Form 1 Parent Interview

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

Attachment 3h - English
PATH Study Data Collection Instruments:
Parent Interview
June 18, 2013

PATH
Parent Questionnaire
Version 7.5
Number of
questions

Section
All

PATH – Wave 1
Parent Questionnaire

85

ii

PATH
Parent Questionnaire
Version 7.5
OMB Control Number: 0925-0664

Expiration Date: 11/30/2015

Public reporting burden for this collection of information is estimated to average 14 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 Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (XXXX-XXXX). Do
not return the completed form to this address.

PATH – Wave 1
Parent Questionnaire

iii

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0001

Screen ID:

What is your relationship to {Child’s first name}?
[Would you say biological, adopted or step mother / father?]
1
2
3
4
5
6
7
8
9
10
11
12
91
92
-8
-7

BIOLOGICAL MOTHER
BIOLOGICAL FATHER
ADOPTED MOTHER
ADOPTED FATHER
STEP MOTHER
STEP FATHER
FOSTER MOTHER
FOSTER FATHER
GRANDMOTHER
GRANDFATHER
AUNT
UNCLE
OTHER RELATIVE
NON RELATIVE
DON’T KNOW
REFUSED

(SPECIFY) ________________
(SPECIFY)________________

ASK: Parent/guardian of sampled youth, about each sampled youth and each shadow sample youth
GO TO: IF ASKING ABOUT A SAMPLED YOUTH, GO TO PT0045
IF ASKING ABOUT A SHADOW SAMPLE YOUTH, GO TO BOX P4

PROGRAM: If parent has already completed an interview for another SP youth, do not repeat PT0045,
PT0046, PT0047, PR1045, PR1050 and PM0001
PATH ID:

PT0045

Screen ID:

Do you have a spouse or partner that lives here?
[If your spouse or partner is deployed for military active duty, please consider them as living here.]
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PT0047
GO TO PT0047
GO TO PT0047

ASK: Parent/guardian of sampled youth.

PATH – Wave 1
Parent Questionnaire

1

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0046

Screen ID:

What is your spouse or partner’s first name?
{PROGRAM NOTE: LIST FIRST NAMES OF EVERYONE ON THE GRID WHO IS AGED 11 YEARS
OLD OR OLDER IN HH SCREENER WITH THEIR AGE, ORDERED BY OLDEST TO YOUNGEST}
IF NEEDED, CLARIFY THAT YOU ARE ASKING ABOUT THE SPOUSE OR PARTNER THAT LIVES IN
THE HOUSE. READ NAMES IF NECESSARY. ENTER AN X NEXT TO THE SPOUSE OR
PARTNER’S NAME.
1
-8
-7

CONTINUE
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth who say they have a partner that lives in the home (PT0045=1).
PROGRAM: List everyone on the grid who is age 11 or older, with a logic check if a biological relation is
selected.
PATH ID:

PT0047

Screen ID:

What is your marital status? Are you now married, widowed, divorced, separated or never married?
1
2
3
4
5
-8
-7

NOW MARRIED
WIDOWED
DIVORCED
SEPARATED
NEVER MARRIED
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.

PATH – Wave 1
Parent Questionnaire

2

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0002

Screen ID:

What is {FIRST NAME filled from PT0046}’s relationship to {Child’s first name}?
[Would you say biological, step, adopted or foster mother / father?]
1
2
3
4
5
6
7
8
9
10
11
12
91
92
-8
-7

BIOLOGICAL MOTHER
BIOLOGICAL FATHER
ADOPTED MOTHER
ADOPTED FATHER
STEP MOTHER
STEP FATHER
FOSTER MOTHER
FOSTER FATHER
GRANDMOTHER
GRANDFATHER
AUNT
UNCLE
OTHER RELATIVE
NON RELATIVE
DON’T KNOW
REFUSED

(SPECIFY)________________
(SPECIFY)________________

ASK: Parent/guardian of sampled youth that select a name in PT0046.
PROGRAM: FILL {FIRST NAME filled from PT0046} with first name selected in PT0046. If parent has
already completed an interview for another SP youth, PT0046 is not repeated for additional sampled
youth. In this case, fill FIRST NAME from PT0046 with the first name provided in the completed interview
from the first sampled youth.
BOX P2
If sampled youth is a twin or part of a multiple birth (as identified in the Household Screener HM0014=1),
ask items PM0016 – PM0021 following skips appropriately, for the sampled youth this interview is about.
Ask PM0016-PM0021 1 time for each set of twins or multiple births. Ask these questions for the first child
in the set; do not repeat for subsequent children in set.
If the sampled youth is a twin (If 2 children are the same age AND HM0014=1), go to PM0016. If the
sampled youth is part of a multiple birth (If 3 or more children are the same age AND HM0014=1), go to
PM0018.
Else go to PT0009.

