I 9UDK
soma other Dlaca? 1
aa. About how long does it USUALLY taka you to traval to this I ~
(place in question 3)7{
I ❑ MinutesI 20 Hours
I NumberI ~3 ❑ It varies
i 999CIDK-- ——————------- —————---—-. —--- ——————-––--’l-––––-–––––--––––-––––------------–––––
b. Onceyou gettottislnlace inquestion 3), about howlongdoyou ~I {
-E@!10 Minutes
usually have to wait bafora you gat madical cara? 20 HoursI
I NumbarI msnlt varies
] 999CIDK1
!5. Istheracurrantly apa@icular person youseaatttisplaca?I ~
I ❑ IYesI
20NoI 9nDK
16. Whanwasthe lasttimayou wanttothisplace?
~I1 I ❑ Less than one year ago
201 to3yearsagoI
So More than 3 years agoI 9nDK
1 @
ITEM ;Refer to sex of SP.
lnMala (Sectiorr P)
01 I znFemale (7)
I ITa. When was tha last time you saw a gynecologist? I @
I ❑ Less than one year agoI 201 to3years ago }
(7b)
I saMora than 3 years agoAn Never
I}
(Section P)9nDK
—- ————--- ————------- ————- ——----— ————____________________________________________ --–.
b. Was this visit for a chack-up, for a spacific gynecological T-zI I ❑ Check-up
problam or for some other problam? 2DGynecological problemI3❑ Other Droblem
I enDK
Notes
200
I
ITEM❑ SPwashousehold repondentfor HIS-1 (Transcribe from
I
PIf?efar to /-//S- 7.
page 20–2 1, question 5, then Section Q)II
❑ SPwaa NOThousehold repondentfor HIS-1 (7)I
1. About how tall are you without shoes?II
@
FeetII
InchesI
2. About how much do you weigh without ehoes? I &
Note: If SP is pregnant, weight referred to is pre-pregnancy weight. [ Pounds
Notes
The next questione ere about certein kinds of medioel tests and examinations.
1
1a. Hava you aver had a tast for oral cancar in which tha doctor
}
I 5
/o ❑ I think so
or dantist pulls on your tongua, somatimas with gauze(lb)
wrappad around it, and faals undar the tongue and inside thaI El Yes
cheeks?I 20No
I 7❑ Refused
}
(5)9❑ DK, not sure
-----------------------------------------k--------------------------------------b. How meny timas have you baen checked for EEz
orei cencer in your Iifatime? Il— Times (2)
: 99CIDK(7C)_-_--_----------_----------------_-------L-------------------------------------- ----
c.lsitlassthan 10,10t020,0r morathan20timas? I k1❑ Less than 10
[ 2nloto20! 3❑ More thsn 20
9CIDKI
2a. When did you hava your most raoent oral cancar axam? I
Id~
E
I Year 1I
I OR If 3 years ago or E
I
I
{}
less (3)I ❑ Days ago2❑ Weeks ago if more thsn 3 yeara
Number 3❑ Months ago ago (5)
4 •l Years ago] 999nDK(2b)
-----------------------------------------+--------------------------------------b. Was it within tha past yaar, batwaan 1 and 3 yeara ago, or ovar I , ❑ within the ~a5t year ~3)
I
I
~-Tc.
3 years ago? 2 El 1to 3 years ago
! 3•l Over 3 yaara ago (5)9CIDK
I
a. What type of madical parson examined you when you had17
Iyour last chack-up for oral cancar?
1❑ Physician2❑ DentistI3❑ Dental hygenist
I a ❑ Other (Specify) ~II
; 90DK
HANDCARDQ l. Readcategoriea iftelephoneintervie w. I ~I ❑ Because of a specific oral problem
a. Whatwasthemainraasonyouhadthischeck-up?I 2❑ Follow-up to a pravious oral problemI
Mark only ona.3❑ Part of a routine physical exam4❑ Part of a routina dental examI
/a ❑ Other (Specify) ~
II
9CIDKI
HAND CARD Q2. Read categories if telephone interview. I 1sI❑ Spendingtoomuchtime inthesun
/5. Which of thesa do you think increasas a parson’s chances of ,
202❑ Excessive drinking of alcoholic beverages 21
gatting oral cancar, that is cancer of tha lip, mouth, tongue, I 3❑ Excessive coffee drinkingor throat?
224 ❑ Smoking cigarettes, cigars, or a pipe
I 23
(Pleese give me the numbers from tha card.)5❑ Use of chewing tobacco or snuff 24
I 7❑ Refused 26Mark each that applies. I s ❑ Something else (Specify) ~
1
I 9nDK E
Notas
ige 8 FORM H13.2B [349:
202
Section Q - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued
6a. Hava you avar had your skin chacked for cancer either by aI I 27
I ❑ Yes (6b)darmatolog[st or some other kind of doctor? I 20No
I 7 ❑ Refused
I }
(lo)9UDK
._-_-----____._--____---__-..__----------L-------------------------------------- ----b. Howmanytimeshavayouhadyourskin checkedforcancerin / *
your Ilfatima? I — Times
I 99 CIDK
T#t. When did you have your most recent skin exam?I I30-33II ~x!--
1Month Year
I ORIf 3 years ago or M
{1
I ❑ Days ago less (8)
I 2❑ Weeks ago If more than 3 years
Number 3 ❑ Months ago ago (10)
~ 999 ❑ DK (7b) 4 ❑ Years ago
___________----------__---___---___--____k-------------------------------------- –––-b. Was It within tha paat year, batwean 1 and 3 I I ❑ Within the past year
I
I
I
/
T.-3L
years ago, or ovar 3 yeara ago7(8)
2 •l 1to 3 years ago3❑ Over 3 years ago (lo)9nDK
8. What kind of doctor cltackad your akin for cancar the lastI
I ❑ General practitioner I 38
timeyouhadaskin exam? ; 2❑ DermatologistI 8 ❑ Other (Specify) ~
I
I 9DDK
HAND CARD (23. Read categories if telephone intervie w.1
I I ❑ Because of a specific ekin problem I 39
g. Whatwasthamainraasonyouhadthisskin exam? I 2❑ Follow-up to a previous skin problem3 ❑ Part of a routine physical exam/ As a screening exam
IMark oniy ona. a ❑ Other (Specify) ~
I
I9cl DK
II
10. lfyouwsratogooutsideonaverysunnydayforMORE40
Ithanonehour - !
a. How likely ara you to waar protactiva clothing such as wida I ❑ Very likelyIbrimmed hats or long sleeved shirts? Would you say vary likely, \ zDSomewhat Iikalysomowhatlikely, orunlikaly? 3DUnlikely
-—___--——__——___—____— ___________________ L__–––___–––_––––__–––___–––--–––__–-– ----
b. Howiikelyarayoutoavoidthe sunbystayingintheshade;very \ lDVe~like\Y kIikaly, somawhat likely, or unlikely? I 2❑ Somewhat likely
I3 ❑ Unlikely
-—___ -- —___ —_____________________________ ;-------- ————————-——————————-————-——-—— ---
C. How[ikelyara youtousesunscreen orsunblock lotion; veW I I ❑ Very likely T2?-Iikaly, somawhet likely, or unlikaly?
I 2❑ Somewhat likely
30 Unlikely1
HAND CARD Q4. Read categories if telephone intertdew.II I ❑ Getasevere sunburn with blisters
~
I11a. Aftar sevaral months of not baing in tha sun, if you THEN I 2❑ A severe sunburn for a few days with peeling
want out in the sun without sunscraan or protective clothing 3❑ Mildly burned with some tanning
for an hour, which one of these would happen to your skin?I
4❑ Turning darker without sunburnI
(Plaase give ma a number from the card.)5❑ Nothing would happen in an hour
I s ❑ Other (Specify) ~
Mark only one.I
I9CIDK
1________________________________________________________________________________HAND CARD Q5. Read categories if telephone interview. [ 1 ❑ Very dark and deeply tanned m
b.lfyou wamoutinthe aunfora longtime repeatedly, which one ~ 3DMildly tanned2❑ Moderately tanned
of thasa things would happen to your skin? I 4❑ Only freckled or no suntan at all
(Ptaasa giva ma a number from the card.) I 5❑ Repeated sunburnsI
Mark only one..9❑ Other (Specify) ~
;
9nDK
!2. lnyouropinlon, howaanaitiveisyour aMntosuntight; isit I ❑ Extremely sensitive&
axtrsmaly sansitiva, moderately sensitive, mildly sensitive, or 2❑ Moderately sensitivenot sansitiva at all? 30 MilrJlyserwitive
40 Notsansitive at all9CIDK
... ,,,. . . ,. . .“, m-—- .lnl .K1..., .-.., rage Y
203
Sac*inn Q — CANCER SCREENING KNOWLEDGE AND PRACTICE — Continued---.. -.. — —----- —--——--——-—--——---———————1
ITEM I I❑ Male, under 40 (Section R)46
QIRefer to age and sex. 2 ❑ Ma[a, 40+ (31)1
3 ❑ Female (73)1
I Sa. Have you ever had a Pap smaar tast? I I ❑ Yes (73b)47
Read if neceaaary: A Pap ●maar is a routine gynacologic test in \ 20 NO (16)
which tha doctor axamines the cervix and I 7 ❑ Refusedsends a cell sample to the lab. }
(Item Q2)eaDK
——————-— —.. -- —- —- ——-— ———--— ————- ————____; ––––– ___. __________ ———-- —--------------
b. How many Pap smaar teats hava you evar hadT
--—I 4a
I ❑ Less than 10in your Iifetima? Less than 10,10 to 20, or I 2clloto20more than 207
/3 ❑ Mora than 209nDK
14a. When did you hava your most recent Pap smaar teat?I49-52
~LMonth Year
OR If 3 years agoorless(15) =
{}
1❑ Days ago if mora than 3 years ego (16)2 ❑ Weeks ago
Number3 ❑ Months ago4 El Yeara ago
9e9 ❑ DK (14b)_________________ ——-------------------------- *–––––_––--- _—— —--__ --_____ -—-- __--- ——-—
b. Was it within the past yaar, batwsan 1 and 3 I
I /
E
yaars ago, or ovar 3 yaars ago7I ❑ Within the past yeer (71j)2 •l 1 to 3 years ago
/ 3 ❑ Over 3 years ago (76)9CIDK
HAND CARD Q6. Read categories if telephona interview. ! I ❑ Because of a specific gynecological problem (1 5b)67
15a.What was the main reason you had this Pap smaar tast72 ❑ Follow-up to a previous gynecological problem
I3 ❑ Part of a routine physicai ( or pragnancy) exam
Mark only one.I s ❑ Other (Specify) ~
I
i}
(17)
9nDK________ ---- __-__________________ ------- L --------------------------------------- –~8– -
b. What was the probiem? ; I H Blaeding
I
I
I
I
III
E
59
Mark all mentionad, do not probe.2 ❑ Pain 603 ❑ Discharga al
i4 ❑ itching 625❑ Burning6 ❑ infection (17)
s ❑ Other (Specify) ~
E63
9CIDK
; ;1
16. What is the most important reason why you have [nevar had Ia6
a Pap amaar taatlnot had a Pap smaar tast in tha past fawyears]?
o ❑ No reason/Never thought about it/ Didn’t know I shouldI I ❑ Not needed/Haven’t had any problemsI
Mark only one.2❑ Put it off/Laziness3 ❑ Costs too much/No insuranceI4 ❑ Doctor didn’t recommend it
; 5 ❑ Don’t go to or don’t like doctors
I 6 ❑ Had a hysterectomya ❑ Other (Specify) ~
!
