Update CHIS 2007 Questionnaire

Attachment 2
CHIS 2007 Cancer Control Module (CCM) and
Demographic Core Questionnaire Items

1

CALIFORNIA HEALTH INTERVIEW SURVEY 2007
OMB No. 0925-XXXX
Expires: XX-XX-200X
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to: NIH Project Clearance Branch, 6705 Rockledge Dr., MSC 7974, Bethesda, MD 20892-7974,
Attn: PRA (0925-XXXX). Do not return the completed form to this address.

TABLE OF CONTENTS
ADULT QUESTIONNAIRE
MODULE A – CANCER SCREENING ...................................................................................................... 3
MODULE D – WOMEN’S HEALTH, HPV, HRT.................................................................................. 110
MODULE H – DISCRIMINATION .......................................................................................................... 15
DEMOGRAPHICS ..................................................................................................................................... 21
EMPLOYMENT, INCOME, AND POVERTY STATUS ......................................................................... 36
MODULE B–HPV (ADOLESCENT) ........................................................................................................ 43
DEMOGRAPHICS (ADOLESCENT) ....................................................................................................... 44

2

MODULE A – CANCER SCREENING
PROGRAMMING NOTE QA07_D1
IF AAGE < 40 OR [AA2A = 1 (BETWEEN 18 AND 29) OR 2 (BETWEEN 30 AND 39)] OR
ENUM.AGE < 40 OR AGE IS UNKNOWN, GO TO QA07_D25;
ELSE CONTINUE WITH QA07_D1
QA07_A1

Have you ever had a Sigmoidoscopy or Colonoscopy? These are exams in which a health
care professional inserts a tube into the rectum to look for signs of cancer or other problems.
[IF NEEDED, SAY: "For a Sigmoidoscopy a flexible tube is inserted into the rectum to
look for problems. A Colonoscopy is similar, but uses a longer tube, and you are usually
given medication through a needle in your arm to make you sleepy and told to have
someone else drive you home. ”]

YES...........................................................................1
NO.............................................................................2 [GO TO QA07_D8]
REFUSED............................................................... -7 [GO TO QA07_D8]
DON'T KNOW ....................................................... -8 [GO TO QA07_D8]
QA07_A2

How long ago did you have your most recent exam?
A YEAR AGO OR LESS .........................................1
MORE THAN 1 YEAR AGO UP TO
2 YEARS AGO.........................................................2
MORE THAN 2 YEARS AGO UP TO
3 YEARS AGO.........................................................3
MORE THAN 3 YEARS AGO UP TO
5 YEARS AGO.........................................................4
MORE THAN 5 YEARS AGO UP TO
10 YEARS AGO.......................................................5
MORE THAN 10 YEARS AGO ..............................6
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

QA07_A3

Did you have this exam…
AS PART OF A ROUTINE PHYSICAL EXAM
OR SCREENING TEST,..........................................1
BECAUSE OF A SPECIFIC PROBLEM, OR.........2
AS A FOLLOW-UP TO AN EARLIER TEST
OR SCREENING EXAM? .......................................3
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

3

QA07_A4

Was this MOST RECENT exam a sigmoidoscopy, colonoscopy, or something else?
[IF NEEDED, SAY: "For a SIGMOIDOSCOPY, a flexible tube is inserted into the rectum
to look for problems. A COLONOSCOPY is SIMILAR, but uses a longer tube, and you
are usually given medication through a needle in your arm to make you sleepy, and told to
have someone else drive you home]
SIGMOIDOSCOPY..................................................1
COLONOSCOPY.....................................................2
SOMETHING ELSE ................................................3
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA07_D8:
IF [QA07_D1 = 2 (NEVER HAD SIGMOIDOSCOPY OR COLONOSCOPY)], CONTINUE WITH
QA07_D8 AND DISPLAY "NEVER had";
ELSE IF QA07_D5 = 0 (NONE IN LAST 10 YEARS) OR QA07_D2 = 6 (MOST RECENT OVER 10
YEARS AGO), CONTINUE WITH QA07_D8 AND DISPLAY "NOT had" AND "in the last 10 years";
ELSE GO TO QA07_D9
QA07_A5

During the past 12 months has a doctor or other health professional recommended that you
have a sigmoidoscopy or colonoscopy?
YES...........................................................................1
NO.............................................................................2
DID NOT GO TO DOCTOR IN
PAST 12 MONTHS................................................92
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

QA07_A6

What is the ONE most important reason why you have {NEVER had/NOT had} one of
these exams {in the last 10 years}?
NO REASON/NEVER THOUGHT ABOUT IT .....1
DIDN'T KNOW I NEEDED THIS TYPE OF TEST2
DOCTOR DIDN'T TELL ME I NEEDED IT ..........3 [GO TO QA07_D10]
HAVEN'T HAD ANY PROBLEMS........................4
PUT IT OFF/LAZINESS..........................................5
TOO EXPENSIVE/NO INSURANCE/COST .........6
TOO PAINFUL, UNPLEASANT, OR
EMBARRASSING ...................................................7
HAD ANOTHER TYPE OF COLORECTAL EXAM 8
DON'T HAVE A DOCTOR .....................................9
OTHER ...................................................................91
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

QA07_A7

The following questions are about the blood stool or occult blood test, a test to determine
whether you have blood in your stool or bowel movement. The blood stool test can be

4

done at home using a kit. You smear a small amount of stool on cards at home and send
the cards back to the doctor or lab.
Have you ever done a blood stool test, using a HOME test kit?
YES...........................................................................1
NO.............................................................................2 [GO TO QA07_D16]
REFUSED............................................................... -7 [GO TO QA07_D17]
DON'T KNOW ....................................................... -8 [GO TO QA07_D17]
QA07_A8

How long ago did you do your most recent HOME blood stool test?
A YEAR AGO OR LESS .........................................1
MORE THAN 1 YEAR AGO UP TO
2 YEARS AGO.........................................................2
MORE THAN 2 YEARS AGO UP TO
3 YEARS AGO.........................................................3
MORE THAN 3 YEARS AGO UP TO
5 YEARS AGO.........................................................4
MORE THAN 5 YEARS AGO ................................5
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

QA07_A9

Did you take this test…
AS PART OF A ROUTINE PHYSICAL EXAM
OR SCREENING TEST,..........................................1
BECAUSE OF A SPECIFIC PROBLEM, OR.........2
AS A FOLLOW-UP TO AN EARLIER TEST
OR SCREENING EXAM? .......................................3
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA07_D16:
IF QA07_D10 = 2 (NEVER HAD HOME STOOL TEST), CONTINUE WITH QA07_D16 AND
DISPLAY "NEVER had";
ELSE IF QA07_D11 > 1 (NONE IN PAST YEAR), CONTINUE WITH QA07_D16 AND DISPLAY
"NOT had" and "in the past year";
ELSE GO TO QA07_D17
QA07_A10

What is the most important reason you have {NEVER had /NOT had} a HOME blood
stool test {in the past year}?
NO REASON/NEVER THOUGHT ABOUT IT .....1
DIDN'T NEED/DIDN'T KNOW I NEEDED
THIS TYPE OF TEST..............................................2
DOCTOR DIDN'T TELL ME I NEEDED IT ..........3 [GO TO PN QA07_D18]
HAVEN'T HAD ANY PROBLEMS........................4
PUT IT OFF/LAZINESS......................……………5
TOO EXPENSIVE/NO INSURANCE/COST .........6

5

TOO PAINFUL, UNPLEASANT,
EMBARRASSING…… ...........................................7
HAD ANOTHER TYPE OF COLORECTAL
EXAM….............................................................…..8
DON'T HAVE A DOCTOR .....................................9
OTHER ...................................................................91
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8
QA07_A11

In the past 12 months, has a doctor or other health professional recommended that you
have a home blood stool test?
YES...........................................................................1
NO.............................................................................2
DID NOT GO TO DOCTOR
IN PAST 12 MONTHS...........................................92
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA07_D18:
IF FEMALE GO TO PN QA07_D25;
IF MALE AND [AGE < 40 OR BETWEEN 18 AND 29 OR BETWEEN 30 AND 39 OR ENUM.AGE <
45 OR IF AGE IS UNKNOWN], GO TO QA07_D25;
ELSE CONTINUE WITH QA07_D18
QA07_A12

Have you ever HEARD OF a PSA or "prostate-specific antigen" test to detect prostate
cancer? A PSA test is a blood test to detect prostate cancer.
YES...........................................................................1
NO.............................................................................2 [GO TO QA07_D25]
REFUSED............................................................... -7 [GO TO QA07_D25]
DON'T KNOW ....................................................... -8 [GO TO QA07_D25]

QA07_A13

Have you ever HAD a PSA test?
YES...........................................................................1
NO.............................................................................2 [GO TO QA07_D25]
REFUSED............................................................... -7 [GO TO QA07_D25]
DON'T KNOW ....................................................... -8 [GO TO QA07_D25]

QA07_A14

How long ago did you have your most recent PSA test?
A YEAR AGO OR LESS .........................................1
MORE THAN 1 YEAR AGO UP TO
2 YEARS AGO.........................................................2
MORE THAN 2 YEARS AGO UP TO
3 YEARS AGO.........................................................3
MORE THAN 3 YEARS AGO UP TO
5 YEARS AGO.........................................................4
MORE THAN 5 YEARS AGO ................................5

6

REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA07_D34:
IF QA07_D32 = 8, SET QA07_D34 = 1 AND GO TO PROGRAMMING NOTE QA07_D35;
ELSE CONTINUE WITH QA07_D34
QA07_A15

Have you had a hysterectomy?
[IF NEEDED, SAY: "A hysterectomy is when the uterus or womb is removed, not just
having your tubes tied to prevent pregnancy."]
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA07_D35:
IF QA07_D32 = 8 (HYSTERECTOMY), DISPLAY "You said that you had a hysterectomy. Were your
ovaries removed?";
ELSE IF QA07_D34 = 1 (YES, HAD A HYSTERECTOMY), DISPLAY "Were your ovaries
removed?";
ELSE DISPLAY "Have you had an operation to have your ovaries removed?"
QA07_A16

{You said that you had a hysterectomy. Were your ovaries removed?/Were your ovaries
removed?/Have you had an operation to have your ovaries removed?}
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA07_D26:
IF MALE, GO TOQA07_E1; IF FEMALE CONTINUE WITH QA07_D26
QA07_A17

Have you ever had a Pap smear test to check for cervical cancer?
[IF NEEDED, SAY: "A pap smear is a routine cancer test for women in which the doctor
examines the cervix during a gynecological exam, and takes a cell sample from the cervix
with a small stick or brush and sends it to the lab. This is not a test for detecting sexually
transmitted diseases."]
YES...........................................................................1
NO.............................................................................2 [GO TO QA07_D32]
REFUSED............................................................... -7 [GO TO QA07_D33]
DON'T KNOW ....................................................... -8 [GO TO QA07_D33]

7

QA07_A18

How many Pap smear tests have you had in the last 6 years?
_____ PAP SMEARS
................... [HR: 0-99]
NONE .......................................................................0
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

QA07_A19

How long ago did you have your most recent Pap smear test?
A YEAR AGO OR LESS .........................................1
MORE THAN 1 UP TO 2 YEARS AGO.................2
MORE THAN 2 UP TO 3 YEARS AGO.................3
MORE THAN 3 UP TO 5 YEARS AGO.................4
MORE THAN 5 YEARS AGO ................................5
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

[GO TO PN QA07_A23]
[GO TO PN QA07_A23]

[GO TO PN QA07_A23]
[GO TO PN QA07_A23]

IF AD4 = 1 (Ever had a Pap test) and AD12= 2, -7, or -8 (Did not have a hysterectomy)
CONTINUE WITH QA07_A20;
QA07_A20

Have you ever had a Pap smear test where the results were NOT normal?

YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8
QA07_A21

What is the ONE most important reason why you have {NEVER had a Pap smear/NOT
had a Pap smear in the last 3 years}?
NO REASON/NEVER THOUGHT ABOUT IT .....1
DIDN'T KNOW I NEEDED THIS TYPE OF TEST2
DOCTOR DIDN'T TELL ME I NEEDED IT ..........3 [GO TO PN QA07_D34]
HAVEN'T HAD ANY PROBLEMS........................4
PUT IT OFF/LAZINESS..........................................5
TOO EXPENSIVE/NO INSURANCE/COST .........6
TOO PAINFUL, UNPLEASANT,
OR EMBARRASSING.............................................7
HYSTERECTOMY ..................................................8
DON'T HAVE A DOCTOR .....................................9
OTHER ...................................................................91
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

QA07_A22

In the past year, has a doctor or other health professional recommended that you have a
Pap smear?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

8

QA07_A23

Have you ever had a mammogram?
[IF NEEDED, SAY: "A mammogram is an x-ray taken of each breast
separately by a machine that flattens or squeezes each breast."]
YES...........................................................................1
NO.............................................................................2
[READ DEFINITION, IF STILL NO, GO TO PN QA07_E24]
REFUSED............................................................... -7 [GO TO PN QA07_E27]
DON'T KNOW ....................................................... -8 [GO TO PN QA07_E27]

PROGRAMMING NOTE QA07_D36:
IF AAGE < 30 OR AA2A = 1 (BETWEEN 18 AND 29) OR ENUM.AGE < 30, GO TO NEXT
SECTION;
ELSE IF RESPONDENT REPORTED HAVING A MAMMOGRAM, CONTINUE WITH QA07_D37
QA07_A24

How many mammograms have you had in the last 6 years? Your best estimate is fine.
_____ MAMMOGRAMS
[HR: 0-99]
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

QA07_A25

How long ago did you have your most recent mammogram?
A YEAR AGO OR LESS .........................................1
MORE THAN 1 UP TO 2 YEARS AGO.................2
MORE THAN 2 UP TO 3 YEARS AGO.................3
MORE THAN 3 UP TO 5 YEARS AGO.................4
MORE THAN 5 YEARS AGO ................................5
REFUSED.................................................................7
DON'T KNOW ....................................................... -8

[GO TO QA07_4]
[GO TO QA07_E24]
[GO TO QA07_E24]
[GO TO PN QA07_E27]
[GO TO PN QA07_E27]

PROGRAMMING NOTE QA07_D44:
IF RESPONDENT NEVER HAD A MAMMOGRAM, CONTINUE WITH QA07_D44 AND DISPLAY
"NEVER had a mammogram";
ELSE IF RESPONDENT’S MOST RECENT MAMMOGRAM MORE THAN 2 YEARS AGO OR DK,
CONTINUE WITH QA07_D44 AND DISPLAY "NOT had a mammogram in the past 2 years";
ELSE GO TO QA07_D45
QA07_A26

What is the ONE most important reason why you have {NEVER had a mammogram/NOT
had a mammogram in the past 2 years}?
NO REASON/NEVER THOUGHT ABOUT IT ....... 1
DIDN'T KNOW I NEEDED THIS TYPE OF TEST. 2
DOCTOR DIDN'T TELL ME I NEEDED IT............ 3 [GO TO NEXT SECTION]
HAVEN'T HAD ANY PROBLEMS ......................... 4
PUT IT OFF/LAZINESS ........................................... 5
TOO EXPENSIVE/NO INSURANCE/COST ........... 6
TOO PAINFUL, UNPLEASANT,
EMBARRASSING..................................................... 7

9

TOO YOUNG ............................................................ 8
DON'T HAVE A DOCTOR....................................... 9
OTHER..................................................................... 91
REFUSED .................................................................-7
DON'T KNOW..........................................................-8
QA07_A27

In the past 12 months, has a doctor or other health professional recommended that you
have a mammogram?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA07_E13:
IF AAGE < 30 OR QA07_A4 = 1 (BETWEEN 18 AND 29) OR ENUM.AGE < 30, GO TO QAO5_F1;
ELSE CONTINUE WITH QA07_E13 (INCLUDE WOMEN WITH AGE UNKNOWN)
Mammography
QA07_A28
In the past 12 months, has a doctor examined your breasts for lumps?
AF37
[IF NEEDED, SAY: “This is when a doctor touches your breasts to check for
bumps, cysts, or abnormal growth.”]
YES ..................................................................................................1
NO....................................................................................................2
REFUSED.......................................................................................-7
DON’T KNOW...............................................................................-8

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MODULE D – WOMEN’S HEALTH, HPV, HRT

PROGRAMMING NOTE QA07_D31;
IF QA07_A5 = 1 (MALE) OR AGE>65, GO NEXT SECTION;
ELSE CONTINUE QA07_D31.
QA07_D31

Have you ever heard of HPV? HPV stands for Human Papillomavirus.
YES...................................................................... 1
NO........................................................................ 2 [GO TO QA07_D39]
DON’T KNOW ................................................... -7 [GO TO QA07_D39]
REFUSED............................................................ -8 [GO TO QA07_D39]

QA07_D32

Where did you heard about HPV?
A doctor, nurse or other health care professional .............
Family or friends...............................................................
Newspaper or magazine ...................................................
Saw an ad on television ....................................................
Television news ................................................................
Internet ..............................................................................
Other .................................................................................
DON’T KNOW ................................................................
REFUSED.........................................................................

QA07_D33

1
2
3
4
5
6
7
-7
-8

Do you think HPV can cause cervical cancer?
YES................................................................................... 1
NO..................................................................................... 2
DON’T KNOW ................................................................ -7
REFUSED......................................................................... -8

QA07_D34

Do you think HPV can be sexually transmitted?
YES................................................................................... 1
NO..................................................................................... 2
DON’T KNOW ................................................................ -7
REFUSED......................................................................... -8

QA07_D36

Do you think HPV usually goes away on its own?
YES................................................................................... 1
NO..................................................................................... 2
DON’T KNOW ................................................................ -7
REFUSED......................................................................... -8

11

QA07_D37

Do you think HPV causes AIDS?
YES................................................................................... 1
NO..................................................................................... 2
DON’T KNOW ................................................................ -7
REFUSED......................................................................... -8

PROGRAMMING NOTE HPV VACCINE SECTION;
IF SC13A = FEMALE CHILD IN HOUSEHOLD AGE>8, CONTINUE QA07_D39.
IF QA07_A5 = 2 (FEMALE) AND AGE<65, CONTINUE QA07_D39.
QA07_D39

Have you ever heard of a vaccine or shot to prevent cervical cancer?
YES................................................................................... 1
NO..................................................................................... 2 [SKIP TO D40]
DON’T KNOW ................................................................ -7 [SKIP TO D40]
REFUSED......................................................................... -8 [SKIP TO D40]

IF QA07_A5 = 2 (FEMALE) AND AGE<65, CONTINUE QA07_D39a.
IF SC13A = FEMALE CHILD IN HOUSEHOLD AGE>8 AND QA07_A5=1, SKIP TO QA07_D39b.
QA07_D39a Have you ever received the HPV vaccine or shot?
YES ................................................................................... 1 [SKIP TO NEXT SECTION]
NO .................................................................................... 2 [GO TO D40]
DON’T KNOW ............................................................... -7 [SKIP TO NEXT SECTION]
REFUSED......................................................................... -8 [SKIP TO NEXT SECTION]
QA07_D39b Has your daughter ever received the HPV vaccine or shots?
YES .................................................................................... 1 [SKIP TO NEXT SECTION]
NO ...................................................................................... 2 [GO TO PN D40]
DON’T KNOW ................................................................. -7[SKIP TO NEXT SECTION]
REFUSED........................................................................... -8[SKIP TO NEXT SECTION]

IF SC13A = FEMALE CHILD IN HOUSEHOLD AGE>8
SKIP TO QA07_D42.
QA07_D40 A vaccine, or shot that protects against HPV, a virus that can cause cervical cancer, was
recently approved for girls and women ages 9 to 26. Would you be interested in getting the
vaccine?
YES................................................................................... 1 [GO TO QA07_D44]
NO..................................................................................... 2 [GO TO QA07_D41]
NOT SURE ....................................................................... 3 [GO TO QA07_D41]
DON’T KNOW ................................................................ -7 [GO TO QA07_D41]
REFUSED......................................................................... -8 [GO TO QA07_D41]
QA07_D41 What is the MAIN reason you would NOT want to get the vaccine?
Does not need vaccine............................................................. 1 [SKIP TO NEXT SECTION]
Not sexually active .................................................................. 2 [SKIP TO NEXT SECTION]
12

Too expensive.......................................................................... 3 [GO TO QA07_D45]
Too young for vaccine ............................................................. 4 [SKIP TO NEXT SECTION]
Doctor didn’t recommend it..................................................... 5 [SKIP TO NEXT SECTION]
Worried about safety of vaccine.............................................. 6 [SKIP TO NEXT SECTION]
Don’t know where to get vaccine............................................ 7 [SKIP TO NEXT SECTION]
My spouse/family member is against it................................... 8 [SKIP TO NEXT SECTION]
Other........................................................................................ 9 [SKIP TO NEXT SECTION]
DON’T KNOW ....................................................................... -7 [SKIP TO NEXT SECTION]
REFUSED ............................................................................... -8 [SKIP TO NEXT SECTION]
QA07_D42 A vaccine, or shot that protects against HPV, a virus that can cause cervical cancer was recently
approved for girls and women ages 9 to 26. If your daughter’s doctor recommended that she get
the HPV vaccine, would you let her get it?
YES................................................................................... 1
NO..................................................................................... 2
DON’T KNOW ................................................................ -7
REFUSED......................................................................... -8
QA07_D43 What is the MAIN reason you would NOT want your daughter to get the vaccine?
Does not need vaccine............................................................. 1 [SKIP TO NEXT SECTION]
Not sexually active .................................................................. 2 [SKIP TO NEXT SECTION]
Too expensive.......................................................................... 3 [GO TO QA07_D45]
Too young for vaccine ............................................................. 4 [SKIP TO NEXT SECTION]
Doctor didn’t recommend it..................................................... 5 [SKIP TO NEXT SECTION]
Worried about safety of vaccine.............................................. 6 [SKIP TO NEXT SECTION]
Don’t know where to get vaccine............................................ 7 [SKIP TO NEXT SECTION]
My spouse/family member is against it................................... 8 [SKIP TO NEXT SECTION]
Other........................................................................................ 9 [SKIP TO NEXT SECTION]
DON’T KNOW ....................................................................... -7 [SKIP TO NEXT SECTION]
REFUSED ............................................................................... -8 [SKIP TO NEXT SECTION]
QA07_D44. It is anticipated that the cost of the vaccine required to prevent HPV infection will be $360 total
for the series of three shots. Would you get this vaccine if you had to pay all of this cost?
YES................................................................................... 1
NO..................................................................................... 2
DON’T KNOW ................................................................ -7
REFUSED......................................................................... -8
QA07_D45 If all or most of the costs were covered, would you get the vaccine?
YES................................................................................... 1
NO..................................................................................... 2
DON’T KNOW ................................................................ -7
REFUSED......................................................................... -8
PROGRAMMING NOTE QA07_E27
IF AGE>39 AND AD13=2 THEN CONTINUE WITH QA07_E27

13

ELSE GO TO QA07_E31
Hormone Replacement Therapy
QA07_E27
Are you currently taking hormone replacement therapy or HRT?
AD28
YES...........................................................................1
NO.............................................................................2
REFUSED...............................................................-7
DON'T KNOW ....................................................... -8
QA07_E28

[GO TO QA07_E31]

Since you first started, altogether, how long have you been taking hormone replacement
therapy?
A YEAR AGO OR LESS .........................................1
MORE THAN 1 UP TO 2 YEARS ..........................2
MORE THAN 2 UP TO 4 YEARS ..........................3
MORE THAN 4 UP TO 8 YEARS .........................4
MORE THAN 8 YEARS AGO ................................5
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

14

MODULE H – DISCRIMINATION
QA07_H1

These next questions are about events that happen to you in your day-to-day life.
About how often in your day-to-day life are you treated with less courtesy than other peopleWould you say almost everyday, at least once a week, a few times a month, a few times a year,
less than once a year?
ALMOST EVERYDAY .............................................................1
AT LEAST ONCE A WEEK .....................................................2
A FEW TIMES A MONTH........................................................3
A FEW TIMES A YEAR ...........................................................4
LESS THAN ONCE A YEAR ...................................................5
NEVER .......................................................................................6
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H2

About how often in your day-to-day life are you treated with less respect than other peopleWould you say almost everyday, at least once a week, a few times a month, a few times a year,
less than once a year?
ALMOST EVERYDAY .............................................................1
AT LEAST ONCE A WEEK .....................................................2
A FEW TIMES A MONTH........................................................3
A FEW TIMES A YEAR ...........................................................4
LESS THAN ONCE A YEAR ...................................................5
NEVER .......................................................................................6
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H3