PATH – Wave 1
Parent Questionnaire

3

PATH
Parent Questionnaire
Version 7.5
{PROGRAM: Display the following text for the interviewer.}
{CHILD’S FIRST NAME} WAS IDENTIFIED IN THE HOUSEHOLD SCREENER AS PART OF A SET OF
TWINS OR MULTIPLE BIRTHS. THE NEXT SET OF QUESTIONS IS SPECIFIC TO THESE TWINS OR
MULTIPLE BIRTHS.
1

CONTINUE

ASK: If sampled youth is a twin or part of a multiple birth (as identified in the Household Screener
HM0014=1)
PROGRAM: FILL {CHILD’S FIRST NAME} with first name of sampled youth that was identified as a twin
or multiple birth.
PATH ID:

PM0016

Screen ID:

{Child’s first name] was identified as a twin. Is that correct?
1

YES

2

NO

GO TO PT0009

-8

DON’T KNOW

GO TO PT0009

-7

REFUSED

GO TO PT0009

ASK: Parent/guardian of sampled youth that is part of a twin (as identified in the HH Screener HM0015)
PROGRAM: Fill “Twin’s first name” with the other twin’s name that was identified in the HH Screener
HM0015.
DISPLAY: QxQ #P1 AVAILABLE FOR “twin”.
PATH ID:

PM0030

Screen ID:

What is the first name of the child that {Child’s first name} is a twin of?
Name

______________________

-8

DON’T KNOW

GO TO PT0009

-7

REFUSED

GO TO PT0009

ASK: Parent/guardian of sampled youth that is part of a twin (as identified in the HH Screener HM0015)
PROGRAM:
DISPLAY: QxQ #PXX AVAILABLE FOR “twin”.

PATH – Wave 1
Parent Questionnaire

4

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PM0017

Screen ID:

Are {Child’s first name} and {Twin’s first name from PM0030} identical twins?
1

YES

GO TO PT0009

2

NO

GO TO PT0009

-8

DON’T KNOW

GO TO PT0009

-7

REFUSED

GO TO PT0009

ASK: Parent/guardian of sampled youth that is part of a twin (PM0016=1)
PROGRAM: Fill “Twin’s first name” with the other twin’s name that was identified in HM0015.
DISPLAY: QxQ #P2 AVAILABLE FOR “identical twins”.
PATH ID:

PM0018

Screen ID:

{Child’s first name} was identified as part of a multiple birth. Is that correct? [Multiple births refers to
twins, triplets, quadruplets, etc.]
1

YES

2

NO

GO TO PT0009

-8

DON’T KNOW

GO TO PT0009

-7

REFUSED

GO TO PT0009

ASK: Parent/guardian of sampled youth that is part of a multiple birth (as identified in the HH Screener)
PROGRAM: Fill “Multiple’s first names” with the other multiple’s first names that were identified in
HM0015. If two other multiple births, connect names with “and”. If more than two multiples, separate with
commas, and display ‘,and’ before the last multiple’s first name.
DISPLAY: QxQ #P3 AVAILABLE FOR “multiple birth”.
PATH ID:

PM0035

Screen ID:

What are the first names of the other children in the multiple birth with {Child’s first name}?
Name

______________________
[ALLOW UP TO 10
NAMES]

-8

DON’T KNOW

GO TO PT0009

-7

REFUSED

GO TO PT0009

ASK: Parent/guardian of sampled youth that is part of a twin (as identified in the HH Screener HM0015)
PROGRAM:
DISPLAY: QxQ #PXX AVAILABLE FOR “twin”.

PATH – Wave 1
Parent Questionnaire

5

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PM0019

Screen ID:

Are {Multiple’s first names from PM0035} identical to {Child’s first name}?
1

YES

2

NO

GO TO PT0009

-8

DON’T KNOW

GO TO PT0009

-7

REFUSED

GO TO PT0009

ASK: Parent/guardian of sampled youth that is part of a multiple birth (PM0018=1)
PROGRAM: Fill “Multiple’s first names” with the other multiple’s first names that were identified in
HM0015. If two multiple births, connect names with “or”. If more than two multiples, separate with
commas, and display ‘,or’ before the last multiple’s first name.
DISPLAY: QxQ #P4 AVAILABLE FOR “identical”.
PATH ID:

PM0021

Screen ID:

Who is identical to {Child’s first name}? Choose all that apply.
READ RESPONSE OPTIONS IF NEEDED
1

[FILL RESPONSE OPTIONS WITH THE FIRST NAME OF EACH PERSON IN THE
MULTIPLE BIRTH, EXCLUDING {Child’s first name}

2
3
X

[UP TO HOWEVER MANY CHILDREN ARE IN THE MULTIPLE BIRTH]

-8

DON’T KNOW

-7

REFUSED

ASK: Parent/guardian of sampled youth that is part of an identical multiple birth (PM0019=1)
PROGRAM: Allow this question to be choose all that apply. In the database, store the PID of the child or
children the respondent indicates is identical to {Child’s first name}.
DISPLAY: QxQ #P5 AVAILABLE FOR “identical”.

PATH – Wave 1
Parent Questionnaire

6

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0009

Screen ID:

The next series of questions ask about {Child’s first name}’s life at home and in school.
In general, does {Child’s first name} have a curfew or set time that {he/she} needs to be home on school
nights?
IF THE RESPONDENT IS UNSURE HOW TO ANSWER BECAUSE THE CURFEW VARIES BASED ON
THE SITUATION, CODE YES AS LONG AS THE PARENT IS THE ONE WHO SETS THE CURFEW
TIME.
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0011

Screen ID:

In general, does {Child’s first name} have a curfew or set time that {he/she} needs to be home on
weekend nights?
IF THE RESPONDENT IS UNSURE HOW TO ANSWER BECAUSE THE CURFEW VARIES BASED
ON THE SITUATION, CODE YES AS LONG AS THE PARENT IS THE ONE WHO SETS THE
CURFEW TIME.
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.