I 9EIDK
1h. What is tha racommanded age a woman should START1I
W
having Pap smears? Yeara old OR
95 ❑ When aha starts having perioda96❑ When she starts having sexI97❑ Rafused
I913❑ Other (Spacify)
/ 9en DK---------------------------------------------------------------------------- ----
b. At what ago do women no Iongar naari to hava Pap smears or I ,E
is thara no age limit? _ Years old ORI
I es❑ When menstrual perioda stop (naturally or artificially)96 •l No age limit
/ 97 ❑ Refusad9s❑ Other (Specify)Is90 DK
I .,.”.. ,,,. . . ,. . .)ge 10
,U”hl “la-’. ,.-.4
204
Section Q – CANCER SCREENING KNOWLEDGE AND PRACTICE – Continued,
ITEM II ❑ BOX 6, Had a hysterectomy (Item Q3)
Q2Refer to age and question 16 for hysterectomy status. / 2 ❑ 60+ (19)
Ie ❑ Other (78)
1
18a. Do you have menstruel periods? II
1 ❑ Yes (Item Q3)z ❑ NO (f8b)
I3 ❑ Never had periods (78c)
I 7 ❑ Refused (/tern Q3)
.--------- .-----------------------------L----------------------------------------b. Did they stop due to surgery, such as e hysterectomy? I ❑ Yes
I20No }
(Item Q3)
1 3 ❑ Never had periods (78c)--------------------------------------------------------------------------------
c. Was this due to surgery, such es a hysterectomy?I
1EI YesI 20No
ITEM1I
Refer to age.1 ❑ lJnder30 (.Section/?)I
(L3 I 2 ❑ 30 and over (19)
I%. A mammogram is an x-ray takan only of tha breasts by a IlDYes (19b)
machine that presses the braast against a plate. Have you Iaver heard of a mammogram?
20NoII 70 Refused
I }
(26)9cl DK
----------------------------------------t----------------------------------------b. Hava you evar had a mammogram? I I ❑ IYea (79c)
I 20No (24)1 70 RefusedI
9CIDK }(25)
——____——___——___________—_________—____— k–––-––––––––___–––_–––___–––__––––__––_.C.Abouthow many mammograms haveyouavar hadinyour
lifetime?Il—
Mammograms
99CIDKI
?oa, When did you have your (most recent) mammo9ram? I
~M_-1Month Yaar
I
IOR
I
{1
If 3 years agoorIesa(21)I ❑ Daya ago2 ❑ Weeks ago If more than 3 years ago (i
I Number30 Months ago40 Years ago
I 9990 DK (20b)________________________________________________________________________________ .
Ib. Was it within the past year, betwaan 1 and 3 yaars ago, or I
II 1Inwithin the past year (27)
ovar 3 years ago? 20 1 t03 years3❑ Over 3 years ago
I}
(24)9nDK
1
!1. Wherewasthis mammogram done -inadoctor’soffice,a I
clinic,ahospital, anx-rayorradiology Iab,orsomaotharI I ❑ Doctor’s office (private or HMO)I
placa? 20 ClinicI3 ❑ Hospital
[ 4 ❑ X-ray or radiology lab
I 5 ❑ Mammogram van
en Other (Specify) ~IIII
9CIDK
HAND CARD Q7. Read categories if telephone interview. II ❑ Because ofaspecific breast problem (22b)
!Ztl. What was tha main reason you had this mammogram?I 20 Follow-up toaprevioua breast problem
I 30 Baseline mammogramMark only one. 4D Part ofaroutine physical exam/As a screening test
I
I a ❑ Other (Specify) ~
II
sDDK }—____ ---_ -— ——___________________________
b. What was the problem?
;_–– -_ -— ————————————_— —————————-— ———————
I 1❑ Sorenesa
Mark all mentioned. Do not probe.20 Pain3 ❑ Swelling4 ❑ Lumps
50 Fibrocystic breast disease
a ❑ Other [Spacify) ~
! 9D DK II
,.,. . . .. . .,,
71
72
T———
73
T-—-
74
75
76
T———
77
——-7a-79
]80-83
j a4-aa
24)
T—-—
87
1 88
1 89
(23)
909192as9495
ae
Page 11
205
S%etinn n — CANCER SCREENING KNOWLEDGE AND PRACTICE — Continued
:
Zge 12 . . .
16
w“”.. -.. - . . . . . . . . . ------------ ----- --——— _—-. ..—
1
?3. Who made the decision that YOUshould hava this I
I
I
I
I
I 1’
97I ❑ I decided on my own
mammogram? 2 ❑ My doctor ordered it
Mark only one. 3 ❑ Both my doctor end I agreed on ita ❑ Other (Specify) ~ (25)
9aDK
24. What is the most important raason why you have [never,I
98
had a mammogram/not had a mammogram in the pasto ❑ No reaaon/Nevar thought about itioidn’t know I should
faw yaarsl? I I ❑ Not needed/Haven’t had any problems2 ❑ Put it off/LazinessI
Mark only one. 3 ❑ Coats too much/No insuranceI
4 ❑ Doctor didn’t racommand itI 5 ❑ Don’t go to or don’t like doctors
6 ❑ Not old enoughI8 ❑ Other
I 9CIDK
~s. What is the age doctors racommand a woman should start, I 99-1oo
having mammograms? / Years old
i OR96 ❑ When she starts having periods
I e7 ❑ Refusad9s •l Other (Specify) ~
I
I
99 CIDKI I RT 88
A braast physical exam is when the breast is fait for lumps I ~
by a doctor or medical assistant. /I ❑ Yes (26b)
26a. Have you aver had a braast physical axam dona by a I DC20Nodoctor or medical assistant? I 7 ❑ Refused
}
(30)eHDK
——---— ———---— ———---- ————-- —————--— ———--–L–––--––––––-––––--–-––--–––––---––----–
b. How many breast physical exams have you evar had in your /
~
tifetima? Was it lass than 10,10 to 20, or mora than 20?I ❑ Less than 10
I 2nloto20
I 3 ❑ Mora than 209EIDK
I
ZTZI. VixhemTdidyou have your most recant breast physicalI ~
I~E_
I mMonth Year
IOR If 3 years ago or less (28)
/
{1
1❑ Days ago
2 ❑ Weeks ago If more than 3 years ago (29)I 3 ❑ Months agoI Number 4 •l Years ago
I 999 ❑ DK (27b)——————-— —————----— ————————————--— ——————- ~–––– —————-—-— ——---—-- ————------ —------—
b. Was it within the past yaar, bstwaan 1 and 3 years ago, or
I I
EI ❑ Within tha past year (28)
ovar 3 years ago? 2 ❑ 1 to 3 years ago
3 El Ovar 3 years ago(29)
eaDK
Notes
, FORMHIS.2B 13-4.
Section Q — CANCER SCREENING KNOWLEDGE AND PRACTICE — Continued1
HAND CARD Q8. Read categories if telephone interview. I~
I ❑ Because of a specific breaat problem (28b)
28a. VJxJ;,wastha main raason you had this braast physicalI 2 ❑ Follow-up to a previous braast problem
3 ❑ Part of a routine physical (or pregnancy) axamI
Merk only one.
8 ❑ Other (Specify) ~II
I
I
(29)
9CIDK
——_ -- —----------------------------------
b. What was tha problam?
;–––––––––-–– ——————--— ———————————-— ————— _——II
I
I
I
E
16I El Soreness 17
Mark ell mentionad, do not probe. 2 ❑ Pain 183 II Swelling 19
4 ❑ Lumps 20s ❑ Fibrocystic breast disease 21a ❑ Other (Specify) ~
III
I 9EIDK ECI
29. At what age do doctors racommand that a woman should ~I
start having braast physical axama? _ Years old
OR
85 ❑ When she starts developing breasts56 ❑ When she starts having periods97 ❑ Refused
I9a ❑ Other (Specify) ~
I
I
99 CIDKI
Sotl. Do you know how to axamina your own breasts for lumps?&
II I ❑ Yes (30b)
20NoI
7 H RefusedI }
(Itam Q4)
--------------------------------------------------------------------------------
b. About how oftan do you axamina your braasts for lumps? I
I
I
I
{
T-zm1 ❑ Day
_ per 2 ❑ Week
Times 3 ❑ Month4 ❑ Year
IOR
000❑ NeverIam ❑ Other (Specify) ~
II
I99sn DK
ITEM I ~Refer to age.
1 ❑ Under 40 (Section R)
Q4 I 2 ❑ 40 and over (31)I
31 lt. Hava you aver had a chast x-ray?I ~
t ❑ Yes (31b)I 20NoI
9nDK }(34)
——__-___ —_______________________________ :––––– —————-— ———————- ———————————————————
b. How many chast x-rays have you avar had in your Iifetima? I 1❑ Less than 10 m
Was It lass than 10,10 to 20, or morn than 20? 2clloto20II 3 ❑ More than 20
9CIDKI
laa. Whsn did you hava your most recant chest x-ray? I ~
I
~N--- mI Month YearI
ORIf 3 yeara ago or lass (33)
II
{}
I ❑ Daya ago
2 ❑ Weeks ago If more than 3 yaars ago (34)
I 3 ❑ Months agoNumber 4 II Years ago
I999 ❑ DK (32b)
_______________ ------_ ---_ --____________ ;_______________________________________ --–.
b. Was k within tha past yaar, batwaen 1 and 3 yaars ago, or I I ❑ Within th6 past year
I1
I
I
E
over 3 yaars ago? 2 ❑ 1 to 3 years ago [33)
3 ❑ Over 3 years ago9CIDK (34)
I. . . . . . . . --
207
Section Q - CANCER SCREENING KNOWLEDGE AND PRACTICE - ContinuedHAND CARD 09. Read categories if telephone interview. I ~
I ❑ Because of a sDecific chest E.roblem (33b)1
33a. What was tha main raason you had this chast x-ray? 2 ❑ Follow-up to a “previous chest problem:
Mark only one.