About how often in your day-to-day life do you receive poorer service than other people at
restaurants or stores?
ALMOST EVERYDAY .............................................................1
AT LEAST ONCE A WEEK .....................................................2
A FEW TIMES A MONTH........................................................3
A FEW TIMES A YEAR ...........................................................4
LESS THAN ONCE A YEAR ...................................................5
NEVER .......................................................................................6
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H4

About how often in your day-to-day life do people act as if they think you are not smart?
ALMOST EVERYDAY .............................................................1
AT LEAST ONCE A WEEK .....................................................2
A FEW TIMES A MONTH........................................................3
A FEW TIMES A YEAR ...........................................................4
LESS THAN ONCE A YEAR ...................................................5
NEVER .......................................................................................6

15

DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8
QA07_H5

About how often in your day-to-day life do people act as if they are afraid of you?
ALMOST EVERYDAY .............................................................1
AT LEAST ONCE A WEEK .....................................................2
A FEW TIMES A MONTH........................................................3
A FEW TIMES A YEAR ...........................................................4
LESS THAN ONCE A YEAR ...................................................5
NEVER .......................................................................................6
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H6

About how often in your day-to-day life do people act as if they think you are dishonest?
ALMOST EVERYDAY .............................................................1
AT LEAST ONCE A WEEK .....................................................2
A FEW TIMES A MONTH........................................................3
A FEW TIMES A YEAR ...........................................................4
LESS THAN ONCE A YEAR ...................................................5
NEVER .......................................................................................6
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H7

About how often in your day-to-day life do people act as if you are not as good as they are?
ALMOST EVERYDAY .............................................................1
AT LEAST ONCE A WEEK .....................................................2
A FEW TIMES A MONTH........................................................3
A FEW TIMES A YEAR ...........................................................4
LESS THAN ONCE A YEAR ...................................................5
NEVER .......................................................................................6
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H8

About how often in your day-to-day life are you called names or insulted?
ALMOST EVERYDAY .............................................................1
AT LEAST ONCE A WEEK .....................................................2
A FEW TIMES A MONTH........................................................3
A FEW TIMES A YEAR ...........................................................4
LESS THAN ONCE A YEAR ...................................................5
NEVER .......................................................................................6
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H9

About how often in your day-to-day life are you threatened or harassed?
ALMOST EVERYDAY .............................................................1
AT LEAST ONCE A WEEK .....................................................2

16

A FEW TIMES A MONTH........................................................3
A FEW TIMES A YEAR ...........................................................4
LESS THAN ONCE A YEAR ...................................................5
NEVER .......................................................................................6
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8
QA07_H10

What do you think was the main reason for this/these experience(s)? Would you say…?
YOUR ANCESTRY/NATIONAL ORIGIN/ETHNICITY ........1
YOUR GENDER OR SEX.........................................................2
YOUR RACE .............................................................................3
YOUR AGE................................................................................4
YOUR HEIGHT .........................................................................5
YOUR SKIN COLOR ................................................................6
YOUR SEXUAL ORIENTATION ............................................7
YOUR WEIGHT ........................................................................8
YOUR INCOME OR EDUCATIONAL LEVEL.......................9
OTHER (SPECIFY);____________________...........................91
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H11

How often do people dislike you because you are [race/ethnic group] -- often, sometimes, rarely
or never?
OFTEN ......................................................................................1
SOMETIMES ............................................................................2
RARELY ...................................................................................3
NEVER ......................................................................................4
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H12 How often do people treat you unfairly because you are [race/ethnic group] -- often, sometimes,
rarely or never?
OFTEN ......................................................................................1
SOMETIMES ............................................................................2
RARELY ...................................................................................3
NEVER ......................................................................................4
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8
QA07_H13

How often have you seen friends treated unfairly because they are [race/ethnic group] -- often,
sometimes, rarely or never?
OFTEN ......................................................................................1
SOMETIMES ............................................................................2
RARELY ...................................................................................3
NEVER ......................................................................................4
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

17

QA07_H14

If you feel you have been treated unfairly, do you usually:
ACCEPT IT AS A FACT OF LIFE...........................................1
TRY TO DO SOMETHING ABOUT IT ..................................2
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H15

If you have been treated unfairly, do you usually:
TALK TO OTHER PEOPLE ABOUT IT .................................1
KEEP IT TO YOURSELF.........................................................2
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H16

Have you ever experienced discrimination, been prevented from doing something, or been
hassled or made to feel inferior in any of the following situations because of your race,
ethnicity, or color?
At school?
YES............................................................................................ 1
NO.............................................................................................. 2
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H17

How many times did this happen?
ONCE ........................................................................................1
TWO OR THREE TIMES .........................................................2
FOUR OR MORE TIMES.........................................................3
DON’T KNOW .........................................................................-7
REFUSED..................................................................................-8

QA07_H18

Getting hired or getting a job?
YES............................................................................................ 1
NO.............................................................................................. 2
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H19

How many times did this happen?
ONCE ........................................................................................1
TWO OR THREE TIMES .........................................................2
FOUR OR MORE TIMES.........................................................3
DON’T KNOW .........................................................................-7
REFUSED..................................................................................-8

QA07_H20.

At work?
YES............................................................................................ 1

18

NO.............................................................................................. 2
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8
QA07_H21

How many times did this happen?
ONCE ........................................................................................1
TWO OR THREE TIMES .........................................................2
FOUR OR MORE TIMES.........................................................3
DON’T KNOW .........................................................................-7
REFUSED..................................................................................-8

QA07_H22

Getting housing?
YES............................................................................................ 1
NO.............................................................................................. 2
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H23

How many times did this happen?
ONCE ........................................................................................1
TWO OR THREE TIMES .........................................................2
FOUR OR MORE TIMES.........................................................3
DON’T KNOW .........................................................................-7
REFUSED..................................................................................-8

QA07_H24

Getting medical care?
YES............................................................................................ 1
NO.............................................................................................. 2
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H25

How many times did this happen?
ONCE ........................................................................................1
TWO OR THREE TIMES .........................................................2
FOUR OR MORE TIMES.........................................................3
DON’T KNOW .........................................................................-7
REFUSED..................................................................................-8

QA07_H26

Getting service in a store or restaurant?
YES............................................................................................ 1
NO.............................................................................................. 2
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H27

How many times did this happen?

19

ONCE ........................................................................................1
TWO OR THREE TIMES .........................................................2
FOUR OR MORE TIMES.........................................................3
DON’T KNOW .........................................................................-7
REFUSED..................................................................................-8
QA07_H28

Getting credit, bank loans, or a mortgage?
YES............................................................................................ 1
NO.............................................................................................. 2
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H29

How many times did this happen?
ONCE ........................................................................................1
TWO OR THREE TIMES .........................................................2
FOUR OR MORE TIMES.........................................................3
DON’T KNOW .........................................................................-7
REFUSED..................................................................................-8

QA07_H30

On the street or in a public setting?
YES............................................................................................ 1
NO.............................................................................................. 2
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H31

How many times did this happen?
ONCE ........................................................................................1
TWO OR THREE TIMES .........................................................2
FOUR OR MORE TIMES.........................................................3
DON’T KNOW .........................................................................-7
REFUSED..................................................................................-8

QA07_H32

From the police or in the courts?
YES............................................................................................ 1
NO.............................................................................................. 2
DON’T KNOW..........................................................................-7
REFUSED..................................................................................-8

QA07_H33

How many times did this happen?
ONCE ........................................................................................1
TWO OR THREE TIMES .........................................................2
FOUR OR MORE TIMES.........................................................3
DON’T KNOW .........................................................................-7
REFUSED..................................................................................-8

20

DEMOGRAPHICS
Age
PROGRAMMING NOTE QA07_1.1:
SET AADATE = CURRENT DATE (YYYYMMDD)
QA07_1.1

What is your date of birth?
MONTH _____
DAY _____
YEAR _____ [GO TO QA07_1.5]
[RANGE: 1-12] [RANGE: 1-31]
[RANGE: 1898-1985]
REFUSED....................................................................... -7
DON'T KNOW ............................................................... -8
1.
2.
3.
4.
5.
6.

JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE

7.
8.
9.
10.
11.
12.

JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER

PROGRAMMING NOTE QA07_1.2:
IF QA07_1.1 = -7 OR –8 (REF/DK), CONTINUE WITH QA07_1.2;
ELSE GO TO QA07_1.5
QA07_1.2

What month and year were you born?
MONTH _____
[RANGE: 1-12]
REFUSED
DON'T KNOW
1.
2.
3.
4.
5.
6.

JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE

YEAR _____
[RANGE: 1898-1985]
-7
-8
7.
8.
9.
10.
11.
12.

[GO TO QA07_1.5]

JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER

PROGRAMMING NOTE QA07_1.3:
IF QA07_1.1 = -7 OR -8 (REF/DK) THEN CONTINUE WITH QA07_1.3;
ELSE GO TO QA07_1.5
QA07_1.3

What is your age, please?
_____YEARS OF AGE
REFUSED
-7
DON'T KNOW
-8

[GO TO QA07_1.5]

21

PROGRAMMING NOTE QA07_1.4:
IF QA07_1.2 = -7 OR -8 (REF/DK) THEN CONTINUE WITH QA07_1.4;
ELSE GO TO QA07_1.5
QA07_1.4

Are you between 18 and 29, between 30 and 39, between 40 and 44, between 45 and 49,
between 50 and 64, or 65 or older?
BETWEEN 18 AND 291 …………………………..1
BETWEEN 30 AND 392 …………………………..2
BETWEEN 40 AND 44.............................................3
BETWEEN 45 AND 49.............................................4
BETWEEN 50 AND 64.............................................5
65 OR OLDER...........................................................6
REFUSED.................................................................-7
DON'T KNOW .........................................................-8

PROGRAMMING NOTE QA07_1.5:
CALCULATE VALUE OF AAGE BASED ON QA07_1.1, QA07_1.2, OR QA07_1.3 TO USE IN ALL
AGE-RELATED QUESTIONS;
IF QA07_1.1, QA07_1.2, OR QA07_1.3 = -7 OR -8 (REF/DK), THEN USE QA07_1.4;
ELSE USE ENUM.AGE
Gender
QA07_1.5
Are you male or female?
MALE ........................................................................1
FEMALE ...................................................................2
REFUSED.................................................................-7
DON'T KNOW .........................................................-8
Ethnicity
QA07_1.6

Are you Latino or Hispanic?
YES............................................................................1
NO ……………………….........................................2
REFUSED.................................................................-7 [GO TO PN QA07_1.8]
DON'T KNOW .........................................................-8

QA07_1.7

And what is your Latino or Hispanic ancestry or origin? Such as Mexican, Salvadoran,
Cuban, Honduran-- and if you have more than one, tell me all of them.
[IF NECESSARY, GIVE MORE EXAMPLES]
[CODE ALL THAT APPLY.]
MEXICAN/MEXICANO ......................................... .1
MEXICAN AMERICAN ......................................... .2
CHICANO………………… .................................... .3
SALVADORAN ……………………………………4
GUATEMALAN …………………………………...5
COSTA RICAN …………………………………….6
HONDURAN ……………………………………….7

22

NICARAGUAN …………………………………….8
PANAMANIAN ……………………………………9
PUERTO RICAN ………………………………….10
CUBAN ……………………………………………11
SPANISH-AMERICAN (FROM SPAIN)................12
OTHER LATINO (SPECIFY): ___________..........91
REFUSED …………………………………………-7
DON'T KNOW …………………………………….-8
PROGRAMMING NOTE QA07_1.8:
IF QA07_1.5 = 1 (YES), DISPLAY “You said you are Latino or Hispanic. Also…”
IF MORE THAN ONE RACE GIVEN, AFTER ENTERING RESPONSES FOR QA07_1.8,
CONTINUE WITH PROGRAMMING NOTE QA07_1.9;
ELSE FOLLOW GOS AS INDICATED FOR SINGLE RESPONSES
Race
QA07_1.8
{You said you are Latino or Hispanic. Also} please tell me which one or more of the
following you would use to describe yourself. Would you describe yourself as Native
Hawaiian, Other Pacific Islander, American Indian, Alaska Native, Asian, Black, African
American, or White?
[IF R GIVES ANOTHER RESPONSE YOU MUST SPECIFY WHAT IT IS]
[CODE ALL THAT APPLY.]
IF ONLY ONE RACE…
WHITE ......................................................................1
BLACK OR AFRICAN AMERICAN.......................2
ASIAN .......................................................................3
AMERICAN INDIAN OR ALASKA NATIVE .......4
OTHER PACIFIC ISLANDER .................................5
NATIVE HAWAIIAN...............................................6
OTHER (SPECIFY): _____________ .....................91
REFUSED.................................................................-7
DON'T KNOW .........................................................-8

