1 Appendix B2: Full Survey

National Institutes of Health
U.S. Department of Health and Human Services
OMB # 0925-0538
Expiration Date: March 30, 2009

Health
Information

National Trends Survey

OM-2-E

A5. Based on the results of your most recent search
for information about health or medical topics,
how much do you agree or disagree with each of
the following statements?

A: Looking For Health Information
A1. Have you ever looked for information about
health or medical topics from any source?
Yes
No

GO TO A6 in the next column
a. It took a lot of effort to get the
information you needed .............

A2. The most recent time you looked for information
about health or medical topics, where did you go
first?

X

Mark

b. You felt frustrated during your
search for the information ..........

only one.

c.

Books
Brochures, pamphlets, etc.
Cancer organization
Family
Friend/Co-worker
Doctor or health care provider
Internet
Library
Magazines
Newspapers
Telephone information number
Complementary, alternative, or unconventional
practitioner
Other-Specify

You were concerned about the
quality of the information ...........

d. The information you found was
hard to understand ....................

A6. Overall, how confident are you that you could
get advice or information about health or
medical topics if you needed it?
Completely confident
Very confident
Somewhat confident
A little confident
Not confident at all

A7. In general, how much would you trust
information about health or medical topics from
each of the following?

A3. Did you look or go anywhere else that time?
Yes
No

A4. The most recent time you looked for information
about health or medical topics, who was it for?

a. A doctor ......................................
b. Family or friends .........................

Myself
Someone else
Both myself and someone else

c.

Newspapers or magazines .........

d. Radio ..........................................
e. Internet........................................
f.

Television....................................

g. Government health agencies ......
h. Charitable organizations .............
i.

1

Religious organizations and
leaders ........................................

A8. Imagine that you had a strong need to get
information about health or medical topics.
Where would you go first?

X

Mark

A11. Genetic tests that analyze your DNA, diet and
lifestyle for potential health risks are currently
being marketed by companies directly to
consumers. Have you heard or read about
these genetic tests?

only one.

Books
Brochures, pamphlets, etc.
Cancer organization
Family
Friend/Co-worker
Doctor or health care provider
Internet
Library
Magazines
Newspapers
Telephone information number
Complementary, alternative, or unconventional
practitioner
Other-Specify

Yes
No

B: Using the Internet to Find Information
B1. Do you ever go on-line to access the Internet or
World Wide Web, or to send and receive e-mail?
Yes
No

GO TO C1 on the next page

B2. When you use the Internet, do you access it
through...
Yes No

a. A regular dial-up telephone line ...............

A9. Have you ever looked for information about
cancer from any source?

b. Broadband such as DSL, cable or FiOS ..

Yes
No

c.

A cellular network (i.e., telephone,
3G/4G) .....................................................

d. A wireless network (Wi-Fi) ......................

A10. How much attention do you pay to information
about health or medical topics from each of the
following sources?

B3. Do you access the Internet any other way?
Yes- Specify!
No

B4. In the past 12 months, have you used the
Internet to look for health or medical information
for yourself?

a. In online newspapers ................
b. In print newspapers ...................
c.

Yes
No

In special health or medical
magazines or newsletters ..........

d. On the Internet ..........................
e. On the radio ...............................
f.

B5. Is there a specific Internet site you like to go to
for health or medical information?

On local television news
programs ...................................

Yes
No

g. On national or cable television
news programs ..........................

GO TO B7 on the next page

B6. Specify which Internet site you especially like as
a source of health or medical information:

2

B7. In the last 12 months, have you used the
Internet for any of the following reasons?

C2. Do you have any of the following health
insurance or health coverage plans:

Yes No

Yes No

a. Looked for information about quitting
smoking ....................................................

a. Insurance through a current or former
employer or union (of you or another
family member) ........................................

b. Bought medicine or vitamins on-line ........
c.

b. Insurance purchased directly from an
insurance company (by you or another
family member) ........................................

Participated in an on-line support group
for people with a similar health or
medical issue ............................................

c.

d. Used e-mail or the Internet to
communicate with a doctor or doctor’s
office .........................................................

d. Medicaid, Medical Assistance, or any
kind of government-assistance plan for
those with low incomes or a disability ......

e. Used a website to help you with your
diet, weight, or physical activity ................
f.

e. TRICARE or other military health care ....

Looked for a health care provider .............

f.

g. Downloaded health-related information
to a mobile device, such as an MP3
player, cell phone, tablet computer or
electronic book device ..............................

Wrote in an on-line diary or “blog” (i.e.,
Web log) about any type of health topic ...

j.

Kept track of personal health information
such as care received, test results, or
upcoming medical appointments ..............

k.

Looked for health or medical information
for someone else ......................................

VA (including those who have ever used
or enrolled for VA health care) .................

g. Indian Health Service ..............................

C3. Do you have any other health care coverage
plan for yourself (please do not include dental or
vision plans)?

h. Visited a “social networking” site, such
as “Facebook” or “LinkedIn” to read and
share about medical topics .......................
i.

Medicare ..................................................

Yes-Specify
No

C4. About how long has it been since you last visited
a doctor for a routine checkup? A routine
checkup is a general physical exam, not an
exam for a specific injury, illness, or condition.

B8. Have you done anything else health-related on
the Internet?

Within past year (anytime less than 12 months
ago)
Within past 2 years (1 year but less than
2 years ago)
Within past 5 years (2 years but less than
5 years ago)
5 or more years ago
Don't know
Never

Yes-Specify
No

C: Your Health Care

C5. In the past 12 months, not counting times you
went to an emergency room, how many times
did you go to a doctor, nurse, or other health
professional to get care for yourself?