3 ❑ Part of a routine physical exem/As a screening test
I 4 ❑ For employment reasons
; 5 ❑ Because of hospitalization8 ❑ Other (Specify) ~
I
\
(34)
1
I sDDK )I-------------------------------------------------------------------------------- ——-
b. What was the problam? I
I
I
I
E
41
Mark all mantioned, do not probe.1 •l Coughing
42
2 ❑ Chest pain43
;3 •l Pneumonia
44
4 ❑ Bronchitis45
5 ❑ Emphysema4e
6 ❑ Shortness of breath47
T •l Injury48
Is ❑ Other (Specify)
/ 9 ❑ DK/Refusadm
kla. A proctoscopic exam ia whan a tuba is insertad in tha rectumI &
/to check for problems. Have you evar heard of a proctoscopic ,I ❑ Yes (34b)
exam?20No
I 7 ❑ Refused
I 1(37)9UDK
—-—-——————---——---- ———-—--—---- —-——--————L__ ——— —_ ——L——__— —--__ -———_--— —-- ——---— —
b. Have you ever had a proctoscopic exam? EI ❑ Yes (34c)
i 2DN0
I 7 ❑ Refused
I }
(37)9CIDK
-----------------------------------------t------------------------------------------C. Howmanyproctoscopic axamshavayou everhadin I&E
your Iifetima? i_ Proctoscopic exams
; 99 CIDK1
]Sa, Whan did you have your (most racant) proctoscopic axam? I &
,19 \I ~—
I Month Year mI OR1
I
{1
1❑ Days agoIf 3 yaara ago or Iaaa (36)
2 ❑ Weeka ago If mora than 3 years ago (37)
Number 3 ❑ Montha ago4 ❑ Years ago
! 999n DK(35b)-------------____----___------__----___--L______________________________________
b. Was it within the past year, betwaan 1 and 3 yaara ago, I 1 ❑ within the peat year
}
mor over 3 years ago? (36)
201 to3yearsago
/ 30 0ver3 years ego
}(37)
enDK1
HAND CARD Q1O. Readcategorfea iftelephone intewiaw.1
; I ❑ Because ofaspecific health problem (36fJ)~
36a. What was the main reason you had this proctoscopic exam? ] 2 ❑ Follow-up to a previous health problem3 ❑ Part of a routine physical exam/Aa a screening test
Mark only ona.I
a ❑ Other (Specify) ~I
\
(371
i
I----- _- ——— — — _____________________________
b. What was the problom?:–
Mark all mentioned, do not probe. i
I
II
9CIDK)
—---- ——--— —---- ——-—--— —--- —- ———---— ——~_g3-
I ❑ Bleeding20 Pain
3 II Constipation
4 ❑ Bowal trouble
5 ❑ Blood in stoolE
64666a
67
68
s ❑ Other (Spacify)9CIDK E
Votes
Ige 14 FORM H13-2B (3-4.
208
Section Q – CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued
3ra. A digitai rectai exam ia when a finger is insertad in tha70
ractum to chack for probiama. Haveyouavar haard of thisaxam? I ❑ Yes (37b)
20No7 ❑ Refused
9CIDKI 1(41)
___________ ———____ ---- ———--______ —————---- L–––––--–––––__–––––---––––-_–––––-____ –-–.
b. Have you ever had a digital ractal exam? T.-.?LI I ❑ Yes (37c)
2DN0 (40)I
7D RefusedI 9nDK 1(41)
———-—-— ----- ———————--- ——————-— —-- ——————-— L______________________________________ ____
C, Howmrmydigital ractalexams haveyou everhadinyour TJl-fifatima? Was it iessthan 10,10 to 20, or morathan 20?
I I ❑ Lessthen 102clloto20
r3D More than20
I 9nDK
ISa. Whandid youhavayour moatracant digitairactalexam?I [ 73-76I
; &2L
I Year E
I OR
{1
If 3 years ago or less 139)I ❑ Days ago2 ❑ Weeks ago If more than 3 years ago (40)
I
I Number 3n Months ago4C! Years ago
[ 999DDK (38b)————----- ————-- —--- —- ————- ——————_––––_L_-L–____–––––_–____________________–_____ ____
b. Wasitwithintha pastyaarrbatwaan land3 I
I
I
/
U!_.yaara ago, or ovar 3 years ago? I Hwithinthe past year (39)
2CI 1 to3 years ago3 ❑ Over 3 years ago (40)9i3DK
,
HAND CARD Q 10. Read categories if telephone interview. II ❑ Because ofaspecific health probiem(39b)
61
39a. Whatwaatha mainraason youhadtMsfigitai ractalaxam? [20 Follow-up toaprevious health problem3D Part of aroutine physical exam/As a screening test
Mark only one. ; en Other (Specify)v
II
}
(41)
9ci DK———_------ —_____ --__ —————-_— ————_________
b. What was tha problam?~_____–––––– _———————-____——-—————— _____I ,
I
I
IE
—-—-
01 ❑ Blood in stool82-83
020 Pain84-a5
Mark all mentioned, do not probe.03 ❑ Constipation
86-a7
o.tnBoweltrouble88-89
/ 05D Difficulty urinating90-91
060 Prostate enlargement92-93
07 ❑ BiaedingI (41)
I oaaHemorrhoids
090 Diverticulitis
I E
94-9596-97~ 9a E10ther(Specify)~
/98-as
100-101
I 99 ❑ DK/RefusedI 1
E!EE
LO. Whatistha moatimportant reason whyyouhava[navar I 104
had a digital ractai axam/not had a digital ractal axam inon Noreason/Never thought about it/Didn’t know iahould
tha past faw yaarsl?I I ❑ Notneeded/Haven’t hadanyprobiems
1 2D Putit off/Laziness3 ❑ Costs too much/No insurance
IMark only one.
40 Doctor didn’t recommend itI 5U Don’tgo toordon’t like doctora
I s ❑ Other
90DKI1
Jotes
.-IMHIS.26[3.4.92) Page It
209
pimrSbmtinn Q - CANCER SCREENING KNOWLEDGE AND PRACTICE – Continued ~------- .— —-.---—------—— ----- —---——--—————–—–
1
ala. A blood stool testis when the stool is examined to6
determine whether it contains blood. Heve you ever heard i I ❑ Yes (47b)
of a blood stool tast?20No
I 7❑ RefusedI }
(Section R)9CIDK
-- ——————. ..- —————----— ————---- —- —————---- ~_–––– -_ ——————----- ——----— -- ——---— —————
b. Have you ever had a blood stool tast? I EI lZYes (47c)
I 2 ❑ NO (46)
/}
~ ~ ~~d (Section R)
I-----------------------------------------------------------------------------c. About how many blood stool tasts have you avar had in
---
I Eyour tifetima? _ Blood stool tests
II 99n DK
H?a. Whan did you have your (moat recent) blood stool taat?I ~
I d=
: Yeer EOR
{1
If 3 years ago or less (43)1 ❑ Days ago2❑ Weeks ago if more than 3 years ago (46)
Number 3❑ Months ego4❑ Years ego] 999❑ DK (42b)
————————-------- ———————- —- ———-—-..— ————————b. Wasitwithin tha pest year, batwaen 1 and 3 years ago,
~___–––––––_________ ––________I H Within the psst year
I
i
Eor over 3 yeara ago~
(43)2 •l 1 to 3 years ago
/3❑ Over 3 years ago (46)91JDK
ks. Oid you parform this blood stool test yoursalf or was it done I I ❑ Self-tested~
by a doctor or other medical parson? I 2❑ Doctor/medical person9nDKI
HAND CARD Q 10. Read categories if telephone interview.II 1 ❑ Because of a specific health problem (44b)
~
a&l. What was the main reason you had this blood stool tast? 2❑ Follow-up to a previous health problemI3❑ Part of a routina physical exam/As a screening test
Mark only one.I s ❑ Other (Specify) ~I
I
}
(45)
9EIDK_________________________________________;______________________________________ -78-.
b. What waa the problem? I I ❑ Hemorrhoids2 ❑ Pain
I
I
E
20
Mark all mentioned, do not probe.3❑ Bleeding
21
4 •l Constipation22
; 5❑ Bowel trouble23
6❑ Blood in stool2426
7 •l Ulcers
s ❑ Other (Specify) ~26
Is ❑ DK/Refused E
45. Who made the decision that you should hava this blood I &
stool tast? I 1❑ I decided on my own
I2 ❑ My doctor ordered it
Mark only one.3 ❑ Both my doctor and I agreed on it
I a ❑ Other (Specify) ~
I
I
I II
(Saction R)
9CIDK
46. What is the moat important reason why you hava [navar 2s
had a blood stool tesffnot had a blood stool test in the past; o ❑ No reason/Never thought about it /Oidn’t know I should
faw yaarsl? I ❑ Not needed/Haven’t had any problemsI2 ❑ Put it off/Lazinees
I 3❑ Costs too much/No insuranceMark only one. I 4❑ Doctor didn’t recommend it
s ❑ Don’t go to or don’t like doctorsIs ❑ Other
: 9EIDK
Notes
. . . .. . .. . . ,. . .ige 16 ,.J.nl“1=.. .. . . .
210
riiF6ii
1. Haa a medical doctor ever told you that you had cancer of any II ❑ Yes (2) L-L
kind (including any cancar You have already mentioned)? I 2 ❑ No (Section S)
2. How many diffarant kinds of cancer have you had?II
~
,I
1}
— ‘umber ‘f Cancera If 1 cancer (3)9nDK If 2 or more cancers (4)
I
aa. What kind of cancw was it?1I ~
I
I 799n DK.---. -- —----- ———————- —————————————————___
b. What part of tha body waa affected?;–-_–– —————————————————___— ——————-— ———— ——.
I TE!z
1
1 990 DK-— ——-— ———---- ——--— —————————————————-— .—— —&_-– ————-- ————————. ————- ————- ——-— ———— ——-
C. In what yaar was this cancar first diagnosad? I TEE1 _ Year (3e)
I 99❑ DK (3d)———----------- ——————--— ————————————-— ————L–_______–_______ –_____ –– ______________ ____
d. How old ware you when this cancer was first diagnosed? II&N1l—
Age
99n DK—----- —- —----- ——————-— —————————————- —————HAND CARD G 1. Read categories if telephone interview.
;__––– ———————————————————————————-— ————
I
~
I ❑ Ihadnosymptoma anditwas detacted duringa
r3. (Pleasa lookatthia cardandtall ma)howwasyour cancar I routine check-upfirst datected? I ZO Inoticed something waswrong andwentto a doctor
1Mark only one.