PATH – Wave 1
Parent Questionnaire

7

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0019

Screen ID:

Please look at this list. How would you describe how {Child’s first name} has performed at school in the
past 12 months? Would you say {Child’s first name}’s grades are..
READ RESPONSE OPTIONS ALOUD.
1
Mostly A’s,
2
A’s and B’s,
3
Mostly B’s,
4
B’s and C’s,
5
Mostly C’s,
6
C’s and D’s,
7
Mostly D’s,
8
D’s and F’s,
9
Mostly F’s, or
10
My child’s school is ungraded?
-8
DON’T KNOW
-7
REFUSED
ASK: Parent/guardian of sampled youth.
DISPLAY: Digital showcard #1.
PATH ID:

PT0030

Screen ID:

In the past 12 months, how often did {Child’s first name} miss school due to illness? Would you say
never, rarely, sometimes, often, or very often?
1
NEVER
2
RARELY
3
SOMETIMES
4
OFTEN
5
VERY OFTEN
-8
DON’T KNOW
-7
REFUSED
ASK: Parent/guardian of sampled youth.
DISPLAY: QxQ #P6 AVAILABLE FOR “illness”.

PATH – Wave 1
Parent Questionnaire

8

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0021

Screen ID:

As far as you know, has {Child’s first name} ever smoked a cigarette or used other tobacco products,
such as e-cigarettes, cigars, a pipe, a hookah, smokeless tobacco, dissolvable tobacco, bidis or kreteks?
Please look at this list. Would you say…
READ RESPONSE OPTIONS ALOUD.
1
2
3
4
-8
-7

You know that {she/he} has
You strongly suspect {she/he} has,
You don’t think {she/he} has or
You are confident {she/he} has not?
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
DISPLAY: Digital showcard #2M/#2F/#2O.
PATH ID:

PR1045

Screen ID:

These next few questions ask about the rules of using tobacco inside your home. Please think about
everyone who might be in your home including children, adults, visitors, guests, or workers.
For tobacco products that are burned, such as cigarettes, cigars, pipes or hookah, which statement best
describes the rules about smoking these products inside your home? Please look at this list. Would you
say…
READ RESPONSE OPTIONS ALOUD.
1
2
3
-8
-7

It is not allowed anywhere or at any time inside my home,
It is allowed in some places or at some times inside my home, or
It is allowed anywhere and at any time inside my home?
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
DISPLAY: Digital showcard #3.

PATH – Wave 1
Parent Questionnaire

9

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PR1050

Screen ID:

Now think about other tobacco products that are not burned, like smokeless tobacco, dissolvable
tobacco, and e-cigarettes. Which statement best describes the rules about using these products inside
your home? Please look at this list. Would you say…
READ RESPONSE OPTIONS ALOUD.
1
2
3
-8
-7

It is not allowed anywhere or at any time inside my home,
It is allowed in some places or at some times inside my home, or
It is allowed anywhere and at any time inside my home?
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
DISPLAY: Digital showcard #4.
PATH ID:

PT0029

Screen ID:

Do you think cigarettes or tobacco might be available to {Child’s first name} at your home?
1
2
-8

YES
NO

-7

REFUSED

DON’T KNOW

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0003

Screen ID:

Does {Child’s first name} have {another parent | a parent} who lives somewhere else?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PT0035
GO TO PT0035
GO TO PT0035

ASK: Parent/guardian of sampled youth.
PROGRAM: IF PT0001 < 7, DISPLAY “another parent”. IF PT0001 => 7 OR IF PT0001 = DK OR RF,
DISPLAY “a parent”

PATH – Wave 1
Parent Questionnaire

10

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0006

Screen ID:

How often does {Child’s first name} stay there? Would you say never, less than half the time, about half
the time, or more than half the time?
1
2
3
4
-8
-7

NEVER
LESS THAN HALF THE TIME
ABOUT HALF THE TIME
MORE THAN HALF THE TIME
DON’T KNOW
REFUSED

GO TO PT0035

ASK: Parent/guardian of sampled youth if that child has another parent who lives somewhere else
(PT0003=1).
PATH ID:

PT0005

Screen ID:

Do you think cigarettes or tobacco might be available to {Child’s first name} when {he/she} is at the other
parent’s home?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth where child spends time at other parent’s house (PT0006>1)
PATH ID:

PT0035

Screen ID:

The next series of questions ask about {Child’s first name}’s health.
In general, would you say {Child’s first name}’s overall health is excellent, very good, good, fair, or poor?
1
2
3
4
5
-8
-7

EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
DISPLAY: QxQ #P7 AVAILABLE FOR “overall health”.

PATH – Wave 1
Parent Questionnaire

11

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0007

Screen ID:

About how tall is {Child’s first name} without shoes? Please enter height in either feet and inches or
meters.
I___I___I
1
FEET
I___I___I
2
INCHES
I__I__I.I__I__I
3
METERS
-8
DON’T KNOW
-7
REFUSED
ASK: Parent/guardian of sampled youth.
PROGRAM: Allow entry for either feet and inches or meters – not both. Range check: Feet (3 to 8);
Inches (0 to 11).
PATH ID:

PT0008

Screen ID:

About how much does {Child’s first name} weigh without clothes or shoes? Please enter weight in either
pounds or kilograms.
I___I___I___I
1
POUNDS
I___I___I___I
2
KILOGRAMS
-8
DON’T KNOW
-7
REFUSED
ASK: Parent/guardian of sampled youth.
PROGRAM: Allow entry for either pounds or kilograms – not both. Range check: Meters (0.9 to 2.7).
PATH ID:

PX0302

Screen ID:

In the past 12 months, has {Child’s first name} visited an emergency room or urgent care center for a
health problem, accident or injury?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PX0186
GO TO PX0186
GO TO PX0186

ASK: Parent/guardian of sampled youth.
DISPLAY: QxQ #P8 AVAILABLE FOR “urgent care center” and “health problem”.