[GO TO QA07_1.15]
[GO TO QA07_1.15]
[GO TO QA07_1.12]
[GO TO QA07_1.9]
[GO TO QA07_1.13]
[GO TO QA07_1.15]
[GO TO QA07_1.15]
[GO TO QA07_1.15]
[GO TO QA07_1.15]

PROGRAMMING NOTE QA07_1.9:
IF QA07_1.8 = 4 (AMERICAN INDIAN OR ALASKA NATIVE) AND [QA07_1.8 = 2 (NATIVE
HAWAIIAN) OR QA07_1.8 =5 (OTHER PACIFIC ISLANDER) OR QA07_1.8 = 3 (ASIAN) OR
QA07_1.8= 2 (BLACK OR AFRICAN AMERICAN)
OR QA07_1.8= 1 (WHITE) OR QA07_1.8= 91 (OTHER (Specify))], CONTINUE WITH QA07_1.9;
ELSE GO TO PROGRAMMING NOTE QA07_1.13
QA07_1.9

You said, American Indian or Alaska Native, and what is your tribal heritage? If you
have more than one tribe, tell me all of them.
[CODE ALL THAT APPLY.]
APACHE ...................................................................1
BLACKFOOT/BLACKFEET ...................................2
CHEROKEE ..............................................................3
CHOCTAW ...............................................................4

23

MEXICAN AMERICAN INDIAN ...........................5
NAVAJO ...................................................................6
POMO........................................................................7
PUEBLO....................................................................8
SIOUX .......................................................................9
YAQUI .....................................................................10
OTHER TRIBE [Ask for spelling] (SPECIFY):__ ..91
REFUSED.................................................................-7
DON'T KNOW .........................................................-8
QA07_1.10

Are you an enrolled member in a federally or state recognized tribe?
YES............................................................................1
NO..............................................................................2 [GO TO PN QA07_1.12]
REFUSED.................................................................-7 [GO TO PN QA07_1.12]
DON'T KNOW .........................................................-8 [GO TO PN QA07_1.12]

QA07_1.11

Which tribe are you enrolled in?
APACHE
MESCALERO APACHE, NM..................................1
APACHE (NOT SPECIFIED)...................................2
OTHER APACHE [Ask for spelling] (SPECIFY): ...3
BLACKFEET
BLACKFOOT/BLACKFEET ...................................4
CHEROKEE
WESTERN CHEROKEE ..........................................5
CHEROKEE (NOT SPECIFIED) .............................6
OTHER CHEROKEE [Ask for spelling] (SPECIFY)7
CHOCTAW
CHOCTAW OKLAHOMA.......................................8
CHOCTAW (NOT SPECIFIED)...............................9
OTHER CHOCTAW [Ask for spelling] (SPECIFY):10
NAVAJO
NAVAJO (NOT SPECIFIED)..................................11
POMO
HOPLAND BAND, HOPLAND RANCHERIA......12
SHERWOOD VALLEY RANCHERIA...................13
POMO (NOT SPECIFIED) ......................................14
OTHER POMO [Ask for spelling] (SPECIFY): ......15
PUEBLO
HOPI .........................................................................16
YSLETA DEL SUR PUEBLO OF TEXAS .............17
PUEBLO (NOT SPECIFIED) ..................................18
OTHER PUEBLO [Ask for spelling] (SPECIFY): ..19
SIOUX
OGLALA/PINE RIDGE SIOUX..............................20
SIOUX (NOT SPECIFIED)......................................21
OTHER SIOUX [Ask for spelling] (SPECIFY):......22
YAQUI
PASCUA YAQUI TRIBE OF ARIZONA ...............23

24

YAQUI (NOT SPECIFIED) .....................................24
OTHER YAQUI [Ask for spelling] (SPECIFY): .....25
OTHER
OTHER [Ask for spelling] (SPECIFY): ..................91
REFUSED.................................................................-7
DON'T KNOW .........................................................-8
PROGRAMMING NOTE QA07_1.12:
IF QA07_1.8= 3 (ASIAN) AND [QA07_1.8= 6 (NATIVE HAWAIIAN) OR QA07_1.8= 5 (OTHER
PACIFIC ISLANDER) OR QA07_1.8 = 4 (AMERICAN INDIAN OR ALASKA NATIVE) OR
QA07_1.8 = 2 (BLACK OR AFRICAN AMERICAN) OR QA07_1.8 = 1 (WHITE) OR QA07_1.8 = 91
(OTHER (Specify))], CONTINUE WITH QA07_1.11;
ELSE GO TO PROGRAMMING NOTE QA07_1.13
QA07_1.12

You said Asian, and what specific ethnic group are you, such as Chinese, Filipino,
Vietnamese? If you are more than one, tell me all of them.
[CODE ALL THAT APPLY.]
BANGLADESHI .......................................................1
BURMESE ................................................................2
CAMBODIAN...........................................................3
CHINESE ..................................................................4
FILIPINO...................................................................5
HMONG ....................................................................6
INDIAN (INDIA) ......................................................7
INDONESIAN...........................................................8
JAPANESE................................................................9
KOREAN..................................................................10
LAOTIAN.................................................................11
MALAYSIAN ..........................................................12
PAKISTANI .............................................................13
SRI LANKAN ..........................................................14
TAIWANESE ...........................................................15
THAI.........................................................................16
VIETNAMESE.........................................................17
OTHER ASIAN (SPECIFY): ...................................91
REFUSED.................................................................-7
DON'T KNOW .........................................................-8

PROGRAMMING NOTE QA07_1.13:
IF QA07_1.8 = 5 (OTHER PACIFIC ISLANDER), CONTINUE WITH QA07_1.13;
ELSE GO TO PROGRAMMING NOTE QA07_1.14
QA07_1.13

You said you are Pacific Islander. What specific ethnic group are you, such as Samoan,
Tongan, or Guamanian? If you are more than one, tell me all of them.
[CODE ALL THAT APPLY.]
SAMOAN/AMERICAN SAMOAN .........................1

25

GUAMANIAN ..........................................................2
TONGAN ..................................................................3
FIJIAN .......................................................................4
OTHER PACIFIC ISLANDER (SPECIFY): ...........91
REFUSED.................................................................-7
DON'T KNOW .........................................................-8
PROGRAMMING NOTE QA07_1.14:
IF QA07_1.5 = YES (LATINO) AND [QA07_1.8 = 6 (NATIVE HAWAIIAN) OR QA07_1.8 = 5
(OTHER PACIFIC ISLANDER) OR QA07_1.8 = 4 (AMERICAN INDIAN OR ALASKA NATIVE)
OR QA07_1.8 = 3 (ASIAN) OR QA07_1.8 = 2 (BLACK OR AFRICAN AMERICAN) OR QA07_1.8 = 1
(WHITE) OR QA07_1.8 = 91 (OTHER)], CONTINUE WITH QA07_1.14;
ELSE IF MULTIPLE RESPONSES TO QA07_1.8 OR QA07_1.12 OR QA07_1.12 [NOT COUNTING 7 OR -8 (REF/DK)] CONTINUE WITH QA07_1.14;
ELSE GO TO QA07_1.15
[NOTE: FOR QA07_1.14 RESPONSES, INCLUDE "Specify" RESPONSE FOR 91 (OTHER
LATINO); IF QA07_1.7 = -7 (REFUSE), INSERT “Latino”]
IF QA07_1.6 = 1 (YES, LATINO) AND ANY OF QA07_1.7 = 1 THRU 12, DO NOT DISPLAY
QA07_1.14 = 14 (LATINO).
IF QA07_1.8 = 5 (OTHER PACIFIC ISLANDER) AND QA07_1.12 = 1 THRU 4, DO NOT DISPLAY
QA07_1.14 = 17 (OTHER PACIFIC ISLANDER).
IF QA07_1.8= 3 AND ANY OF QA07_1.12 = 1 THRU 17, DO NOT SAY QA07_1.14 = 19 (ASIAN)
QA07_1.14

You said that you are: [INSERT MULTIPLE RESPONSES FROM AA5, AA5A, AA5E
AND AA5E1].
Of these, which do you most identify with?

[IF R UNABLE TO CHOOSE ONE, OFFER OPTION “BOTH/ALL/MULTIRACIAL”]
MEXICAN/MEXICANO ..........................................1
MEXICAN AMERICAN ..........................................2
CHICANO .................................................................3
SALVADORAN........................................................4
GUATEMALAN .......................................................5
COSTA RICAN.........................................................6
HONDURAN ............................................................7
NICARAGUAN ........................................................8
PANAMANIAN ........................................................9
PUERTO RICAN .....................................................10
CUBAN ....................................................................11
SPANISH-AMERICAN (FROM SPAIN)................12
LATINO, OTHER SPECIFY ...................................13
LATINO ...................................................................14
NATIVE HAWAIIAN..............................................16
OTHER PACIFIC ISLANDER ................................17
AMERICAN INDIAN OR ALASKA NATIVE ......18
ASIAN ......................................................................19
BLACK OR AFRICAN AMERICAN......................20
WHITE .....................................................................21

26

RACE, OTHER SPECIFY .......................................22
BANGLADESHI ......................................................30
BURMESE ...............................................................31
CAMBODIAN..........................................................32
CHINESE .................................................................33
FILIPINO..................................................................34
HMONG ...................................................................35
INDIAN (INDIA) .....................................................36
INDONESIAN..........................................................37
JAPANESE...............................................................38
KOREAN..................................................................39
LAOTIAN.................................................................40
MALAYSIAN ..........................................................41
PAKISTANI .............................................................42
SRI LANKAN ..........................................................43
TAIWANESE ...........................................................44
THAI.........................................................................45
VIETNAMESE.........................................................46
ASIAN, OTHER SPECIFY......................................49
SAMOAN/AMERICAN SAMOAN ........................50
GUAMANIAN .........................................................51
TONGAN .................................................................52
FIJIAN ......................................................................53
PACIFIC ISLANDER, OTHER SPECIFY ..............55
BOTH/ALL/MULTIRACIAL ..................................90
NONE OF THESE....................................................95
REFUSED.................................................................-7
DON'T KNOW .........................................................-8
Marital status
QA07_1.15
Are you now married, living with a partner in a marriage-like relationship, widowed,
divorced, separated, or never married?
[IF R MENTIONS MORE THAN ONE, CODE THE LOWEST NUMBER THAT APPLIES]
MARRIED .................................................................1
LIVING WITH PARTNER .......................................2
WIDOWED ...............................................................3
DIVORCED...............................................................4
SEPARATED ............................................................5
NEVER MARRIED...................................................6
REFUSED.................................................................-7
DON'T KNOW .........................................................-8
QA07_1.16
What is the highest grade of education you have completed and received credit for?
Educational attainment
NO FORMAL EDUCATION...................................30
GRADE SCHOOL
1ST GRADE ..............................................................1
2ND GRADE.............................................................2
3RD GRADE .............................................................3
4TH GRADE………………………………………..4

27

5TH GRADE………………………………………..5
6TH GRADE .............................................................6 (Primaria)
7TH GRADE .............................................................7
8TH GRADE .............................................................8
HIGH SCHOOL OR EQUIVALENT
9TH GRADE .............................................................9 (Secundaria)
10TH GRADE ..........................................................10
11TH GRADE ..........................................................11
12TH GRAD.............................................................12 (Preparatoria)
4-YEAR COLLEGE OR UNIVERSITY
1ST YEAR (FRESHMAN) ......................................13
2ND YEAR (SOPHOMORE) ..................................14
3RD YEAR (JUNIOR) .............................................15
4TH YEAR (SENIOR) (BA/BS) ..............................16
5TH YEAR ...............................................................17
GRADUATE OR PROFESSIONAL SCHOOL
1ST YEAR GRAD OR PROF SCHOOL .................18
2ND YEAR GRAD OR PROF SCHOOL (MA/MS)19
3RD YEAR GRAD OR PROF SCHOOL ................20
MORE THAN 3 YEARS GRAD OR
PROF SCHOOL (PhD).............................................21
2-YEAR JUNIOR OR COMMUNITY COLLEGE
1ST YEAR................................................................22
2ND YEAR (AA/AS) ...............................................23
VOCATIONAL, BUSINESS, OR TRADE SCHOOL
1ST YEAR................................................................24
2ND YEAR...............................................................25
MORE THAN 2 YEARS..........................................26
REFUSED.................................................................-7
DON'T KNOW (OUT OF RANGE) ........................-8
QA07_1.17
In what country were you born?
Country of birth
[SELECT FROM MOST LIKELY COUNTRIES]
UNITED STATES….................................................1
AMERICAN SAMOA...............................................2
CANADA ..................................................................3
CHINA.......................................................................4
EL SALVADOR........................................................5
ENGLAND ................................................................6
FRANCE....................................................................7
GERMANY ...............................................................8
GUAM .......................................................................9
GUATEMALA .........................................................10
HUNGARY ..............................................................11
INDIA .......................................................................12
IRAN.........................................................................13
IRELAND.................................................................14
ITALY ......................................................................15
JAPAN ......................................................................16