30 Inoticed something waswrong butdidnottalk to a doctorabout it until my regular physical examI
s ❑ It was detected in some other way (Specify) ~IIII 9nDKII
ITEM Refertoqueation 3cor3d for when the cancer
~
I ❑ Morethan 10years ago (Section S)I
RIwas FIRST DIAGNOSED. I 20 100rfewer years ago(6)
1 1
aa. What kind of cancar was diagnosad first? I ~
I
I 799n DK_----___-----___-----__-_---_____---____-L-------------------------------------- –-–-
b.Whatpartoftha bcdywasaffacted? TEzII
I 99UDK--------------------------__-------------L-------------------------------------- –-–-
C.Whatyaarwas thiscancarfirat diagnoaed? I E%?!II _ Year {4e)
~ 99DDK (4d)---------------------------_------_-_____+______________________ __
d. Hawoldwareyou whenthiscancerwas firstdiagnosad? I IzEz!!_ Aga
I99CIDK
----—---—____—_______——_____———_____———__ L––––--–––––––––––––––––––_–––––––__–-– –-–.
HAND CARD G 1. Read categories if telephone interview. kI I ❑ lhadnosymptoms anditwas detected duringaO.(Plaaselook atthiscard andtellma) howwastie fcancarin4a) i routine check-up
first datectad? z ❑ I noticed something was wrong and went to a doctorI
Mark only one.3❑ I noticed something was wrong but did not talk to a doctor
I about it until my regular physical exam
I s ❑ It was detected in some other way (sPf?CifY)~
I
t 90DK
Notes
!M HIS2B [34921 Page 17
211
Section R – CANCER SURVIVORSHIP – Continued
5a. What kind of cancar was diagnosed most racantly? I ~
/, 799n DK
—————————----- ———————--- ————————————---__ L ______________________________________ ---
b. What part of the body was affeated? @I
I
] 99 CIDK
-----------------------------------------k--------------------------------------c. In what yaar was this cancar first diagnosed? T&z
I_ Year (R2)
: 990DK (5d)-----------------------------------------t-------------------------------------- ---
d. Howoldwarayou whanthiscancarwas firstdiagnosad? &I _ Age
I 990 DKII
ITEM Refer to q“estjon 5Gor 5d for when the most
~
1 I ❑ More than 10 years ago (Section S)
R2 recent cancer was FIRST DIAGNOSED. 2 ❑ 10 or fewer years ago (6)I
The following quastions refer only to theI 3a
a or 560.1 ❑ Internist, general practitioner
I 39
HAND CARD G2. Read each category if telephone interviaw.2 •l Cancer specialist (oncologist) 40
I
6. Whattypesofdoctorsdidyousaaforyourdiagnosis3 ❑ General surgeon 41
Iandtraatmant?
4 ❑ Cancer surgeon 42
5 ❑ Plastic surgeon/Reconstructive surgeonIMark each that applies.
43
6 H Radiologist 44I B ❑ other apecialiat (SpeCifY} ~
I
I9CIDK
I EI
7a. Didyougatmora thanonaopinionabout tha~
typaoftraatmant youshouldhava?I EIYesI20No
I 9CIDK——————————---------———————————--------——— ~––––––-- ---——.———-—-—--———————— -------
HAND CARD G3. Read each category if telaphone interview. I
I
I
I
I E
_— -
I ❑ Surgery toremovethetumor47
2 ❑ Radiation48
b. What typas of traatmant did you raceive for this cancar? 3 ❑ Chemotherapy40
4 •l Special diata50
Mark each that applies. 5 ❑ Self healing techniques, including imaging51
a ❑ Other (Specify) ~62
I
I 91JDK E
8. After yourcancerwasdiagnossd, didyouracaivaanyI
I ❑ Yes (10)@
counseling or join any support groups to halp you cope? I2 ❑ No (9)
I 90 DK (10)
HAND CARD G4. Read categories if telephone interview. I1 ❑ ldidn’t know itwasavailable (9b)
p
I9a. What was tha main raason you did not gat counsafing?
20 Ididn’t wantit3 ❑ I didn’t think I needed it, )
Mark only one. i s ❑ Some other reason (Specify) ~\ (10)
I
i 9Ei DKJ-_____________________-------------------L-------------------------------------- ---
b. Would youhavahan intarastd inr=aiving oounsafingifyou / L!?!!hadknownabout ft?
1•l YeaI 20NoI
9CIDK,
10. Didadoctor,nuraa,orsooiaiworkargivayouwrittan&
!information about your cancar or its traatmant?
lfNO,ASK–I
Evanthoughno onagavayouany writtaninformation didyou ;lUYes (17)
piokanyuponyour own? 2 ❑ No, no information givenI
If Yes, mark box 3.3 ❑ No, but I picked it up myself
}
(12)
If No, mark box 2.9CIDK
/
Notes
~ge 18 FORMH12-28[2-4
212
Section R – CANCER SURVIVORSHIP – Continued
HAND CARD G5. Read each category if telephone interview. I I ❑ General information about cancer58
11a. What subjects did the materials cover? (Anything alsa?) I 2 ❑ Information about your specific type of cancer59
I 3 ❑ Cancer treatment options60
Mark each that applies. I 4 ❑ Coping with the physical side effects of cancer treatment61
5 ❑ Coping with the emotional effects of cancer62
I
I 8 ❑ Other (Specify) ~63
III 9EIDK
E._______-_._----_-.--------------------.-L--------------------------------------
b. [Was thisiMfara any of thesal malarial helpful? I EEI •l YesI2DN0
I 90DK
HAND CARD G6. Read 12b categories if telephone interview.I ~
lZa. Aftaryouwerediagnosadwith cancer,didyoucontactanyof / 1❑ Yea (12b)thase cancer organizations? I 2UN0 (13)--------------------------------------------------------------------------------
b. Which cancer organizations did you contact? (Any others?)———
II ❑ American Cancer Society 67
I z ❑ National Cancer Institute68
Mark each that applies. 3UThel-800–4-CANCER HOTLINE 69I
8 ❑ Other 70I 9 ❑ Don’t know 71
13. Did you participate in a raseerch study or clinical trial as a part of I 1❑ Yes~
your cancertrtratmant? I 20No91JDK,
1aa. Not counting Medicare or Medicaid, did you hava healthI
I ❑ Yes (74b) 73
insuranca that paid for all or part of your treetment? I 20No
}(15)
9nDK————__--_-—----——_--___————__—————-————-_ ;_––-_ ———————————————————--—————--———-—
HANDCARDG7. Readallcategories iftelephoneintervie w, I 1 ❑ Yea — Coet to me increased FI
b. Did your haakh insurance change in any of these ways becausa ~2❑ Yes — My insurance was cancelledor not renewed
of your cancar?8❑ Yes – Other change (Specify) ~
I
Mark only one. Io ❑ No — Did not change
,15a.Were you EVER deniad health or Iifa insurance coveraga because I I ❑ Yes
~
ofyourcancar? 20NoI9CIDK
——————----—-—--————-___—————_——————————-— ;–––-_b. Ware vou EVERaskad to waiva covarage of your cancer in order I
———-————————————————-——————————-—..
I lJYes Eto gat health insurance? I 20NoI
9UDK
16a. Werayouworting atajoborbusiness immetiataly BEFORE your ~77
1 a Ye8 (16b)diagnosis of cancer? I zONO (77).—— —--- ———---— ———-— ————————————————————-—
b. Were you self-amployad?L––__––––– _______________________ –––__– ––-1 IxLI 1❑ Ye8 (77)I 20No (76c)
-— ———_— ———________ ——____— ——__— ——__— ——————;––––– ———-—-— ——-— —————. . ..- ———..- ————---------C. Didyour amployerhava along-term disability plan I EI ❑ Yes
that covered cancery I20NoI
1 1(18)9UDK
17a. Hava you workad at e job for pay AFTER your IlD Yes (77b)
@
cancar was diagnosed? I 20 No (Section S)________________________________________________________________________________
b. Ware vou salf-employad?I EI ❑ IYes(Section S)I 20 NO (18)
18. Somepaopla haveproblems withamploymant becauseof I ~
cancer. Have you EVER. . . Ia. Facadon-th~Job problamefrom youremployer orsupewisor I ❑ Yes
directly relatad to your cancar?II 20No
_——___— —________________ ———__— ———_— ——————!––––––––– _––––––––– ––____-–___________– –––
I U%1❑ IYasb. Baen fbad or laid off from your job because of your cancer? ! 20No
-—-—————----—-———-——___—————_———————————— ~———-_———— ————————————————-—————-————-—I EI ❑ IYes
C. Faltyou couldnrt change jobs becausaof yourcancer? 20No-—-————----—-———---———--————-——————————-— L________––_____–––––__–––____________ ---
d, Faltyoucouldn’t takeanawjobbecausa ofachangainTJ?!LI I UYes
Insuranca ralated to your cencer? 20No-———__--.--_--____—_______—___———_———___— ~____–––__––– ——.———————————-————-————-—
I Ee. Refrainedfromapplying forenewjobbecauseyoudidn’twent I •l Yes
your madical racords made public? ; 20NoI
. . ...- . .
213
1.
1 L
Now, I’m going to ask your opinion about cartain haalth problams. IFor thasa quastions, if you ara not sura, faal fraa to tall ma that.
I ❑ Heart diaease
I 2CI AIDS
HAND CARD S 1. Read categories if telephone interview.30 Diabetes
/ 40 Cancer
Of thase four diseasas, which ONE do you think is the country’s70 Refused
[most sarious haalth problem? 9nDK
/Mark only one. I
IREFER TO CARDS 1. Read categories if telephone intarview.