PATH – Wave 1
Parent Questionnaire

12

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0034

Screen ID:

How many visits to the emergency room or urgent care center has {Child’s first name} made in the past
12 months?
|__|__|__|
1
VISITS
-8
DON’T KNOW
-7
REFUSED
ASK: Parent/guardian of sampled youth who has visited an emergency room or urgent care in the past
12 months (PX0302=1).
DISPLAY: QxQ #P9 AVAILABLE FOR “urgent care center”.
PATH ID:

PX0186

Screen ID:

Does {Child’s first name} have serious difficulty walking or climbing stairs?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
PATH ID:

PX0188

Screen ID:

Does {Child’s first name} have difficulty dressing or bathing?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
PATH ID:

PX0191

Screen ID:

Is {Child’s first name} blind or does {he/she} have serious difficulty seeing, even when wearing glasses?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.

PATH – Wave 1
Parent Questionnaire

13

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PX0190

Screen ID:

Is {Child’s first name} deaf or does {he/she} have serious difficulty hearing?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
PATH ID:

PX0189

Screen ID:

Because of a physical, mental, or emotional condition, does {Child’s first name} have serious difficulty
concentrating, remembering, or making decisions?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
GO TO: If sampled youth is 15 years old or older (HM0006 >= 15), go to PX0187
Else go to PT0050.
PATH ID:

PX0187

Screen ID:

Because of a physical, mental, or emotional condition, does {Child’s first name} have difficulty doing
errands alone such as visiting a doctor's office or shopping?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth who are 15 years old or older (HM0006 >= 15)
PATH ID:

PT0050

Screen ID:

Has {Child’s first name} ever been told by a doctor or other health professional that {he/she} has high
blood pressure?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PT0051
GO TO PT0051
GO TO PT0051

ASK: Parent/guardian of sampled youth

PATH – Wave 1
Parent Questionnaire

14

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0041

Screen ID:

How old was {Child’s first name} when {he/she} was first told {he/she} had high blood pressure?
1

|___|___| YEARS OLD

-8

DON’T KNOW

-7

REFUSED

GO TO PT0051

ASK: If sampled youth ever had high blood pressure (PT0050=1)
PATH ID:

PT0253

Screen ID:

Was {Child’s first name} less than 12 years old, 12 to 14 years old, or 15 to 17 years old?
1
LESS THAN 12 YEARS OLD
2
12 TO 14 YEARS OLD
3
15 TO 17 YEARS OLD
-8 DON’T KNOW
-7 REFUSED
ASK: All respondents who refused to give or did not know age (PT0041=DK,R)
PATH ID:

PT0051

Screen ID:

Has {Child’s first name} ever been told by a doctor or other health professional that {he/she} has high
cholesterol?
1
YES
2
NO
GO TO PT0031
-8 DON’T KNOW
GO TO PT0031
-7 REFUSED
GO TO PT0031
ASK: Parent/guardian of sampled youth
PATH ID:

PT0043

Screen ID:

How old was {Child’s first name} when {he/she} was first told {he/she} had high cholesterol?
1

|___|___|___| YEARS OLD

-8

DON’T KNOW

-7

REFUSED

GO TO PT0031

ASK: If sampled youth ever had high cholesterol (PT0051=1)

PATH – Wave 1
Parent Questionnaire

15

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0254

Screen ID:

Was {Child’s first name} less than 12 years old, 12 to 14 years old, or 15 to 17 years old?
1
LESS THAN 12 YEARS OLD
2
12 TO 14 YEARS OLD
3
15 TO 17 YEARS OLD
-8 DON’T KNOW
-7 REFUSED
ASK: All respondents who refused to give or did not know age (PT0043=DK,R)
PATH ID:

PT0031

Screen ID:

Has {Child’s first name} ever been told by a doctor or other health professional that {he/she} has
asthma?
1
YES
2
NO
GO TO PT0033
-8
DON’T KNOW
GO TO PT0033
-7
REFUSED
GO TO PT0033
ASK: Parent/guardian of sampled youth.
DISPLAY: QxQ #P10 AVAILABLE FOR “asthma”.
PATH ID:

PT0038

Screen ID:

How old was {Child’s first name} when {he/she} was first told {he/she} had asthma?
1

|___|___|___| YEARS OLD

-8

DON’T KNOW

-7

REFUSED

GO TO PT0022

ASK: If sampled youth ever had asthma (PT0031=1)
DISPLAY: QxQ #P11 AVAILABLE FOR “asthma”.
PATH ID:

PT0260

Screen ID:

Was {Child’s first name} less than 12 years old, 12 to 14 years old, or 15 to 17 years old?
1
LESS THAN 12 YEARS OLD
2
12 TO 14 YEARS OLD
3
15 TO 17 YEARS OLD
-8 DON’T KNOW
-7 REFUSED
ASK: All respondents who refused to give or did not know age (PT0038=DK,R)