28

KOREA.....................................................................17
MEXICO...................................................................18
PHILIPPINES...........................................................19
POLAND ..................................................................20
PORTUGAL .............................................................21
PUERTO RICO ........................................................22
RUSSIA ....................................................................23
TAIWAN ..................................................................24
VIETNAM ................................................................25
VIRGIN ISLANDS...................................................26
OTHER (SPECIFY):_____________________ ......91
REFUSED.................................................................-7
DON'T KNOW .........................................................-8
PROGRAMMING NOTE QA07_1.18:
IF QA07_1.17 NE 1 (NOT BORN IN US), GO TO QA07_1.20
ELSE IF QA07_1.17 = 1 (BORN IN US) CONTINUE WITH QA07_1.18
QA07_1.18
In what country was your mother born?
Mother’s/Father’s country of birth
[SELECT FROM MOST LIKELY COUNTRIES]
[FOR RESPONDENTS WHO WERE ADOPTED, QUESTION REFERS TO ADOPTIVE PARENTS]
UNITED STATES….................................................1
AMERICAN SAMOA...............................................2
CANADA ..................................................................3
CHINA.......................................................................4
EL SALVADOR........................................................5
ENGLAND ................................................................6
FRANCE....................................................................7
GERMANY ...............................................................8
GUAM .......................................................................9
GUATEMALA .........................................................10
HUNGARY ..............................................................11
INDIA .......................................................................12
IRAN.........................................................................13
IRELAND.................................................................14
ITALY ......................................................................15
JAPAN ......................................................................16
KOREA.....................................................................17
MEXICO...................................................................18
PHILIPPINES...........................................................19
POLAND ..................................................................20
PORTUGAL .............................................................21
PUERTO RICO ........................................................22
RUSSIA ....................................................................23
TAIWAN ..................................................................24
VIETNAM ................................................................25
VIRGIN ISLANDS...................................................26
OTHER (SPECIFY):_____________________ ......91

29

REFUSED.................................................................-7
DON'T KNOW .........................................................-8
QA07_1.19

In what country was your father born?

[SELECT FROM MOST LIKELY COUNTRIES]
[FOR RESPONDENTS WHO WERE ADOPTED, QUESTION REFERS TO ADOPTIVE PARENTS]
UNITED STATES….................................................1
AMERICAN SAMOA...............................................2
CANADA ..................................................................3
CHINA.......................................................................4
EL SALVADOR........................................................5
ENGLAND ................................................................6
FRANCE....................................................................7
GERMANY ...............................................................8
GUAM .......................................................................9
GUATEMALA .........................................................10
HUNGARY ..............................................................11
INDIA .......................................................................12
IRAN.........................................................................13
IRELAND.................................................................14
ITALY ......................................................................15
JAPAN ......................................................................16
KOREA.....................................................................17
MEXICO...................................................................18
PHILIPPINES...........................................................19
POLAND ..................................................................20
PORTUGAL .............................................................21
PUERTO RICO ........................................................22
RUSSIA ....................................................................23
TAIWAN …………………………………………..24
VIETNAM ................................................................25
VIRGIN ISLANDS...................................................26
OTHER (SPECIFY):_____________________ ......91
REFUSED.................................................................-7
DON'T KNOW .........................................................-8
QA07_1.20
What languages do you speak at home?
Language(s) spoken at home
[CODE ALL THAT APPLY.]
[PROBE: "Any others?"]
ENGLISH ..................................................................1
SPANISH...................................................................2
CANTONESE............................................................3
VIETNAMESE..........................................................4
TAGALOG ................................................................5
MANDARIN .............................................................6
KOREAN...................................................................7
ASIAN INDIAN LANGUAGES...............................8

30

RUSSIAN ..................................................................9
OTHER1 (SPECIFY): ..............................................91
OTHER2 (SPECIFY): ..............................................92
REFUSED.................................................................-7
DON’T KNOW.........................................................-8
PROGRAMMING NOTE QA07_1.21:
IF INTERVIEW NOT CONDUCTED IN ENGLISH, CONTINUE WITH QA07_1.21
IF INTERVIEW CONDUCTED IN ENGLISH AND R SPEAKS LANGUAGE OTHER THAN
ENGLISH AT HOME), CONTINUE WITH QA07_1.21 AND DISPLAY: “Since you speak a language
other than English at home, we are interested in your own opinion of how well you speak English…”
AND DROP RESPONSE CATEGORY “NOT AT ALL”;
ELSE IF QA07_1.20 = 1 ONLY (ENGLISH IS ONLY LANGUAGE SPOKEN AT HOME), GO TO PN
QA07_1.22
QA07_1.21

{Since you speak a language other than English at home, we are interested in your own
opinion of how well you speak English} Would you say you speak English …
English proficiency
Very well ...................................................................1
Well............................................................................2
Not well or .................................................................3
Not at all?...................................................................4
REFUSED.................................................................-7
DON'T KNOW .........................................................-8

PROGRAMMING NOTE QA07_1.22:
IF QA07_1.17 = 1 (USA) OR 2 (AMERICAN SAMOA) OR 9 (GUAM) OR 22 (PUERTO RICO) OR 26
(VIRGIN ISLANDS), GO TO PROGRAMMING NOTE QA07_1.25;
ELSE CONTINUE WITH QA07_1.22
Citizenship-Immigration status
QA07_1.22
The next questions are about citizenship and immigration. Your answers are confidential
and will not be reported to the INS.
Are you a citizen of the United States?
YES............................................................................1 [GO TO PN QA07_A1.25]
NO..............................................................................2
APPLICATION PENDING.......................................3
REFUSED.................................................................-7
DON'T KNOW .........................................................-8
QA07_1.23

Are you a permanent resident with a green card?
IF NEEDED, SAY: "People usually call this a "Green Card"
but the color can also be pink, blue, or white."
YES............................................................................1
NO..............................................................................2
APPLICATION PENDING.......................................3
REFUSED.................................................................-7
DON'T KNOW .........................................................-8

31

QA07_1.24

About how many years have you lived in the United States?
[FOR LESS THAN A YEAR, ENTER 1 YEAR]
_____ (NUMBER OF YEARS)
_____ YEAR (FIRST CAME TO LIVE IN U.S.)
REFUSED.................................................................-7
DON'T KNOW .........................................................-8

PROGRAMMING NOTE QA07_1.25:
IF AAGE > 70 OR QA07_1.4 = 6 (65 OR OLDER) OR ENUM.AGE > 70 OR IF AGE IS UNKNOWN,
GO TO PROGRAMMING NOTE QA07_1.28;
ELSE CONTINUE WITH QA07_1.25
Sexual orientation
QA07_1.25
We are asking a few questions about people’s sexual experiences. All answers will be
kept private.
In the past 12 months, how many sexual partners have you had?
_______ NUMBER OF SEXUAL PARTNERS
[GO TO PN QA07_1.27]
REFUSED
-7 ......................[GO TO PN QA07_1.28]
DON’T KNOW.........................................................-8
QA07_1.26

Can you give me your best guess?

[IF R PROVIDES EXACT NUMBER, ENTER AS GIVEN.
OTHERWISE CODE INTO CATEGORIES PROVIDED]
_________ PARTNERS
1 PARTNER ..............................................................1
2-3 PARTNERS.........................................................2
4-5 PARTNERS.........................................................3
6-10 PARTNERS.......................................................4
MORE THAN 10 PARTNERS .................................5
REFUSED.................................................................-7
DON’T KNOW.........................................................-8
PROGRAMMING NOTE QA07_1.27:
IF QA07_1.25 = 0 (NO SEXUAL PARTNERS IN LAST 12 MONTHS), GO TO PROGRAMMING
NOTE QA07_1.29;
ELSE CONTINUE WITH QA07_1.27
IF QA07_1.24 OR QA07_1.25 = 1 (ONE PARTNER IN LAST 12 MONTHS), DISPLAY “Is that
partner male or female?”
QA07_1.27

{Is that partner male or female?} In the past 12 months, have your sexual partners been
male, female, or both male and female?
MALE ........................................................................1
FEMALE ...................................................................2
BOTH MALE AND FEMALE..................................3

32

REFUSED.................................................................-7
DON’T KNOW.........................................................-8
PROGRAMMING NOTE QA07_1.28:
IF QA07_1.5=1 (MALE), DISPLAY “Gay” in question and “Gay” in Help Screen,
ELSE IF QA07_1.5=2 (FEMALE), DISPLAY “Gay, Lesbian” in question and “Gay and Lesbian” in
Help Screen
IF AAGE > 70 OR QA07_1.4 = 6 (65 OR OLDER) OR ENUM.AGE > 70 OR IF AGE IS UNKNOWN,
Read “The next question is about sexual orientation. All answers will be kept private.” and continue
with QA07_1.28
QA07_1.28

Do you think of yourself as straight or heterosexual, as gay {, lesbian} or homosexual, or
bisexual?
[IF NEEDED, SAY: “Straight or Heterosexual people have sex with,
or are primarily attracted to people of the opposite sex,
Gay {and Lesbian} people have sex with or are primarily
attracted to people of the same sex, and Bisexuals have sex with or
are attracted to people of both sexes”.]

STRAIGHT OR HETEROSEXUAL.........................1
GAY, LESBIAN, OR HOMOSEXUAL ...................2
BISEXUAL................................................................3
NOT SEXUAL/ CELIBATE/ NONE........................4
OTHER (SPECIFY): .................................................5
REFUSED.................................................................-7
DON’T KNOW.........................................................-8
County of residence
QA07_1.29
To be sure we are covering the entire state, what county do you live in?
ALAMEDA ...............................................................1
ALPINE .....................................................................2
AMADOR..................................................................3
BUTTE ......................................................................4
CALAVERAS ...........................................................5
COLUSA ...................................................................6
CONTRA COSTA.....................................................7
DEL NORTE .............................................................8
EL DORADO ............................................................9
FRESNO ...................................................................10
GLENN.....................................................................11
HUMBOLDT............................................................12
IMPERIAL ...............................................................13
INYO ........................................................................14
KERN .......................................................................15
KINGS ......................................................................16
LAKE........................................................................17
LASSEN ...................................................................18
LOS ANGELES........................................................19

33

MADERA .................................................................20
MARIN .....................................................................21
MARIPOSA..............................................................22
MENOCINO.............................................................23
MERCED..................................................................24
MODOC ...................................................................25
MONO ......................................................................26
MONTEREY ............................................................27
NAPA .......................................................................28
NEVADA .................................................................29
ORANGE..................................................................30
PLACER ...................................................................31
PLUMAS ..................................................................32
RIVERSIDE .............................................................33
SACRAMENTO.......................................................34
SAN BENITO...........................................................35
SAN BERNARDINO ...............................................36
SAN DIEGO .............................................................37
SAN FRANCISCO ...................................................38
SAN JOAQUIN ........................................................39
SAN LUIS OBISPO .................................................40
SAN MATEO ...........................................................41
SANTA BARBARA.................................................42
SANTA CLARA.......................................................43
SANTA CRUZ .........................................................44
SHASTA...................................................................45
SIERRA ....................................................................46
SISKIYOU................................................................47
SOLANO ..................................................................48
SONOMA .................................................................49
STANISLAUS ..........................................................50
SUTTER ...................................................................51
TEHAMA .................................................................52
TRINITY ..................................................................53
TULARE...................................................................54
TUOLUMNE ............................................................55
VENTURA ...............................................................56
YOLO .......................................................................57
YUBA .......................................................................58
REFUSED.................................................................-7
DON'T KNOW .........................................................-8
PROGRAMMING NOTE QA07_1.30:
IF ADVANCE LETTER SENT, ASK QA07_1.30;
ELSE GO TO QA07_1.31
Geographic location
QA07_1.30
Your phone number was randomly selected for this study by a computer. We were able
to match an address to your phone number to send a letter to your home explaining the
purpose of this study.