[z. Tothebastof yourknowladge, which TWOofthasadiaaasaa \ 3DDiabetes
caused the moat daaths in the United Stataa in tha PAST YEAR? , 4 ❑ CancerI
Mark only two.7 •l Refused
I 9CIDKI
s. Have you evar haard of – I YES NO Refused DK @
a. the American Cancar Sociaty? la. lCl 20 70 9n.---.-..---.-----------------------------L-------------------------------------- -––
b. thaCancer information Sarvice? /b.lUL-L
20 70 90-----------------------------.--------.--L-------------------------------------- -–-
Ll!_C. tha National Cancar Instituta? Ic.in 20 70 90
-------------------------_--------_______L______________________________________ ---
d.tha l-800-4-Cancer Hotline?w
ld.lCl 20 70 90
c%. In your opinion, how much progress has baan made overall in I p
tha fight againat cancar in the past twanty years? Would youI ❑ A great deal
say a graat deal of progress, soma prograss, very little / 2 ❑ Some progress
progress, or no progress? 3ClVerylittleI4 ❑ No progress
I 5 ❑ Depends on type of cancer
I 7 ❑ Refused9nDK
I
HANDCARDS2.I p
5. Please tell me which of these You think causas more cancer in ~1❑ A, personal
the United States.2 ❑ B, environment
I3 ❑ Both
A. Personal behaviors, such as smoking or eating habita.I 7 ❑ Refused
OR 8 ❑ Neither/other (Specify) ~
B. Factora you have little control ovar, such as environmentalpollutionorfamily history.
I 9CIDK1
ITEMI ~
SIRefer to sex of SP
In Female (6)I
2 ❑ Male (8)
HANDCARDS3.I
I6. {If cancer of the (bed
fair pO~ror you=~~v ‘arly, whati52r
GOOD FAIR POOR REFUSED DK/NOTSURE
p!rsonschanceo survwing?WouIdyousaygood, I,
I Ea. braast Ia.l Cl 20 30 70 90
-------------------------------------------------------------------------------- –––
b.cewix?b
lb.lEl 20 30 70 90-----------------------------------------f______________________________________ ---
I.JzC. colon or rectum? Ic.in 20 30 70 90
_______________________________________________________________________ - —-------I
d. !ung? ~d.ltltz!i
20 30 70 90---------------------------------------------------------------------------------
(3. fivar? EIe.in 20 30 70 90
Notea
214
Section S - GENERAL KNOWLEDGE AND ATTITUDES - Continued
HAND CARD S4. Read each category if telephone interview.I 20
0 ❑ None of these -.I
7a. Which of these things do You think increases a woman’sI ❑ Increasing age
II H
-.
2 ❑ High fat diet22
chanca of gatting cancar of tha braast? 3 ❑ Low fiber diet23. .
(Plaase giva me tha numbara from tha card.)I 4 ❑ SmokingIII
I
u
Z*
5 ❑ Family history 25
Mark each that appliea. e ❑ Having multiple sexual partners 26
7 ❑ Refused 27
9nDK 2a_-----_____--_---_---___---__-----_----_-;----.---__---___-----_..-__-----____--T_r__
REFER TO CARD S4. Read each category if te/eDhone interview. ! o ❑ None of these
b. Which of thaaa things do you think increeses a women’schance of gatting cancer of tha carvix?
I I ❑ Increasing ageI 20 High fat diet, 3 ❑ Low fiber diet
(Plaasa giva ma tha numbars from tha card.)I 4 ❑ Smoking
50 Family historyIMark each that applies. I en Having multiple aexual partners
7 ❑ RefusedI 9nDK 4
2s303132333435362.7
____________________ ___________ ;__________ —_____ ———____—————————------ J
REFER TO CARD S4. Read each catagory if telephone interview.
———
I o ❑ None of these
III
I
I
I
)
38
I ❑ increasing age39
C. Which ofthasathings doyouthink incraasasawoman’s 2❑ High fat diet40
chanca of getting cancar of tha colon or ractum? 3 ❑ Low fiber diet 41
(Piaase giva ma tha numbars from the card.)4 II Smoking (Item S2) 42
5 ❑ Family hlatory 43
Mark aach that applies. 6 ❑ Having muitipte SeXUal pattnerS 447 ❑ Refused 45
I 9CIDK 4a
I
HAND CARD S3.I
8. {If cancar of the (body part) is datacted early, what is a GOOD FAIR POOR REFUSED DK/NOT SURE
person’s chance of surviving? Would you say good, 1
fair, poor or you ara not sura?}III Sa E
a. prostata ia.liJ 20 30 70—- —------- —--- ———---— ——-— —- ——-— —- —- —————- !––––-–––– -–––––––––– ––––––-––– ––-–––– -- –––-
b. coion or rectum?,~ Lxlb.lCl 20 30 70
_--.-------------------------------------&-------------------------------------- –––-s~ k
c. lung? IC.in 2n 30 7D_––––__L–––_– _________________________________ ____
CI. liver?,~ IU!L
ld.lCl 20 30 70
HANDCARDS4. Readeachcatagory iftelephoneinterview.I 51I o ❑ None of theseI I ❑ Increasing age
62
9a. Whichofthesethingsdoyouthink increasesa man’schance I 2D High fat diet5’3
of gatting cancar of tha prostate? I 3DLowfiber diet54
(Plaasa give ma the numbers from the card.)4ElSmoking 55
IsD Family history 56
Mark each that applies. I 60 Having multiple sexual partners 57
70 Refused 58I
9CIDK 69
-----------------------------------------F-------------------------------------- 80REFER TO CARD S4. Read each category if telephone interview.
———
on None of theseI al
I ❑ Increasing ageb. Which of these things doyouthink incraaaaa aman'schanca ~ ~DHighfattiet 62
of gatting cancer of the coion or rectum? I 3nLowfiberdiet63
(Plaase giva ma tha numbars from tha card.) 4ClSmoidng64
I5DF8mily history
65
Mark each that applies.I 60 Having multiple sexual partners 66
I 70 Refused 67
9nDK 68I1
ITEM Refer to Question I in Section R on page 17 toI
69in’’Yes’’markedinl (Section J)
S2 determine if SP reported having cancer. I 2❑ Ail other (70)
10. Howconcernad arayouaboutgatting cancarinthafutura? \ lo Very concernedE
WouldyousayyouaravaWconcarnad, somawhatconcarnad, Ior not at ail concerned?
zD Somewhat concerned30 Notat ail concernedI7 ❑ Refused
I 9nDK
Iotea
MHIS.2B {3491} Page 21
215
These next questions are about cigerette smoking. I ~I •l Yes (2)
1. Heva You smoked et least 100 cigarattqa in your entira life? I 20No
If asked: approximately 5 packsII }
(Section W)9UDK
z. How old were you whan you first started smoking cigarettes I6-7
fairly ragularly? I _ Age
;, 00 ❑ Never smoked regularlyI 99CIDK
3. Do you smoke cigarettes now?I 8
I ❑ Yes (4)I
2❑ No (5)I
4. Do you now amoka cigarettes avary day or some days? I 9I ❑ Every day (6)
I 2❑ Some days (7)
I
5. Do you now smoka cigarattas “not at all” or “some days”?I ~
I ❑ Not at all (Section V)I
2❑ Some days (7)I
6. On the average, how many cigarettes do you now smoke a day? /I
I
}
~
_ Cigarettes a day
(Number)(Section U)
[ 99n DK
T& On how many of the past 30 days did you smoke cigarettes?1I
@
~ 00 ❑ None (Section V)
I_ Days
I (Number)I
}
(7b)
I 99CIDK——— ——— ——— ——— ——- --- ——— ——— ——— —-— .— -
b. On tha avaraga, whan you smoked, about how many cigarettes ,lr_–––– ——— ——— —-- ——— ——— ——— —-- ——— ——
I
}
Edid you smoka a day?
— Ggarettes a day (Section u)(Number)
/\ 99 CIDK
Notea
age 22FORMHIS.2B[3.4.9
216
ITEM Refer to question 4, page 22, Section T to
UI determine if SP no w smokes every day.
II I ❑ Every day in 4 (4)I
2 ❑ All others (1)I
. .
I1. Hava you EVER smoked cigaraties every day for at I
I ❑ Yes (2)~
least 6 months? II 20NoI 190lx“2)I
Za. About how long has it been since you last smokedII I ❑ Days
~
cigarettes every day? I
II
{1
(3)2 ❑ Weeks
Number 3 ❑ Month If 1 year or 12 months ago, go to 2b;
4 ❑ Years otherwise go to 3.
I 999 ❑ DK (2b)____; _–––––––––– ————.——————————————.
b. Was it within the past year or a year or more ago? I--------=
1❑ Within the past yearII 20 1 year or more
9CIDKI
aa, On tha average, how many cigarattee did you smoke a day I ~
witan you last smokad every day? II Cigarettes a dayI Number
I 99n DK————--- ———————————--— —————————. _ ;____________––––––__________––—––-––––– –––6
b. Whatisthetotalnumberofyaarsyou smokedeveryday?Do / k
not include any time you stayed off cigarettes for at least 600❑ None or less than one year
Imonths or longer? I
YearsII }
(12)
99 CIDKII
a, Whatisthetotal number ofyearsyou havesmoked everyday? Ib
Donotinclude anytime youstayed offcigaretias foratleaat6 I00❑ None or less than one year
months or Iongar. IYears
199n DK
SIL ~n:e;~ EVER stopped smoking for one day or I ~
I 1 ❑ Yes (5b)I 20NoII
},D DK ’12)
———————----- ————————————————————————————+––––––––– –_––––––_– ––––––_––– –––___–––– –-–.
b. In your whole life how many times hava you stopped @
smoking for one day or longer, including the last tima?III TimesI Number
I 99 CIDKII
6a. During the PAST 12 MONTHS, have you stoppedI ~
smoking for one day or longer?I 1❑ Yes (6b)II 20NoI
}, ❑ DK ‘6”
—-----—-----————————— ------------------- +--------------------------------------- -––-b. How many times during the pact 12 months have you I *
stopped smoking for one day or longer? II Times
1 Number \(7)
I 99n DKI J
-----———————————————————————————————————+.–––– _———————____——————___—————————————-C. Howlongagowasthelasttimayou stoppedsmokingfor I UC
onadayorlonger? I I ❑ l—5yearsI 20 6—10yearsII 30 10yeara or moreI 9nDKI
7. Howlongdid youactually steyoffcigereties the Iasttimeyou jI 36-38
stopped smoking? I
I
I {
ID Days2 ❑ Weeks
Number 30 Month
4 ❑ Years
999 CIDKI
HAND CARD U1. I 3940
8. The iasttime you stopped smoking did you stop onI I ❑ I stopped on purpose 41
purposa, wereyou sick, or wae there soma other reason 2 ❑ I could not smoke becauee i was sickIyou couldn’t smoke?
42s ❑ I could not smoke for some other reason
I
Mark all that apply.9nDK
I
IM H13.2E {3.4.921 Page 2<
217
Section U – CURRENT SMOKER - Continued.-
ITEMU2
Refer to question 8.