PATH – Wave 1
Parent Questionnaire

16

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0022

Screen ID:

In the past 12 months, has {Child’s first name} taken medications regularly for asthma?
[Taken regularly means according to a health care provider’s instructions.]
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PT0125
GO TO PT0125
GO TO PT0125

ASK: If sampled youth ever had asthma (PT0031=1)
DISPLAY: QxQ #P12 AVAILABLE FOR “asthma”.
PATH ID:

PT0036

Screen ID:

Please look at this list. In the past 12 months, which of the following medications did {Child’s first name}
regularly take for asthma? Choose all that apply.
READ TEXT BEFORE THE HYPEN ALOUD.
Quick-relief inhaler - FOR EXAMPLE: ALBUTEROL (PROAIR, VENTOLIN, XOPENEX),
1
IPRATROPIUM (ATROVENT), OR A COMBINATION INHALER (COMBIVENT)
Controller or long-acting inhaler including steroid inhaler – FOR EXAMPLE:
2
BECLOMETHASONE (QVAR), FLUTICASONE (FLOVENT), SALMETEROL
(SEREVENT), TIOTROPIUM (SPIRIVA), OR A COMBINATION INHALER (ADVAIR)
Other controlling medication – FOR EXAMPLE: MONTELUKAST (SINGULAIR),
3
ZAFIRLUKAST (ACCOLATE), THEOPHYLLINE, ROFLUMILAST (DALIRESP)
Oral or injected steroid medication – FOR EXAMPLE: PREDNISONE, PREDNISOLONE
4
(ORAPRED), DEXAMETHASONE (DECADRON)
5
Oxygen therapy
6
Other asthma medication
-8 DON’T KNOW
-7 REFUSED
ASK: If sampled youth took medications for asthma (PT0022=1)
DISPLAY: Digital showcard #5.
QxQ #P13 AVAILABLE FOR “medications” and “asthma”.

PATH – Wave 1
Parent Questionnaire

17

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0125

Screen ID:

In the past 12 months, has {Child’s first name} had an asthma attack that required use of an oral or
injected steroid medication at the time of the attack?
[Examples of oral or injected steroid medications include prednisone, prednisolone (Orapred), and
dexamethasone (Decadron).]
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PT0127
GO TO PT0127
GO TO PT0127

ASK: If sampled youth ever had asthma (PT0031=1)
DISPLAY: QxQ #P14 AVAILABLE FOR “asthma attack”.
PATH ID:

PT0039

Screen ID:

In the past 12 months, how many asthma attacks has {Child’s first name} had that required use of an
oral or injected steroid medication at the time of the attack?
1

|___|___|___|

-8

DON’T KNOW

-7

REFUSED

ASK: If sampled youth ever had asthma attack and needed medication (PT0125=1)
DISPLAY: QxQ #P15 AVAILABLE FOR “asthma attacks”.
PATH ID:

PT0127

Screen ID:

In the past 12 months, has {Child’s first name} had to visit an emergency room or urgent care center
because of asthma?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PT0033
GO TO PT0033
GO TO PT0033

ASK: If sampled youth ever had asthma (PT0031=1).
DISPLAY: QxQ #P16 AVAILABLE FOR “urgent care center” and “asthma”.
PATH ID:

PT0282

Screen ID:

In the past 12 months, how many times has {Child’s first name} had to visit an emergency room or
urgent care center because of asthma?
1

|___|___|___| TIMES

-8

DON’T KNOW

-7

REFUSED

ASK: If sampled youth ever had to go to emergency room for asthma (PT0127=1)
DISPLAY: QxQ #P17 AVAILABLE FOR “urgent care center” and “asthma”.

PATH – Wave 1
Parent Questionnaire

18

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0033

Screen ID:

In the past 12 months, has {Child’s first name} been told by a doctor or other health professional that
{he/she} has bronchitis, pneumonia, or chronic cough?
1
YES
GO TO PT0052
2
NO
-8
DON’T KNOW
GO TO PT0052
-7
REFUSED
GO TO PT0052
ASK: Parent/guardian of sampled youth.
PATH ID:

PT0040

Screen ID:

Has {Child’s first name} ever been told by a doctor or other health professional that {he/she} had
bronchitis, pneumonia, or chronic cough?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: If sampled youth has not had bronchitis in past 12 months (PT0033=2)
PATH ID:

PT0052

Screen ID:

Has {Child’s first name} ever been told by a doctor or other health professional that {he/she} has ADHD
or ADD?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PT0049
GO TO PT0049
GO TO PT0049

ASK: Parent/guardian of sampled youth
DISPLAY: QxQ #P18 AVAILABLE FOR “ADHD or ADD”.
PATH ID:

PT0048

Screen ID:

In the past 12 months, has {Child’s first name} taken medications regularly for ADHD or ADD?
[Taken regularly means according to a health care provider’s instructions.]
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: If sampled youth ever had ADHD/ADD (PT0052=1).
DISPLAY: QxQ #P19 AVAILABLE FOR “ADHD or ADD”.