34

To help us better understand the environment you live in and how it may affect your
health, can you confirm your address? Your street address will not be given out to
researchers or any other organization and, like your telephone number, will be protected
and kept confidential.
Is your current address {R’s address and street}?
YES............................................................................1 [GO TO NEXT SECTION]
NO………………………………………………….2
REFUSED…………………………………………-7
DON'T KNOW .........................................................-8
QA07_1.31

What is your zip code?
_______(ZIP CODE)
REFUSED.................................................................-7
DON'T KNOW .........................................................-8

QA07_1.32

To help us better understand the environment you live in and how it may affect your
health, can you tell me your address? Your street address will not be given out to
researchers or any other organization and, like your telephone number, will be protected
and kept confidential.
___________ (HOUSE ADDRESS NUMBER)
_______________________(NAME OF STREET, VERIFY SPELLING)
NO..............................................................................2
REFUSED.................................................................-7
DON'T KNOW……………. ....................................-8

QA07_1.33

Can you tell me just the name of the street you live on?
____________________________(NAME OF STREET)
REFUSED.................................................................-7 [GO TO NEXT SECTION]
DON'T KNOW .........................................................-8 [GO TO NEXT SECTION]

QA07_1.34

And what is the name of the street down the corner from you that crosses your street?

____________________________(NAME OF CROSS-STREET)
REFUSED.................................................................-7
DON'T KNOW .........................................................-8
Follow-up survey permission
QA07_A1.35
Do you think you would be willing to do a follow-up to this survey some time in the
future?
YES............................................................................1
MAYBE/PROBABLY YES ......................................2
DEFINITELY NOT...................................................3
REFUSED.................................................................-7
DON'T KNOW .........................................................-8

35

EMPLOYMENT, INCOME, AND POVERTY STATUS
Employment status
QA07_12.1
Which of the following were you doing last week?
Working at a job or business.......................................1
With a job or business but not at work ......................2
Looking for work or....................................................3
Not working at a job or business?...............................4
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8
QA07_12.2

[GO TO QA07_12.3]
[GO TO QA07_12.9]
[GO TO QA07_12.3]
[GO TO QA07_12.3]

What is the main reason you did not work last week?
[IF NEEDED, SAY: “Main reason is the most important reason.”
KEEPING HOUSE/CARING FOR CHILDREN
OR OTHERS ............................................................1 [GO TO QA07_12.9]
VACATION OR LEAVE ...........................................2
COULDN'T FIND A JOB ..........................................3
GOING TO SCHOOL/STUDENT .............................4
RETIRED ...................................................................5
[GO TO QA07_12.9]
PHYSICAL DISABILITY .........................................6
UNABLE TO WORK.................................................7
ON LAYOFF OR STRIKE.........................................8
OTHER .......................................................................91
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8

QA07_12.3

How many hours per week do you usually work at all jobs or businesses?

[IF WORKS > 95 HOURS, ENTER 95. IF DOES NOT WORK, ENTER 0 (ZERO).]
_____ HOURS
[HR: 0-95]
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8
PROGRAMMING NOTE QA07_12.4
IF QA07_12.1 = 3 (LOOKING FOR WORK) OR QA07_12.2 = 3 (COULDN’T FIND A JOB) OR
QA07_12.3 = 0 (NO HOURS WORKED), GO TO QA07_12
QA07_12.4

On your main job, are you employed by a private company, the government, or are
you self-employed, or are you working without pay in a family business or farm?
[IF NEEDED, SAY: “Where did you work most hours?”]
PRIVATE COMPANY, NON-PROFIT
ORGANIZATION, FOUNDATION..........................1
GOVERNMENT ........................................................2
SELF-EMPLOYED ....................................................3
FAMILY BUSINESS OR FARM ..............................4

36

REFUSED...................................................................-7
DON'T KNOW ...........................................................-8
QA07_12.5
What kind of business or industry is this?
Occupation and industry
[IF NEEDED, SAY: “What do they make or do at this business?”]
[INTERVIEWER: ENTER DESCRIPTION]
_________________________ (BUSINESS OR INDUSTRY)
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8
QA07_12.6

What is the main kind of work you do?
[MAIN JOB = WHERE WORKS MOST HOURS.]
[INTERVIEWER: ENTER DESCRIPTION]
___________________________ (OCCUPATION)
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8

QA07_12.7
How long have you worked at your main job?
Time on current job
[IF NEEDED, SAY: “That is, for your current employer?”]
_____ MONTHS
[HR: 0-12]
_____ YEARS
[HR: 0-50]
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8
PROGRAMMING NOTE QA07_12.8:
IF QA07_12.4 = 2 (GOVERNMENT EMPLOYEE), GO TO QA07_12.10;
IF QA07_12.4 = 3 OR 4 (SELF-EMPLOYED/FAMILY FARM), CONTINUE WITH QA07_12.8
AND DISPLAY "Including yourself, about";
ELSE CONTINUE WITH QA07_12.8 AND DISPLAY "About"
Firm size
QA07_12.8
{Including yourself, about / About} how many people are employed by {your
employer/you} at all locations?
[IF NEEDED SAY: “Your best guess is fine.”]
FEWER THAN 10......................................................1
10-50 ...........................................................................2
51-99 ...........................................................................3
100-999 .......................................................................4 [GO TO QA07_12.10]
1,000 OR MORE ........................................................5
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8
QA07_12.9

Did you work at any time in the last month?

37

YES.............................................................................1
NO...............................................................................2
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8

[GO TO PN
QA07_12.12]

QA07_12.10

What is your best estimate of all your earnings last month before taxes and other
deductions from all jobs and businesses, including hourly wages, salaries, tips and
commissions?
Earnings, last month
[IF AMOUNT GREATER THAN $999,995, ENTER "999,995"]
$_____________ AMOUNT
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8

PROGRAMMING NOTE QA07_12.12
IF RESPONDENT MARRIED AND LIVING WITH SPOUSE, CONTINUE WITH QA07_12.12
AND DISPLAY “spouse’s”;
ELSE IF RESPONDENT LIVING WITH PARTNER, CONTINUE WITH QA07_12 AND
DISPLAY “partner’s”;
ELSE GO TO QA07_12.13
QA07_12.12

What is your best estimate of all your spouse’s earnings last month before taxes and
other deductions from all jobs and businesses, including hourly wages, salaries, tips
and commissions?
[IF AMOUNT GREATER THAN $999,995, ENTER "999,995"]

$_______________ AMOUNT
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8
Annual household income
QA07_12.13
What is your best estimate of your household’s total annual income from all sources
before taxes in 2002?
[IF NEEDED SAY, “Include money from jobs, social security, retirement income, unemployment
payments, public assistance and so forth. Also include income from interest,
dividends, net income from business, farm, or rent and any other money income.”]
[IF AMOUNT GREATER THAN $999,995, ENTER "999,995"]
$_______________ AMOUNT
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8
QA07_12.14

I have entered that your annual household income is (AMOUNT). Is that correct?
YES.............................................................................1
NO...............................................................................2
REFUSED...................................................................-7

38

DON'T KNOW ...........................................................-8
PROGAMMING NOTE QA07_12.15:
IF QA07_12.13= -7 or -8 CONTINUE WITH QA07_12.15;
ELSE GO TO PROGRAMMING NOTE QA07_12.21
QA07_12.15

We don’t need to know exactly, but could you tell me if your household’s annual
income from all sources before taxes is more than $20,000 per year or is it less?
MORE.........................................................................1 [GO TO QA07_12.17]
EQUAL TO $20K OR LESS......................................2
REFUSED...................................................................-7
[GO TO PN
DON'T KNOW………………………………………-8
QA07_12.21]

QA07_12.16

Is it …
$5,000 or less, or.........................................................1
$5,001 to $10,000, or ..................................................2
$10,001 to $15,000, or ................................................3

[GO TO PN

QA07_12.21]
$15,001 to 20,000?......................................................4
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8
QA07_12.17

Is it more or less than $70,000 per year?
MORE.........................................................................1 [GO TO QA07_12.19]
EQUAL TO $70K OR LESS......................................2
REFUSED...................................................................-7
[GO TO PN
DON'T KNOW ...........................................................-8
QA07_12.21]

QA07_12.18

Is it …
$20,001 to $30,000,
1 ............................................
$30,001 to $40,000, ....................................................2
$40,001 to $50,000, ....................................................3
$50,001 to $60,000, or ................................................4 [GO TO PN

QA07_12.21]
$60,001 to $70,000?....................................................5
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8
QA07_12.19

Is it more or less than $135,000 per year?
MORE.........................................................................1 [GO TO PN

QA07_12.21]
EQUAL TO $135K OR LESS....................................2
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8

39

[GO TO PN
QA07_12.21]

QA07_12.20

Is it …
$70,001 to $80,000, ....................................................1
$80,001 to $90,000, ....................................................2
$90,001 to $100,000, or ..............................................3
$100,001 to $135,000?................................................4
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8

PROGRAMMING NOTE QA07_12.21:
IF R IS ONLY MEMBER OF HH, GO TO PROGRAMMING NOTE QA07_12.22;
ELSE CONTINUE WITH QA07_12.21
Number of people supported by income
QA07_12.21
Including yourself, how many people living in your household are supported by your
total household income?
_____ NUMBER OF PEOPLE [HR: 1-20]
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8
PROGRAMMING NOTE QA07_12.22:
QA07_12.22 MUST BE LESS THAN QA07_12.21
IF NO CHILDREN UNDER 18 IN HH (AS DETERMINED FROM CHILD ENUMERATION
QUESTIONS) OR TOTAL NUMBER OF PEOPLE LIVING IN HH (AS DETERMINED BY
ADULT PLUS CHILD ENUMERATION) = QA07_12.21, GO TO PROGRAMMING NOTE
QA07_12.23;
ELSE CONTINUE WITH QA07_12.22
QA07_12.22

How many of these {INSERT NUMBER FROM AK18} people are children under
the age of 18?
_____ NUMBER OF CHILDREN (UNDER AGE 18)
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8

40

PROGRAMMING NOTE QA07_12.23:
OBTAIN THE FEDERAL POVERTY 100%, 200%, AND 300% LEVEL CUTOFF
POINTS FROM
THE 2002 FEDERAL POVERTY GUIDELINE USING THE TOTAL HOUSEHOLD
SIZE AND NUMBER OF
CHILDREN FROM QA07_12.21 AND QA07_12.22 RESPECTIVELY.
BASE.POVRT130POVRT200
BASE.POVRT100 BASE.POVRT200
SCRN.RADLTCNT
SCRN.KIDCNT
(THE 200% AND 300% VALUES WERE DERIVED BY MULTIPLYING THE CENSUS
POVERTY 2002 THRESHOLD "SIZE OF FAMILY UNIT" BY "RELATED
CHILDREN UNDER 18 YEARS" TABLE AMOUNTS BY 2 AND 3, RESPECTIVELY,
THEN ROUNDING TO THE NEAREST 100 DOLLARS. REFER TO
SPECIFICATIONS ADDENDUM xxx FOR THE TABLE OF VALUES. THE 100%
POVERTY CUTOFF VALUE WILL BE STORED IN CATI VARIABLE POVRT100,
THE 200% POVERTY CUTOFF VALUE WILL BE STORED IN CATI VARIABLE
POVRT200 AND THE 300% VALUE IN CATI VARIABLE POVRT300).
IF EITHER QA07_12.21 OR QA07_12.22 IS MISSING, USE THE TOTAL NUMBER OF
ADULTS ENUMERATED IN THE SCREENER (GIVEN BY CATI VARIABLE
RADLTCNT) AND THE TOTAL NUMBER OF CHILDREN ENUMERATED IN
OTHER SECTION OF THE ADULT INTERVIEW (GIVEN BY CATI VARIABLE
KIDCNT) INSTEAD.
ASCERTAIN IF THE HOUSEHOLD INCOME IS ...
1 AT OR BELOW 100% FPL,
2 ABOVE 100% FPL BUT AT OR BELOW 130% FPL,
3 ABOVE 130% FPL BUT AT OR BELOW 200% FPL
4 ABOVE 200% FPL BUT AT OR BELOW 300% FPL,
5 ABOVE 300% FPL, OR
6 UNKNOWN BECAUSE HOUSEHOLD INCOME WAS NOT GIVEN.
IF QA07_12.13= -7 OR -8 (REF/DK) AND IF THE HOUSEHOLD'S 100% CUTOFF
VALUE FALLS WITHIN A RESPONSE FROM QA07_12.16, QA07_12.18, OR
QA07_12.20 OR QA07_12.15= -7 OR QA07_12.17= -7 OR QA07_12.19= -7, ASK
QA07_12.23 USING POVRT100 (THE 100% FPL CUTOFF DISPLAY AMOUNT); ELSE
GO TO PROGRAMMING NOTE QA07_12.24
QA07_12.23