II ❑ Box 2, Stopped for sickness ONLY (7 7)
I2 ❑ All othere (9)
IHAND CARD U2. Read each category if telephone intewiew. I ❑ Concern about my future health
I
I
I
E
.-
145
9. The last tima you stoppad smoking, what were the reasons ~2 ❑ Concern about my health at the time 463 ‘d Pressure from family and friends
you stoppad?47
4 El Cost of cigarettes 48
Mark each that applies. 5 ❑ Pregnancy 498 ❑ Some other reaaon (sp.!?Cify) 50
9CIDK
10. The LAST TIME you stoppad smoking, did you - IYes No DK
(1) Stop smoking along with friends or relatives who were also !trying to quit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :(1) In 20 90 m
(2) Use a prescription chewing gum called “Nicorette”? . . . ...(2) In 20 90 EE
(3) Follow instructions in a pamphlet or book? . . . . . . . . . . . . ~(3) 1❑ 20 90 E
(4) Use a stop-smoking clinic or program? . . . . . . . . . . . . . . ..~(4) In 20 90 E
(5) Stop all at once, or stop “cold turkey”? . . . . . . . . . . . . ...1(5) In 20 90 IIzE
[6) Use any other mathod?I
. . . . . . . . . . . . . . . . . . . . . . . . . . . I {6) 1❑ Specify ~ 20 90 EIII
I
11. When trying to stop smoking, have you EVER - I ~
a. gradually dacreasad tha number of cigarettesYes No DK
Iyou smokad in a day? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In 20 90
I----------------------------------------k--------------------------------------- ~
b. switched to lowar tsr or nicotine cigarettes? . . . . . . . . . . . . . . . . 1❑/ 20 90
1 z. Do you think that your smoking affects your haalth now?I &
1❑ YesI 20No
9nDKI
13. How likely do you think it is that you will have serious healthp
problams from smoking if you continua to smoke? Do you I ❑ Unlikely
think it is unlikely, somewhat Iikaly, or vary Iikaly? 2 ❑ Somewhat likely3 H Very likely
I Ask for each “Yes” in 14a.
14fL In the past yaar have you saen a – / b. During the past year, didI any. . . advise you to stop
smoking?t
I 1I
IYes No DK Yes No DK
I
(1) Medical doctor? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In 20 ‘n d 10 2D go EI
(2) Dentist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 20 9D l--=--l In 2D SD E
I
ITEM Refer to q“esfion 14b(l) and 14b(2) to deterrnineif ~
U31❑ Yes in 14b[l) or14b(2) (76)
medical doctor or dentist adviaed the 5P to stop smoking. I 2 ❑ All others (15)
E
I I
15. Has a medical doctor or dantiat EVER advisad you to stopI ~
smoking? ; 1❑ Yes20No
I 9DDK1
16a. Are you seriously considering stopping within theII ~
naxt 6 months? 1❑ Yes (76b)I 2nNo(f7)
I 90 DK (76b)1-———__-————____————____ ———______________
b. Are you planning to stop within the naxt 30 days?~___-–– ------ ———-— ————---- ——-- —---------1
~
I ❑ Yes
I 20No9nDKI
1 ~. About how oftan in the past 12 months has anyona asked Io❑ Never
I
\
Eyou not to smoke when you were smoking or were about tosmoke? Never, once or twica, several times, or many times? I 1•l Once or twice (Section W)
2 ❑ Several timesI 3❑ Many times )I
ige 24 FORM HIS.2B [3.44
218
1. Have you EVER smoked cigarattaa every day for at I I ❑ Yes (3) I_Z!?_least 6 months? 20NoI
I }, ❑ DK ‘2)
z. How long has it been since you completely stopped I ~I ‘d Days
●moklrsg cigarettaa? I
I
I {}
2 ❑ Weeks
(Number) SD Months ‘7)4 ‘d Yesrs
I 999 ❑ DK (7)I
Sa. About how long hes it bean since you Ieat smoked II
II {1
I ❑ Days~
clgerettee every day?(4)
2 ❑ Weeke(Number) 3 ❑ Months If 1 year or 12 months ago, go to 3b;
4 ‘d Yesrs otherwise go to 4.
I 999❑ DK (3b);–––––––. —————————————.————————.
b. Was it within tha paat yaar or a year or more ago? I ------ ’-EI ❑ Within the past year/. 2❑ 1year or moreI 9CIDKI
4, On tha averaga, how meny cigarattas did you smoke a day when ~~
you last smokad evary day? I Cigarettes per dayI (Number)I
99n DKI
5. What is tha totai numbar of years you smokad evary day?,I k
Do not include any tima you stayed off cigarattea for at00❑ None or less then one yearI
Iaast 6 months or longer. II
YesrsI
6. 1ssyour whole life, how many timaa hava you atopped&
Ismoking for one day or Iongar, including tha last Timestime? I (Number)
I 99 CIDK
HAND CARD U1. I 84I 85
7. Whan You stoppad smoking comislataly,did Youstop on purpose, ~I ❑ I stopped on purpose 86
wara you sick, or was there soma other raason you couldn’t 2 ❑ I could not smoke because I was sick
smoke?87
a ❑ Icould not smoke for some other reason
Mark each that applies.9nDK
ITEMVI
Refer to question 7.
II ❑ Box 2, Stopped for sickness ONLY (10)
I 2❑ All others (8)I I
HAND CARD U2. Read each category if telephone interview.I 69
I ❑ Concern about my future healthI
eo
8, When You stoppad smoking complataly, what wera tha 2❑ Concern 8bout my health 8t the time 91raasons you stoppad? 3 ❑ Pressure from family and friends 92
Merk each that applies.4 ❑ Cost of cigarettes 935 ❑ Pregnancy
Ie4
E ❑ some other reason (Specify) ~
I
IenDK 95
I
g. When You stoppad smoking cigarettes compiataiy, did you – ~ Yes No DKI I
(1) Stop smoking along with friands or ralatives who wera also Itrying to quit? \(l)lcl 20 90
3
96. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(2) Usa a prescription chewing gum callad “Nicorette”? . . . . . ;(2)10 20 90 e7
(3) Foliow instructions in a pamphlat or book? . . . . . . . . . . . . ! (3) I ❑ 20 90 98
I
(4) Use a stop-smoking clinic or program? . . ‘(4)10. . . . . . . . . . . . . . 20 90 m
(5) Stop all at onca, or stop “’cold turkey”’? . . . . . . . . . . . . . . . ~ (5) I ❑ 20
(6) Use any othar mathod?
90
I~
100
~ (6) I ❑ Specify ~ 20 90 101. . . . . . . . . . . . . . . . . . . . . . . . . . .
I
10. When trying to stop smoking, did you EVER –I
Yes No DK 102
a. gradualiy decrease tha numbar of cigarettaa youI
smokad in a day?I
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In 20 90
I J
______ ----- __-__ ._______________________ L _______________________________________ _lz=
b. switch to lower tar or nicotine cigarattas? . . . . . . . . . . . . . . . . . ~ I ❑ 20 90
ORMHIS-29[S4921 Page 25
219
IJLThese next questions are about other tobacco products. I
1a.Hava you aver smoked a pipa?I I ❑ Yes (lb)
20NoI}so DK ‘2’
-———————————_——_________________________ ,b. Havayousmokad apipaat least 50timesinyour entire hfe? I
~-–––– ——-____ -— — ________________________
uI lJYes(lc)20No
/ 1,DDK ‘2)
----------------------------------------t--------------------------------------- ----C. Doyousmokeapipanow? LL-
1 10Yes (Id)I 20No (2)
-———________________-——-———_____________d. On tha average, how many days par month do you
+___________ _--_____________________——__I IxE
smokeapipe?00❑ Less than one dsy a month
II
Days per monthi
30❑ Every dayI 99n DK
Za. Have you evar smoked cigars?1I
&lCIYes (2b)
I 20No
}eaDK ‘3)_---——-—————____________________________ ‘
b. Have you smoked at Iaast 50 cigars in your entira life?
~–––__ “——--——————————— --------—— ---------1 E
I ❑ Yes (2c)1I
I }
20No,DDK ‘3)
----------------------------------------t--------------------------------------- --–-C. Doyousmokecigarsnow? b
I In Yes (2d)20No(3)
————____________________________________ ______________________________ ____
d. On the averaga, how many days par month do you 00❑ Less than one day a month m
smoke cigars? 1I Days per month
I 30❑ Every day99CIDK1
sa. Haveyouavar usedsnuff,suchas SkoaI,Skoal ~
Bandits, orCopanhagan? / lDYes(3b)
20NoI
},DI)K ‘4)----------------------------------------i-------:_______________________________ ----
b. Have you used snuff at least 20 times in your entire life? lJ!!-1 lCl Yes(3c)
20NoI 1,DDK ‘4)——————__________________________________
C. Howoldwara youwhan you first usadsnuff?+–- ———————————————————————____________
I E
I Age
99nDK---—————— _______________________________
d. Doyouusesnuff now?;–––_ ----————————————--—————— ___________I =I ❑ Yes
; 20No----------------------------------------&--------------------------------------- ----
@. Altogether,abouthowlong [haveyouusedkfidyouusalsnuff? ~ *000❑ Less than one monthI
I
{
I ❑ Months2❑ Years
f.
I
I 999 CIDK——______________________________________ +__–––– ———————————----— _________________
Ontheaverage,howmanydays permonth[dokiid]youuseit? I w00❑ Less than one day a month1
I Days per monthI
30 ❑ Evary day/ 99n DK
----------------------------------------t--------------------------------------- ---g. Onthadaysthat youuse(d)snuff, howmanytimes -@z!
[dolcfidlyouusait?I 00❑ Less than one time per day
ITime(a)perday
[9snDK
----------____________________________--;--------------------------------------- ----h.[Do/Did]youuse snuffbysniffingit orbyplacingit UL-
in your mouth? I ❑ ISniffing
2 ❑ Mouth
Mark only one. 3 ❑ Both
Page 26 FORM H13.2B (3+9
220
Section W – OTHER TOBACCO USE – Continued1
3i. Hava you EVER been advised to stop using snuff by a -I Yes No DK
I
(1)Madical doctor? . . . . . . . . . . . . I. . . . . . . . . . . . . . . . . . . . In 2U 90
I E28
(2) Dantist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In 20 9029
I,
Aa. Hava you ever used chewing tobacco, such es Redman, I@
Lavi Garrett, or Beechnut?I ❑ Yes (4b)
I 20No
I 1QD Dl( ‘5).—————————________ ——_———————___—————————
b. Hava you usad chewing tobacco at least 20 times in your
~–––––––– ———————————I
I II Yes (4c)antira Iifa? I 20No
I 1soDK ‘5’
.————————————————————-LE
----------------------------------------L--------------------------------------- –––-
C. How old were you when you first used chewing tobacco? =I Age
I 99n DK-------------------------------------------------------------------------
d. Do you use chewing tobacco now?I
-------mI ❑ Yes
I20No
—————-------———------————————---———————— L–––––––––_________________________––___ --–.
f). Altogether, about how long [have you used/ did you use] &I
chawingtobacco?000❑ Less than one month
I
I{
I ❑ Months2❑ Years
I999n DK
-_______________________________________L_______________________________________ –––.f. On tha average, how many days per month [do/did] YOUuse it? j Ix@
00❑ Less than one day a monthIII Days per month
I 30❑ Every day990DKI
----------------------------------------k--------------------------------------- -——-
$Onthadaysthatyouuse(d) chewingtobacco, howmanytimes ~ I!Wll
[doldidl You use it?00❑ Less than one time per day
III Time(s) per day
99CIDK--_-------------------------------------;____________________________________________
h. HaveyouEVER beenedvisedtostop using Ichewingtobecco bya-
Yes No DK
,(1) Madical doctor? I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 20 90 E42
(2) Dantist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I ID 20 90 43
& Nowlamgoingtoreada listofstatamentsaboutcigaretiesmoMng. Afterlreadeachone,pleasetall mewhetheryouagree,disagrae, or have no opinion.