PATH – Wave 1
Parent Questionnaire

19

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0049

Screen ID:

In the past 12 months, has {Child’s first name} been told by a doctor, dentist or other health professional
that {he/she} has dental health issues, such as cavities, gum disease or dental stains?
[Dental health issues do NOT include orthodontia or braces.]
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PT0281
GO TO PT0281
GO TO PT0281

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0044

Screen ID:

Has {Child’s first name} ever been told by a doctor or a health professional that {he/she} has dental
health issues, such as cavities, gum disease, or dental stains?
[Dental health issues do NOT include orthodontia or braces.]
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: If sampled youth has not had dental issues in past 12 months (PT0049=2)
PATH ID:

PT0281

Screen ID:

Has {Child’s first name} ever been told by a doctor or other health professional that {he/she} has
diabetes, sugar diabetes, high blood sugar, or borderline diabetes?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PM0001
GO TO PM0001
GO TO PM0001

ASK: Parent/guardian of sampled youth
PATH ID:

PT0042

Screen ID:

How old was {Child’s first name} when {he/she} was first told {he/she} had diabetes, sugar diabetes, high
blood sugar, or borderline diabetes?
1

|___|___| YEARS OLD

-8

DON’T KNOW

-7

REFUSED

GO TO PM0001

ASK: If sampled youth ever had diabetes (PT0281=1)

PATH – Wave 1
Parent Questionnaire

20

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PT0263

Screen ID:

Was {Child’s first name} less than 12 years old, 12 to 14 years old, or 15 to 17 years old?
1
LESS THAN 12 YEARS OLD
2
12 TO 14 YEARS OLD
3
15 TO 17 YEARS OLD
-8
DON’T KNOW
-7
REFUSED
ASK: All respondents who refused to give or did not know age (PT0042=DK,R)
PATH ID:

PM0001

Screen ID:

These next few questions are about you.
What is the highest grade or year of school that you completed?
1
UP TO 8TH GRADE
2
9TH TO 11TH GRADE
3
12TH GRADE BUT NO DIPLOMA
4
HIGH SCHOOL DIPLOMA/EQUIVALENT
5
VOC/TECH PROGRAM AFTER HS BUT NO VOC/TECH DIPLOMA
6
VOC/TECH DIPLOMA AFTER HS
7
SOME COLLEGE BUT NO DEGREE
8
ASSOCIATE’S DEGREE (A.A., A.S.)
9
BACHELOR’S DEGREE (B.A., B.S.)
10
SOME GRADUATE OR PROFESSIONAL SCHOOL BUT NO DEGREE
11
MASTER’S DEGREE (M.A., M.S.)
12
DOCTORATE DEGREE (PH.D., ED.D)
13
PROFESSIONAL DEGREE BEYOND BACHELOR’S (MEDICINE/MD;
DENTISTRY/DDS; LAW/JD/LLB; ETC)
-8
DON’T KNOW
-7
REFUSED
ASK: Parent/guardian of sampled youth.
PROGRAM: For parent respondent of more than one youth, do not ask this if parent already completed
interview for first sampled youth.

PROGRAM:
Ask questions PN0001 to PN0003 only of parents/guardians who are not the Household Screener
Respondent and who have not been sampled for the Adult survey. All respondents who are the
Household Screener Respondent or who have been sampled for the Adult survey or is a parent
respondent of more than one youth and already completed interview for first sampled youth, go to BOX
P4.

PATH – Wave 1
Parent Questionnaire

21

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PN0001

Screen ID:

Please look at this picture. In the past 30 days, have you smoked a cigarette, a cigar, or a pipe, even one
or two puffs?
1
YES
2
NO
-8
DON’T KNOW
-7
REFUSED
ASK: All respondents.
DISPLAY: Digital showcard #6.
PATH ID:

PN0002

Screen ID:

Please look at this picture. In the past 30 days, have you used smokeless tobacco, such as chewing
tobacco, snuff, snus or dip, even one or two times?
[Do not include e-cigarettes or products such as a nicotine patch, gum, inhaler, nasal spray, lozenge or
pill].
1
YES
2
NO
-8
DON’T KNOW
-7
REFUSED
ASK: All respondents.
DISPLAY: Digital showcard #7.
PATH ID:

PN0003

Screen ID:

Please look at this picture. In the past 30 days, have you used e-cigarettes, a hookah, or dissolvable
tobacco, even one or two times?
1
YES
2
NO
-8
DON’T KNOW
-7
REFUSED
ASK: All respondents.
DISPLAY: Digital showcard #8.

PATH – Wave 1
Parent Questionnaire

22

PATH
Parent Questionnaire
Version 7.5

CONTACT INFORMATION
BOX P4
ASK CONTACT INFORMATION 1 TIME FOR EACH PARENT RESPONDENT. IF PARENT IS AN SP
AND HAS ALREADY PROVIDED CONTACT INFORMATION AT THE END OF THE ADULT
INTERVIEW OR FOR ANOTHER SAMPLED YOUTH OR SHADOW YOUTH, DO NOT ASK CONTACT
INFORMATION AGAIN, GO TO BOX P3 THEN RETURN TO IMS.
PATH ID:

PL0001

Screen ID:

I’d like to take a brief moment to confirm your contact information for my records. I’ll use this information
to contact you about [INSERT ALL SAMPLED YOUTH AND SHADOW SAMPLED CHILDREN’S
NAMES]’s participation in the study.
Can you tell me your full name?
VERIFY ALL SPELLING. IF PERSON HAS NO MIDDLE NAME, LEAVE MIDDLE INITIAL BLANK. IF
NEEDED: FULL NAME INCLUDES FIRST NAME, MIDDLE INITIAL, AND LAST NAME.
NAME: ______________________________________________________________
FIRST
MI
LAST
I need to confirm your street address. Is this address correct?
[DISPLAY ADDRESS FROM THE SAMPLE FILE IN AN EASY TO READ FORMAT.]
READ ADDRESS. VERIFY ALL SPELLING. PROBE FOR APT NUMBER IF NEEDED. DO NOT
ENTER A PO BOX HERE.
___________________________________________________________________
STREET
APT #
___________________________________________________________________
CITY
STATE
ZIP
PROGRAMMER NOTE: PRE-POPULATE NAME FIELDS (FIRST, MI, LAST) BASED ON INFO
OBTAINED IN THE SCREENER. If the first name is don’t know or refused, continue on to ask MI and
LAST. If Street is don’t know or refused, continue on to ask the rest of the address fields.
PATH ID:

PL0002

Screen ID:

Do you receive mail at the address you just gave me?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PL0004

ASK: All respondents.

PATH – Wave 1
Parent Questionnaire

23

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PL0003

Screen ID:

Can I please have your mailing address? VERIFY ALL SPELLING.
_________________________________________________________________
MAILING ADDRESS
__________________________________________________________________
CITY
STATE
ZIP
PROGRAM: If Mailing Address is don’t know or refused, continue on to ask the rest of the address
fields.
PATH ID:

PL0004

Screen ID:

What is the best telephone number to reach you?
ENTER THE NUMBERS ONLY. DO NOT ENTER HYPHENS OR OTHER SYMBOLS.
__________
___________________________ ______
AREA CODE
PHONE NUMBER
EXT
-8

DON’T KNOW

GO TO PL0012

-7

REFUSED

GO TO PL0012

ASK: All respondents.
PROGRAM: If the area code is don’t know or refused, do not ask the rest of the phone number or the
extension.
PATH ID:

PL0005

Screen ID:

Is this a home phone or cell phone number?
1
2
3
-8
-7

HOME
CELL
OTHER
DON’T KNOW
REFUSED

GO TO PL0006
GO TO PL0032
GO TO PL0006
GO TO PL0006
GO TO PL0006

ASK: All respondents.
PATH ID:

PL0032

Screen ID:

May we contact you by text message at this number?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Respondents who said their best number is a cell phone (PL0005=2).

PATH – Wave 1
Parent Questionnaire

24

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PL0006

Screen ID:

Is there a second telephone number where you can be reached?
ENTER THE NUMBERS ONLY. DO NOT ENTER HYPHENS OR OTHER SYMBOLS.
__________
__________________________ ____
AREA CODE
PHONE NUMBER
EXT
-8

DON’T KNOW

GO TO PL0012

-7

REFUSED

GO TO PL0012

ASK: All respondents.
PROGRAM: If the area code is don’t know or refused, do not ask the rest of the phone number or the
extension.
PATH ID:

PL0007

Screen ID:

Is this your home phone or cell phone number?
1
2
3
-8
-7

HOME
CELL
OTHER
DON’T KNOW
REFUSED

GO TO PL0012
GO TO PL0033
GO TO PL0012
GO TO PL0012
GO TO PL0012

ASK: All respondents.
PATH ID:

PL0033

Screen ID:

May we contact you by text message at this number?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Respondents who said their second number is a cell phone (PL0007=2).
PATH ID:

PL0012

Screen ID:

Can you please give me your e-mail address?
VERIFY ALL SPELLING AND PUNCTUATION. RECORD TEXT BEFORE @ SYMBOL IN THE EMAIL
NAME FIELD. TEXT AFTER THE @ SYMBOL IS ENTERED IN THE EMAIL PROVIDER FIELD.
_____________________________@________________
E-MAIL ADDRESS
E-MAIL PROVIDER
-8
DON’T KNOW
-7
REFUSED
ASK: All respondents.
PROGRAM: If respondent says DK or RF to first email address, do not ask for second email address.

PATH – Wave 1
Parent Questionnaire

25

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PL0017

Screen ID:

Of all the contact information you just provided, what is the best way to reach you?
PROBE WITH RESPONSE OPTIONS IF NECESSARY.
IF RESPONDENT SAYS CELL PHONE, PROBE ON PHONE CALL OR TEXT MESSAGE.
1
2
3
4
5
-8
-7

HOME PHONE
CELL PHONE
TEXT MESSAGE
E-MAIL
OTHER
DON’T KNOW
REFUSED

ASK: All respondents.
PATH ID:

PL0018

Screen ID:

Do you anticipate moving or relocating either permanently or temporarily in the next 6 to 12 months?
1
2
3
-8
-7

YES
NO
MAYBE
DON’T KNOW
REFUSED

GO TO PL0030
GO TO PL0030
GO TO PL0030

ASK: All respondents.
PATH ID:

PL0019

Screen ID:

Can you tell me more about your plans to move? [For example, your new street address or the city or
state to which you plan to move?]
PROBE FOR AND RECORD ANY KNOWN INFORMATION.
__________________________________________________________________
-8
DON’T KNOW
-7
REFUSED
ASK: Respondents that plan to move (PL0018=1 or 3).
PATH ID:

PL0030

Screen ID:

Do you anticipate {Child’s first name} moving or relocating either permanently or temporarily in the next 6
to 12 months?
1
2
3
-8
-7

YES
NO
MAYBE
DON’T KNOW
REFUSED

GO TO PL0020
GO TO PL0020
GO TO PL0020

ASK: Parent/guardian of sampled youth, about each sampled youth and each shadow sample youth.