I need to ask just one last, very specific question about income. Was your total
annual household income before taxes less than or more than ${POVRT100}?
EQUAL TO OR LESS......................................... 1 [GO TO NEXT SECTION]
MORE.................................................................. 2
REFUSED............................................................ -7
DON'T KNOW .................................................... -8

PROGRAMMING NOTE QA07_12.24:
IF QA07_12.13= -7 OR -8 (REF/DK) AND IF THE HOUSEHOLD'S 200% CUTOFF
VALUE FALLS WITHIN A RESPONSE FROM QA07_12.16, QA07_12.18, OR
QA07_12.20 OR IF QA07_12.15 = -7 OR QA07_12.17 = -7 OR QA07_12.19 = -7,
CONTINUE WITH QA07_12.24 USING POVRT200 (200% POVERTY CUTOFF
DISPLAY AMOUNT);
ELSE GO TO PROGRAMMING NOTE QA07_12.26

41

QA07_12.24

{I need to ask just one last, very specific question about income.} Was your total
annual household income before taxes less than or more than ${POVRT200}?
EQUAL TO OR LESS......................................... 1 [GO TO NEXT SECTION]
MORE.................................................................. 2
REFUSED............................................................ -7
DON'T KNOW .................................................... -8

PROGRAMMING NOTE QA07_12.25:
IF QA07_12.13 = -7 OR –8 (REF/DK) AND IF THE HOUSEHOLD'S 300% CUTOFF
VALUE FALLS WITHIN A RESPONSE FROM QA07_12.16, QA07_12.18, OR
QA07_12.20 OR IF QA07_12.15 = -7 OR QA07_12.17 = -7 OR QA07_12.19 = -7,
CONTINUE WITH QA07_12.26 USING POVRT300 (300% POVERTY CUTOFF
DISPLAY AMOUNT);
ELSE GO TO NEXT SECTION
QA07_12.25

{I need to ask just one last, very specific question about income.} Was your total
annual household income before taxes less than or more than ${POVRT130}?
EQUAL TO OR LESS......................................... 1 [GO TO NEXT SECTION]
MORE.................................................................. 2
REFUSED............................................................ -7
DON'T KNOW .................................................... -8

PROGRAMMING NOTE QA07_12.26:
IF QA07_12.13 = -7 OR –8 (REF/DK) AND IF THE HOUSEHOLD'S 300% CUTOFF
VALUE FALLS WITHIN A RESPONSE FROM QA07_12.16, QA07_12.18, OR
QA07_12.20 OR IF QA07_12.15 = -7 OR QA07_12.17 = -7 OR QA07_12.19 = -7,
CONTINUE WITH QA07_12.26 USING POVRT300 (300% POVERTY CUTOFF
DISPLAY AMOUNT);
ELSE GO TO NEXT SECTION
QA07_12.26

{I need to ask just one last, very specific question about income.} Was your total
annual household income before taxes less than or more than ${POVRT300}?
EQUAL TO OR LESS................................................1
MORE.........................................................................2
REFUSED...................................................................-7
DON'T KNOW ...........................................................-8

42

Adolescent Questionnaire
MODULE B–HPV
PROGRAMMING NOTEQT07_B1;

IF TA07_A5 = 1 (MALE), GO NEXT SECTION;
ELSE CONTINUE QT07_B1.
QT07_B1 Have you ever heard of HPV? HPV stands for Human Papillomavirus.
YES.......................................................................................... 1
NO ........................................................................................... 2 [GO TO QT07_B3]
DON’T KNOW ......................................................................... -7 [GO TO QT07_B3]
REFUSED ................................................................................ -8 [GO TO QT07_B3]
QT07_B2 Where did you heard about HPV?
A doctor, nurse or other health care professional ................... 1
Family ...................................................................................... 2
Friends..................................................................................... 3
Newspaper or magazine ......................................................... 4
Saw an ad on television........................................................... 5
Television news ....................................................................... 6
Internet..................................................................................... 7
School...................................................................................... 8
Other........................................................................................ 9
DON’T KNOW .......................................................................... -7
REFUSED................................................................................ -8
QT07_B3 Have you ever heard of a vaccine or shot to prevent cervical cancer?
YES.......................................................................................... 1
NO ........................................................................................... 2
DON’T KNOW ......................................................................... -7
REFUSED ................................................................................ -8

QT07_B3a. Have you ever received the HPV vaccine or shots?
YES.......................................................................................... 1 [SKIP TO NEXT SECTION]
NO ........................................................................................... 2
DON’T KNOW ......................................................................... -7
REFUSED ................................................................................ -8
QT07_B4 A vaccine, or shot that protects against HPV, a virus that can cause cervical cancer, was
recently approved for girls and women ages 9 to 26. Would you be interested in getting the
vaccine?
YES.......................................................................................... 1
NO ........................................................................................... 2
NOT SURE .............................................................................. 3
DON’T KNOW ......................................................................... -7
REFUSED ................................................................................ -8

43

DEMOGRAPHICS
PROGRAMMING NOTE QT07_1.1:
SET TADATE = CURRENT DATE (YYYYMMDD)
Age
QT07_1.1
What is your date of birth?
TA1
_____ MONTH _____ DAY
_____ YEAR
[HR: 1-12]
[HR: 1-31]
[SR: 1985-1991]

[GO TO QT07_1.4]

REFUSED...................................................................................... -7
DON'T KNOW .............................................................................. -8
1. JANUARY
2. FEBRUARY
3. MARCH
4. APRIL
5. MAY
6. JUNE

7. JULY
8. AUGUST
9. SEPTEMBER
10. OCTOBER
11. NOVEMBER
12. DECEMBER

PROGRAMMING NOTE QT07_1.2:
IF QT07_1.1 = -7 OR –8 (REF/DK), CONTINUE WITH QT07_1.2;
ELSE GO TO QT07_1.4
QT07_1.2
TA1A

What month and year were you born?
_____ MONTH
[HR: 1-12]

_____ YEAR
[SR: 1985-1991]

[GO TO QT07_1.4]

REFUSED...................................................................................... -7
DON'T KNOW .............................................................................. -8
1. JANUARY
2. FEBRUARY
3. MARCH
4. APRIL
5. MAY
6. JUNE

7. JULY
8. AUGUST
9. SEPTEMBER
10. OCTOBER
11. NOVEMBER
12. DECEMBER

PROGRAMMING NOTE QT07_1.3:
IF QT07_1.2 = -7 OR –8 (REF/DK), CONTINUE WITH QT07_1.3;
ELSE GO TO QT07_1.4
QT07_1.3
TA2

How old are you?
______________ [SR: 12-17]
REFUSED ..................................................................................... -7
DON’T KNOW.............................................................................. -8

44

PROGRAMMING NOTE QT07_1.4:
CALCULATE VALUE OF TEENAGE BASED ON QT07_1.1, QT07_1.2, OR QT07_1.3;
IF QT07_1.1 AND QT07_1.3 ARE NOT KNOWN, USE CHILD ROSTER AGE (ENUM.AGE);
IF TEENAGE <> BETWEEN 12 AND 17, THEN TERMINATE INTERVIEW AND CODE
INELIGIBLE (IT)
Gender
QT07_1.4
Are you male or female?
TA3
MALE ............................................................................................ 1
FEMALE ....................................................................................... 2
REFUSED...................................................................................... -7 [END
INTERVIEW AND
DON”T KNOW ............................................................................. -8 CODE
INELIGIBLE.]
Education
QT07_1.5
Did you attend school last week?
TA4
YES................................................................................................ 1 [GO TO
QT07_1.6]
NO.................................................................................................. 2
ON VACATION............................................................................ 3
HOME SCHOOLED ..................................................................... 4 [GO TO
QT07_1.6]
REFUSED...................................................................................... -7 [GO TO
QT07_1.6]
DON’T KNOW.............................................................................. -8 [GO TO
QT07_1.6]
QT07_1.5A
TA4C

Did you attend school during the last school year?
YES................................................................................................ 1
NO.................................................................................................. 2
REFUSED...................................................................................... -7
DON’T KNOW.............................................................................. -8

QT07_1.6
TA4B

What is the name of the school you go to or last attended?
[RECORD VERBATIM]
______________________________________ (NAME OF SCHOOL)
REFUSED...................................................................................... -7
DON’T KNOW.............................................................................. -8

QT07_1.7

Not including any allowance you may get, have you worked for pay in the past 12
months?

TA5
[IF NEEDED, SAY: Include babysitting, yard work, pet care and any other odd jobs
you were paid for.]

45

[NOTE: ENTER ZERO IF RESPONDENT DID NOT WORK DURING THE
SCHOOL YEAR. IF WORK FOR PAY INTERMITTENLY, ENTER 95]
YES....................................................................................... 1
NO......................................................................................... 2 [GO TO QT05_B1]
REFUSED............................................................................. -7 [GO TO QT05_B1]
DON’T KNOW..................................................................... -8 [GO TO QT05_B1]
Employment
QT07_1.8
TA5A

How many hours do you spend working for pay in a typical week during the school year?
[IF NEEDED, SAY: A typical week is a usual week. Pick the most recent school year.]
_____ NUMBER OF HOURS [HR: 0-60]
REFUSED................................................................................-7
DON’T KNOW........................................................................-8

So we can be sure we have included all races and ethnic groups in California, I need to
ask a few questions about you.
Race/Ethnicity
QT07_2.1
Are you Latino or Hispanic?
TI1
[IF NEEDED, SAY: Such as Mexican, Central or South American?]
YES..........................................................................................1
NO............................................................................................2 [GO TO QT07_2.3]
REFUSED................................................................................-7 [GO TO QT07_2.3]
DON’T KNOW........................................................................-8 [GO TO QT07_2.3]
QT07_2.2

And what is your Latino or Hispanic ancestry or origin? Such as Mexican, Salvadoran,
Cuban, Honduran -- and if you have more than one, tell me all of them.

TI1A
[IF NEEDED, GIVE MORE EXAMPLES]
[CODE ALL THAT APPLY]
MEXICAN/MEXICANO .............................................................. 1
MEXICAN AMERICAN .............................................................. 2
CHICANO .................................................................................... 3
SALVADORAN ........................................................................... 4
GUATEMALAN .......................................................................... 5
COSTA RICAN ............................................................................ 6
HONDURAN ................................................................................ 7
NICARAGUAN............................................................................. 8
PANAMANIAN ........................................................................... 9
PUERTO RICAN .......................................................................... 10
CUBAN ......................................................................................... 11
SPANISH-AMERICAN (FROM SPAIN ...................................... 12
OTHER LATINO (SPECIFY): __________________ ................ 91

46

REFUSED...................................................................................... -7
DON’T KNOW ............................................................................ –8

PROGRAMMING NOTE QT07_2.3:
IF QT07_2.1=1 (YES), CATI DISPLAY “You said you are Latino or Hispanic. Also…”
IF MORE THAN ONE RACE GIVEN, AFTER ENTERING RESPONSES FOR QT07_2.3,
CONTINUE WITH PROGRAMMING NOTE QT07_2.4;
ELSE GO TO SKIPS AS INDICATED FOR SINGLE RESPONSES.
QT07_2.3

{You said you are Latino or Hispanic. Also}, Please tell me which one or more of the
following you would use to describe yourself: Would you describe yourself as Native
Hawaiian, Other Pacific Islander, American Indian, Alaska Native, Asian, Black, African
American, or White?

TI2
[IF R GIVES AN “OTHER” RESPONSE YOU MUST SPECIFY WHAT IT IS]
[CODE ALL THAT APPLY]
WHITE ...............................................................................1 [GO TO QT07_2.10]
BLACK OR AFRICAN AMERICAN ...............................2 [GO TO QT07_2.10]
ASIAN ...............................................................................3 [GO TO QT07_2.7]
AMERICAN INDIAN, ALASKA NATIVE ......................4 [GO TO QT07_2.4]
OTHER PACIFIC ISLANDER .........................................5 [GO TO QT07_2.8]
NATIVE HAWAIIAN .......................................................6 [GO TO QT07_2.10]
OTHER (SPECIFY): _________________........................91 [GO TO QT05_ K10]
REFUSED ..........................................................................-7 [GO TO QT07_2.10]
DON’T KNOW...................................................................-8 [GO TO QT07_2.10]

IF
ONLY
ONE
RACE

PROGRAMMING NOTE QT07_2.4:
IF QT05_ K3 = 4 (AMERICAN INDIAN, ALASKA NATIVE) CONTINUE WITH QT07_2.4;
ELSE GO TO PROGRAMMING NOTE AT QT07_2.7.
QT07_2.4

You said, American Indian or Alaska Native, and what is your tribal heritage? If you
have more than one tribe, tell me all of them.