I
I AGREE/YES DISAGREE/NO NO OPINION/DK&i.So many things cause cencer that it doesn’t
really mattar if you smoke la. ID 20 90 F—————-------————————————————————————————
b. Smoking by a pregnant woman may harm tha baby
;––––– ——————————————————————--——————————————-I b. ID 20 90 E
------------------------------------------------------------------------------------ -C. Thesmokefrom otherpeople’s cigarettesisharmful toyou I c. In 20 9CI E
I------------------------------------------------------------------------------------ -
d. Most daaths from LUNG CANCER are caused byclgaratte smoking id, In 20 90 E-------------------------------------------------------------------------------------
I0. Smoking should not be allowad in indoor public placas I e. 10 20 9CI E
__--------__---________---------_-------L____________________________________________
f. Evan if a parson has smoked for more than 20 years, there is a ~haakh banafit to quitting If. 10 20 90 E
Jotes
IM HIS.2B 13+921 Page 2
221
Section W – OTHER TOBACCO USE — Continued
6a. Do You think smoking is a habit, an addiction, neither, or both? ~ I ❑ HabitI 2 ❑ Addiction
3 ❑ NeitherI4 ❑ Both
I enDKI----------------------------------------t--------------------------------------- –––-
b. In generel, would You say that the smoke from other people’s I Lcigarettesisnotatallannoying toyou,somewhatannoyingto I o ❑ Not annoying at all
you, or very annoying to you7 1❑ Somewhat annoyingI
2 •l Very annoyingI 9CIDK
I
ITEM Refer to question 3, page 22, Section T, to
52
I I ❑ Smokes cigarettes now (7)
WIdetermine if SP smokes cigarettes no w. I a ❑ All other (8)
HAND CARD W. Read categories if telephone interview.~
I ❑ Light up a cigarette and smoke if you wish
7. Whenyouara inside apublicplace thathasnorules about20 Look around toseeif others aresmoking andthen light up
Ismoking, what ara you most likely to do?
s ❑ Ask if others would mindI
4 ❑ Just not smoke
Mark only one.I a ❑ Do something else (Specify) ~
1I
I 9DDK
8. Whenyou areinsidea public placathathas norulesabout I &
smoking and someone else lights up a cigarette, what ere you ~1❑ Ask person not to smoke
most likely to do — ask the person not to smoke, move eway, 2 ❑ Move awayI
do nothing, or something else? 3 ❑ Do nothingI a ❑ Do something else (Specify) ~
I
I9nDK
9. Does ANYONE smoke cigarettes, cigars, or pipes I ~
ANYWHERE INSIDE this home?1❑ Yes (70)
I 20NoI
}(Section X)9nDK
I
10. On an average waak day, how many people smoka anywhere ~~
msida this home? II Number of smokers
I9nDKI
11. On the average, about how many days par week is there I ~
smoking ANYWHERE INSIDE this homa? I o ❑ Less than one day per week/RarelyI 7 ❑ Every dayI
II Days per weekI (Number)I
9DDKI
Jotes
(a.. ,. 4.Page 28
FORMHl&.. ,.,---
222
ITEMI
xlRefer to SP’S “Wa/Wb” boxes in Cl on HIS-1.
I ❑ Wa or Wb box marked (kern X2)I
8 ❑ Other (Section Y)II,
ITEMI 59
Refar to SP’S 6g, page 44 or 45 on HIS- 1.I ❑ Entry of P, F, S, orL (1)
x2II 8 Q Other (SeCtiOn y)
1
These next questions are about smoking in the workplace. I ~1 I ❑ Yes (2)
1, Earlier [you told mrr/1was told] that you wara amployad during ~ 2 ❑ No (Section Y)
tha past two waaka. Is that corract? I 9❑ DK (2)
Za. Altogether, does your amployar have 50 or mora amployaes? ~ I ❑ Yes (2b) m
I
I }; : &; (2C)
——. .._ ———--—___________ . .. ——————————————
b. Doss your amployar hava 50 or more employeas at tha
+––––– ————————___— —______ ———___— ————————
I mbuilding or location whare you work?
I ❑ Yes (3)
I1 1::~;(2C)
----------------------------------------+---------------------------------------C. Does your employer hava 5 or more amployaes at the building f FI •l Yes
or location whara you work? I 20No9DDKI
I
3.
HAND CARD X 1. Read ALL categories if telephone interview.I
IWhich of thase best describes the area in which You workmost of tha timer? I
Mark only one.I
I
I
I
1I
I
I
I
01 ❑ Private enclosed office with doorIS&?!!
02❑ Enclosed office with door shared with one or more other persons03UCubicle04 ❑ Open area05 ❑ Classroom06 ❑ Hospital (not an office)oTalnahomeOfinlnonebuikiing, butnoregular work areaog❑ Mainly work outdoors
1
(5)
I o ❑ Travel to clifferent buildings or sitesII ❑ Ina motor vehicle (7)
98 ❑ Other (SpeCi@) ~
99DDK
aa. During the past 2 weeks, has anyone smokad in yourI
I ❑ Yes (4b)~
IMMEDIATE work area? II 20No
a❑ Did not work in past 2 weeksI J
(5)
I 9 ❑ DK (4b)
———_— ————————————————————————___— ———____b. During tha past 2 waaks, have you avar been bothered by
;–––– ———————————————————————————————————P
cigarette smoke in your immediata work area? / I ❑ Yes20No
I 9nDK
Si3. Does your employer hava an official policy that restrictsI ~
●rooking in any way? I ❑ Yes (5b)I20No
I 1~DDK(/tern X3)
I
---------_____________________--________L--------------------------------------- ____HAND CARD X2. Read ALL categories if telephone intarview. k
I I ❑ Notallowed in ANYindoor orcommon public areas
b. Which of thesa baat describes your amployar’a smoking I 2 ❑ Allowed in SOME public areas, including designated smoking areaspolicy for indoor public or common areas, such as lobbies,rest rooms, and lunch rooms?
3 ❑ Allowed in ALL indoor or common public areasI
Mark only one.4 ❑ Not applicable, no policy for these areas
I 9nDKI
-— —--- __-___ -— —____________ ————————____—HAND CARD X3. Raad ALL categories if telephone interview.
+–––––– —————————————————————————————————I E
1 ❑ Notallowed in ANY work areas(6)C, Which ofthaae bestdescribes youramployer’s emoking I
policy for work araas?2❑ Allowed in SOME work areaa (5d)
I 3 ❑ Allowed in ALL work areas (Item X3)
Mark only one. I 40 Nonapplicable, nopolicy fortheae areas9nDKI 1(5d)
—————————_______________________________d. lssmoking allowed in YOURimmetfiate workarea?
+––––––
1❑ IYes(/tern X3) m-
20No
}~nDK ‘6)
IMH18.2Ei[3.4-92) Page 2!
223
Section X – WORKPLACE TOBACCO SMOKE - Continued1
6a. Are there ever customers or clients in your work area, that is, I I ❑ Yes (6b)~
people who do not work for your employer? 20NoI
}
(Item X3)9nDK
———————--- —------------- —-- —------- —-— ——b. Are these people ellowed to smoke in your work area?
;----- _—— ———______ _________________
I I ❑ Yes m
20NoI9EIDK
I
7. Doas your amployar offar a stop smoking program or anyII I ❑ Yes (Item X3)
~
othar halp to amployeas who want to quit smoking? 20NoI 1(Section Y)9CIDK
/
ITEM Refer to question 3, pege 22, Section T,I I ❑ “Yes,” current smoker (8)
x3 to determine if SP IS e current smoker. I 2❑ “No,” former smoker (g)8 ❑ Other (Section Y)I
8a. Do you evar smoke during the tima you are at work?1 ~/ I ❑ Yes (8b)
20NoI
}sDI)K ‘8C)----------------------------------------L--------------------------------------- –––-HAND CARD X4. I I ❑ In my work area
E
77
b. Where?2❑ In a public area, such as a restroom, lunchroom, lobby,
7a
or other smoking area 79
Mark all that apply. 3❑ Outside the buildingao
4❑ Not applicable — 1work outside or at different sitesal
I 9nDK---------- ————————------ —————————————————————————————___________ ——————————-- ———— ——.
C. Do you fael that you smoka fewer cigarattas par day I •l Yes mbacause of your employar’s smoking policy? 20No
1ASK OR VERIFY: I I •l Yes
~
9. Hava you joinad any quit smoking programs at work in 20Nothe past yaar? 3❑ Quit more than 1 year ago
9CIDKI
Notes
ge 30 FORM HIS-2B (34-W
CARDB
01. Puerto Ricen
02. Cuben
03. Cuban Amarican
04. MexicanlMexicano
05. Mexican American
06. Chiceno
07. Hispano
08. Other Latin American
09. Othar Spanieh or Hispanic
10. American
11. Anglo American
88. Other (Specify)
. s,,1.,,,“,,,,, Pm,2
CARD F2
1. Eating more fiber
2. Eating Iaea sugar
3. Avoiding fooda with additives
4. Eating less fat
5. Eating less salt
6. Eating more fruit and vegetables
7. Taking vitamina
8. None of these changes would be helpful
.S.m,!!,,,,,!.,.”,, P,W,4
CARD H
A. What people eat or drink has little affecton whethar they will devalop majordiseasas.
OR
B. By eating the right kinds of foods,paople can reduce their chances ofdaveloping major diseases.
.
r>,.– –-–,
13
~[
$
PW,3-W, ,,”,, ,t.m$t
CARD GI
?2
01
,-------
,
i~
‘i
~j
,-
,
,
W8$?i ,!nz, ,,.1.,!, P,* ,5,
1. [ had no symptoms and it wasdetected during a routine chackup
2. 1noticed something was wrongand went to a doctor
3. I noticad somathing waswrong but did not talk to adoctor about it until my ragrdarphysical exam
8. It was detected in some otherway (Specify)
260
CARD G2
1. Internist, general practitioner
2. Cancer specialist (oncologist)
3. Generel Surgaon
4. Cancer Surgeon
5. Reconstructive Surgeon
6. Radiologist
8. Othar specialist (Specify)
,m..,!,!s!,4,!.!,,!, ,.,, ,,
CARD G4
1. I didn’t know it was evailabla
2. I didn’t want it
3. I didn’t think I naaded it
8. Some othar reason (Spec;fy)
,“,w,,,,,,,,!.,,,,, ,.O.,8
CARD G3
1. Surgary to remova the tumor
2. Radiation
3. Chemotherapy
4. Special diets
5. Salf haaling techniques,including imaging
8. Other (Specify)
.,
03,-------
!l,.,.
ii;S
-ml!!la.!loz.$,, P.,.t7
CARD G5
1. Ganaral information about cancer
2. Information about your specific typeof cancer
3. Cancar treatmant options
4. Coping with the physical side affectsof cancar treatment
5. Coping with the emotional effects ofcancer
8. Other (Specify)
.4
.s~.-.--
Ks;s;g
g-!4, ,,,,,,,!.,,,0 P.,.,, I*
261
CARD G6
1. American Cancer Sociaty
2. National Cancar Institute
3. The Cancer Information Sarvice:1 -800-4-CANCER
8. Othar
..-! .,,,,4!,>,,,,! ,+ 20
CARD JI
1. Employar
2. Union
3. Co-workers
4. Previoustraining/educetion
5. By resolingabout it
8. Other (Specify)
-la! !Wu,!!.,..!! m. 22
CARD G7
1. Yes - Cost to me increesed
2. Yes -My insurancewascencellador not renewed
8. Yes - Otherchange (Specify)
0. No - Did not chenge
ae
a7
,- . . . . .
