General Population, Adult Women, 25 +

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

American Heart Association Screening Criteria/Demographics:

Screener Section I: DEMOGRAPHICS

Question 1a

(INTERVIEWER: IF MALE ANSWERS PHONE, ASK “May I please speak with a woman in your household who is 25 years of age or older?” IF YES, THEN ASK AGE QUESTION BELOW.)

(INTERVIEWER: IF SPEAKING WITH FEMALE, ASK “Are you 25 years of age or older?”)

1. Yes, speaking (25+)

2. Not available, call back

3. No female in household, or no female 25+ SCREEN OUT

4. Not sure (v) SCREEN OUT

5. Refused (v) SCREEN OUT

Question 2a

Q260 In which country or region do you currently reside?

Question 3a

Are you of Spanish or Hispanic origin, such as Latin American, Mexican, Puerto Rican, or Cuban? <BR><BR>

1 Yes, of Hispanic origin

2 No, not of Hispanic origin

4 Decline to answer SCREEN OUT

Question 3b

Do you consider yourself…?

1 White

2 Black

3 Asian or Pacific Islander

4 Native American or Alaskan Native

5 Mixed Race

6 Some other race

7 Hispanic

8 African American

9 First Nation/Native Canadian

10 South Asian

12 Chinese

13 Korean

14 Japanese

15 Other Southeast Asian

16 Filipino

17 Arab/West Asian

94 Decline to Answer

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 4 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Question 3c

What other race do you consider yourself?

Question 3d

You indicated that you consider yourself of a mixed racial background. With which of the following racial groups do you most closely identify?

1 White

2 Black

3 Asian or Pacific Islander

4 Native American or Alaskan Native

5 Mixed Race

6 Some other race

7 Hispanic

8 African American

9 First Nation/Native Canadian

10 South Asian

12 Chinese

13 Korean

14 Japanese

15 Other Southeast Asian

16 Filipino

17 Arab/West Asian

94 Decline to Answer

If after 600 completed respondents, “No, not of Hispanic origin” for Question 3A and 3B is “White” then SCREEN OUT

Question 4a

Which of the following ranges represents your age?

01 25-29

02 30-34

03 35-39

04 40-44

05 45-49

06 50-54

07 55-59

08 60-64

09 65-74

10 75-84

11 85 or older

99 Refused

Question 5a

In total, how many generations currently live in your household? [INT: IF NEEDED:] For example, if you live alone or only with a spouse or roommate, that would be one generation. If you live with your parents or your children, that would be two generations. If you live with your parents and your children, that would be three generations.

RANGE: 1-5

Question 6a

Which of the following types of health insurance, if any, do you currently have?

[RANDOMIZE first 9 responses]

[MULTIPLE RESPONSE]

1 Health insurance provided by [PHONE: your WEB: my] employer or school

2 Health insurance through a family member's employer or school

3 Private insurance coverage that you pay for out-of-pocket

4 Medicare

5 Medicaid or other public insurance

6 Veteran's Affairs (VA)

7 Some other type of insurance

8 No insurance coverage

9 Don't know (VOL)

10 Refused (VOL)

Question 7a

What is your current height?

|_| feet |_|_| inches

Question 8a

Q1320 What is your current weight?

|_|_|_| pounds

Hispanics only:

Question 9a

Which language do you usually speak at home?

1 Only Spanish

2 Spanish more than English

3 Spanish and English equally

4 English more than Spanish

5 Only English

9 Decline to answer

Hispanics only:

Question 9b

Would you say you can carry on a conversation in Spanish, both understanding and speaking…?

1 Not at all

2 Just a little

3 Pretty well

4 Very well

5 Don't know

9 Refused

Hispanics only:

Question 9c

Would you say you can carry on a conversation in English, both understanding and speaking…?

1 Not at all

2 Just a little

3 Pretty well

4 Very well

5 Don't know

6 Refused

Hispanics only:

Question 9d

Q1340 Would you say you can read a newspaper or book in <U>Spanish</U>…?

1 Not at all

2 Just a little

3 Pretty well

4 Very well

5 Don't know

6 Refused

Hispanics only:

Question 9e

Q1350 You indicated that you consider yourself Hispanic. From what country or region did you or your ancestors come? Please select all that apply.

[MULTIPLE RESPONSE]

1 Cuba

2 Mexico

3 Puerto Rico

4 Central or South America

6. Another country or region:

7. Enter Response after prompting “From what country or region did you or your ancestors come?”

9 Decline to answer

Question 10a

Including you, how many women, 25 or over, live in this household?

Question 11a

Some people feel that the people in Washington, D.C. are out of touch with the rest of the country. Do you feel this is the case?

1 Yes

2 No

Question 12a

Some people also feel that they are left out of things going on around them. Do you feel this is the case?

1 Yes

2 No

Question 13a

In the last month have you…?

1 Yes

2 No

[RANDOMIZE]

1 Read a book

2 Traveled

3 Participated in a team or individual sport

Q1420 Do you own an investment account that is specifically designed to provide for your retirement, or not?

1 Yes

2 No

Question 14a

Some people say that there is too much information being generated these days, considering all the TV news shows, magazines, newspapers, and computer information services. Others say that they like having so much information available. Do you feel overloaded with information or do you like having so much information available?

1 Feel overloaded

2 Like having so much information available

12