PATH – Wave 1
Parent Questionnaire

26

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PL0031

Screen ID:

Can you tell me more about {Child’s first name}’s plans to move? [For example, {Child’s first name}’s
new street address or the city or state to which {Child’s first name} plans to move?]
PROBE FOR AND RECORD ANY KNOWN INFORMATION.
__________________________________________________________________
-8
DON’T KNOW
-7
REFUSED
ASK: Parent/guardian of sampled youth, about each sampled youth and each shadow sample youth, that
plans to move (PL0030=1 or 3).
PATH ID:

PL0020

Screen ID:

In case we cannot reach you, can you please give me the contact information of two relatives, friends or
neighbors who will always know how to get in touch with you? We would prefer to have information for
people who do not live with you.
Who is the first person? VERIFY ALL SPELLING.
__________________________________________________________________
FIRST NAME
MI
LAST NAME
-8
DON’T KNOW
GO TO END
-7
REFUSED
GO TO END
ASK: All respondents.
PROGRAM: If the first name is don’t know or refused, continue on to ask MI and LAST.
PATH ID:

PL0021

Screen ID:

How is [FIRST NAME IN PL0020] related to you?
1
2
3
4
5
6
7
8
9
-8
-7

HUSBAND/WIFE
FATHER/MOTHER (INCLUDING IN-LAWS)
GRANDPARENT
SON/DAUGHTER (INCLUDING IN-LAWS)
GRANDCHILD
BROTHER/SISTER (INCLUDING IN-LAWS)
FRIEND/NEIGHBOR
OTHER RELATIVE (SPECIFY) ________________
OTHER NON-RELATIVE (SPECIFY) ____________
DON’T KNOW
REFUSED

ASK: All respondents.

PATH – Wave 1
Parent Questionnaire

27

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PL0022

Screen ID:

What is [FIRST NAME IN PL0020]’s address and telephone number?
VERIFY ALL SPELLING.
_________________________________________________________________
MAILING ADDRESS
__________________________________________________________________
CITY
STATE
ZIP
_________
__________________________ ____
AREA CODE
PHONE NUMBER
EXT
ASK: All respondents.
PROGRAM: Allow DK/R response for all fields. If Mailing Address is don’t know or refused, continue on
to ask the rest of the address fields. If the area code is don’t know or refused, do not ask the rest of the
phone number or the extension.
GO TO: When phone number is DK/R go to PL0024
PATH ID:
PL0024
Can you please tell me [FIRST NAME IN PL0020]’s e-mail address?

Screen ID:

VERIFY ALL SPELLING AND PUNCTUATION.
_____________________________@________________
E-MAIL ADDRESS
ASK: All respondents.
PATH ID:

PL0025

Screen ID:

What is the name of the second friend or relative? Again, we would prefer someone who does not live
with you.
__________________________________________________________________
FIRST NAME
MI
LAST NAME
-8
-7

DON’T KNOW
REFUSED

GO TO END
GO TO END

ASK: All respondents.
PROGRAM: If the first name is don’t know or refused, continue on to ask MI and LAST.

PATH – Wave 1
Parent Questionnaire

28

PATH
Parent Questionnaire
Version 7.5
PATH ID:

PL0026

Screen ID:

How is [FIRST NAME IN PL0025] related to you?
1
2
3
4
5
6
7
8
9
-8
-7

HUSBAND/WIFE
FATHER/MOTHER (INCLUDING IN-LAWS)
GRANDPARENT
SON/DAUGHTER (INCLUDING IN-LAWS)
GRANDCHILD
BROTHER/SISTER (INCLUDING IN-LAWS)
FRIEND/NEIGHBOR
OTHER RELATIVE (SPECIFY) ________________
OTHER NON-RELATIVE (SPECIFY) ____________
DON’T KNOW
REFUSED

ASK: All respondents.
PATH ID:

PL0027

Screen ID:

What is [FIRST NAME IN PL0025]’s address and telephone number?
VERIFY ALL SPELLING.
_________________________________________________________________
MAILING ADDRESS
__________________________________________________________________
CITY
STATE
ZIP
_________
_________________________
_____
AREA CODE
PHONE NUMBER
EXT
ASK: All respondents.
PROGRAM: Allow DK/R response for all fields. If Mailing Address is don’t know or refused, continue on
to ask the rest of the address fields. If the area code is don’t know or refused, do not ask the rest of the
phone number or the extension.
GO TO: When phone number is DK/R go to PL0029.
PATH ID:
PL0029
Can you please tell me [FIRST NAME IN PL0025]’s e-mail address?
VERIFY ALL SPELLING AND PUNCTUATION.
_____________________________@________________
E-MAIL ADDRESS
ASK: All respondents.

PATH – Wave 1
Parent Questionnaire

29

Screen ID:

PATH
Parent Questionnaire
Version 7.5
Box P3

Screen ID:

END OF INTERVIEW, DISPLAY THE FOLLOWING:
PROGRAM: {THIS RESPONDENT HAS ALREADY PROVIDED CONTACT INFORMATION.}
Thank you for taking the time to answer these questions.
PROGRAM: If this respondent has already provided contact information in a completed adult interview,
display “THIS RESPONDENT HAS ALREADY PROVIDED CONTACT INFORMATION”.
Return to IMS.

PATH – Wave 1
Parent Questionnaire

30