~,n, ,,”.,,. -.!! ,.s.2, ~~
CARD J2
1. 8ecauseit doesn’twork properly
2. Beceuseit interfereswithjobperformance
3. Beceuseit isuncomfortable
4. BecauseI don’t know how to useit
5. Becauseit isnot needed
8. 8ome otherreason (Specify)
>,w-! ,,”. ,,.,,,!, ,’s. 2,.*
262
CARD KI
Television programs
Radio programs
Magazina articlas
Nawapaper articlas
Straat signs/billtroards
Stora displays/store distributedbrochuraa
Bus/straat car/subway displays
Haalth Dapartmant brochuras
Workplaca distributed brochuras
School rfistributad brochuras
Church distributed brochuras
Community organization
Friand/acquaintance
AIDS hotlina
Othar sourca (Specify)
Recaivad no AIDS information inthe past month
.,,,“,,,,,,,,,0,,,,, m, 2,
CARD K3
a. AZT can delay or slow down thasymptoms of AIDS virus infaction
b. AZT curas peopla with AIDS
c. AZT has no known sida affacta
d. AZT ia appropriate for a person with thaAIDS virus infaction ONLY at cartaintimes during the illness
e. There ara other drugs availabla to treatAIDS ralated illnassea
“’M,,,,,,,,!.,,,,, Paw28
.,CARD K2 ——
,_____
1. Very likely
2. Somewhat likely
3, Somawhat unlikely,
4. Very unlikely
5. Dafinitaly not possibla
;3p
I13
*W,,!”.,!.2..!! w. 26
CARD K4
a. You have hemophilia or another .s
blood clotting disorder and havareceived clotting factor
II.
concentrations einca 1977.-------
b. You ara a man who has had sex with ]another man at some time since1977, evan one time.
c. You have taken illagal druga by neadla+at any time sinca 1977.
d. You have had sax for money or drugsat any tima since 1977.
e. Sihce 1977, you ara or heve been ,-$
the aax partner of eny person who ,:could anawer “Yea” to any of the Xitems above on this cerd. j?
,$,
t
,
t
*W!,,”,!,!.,.,!, P,Q.27 ,
2ez
CARD 01
1. I havetwo or moreusueldoctorsorplacasdepanding on what iswrong
2. I havan’t naedtrda doctor/Don’t havaa doctor
3. My previousdoctor is no longeravailabla
4. No careisavailabla/Careistoo far away
5. ~~~’t beenablato find tha right
6. I don’t have insuranca/Can’t afford it
8, Othar reeson
**! ,,S!>,>l. -,!) M. 10
CARD Q2
1. Spanding too much time in the aun
2. Exceaeive drinking of elcoholic beveregea
3. Excessive coffee drinking
4. Smoking cigarettes, tigers, or * pipe
5. Uae of chewing tobacco or enuff
8. Something else (Specify)
9. Don’t know
mm,,,”,,,!.=,!) VW30
—
CARD QI
1. Beceuse of a specific oral problem
2. Follow-up to a previous oral problam
O*3. Part of a routine physical exam
al
~-- _____
4. Part of e routine dantal exam
8. Other (Specify)
j
~
13
,.sm,,,”,!,,.-. !, ,.W2s
CARD Q3
1. Because of a specific ekin problam
2. Follow-up to a previous skin problam
3. Part of a routine physical exam/As ascreening exam
a,
8. Othar (Specify) .3,.. ––---––
;2,5II:g~,!
,
-M!!!”,,,!.*,,, P* 31
264
CARD (I4
1. Get e severe sunburn withblisters
2. A severe sunburn for a fewdeys with peeling
3. Mildly burnad with comatanning
4. Turn darker without sunburn
5. W&g would happen in an
8, Other (Specify)
,,..,,,,,,,,!.,”,,, ,,,,32
CARD Q6
1. Because of a epecificgynecological problam
2. Follow-up to a praviousgynecological problem
3. Part of a routina physicel (orpregnancy) exam
8. Other (Specify)
“cm,,!,,,,,!.,.,,, ,.,03.
CARD Q5
1. Vary dark and daep[y tanned
2. Moderately tannad
3. Mildly tanned
4. Only frackled or no suntanat all
5. Rapeated sunburns m
as
8. Other (Specify)_...----
2:5:38~$
“MO!,,”>)>1.,..1! Ro..
CARD Q7
1. Becausa of a spacificbreaet problam
2. Follow-up to a previousbraast problam
3. 8aseihre mammogram
4. Part of a routina physicalaxam/As a scraening test
8. Othar (Specify)
as
a7
~-------
ii
ij
,-
mtd ,>SWcm.2..!, m. m(
I
265
CARD Q8
1. Because of a specificbreast problem
2. Follow-up to a previousbreast problem
3. Part of a routine physical (orpragntmcy) exam
8. Othar (Specify)
“sWii”mr!.>,m ,* .?4
CARD QI O
1. Because of a spacifichaalth problam
2. Follow-up to a pravioushaalth problam
3. Part of a routina physicalaxam/As a scraaning tast
8. Othar (Specify)
WHO!,!”1,,,.,,,1! ,.C.3,
CARD Q9
1. Bacause of a specificchest problem
2. Follow-up to a praviouschest problem
3. Part of a routine physicalexamlAs a scraening test
4. For employment raasons
5. 8acausa of hospitalization
8. Othar (Specify)
m
as,--------
:.K
~~
ia
,4s.37*IO, mm !!.*.,!
CARD S1
1. Heart disease
2. AIDS
3. Diabatae
4. Cancer
0,0
●1
~... -.. .
,I
:ZIS
X
g
,-
-IO! won !m.m,!, P.w as
,
266
CARD S2
A. Personal behaviors, such assmoking or eating habits.
OR
B. Factors you hava little controlover, such as anvironmantalpollution or family history.
.*M,,,,,,,,!.,.,,, w.40
CARD S4
1. Increasing aga
2. High fat diet
3. Low fibar diat
4. Smoking
5. Family history
6. Having multipla aaxualpartrrars
0. Nona of theaa
WW!,!”,,,!.,..i! P,,.42
CARD S3
1. Good
2. Fair
3. Poor
4. Don’t knowlNot sura
S*
s.
~...-.-_
-,,,”. ,!.-.>!m.,
CARD U1
1.1 stoppad on purpose
2. I could not smokebacause i was sick
S. I could not smoke forsoma other raasaon
s.
267
CARD U2
1. Concern about my futura health
2. Concern about my health at thetime
3. Pressure from family and friands
4. Cost of cigarettes
5. Pragnancy
8. Some other reason (Specify)
.$ IO,,,,,:, !,C.,,,,, Po$l 44
CARD Xl
01. Private enclosad office with door
02. Enclosed office with door sharedwith ona or more other persone
03. Cubicla
04. Open area
05. Classroom
06. Hospitel (not an offica)
07. In a home
08. In ona building, but no regularwork area
09. Mainly work outdoora
10. Traval to different buildings orsitas
11. In a motor vefricla
98. Other (Specify)
.,!0, ,,,,,, !!.,,,,, P,,. 46
CARD W
1. Light up a cigaratte andsmoke if you wish
2. Look around to sae if othersare smoking and than light up
3. Ask if othars would mind
4. Just not smoka
8. Something else (Specify)
“2
w~=. . . .
PW45 $H514, ,,,,,,,!*,*.!!
,1,~
CARD X2
1. Not allowad in ANY indoor orcommon public areas
2. Allowad in SOME publicaraas, including designatedsmoking araas
3. Allowed in ALL indoor orcommon public araas
4. Not applicable, no policy for ;3these areas IR
R~{
,
,
xl
*M, ,!”1,,!.,M!, %.,7
X*
268
CARD X3
1. Not allowad in ANY work areas
2. Allowed in SOME work areas
3. Allowed in ALL work areas
4. Not applicable, no policy forthasa areas
.,,,,,,,,,,,,.,,,,, W,48
MEDICARE
-m!,,,,1,,!.”.,!, P,,.50
Health @ ? Insurance
0 ., . ...0.... . . .“.., ., .,H,,,C*.”.loh. Q. wbl ‘c<LA!. . . ...” *EX
0<1<1-,1,34,1”0-), b,,, ,,E
,. .“,,,.,. TO .,,,.,,”. 0.,.
H“, p,,.1 ,.3”,,.., 7.,.M
Mod’, ,1 ,n, uranc. ,-1+0
.!..
.,”, o&L Q.@4&i
x,
CARD X4 x.. . . . . . .
1. In my work area
2. In a public area such as arastroom, lunchroom, lobby, orothar smoking area
3. Outside tha building
4. Not epplicabla -1 workoutside or at diffarant sitee
,-‘~;$j13
S-! ,!l$.!!.>.$!l ,.,..,
STATE NAMES FOR MEDICAID
MEDI – CAL
California
MEDI – KANM-—
Kansas pmum
~.......
HEALTH CARE COST CONTAINMENTSYSTEM (HCCCS)
Arizona
MEDICAL ASSISTANCE
All other States
~~~~
1$:3
t
,
I,
..m!,!$$,,rm.!.s!! ,.,0 ,!
●U.S.wm PrhtlngOftiw 1993- 301.019/80018269
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