TI2A
[CODE ALL THAT APPLY]
APACHE ....................................................................................... 1
BLACKFEET ................................................................................ 2
CHEROKEE .................................................................................. 3
CHOCTAW .................................................................................. 4
MEXICAN AMERICAN .............................................................. 5
NAVAJO ....................................................................................... 6
POMO............................................................................................ 7
PUEBLO ....................................................................................... 8
SIOUX ........................................................................................... 9
YAQUI .......................................................................................... 10
OTHER TRIBE [Ask for spelling]
(SPECIFY):________________.................................................... 91
REFUSED...................................................................................... -7

47

DON'T KNOW .............................................................................. -8
QT07_2.5
TI2B

Are you an enrolled member in a federally or state recognized tribe?
YES..................................................................................... 1
NO....................................................................................... 2 [GO TO PN QT07_2.7]
REFUSED........................................................................... -7 [GO TO PN QT07_2.7]
DON’T KNOW................................................................... -8 [GO TO PN QT07_2.7]

QT07_2.6
Which tribe are you enrolled in?
TI2C
APACHE
MESCALERO APACHE, NM ........................................................... 1
APACHE (NOT SPECIFIED) ............................................................ 2
OTHER APACHE [Ask for spelling] (SPECIFY)............................... 3
BLACKFEET
BLACKFOOT/BLACKFEET.............................................................. 4
CHEROKEE
WESTERN CHEROKEE..................................................................... 5
CHEROKEE (NOT SPECIFIED) ....................................................... 6
OTHER CHEROKEE [Ask for spelling] (SPECIFY) ........................ 7
CHOCTAW
CHOCTAW OKLAHOMA ................................................................ 8
CHOCTAW (NOT SPECIFIED .......................................................... 9
OTHER CHOCTAW [Ask for spelling] (SPECIFY): ........................ 10
NAVAJO
NAVAJO (NOT SPECIFIED............................................................... 11
POMO
HOPLAND BAND, HOPLAND RANCHERIA ................................ 12
SHERWOOD VALLEY RANCHERIA .............................................. 13
POMO (NOT SPECIFIED) ................................................................. 14
OTHER POMO [Ask for spelling] (SPECIFY) ................................... 15
PUEBLO
HOPI..................................................................................................... 16
YSLETA DEL SUR PUEBLO OF TEXAS......................................... 17
PUEBLO (NOT SPECIFIED ............................................................... 18
OTHER PUEBLO [Ask for spelling] (SPECIFY): ............................. 19
SIOUX
OGLALA/PINE RIDGE SIOUX ......................................................... 20
SIOUX (NOT SPECIFIED) ................................................................. 21
OTHER SIOUX [Ask for spelling] (SPECIFY): ................................ 22
YAQUI
PASCUA YAQUI TRIBE OF ARIZONA........................................... 23
YAQUI (NOT SPECIFIED.................................................................. 24
OTHER YAQUI [Ask for spelling] (SPECIFY): ................................ 25
OTHER
OTHER [Ask for spelling] (SPECIFY): ________________________
REFUSED ............................................................................................ -7
DON'T KNOW..................................................................................... -8

48

91

PROGRAMMING NOTE QT07_2.7:
IF QT07_2.3 = 3 (ASIAN) CONTINUE WITH QT07_2.7;
ELSE GO TO PROGRAMMING NOTE QT07_2.8.
QT07_2.7

You said Asian, and what specific ethnic group are you, such as Chinese, Filipino,
Vietnamese? If you are more than one, tell me all of them.

TI2D
[CODE ALL THAT APPLY]
BANGLADESHI .......................................................................... 1
BURMESE .................................................................................... 2
CAMBODIAN .............................................................................. 3
CHINESE....................................................................................... 4
FILIPINO....................................................................................... 5
HMONG ........................................................................................ 6
INDIAN (INDIA) .......................................................................... 7
INDONESIAN............................................................................... 8
JAPANESE ................................................................................... 9
KOREAN....................................................................................... 10
LAOTIAN...................................................................................... 11
MALAYSIAN .............................................................................. 12
PAKISTANI ................................................................................. 13
SRI LANKAN ............................................................................... 14
TAIWANESE ................................................................................ 15
THAI.............................................................................................. 16
VIETNAMESE.............................................................................. 17
OTHER ASIAN (SPECIFY): _________________ ..................... 91
REFUSED...................................................................................... -7
DON’T KNOW.............................................................................. -8
PROGRAMMING NOTE QT07_2.8:
IF QT07_2.3 = 5 (PACIFIC ISLANDER) CONTINUE WITH QT07_2.8;
ELSE GO TO PROGRAMMING NOTE QT07_2.9.
QT07_2.8

You said you are Pacific Islander. What specific ethnic group are you, such as Samoan,
Tongan, or Guamanian? If you are more than one, tell me all of them.

TI2D1
[CODE ALL THAT APPLY]
SAMOAN/AMERICAN SAMOAN ............................................. 1
GUAMANIAN ............................................................................. 2
TONGAN....................................................................................... 3
FIJIAN ........................................................................................... 4
OTHER PACIFIC ISLANDER (SPECIFY): ............................... 91
_______________________
REFUSED...................................................................................... -7
DON'T KNOW .............................................................................. -8
PROGRAMMING NOTE QT07_2.9

49

IF QT07_2.1 = 1 (YES, LATINO) AND [QT07_2.3 = 6 (NATIVE HAWAIIAN) OR 5 (OTHER
PACIFIC ISLANDER) OR 4 (AMERICAN INDIAN OR ALASKA NATIVE) OR 3 (ASIAN) OR 2
(BLACK OR AFRICAN AMERICAN) OR 1 (WHITE) OR 91 (OTHER (Specify))], CONTINUE WITH
QT07_2.9;
ELSE IF MULTIPLE RESPONSES TO QT07_2.3 OR QT07_2.7 OR QT07_2.8 [NOT COUNTING
-7 OR -8 (REF/DK)], CONTINUE WITH QT07_2.9; ELSE GO TO QT07_2.10.
FOR QT07_2.2 RESPONSES, INCLUDE "Specify" RESPONSE FOR 91 (OTHER LATINO); IF
QT07_2.1 = -7 (REFUSE), INSERT "Latino".
QT07_2.9

You said that you are {DISPLAY RESPONSES FROM QT07_2.2, QT07_2.3,
QT05_1.14, QT07_2.8}. Of these, which do you MOST identify with?

TI2E
[IF R IS UNABLE TO CHOOSE ONE, OFFER OPTION
“BOTH/ALL/MULTIRACIAL”]
MEXICAN/MEXICANO .............................................................. 1
MEXICAN AMERICAN .............................................................. 2
CHICANO .................................................................................... 3
SALVADORAN............................................................................ 4
GUATEMALAN .......................................................................... 5
COSTA RICAN…………………………………………………..6
HONDURAN ................................................................................ 7
NICARAGUAN............................................................................. 8
PANAMANIAN ........................................................................... 9
PUERTO RICAN .......................................................................... 10
CUBAN ......................................................................................... 11
SPANISH-AMERICAN (FROM SPAIN)..................................... 12
LATINO, OTHER SPECIFY ....................................................... 13
LATINO......................................................................................... 14
NATIVE HAWAIIAN .................................................................. 16
OTHER PACIFIC ISLANDER .................................................... 17
AMERICAN INDIAN OR ALASKA NATIVE ........................... 18
ASIAN ........................................................................................... 19
BLACK OR AFRICAN AMERICAN .......................................... 20
WHITE .......................................................................................... 21
RACE, OTHER SPECIFY ........................................................... 22
BANGLADESHI .......................................................................... 30
BURMESE .................................................................................... 31
CAMBODIAN .............................................................................. 32
CHINESE....................................................................................... 33
FILIPINO....................................................................................... 34
HMONG ........................................................................................ 35
INDIAN (INDIA) .......................................................................... 36
INDONESIAN............................................................................... 37
JAPANESE ................................................................................... 38
KOREAN....................................................................................... 39
LAOTIAN...................................................................................... 40
MALAYSIAN .............................................................................. 41
PAKISTANI ................................................................................. 42
SRI LANKAN ............................................................................... 43

50

TAIWANESE ................................................................................ 44
THAI.............................................................................................. 45
VIETNAMESE.............................................................................. 46
ASIAN, OTHER SPECIFY .......................................................... 49
SAMOAN/AMERICAN SAMOAN ............................................. 50
GUAMANIAN ............................................................................. 51
TONGAN....................................................................................... 52
FIJIAN ........................................................................................... 53
PACIFIC ISLANDER, OTHER SPECIFY .................................. 55
BOTH/ALL/MULTIRACIAL ....................................................... 90
NONE OF THESE......................................................................... 95
REFUSED...................................................................................... -7
DON'T KNOW .............................................................................. -8
County of Birth, Citizenship, Immigration Status
QT07_2.10
In what country were you born?
TI3
UNITED STATES......................................................................... 1
AMERICAN SAMOA .................................................................. 2
CANADA ...................................................................................... 3
CHINA........................................................................................... 4
EL SALVADOR............................................................................ 5
ENGLAND .................................................................................... 6
FRANCE ....................................................................................... 7
GERMANY ................................................................................... 8
GUAM ........................................................................................... 9
GUATEMALA .............................................................................. 10
HUNGARY ................................................................................... 11
INDIA ........................................................................................... 12
IRAN.............................................................................................. 13
IRELAND ..................................................................................... 14
ITALY ........................................................................................... 15
JAPAN ........................................................................................... 16
KOREA ......................................................................................... 17
MEXICO........................................................................................ 18
PHILIPPINES................................................................................ 19
POLAND ...................................................................................... 20
PORTUGAL ................................................................................. 21
PUERTO RICO ............................................................................. 22
RUSSIA ......................................................................................... 23
TAIWAN ....................................................................................... 24
VIETNAM ..................................................................................... 25
VIRGIN ISLANDS ....................................................................... 26
OTHER (SPECIFY):_____________________ ........................... 91
REFUSED...................................................................................... -7
DON'T KNOW .............................................................................. -8
PROGRAMMING NOTE QT07_2.11:
IF QT07_2.10 = 1, 2, 9, 22, or 26 (BORN IN USA or US TERRITORY), GO TO QT07_2.14;
ELSE, CONTINUE WITH QT07_2.11

51

QT07_2.11
TI4

Are you a citizen of the United States?
YES..........................................................................................1 [GO TO QT07_2.13]
NO............................................................................................2
APPLICATION PENDING.....................................................3
REFUSED................................................................................-7
DON’T KNOW........................................................................-8

QT07_2.12
TI5

Are you a permanent resident with a green card?
[IF NEEDED SAY: “People usually call this a “Green Card” but the color can also be
pink, blue or white.”]
YES................................................................................................ 1
NO.................................................................................................. 2
APPLICATION PENDING........................................................... 3
REFUSED...................................................................................... -7
DON’T KNOW.............................................................................. -8

QT07_2.13
TI6

About how many years have you lived in the United States?
[FOR LESS THAN A YEAR, ENTER 1 YEAR]
_____ NUMBER OF YEARS [HR: 0-17]
{OR}

_____ YEAR FIRST CAME TO LIVE IN U.S. HR: 1982-2000]
REFUSED...................................................................................... -7
DON’T KNOW.............................................................................. -8
Languages Spoken at Home
QT07_2.14
What languages do you speak at home?
TI7
[CODE ALL THAT APPLY]
[PROBE: “Any others?”]
ENGLISH ...................................................................................... 1
SPANISH....................................................................................... 2
CANTONESE................................................................................ 3
VIETNAMESE.............................................................................. 4
TAGALOG .................................................................................... 5
MANDARIN ................................................................................. 6
KOREAN....................................................................................... 7
ASIAN INDIAN LANGUAGES................................................... 8
RUSSIAN ...................................................................................... 9
OTHER1 (SPECIFY): ___________ ............................................ 91
OTHER2 (SPECIFY): ___________ ............................................ 92
REFUSED...................................................................................... -7
DON’T KNOW.............................................................................. -8

52