C1. Not including psychiatrists and other mental
health professionals, is there a particular doctor,
nurse, or other health professional that you see
most often?

None
GO TO D1 on the next page
1 time
2 times
3 times
4 times
5-9 times
10 or more times

Yes
No

3

C6. The following questions are about your
communication with all doctors, nurses, or other
health professionals you saw during the past 12
months!

C10. In the past 12 months when you talked with a
health care professional, how interested were
they in hearing about the information you found
on-line?
Very interested
Somewhat interested
A little interested
Not at all interested

How often did they do each
of the following:
a. Give you the chance to ask all
the health-related questions you
had? ............................................
b. Give the attention you needed to
your feelings and emotions? .......
c.

D: Your Health, Nutrition
and Physical Activity

Involve you in decisions about
your health care as much as you
wanted? .......................................

D1. In general, would you say your health is...

d. Make sure you understood the
things you needed to do to take
care of your health? .....................

Excellent,
Very good,
Good,
Fair, or
Poor?

e. Explain things in a way you
could understand? .......................
f.

Spend enough time with you? .....

g. Help you deal with feelings of
uncertainty about your health or
health care? .................................

D2. Over the past 2 weeks, how often have you
been bothered by any of the following problems?

C7. In the past 12 months, how often did you feel
you could rely on your doctors, nurses, or other
health care professionals to take care of your
health care needs?
Always
Usually
Sometimes
Never

a. Little interest or pleasure in
doing things ...............................
b. Feeling down, depressed or
hopeless ....................................
c.

C8. Overall, how would you rate the quality of health
care you received in the past 12 months?

d. Not being able to stop or control
worrying .....................................

Excellent
Very good
Good
Fair
Poor

D3. Overall, how confident are you about your ability
to take good care of your health?
Completely confident
Very confident
Somewhat confident
A little confident
Not confident at all

C9. In the past 12 months, have you talked to a
doctor, nurse, or other health professional about
any kind of health information you have gotten
from the Internet?
Yes
No

Feeling nervous, anxious or on
edge ...........................................

GO TO D1 in the next column
4

D4. How often in the past 12 months would you say
you were worried or stressed about having
enough money to buy nutritious meals?

D8. How much sugar-sweetened soda or pop do you
usually drink each day? Do not include diet
sodas or diet pop.

Always
Usually
Sometimes
Rarely
Never

None
12 ounces (1 can) or less
13 to 24 ounces (2 cans)
25 to 36 ounces (3 cans)
37 to 48 ounces (4 cans)
more than 48 ounces

D5. When available, how often do you use menu
information on calories in deciding what to
order?

D9. In a typical week, how many days do you do any
physical activity or exercise of at least moderate
intensity, such as brisk walking, bicycling at a
regular pace, and swimming at a regular pace?

Always
Often
Sometimes
Rarely
Never

None
GO TO D11 below
1 day per week
2 days per week
3 days per week
4 days per week
5 days per week
6 days per week
7 days per week

D6. About how many cups of fruit (including 100%
pure fruit juice) do you eat or drink each day?
None
" cup or less
" cup to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 or more cups

1 cup of fruit could be:
- 1 small apple
- 1 large banana
- 1 large orange
- 8 large strawberries
- 1 medium pear
- 2 large plums
- 32 seedless grapes
- 1 cup (8 oz.) fruit juice
- " cup dried fruit
- 1 inch-thick wedge of

D10. On the days that you do any physical activity or
exercise of at least moderate intensity, how long
are you typically doing these activities?
Write a number in one box below.
Minutes

D11. In a typical week, outside of your job or work
around the house, how many days do you do
leisure-time physical activities specifically
designed to strengthen your muscles such as
lifting weights or circuit training (do not include
cardio exercise such as walking, biking, or
swimming)?

D7. About how many cups of vegetables (including
100% pure vegetable juice) do you eat or drink
each day?
None
" cup or less
" cup to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 or more cups

Hours

1 cup of vegetables could be:
- 3 broccoli spears
- 1 cup cooked leafy greens
- 2 cups lettuce or raw
greens
- 12 baby carrots
- 1 medium potato
- 1 large sweet potato
- 1 large ear of corn
- 1 large raw tomato
- 2 large celery sticks
- 1 cup of cooked beans

None
1 day per week
2 days per week
3 days per week
4 days per week
5 days per week
6 days per week
7 days per week

5

D12. Over the past 30 days, in your leisure time, how
many hours per day, on average, did you sit and
watch TV or movies, surf the web, or play
computer games? Do not include “active
gaming” such as Wii.

D19. A drink of alcohol is 1 can or bottle of beer,
1 glass of wine, 1 can or bottle of wine cooler, 1
cocktail, or 1 shot of liquor.
During the past 30 days, how many days per
week did you have at least one drink of any
alcoholic beverage?

Hours per day

0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

D13. About how tall are you without shoes?
Feet

and

Inches

D14. About how much do you weigh, in pounds,
without shoes?
Pounds

D20. During the past 30 days, on the days when you
drank, about how many drinks did you drink on
the average?

D15. How many times in the past 12 months have you
used a tanning bed or booth?

Drink(s)

0 times
1 to 2 times
3 to 10 times
11 to 24 times
25 or more times

D21. How much sleep do you usually get!
Hours

Minutes

a. On a workday or school day?
(i.e., weekday)? ...........................

D16. When you are outside for more than one hour on
a warm, sunny day, how often do you wear
sunscreen?

b. On a non-work or non-school
day (i.e., weekend)? ....................

Always
Often
Sometimes
Rarely
Never
Do not go out on sunny days

E: Women and Cancer
E1. Are you male or female?
Male
GO TO F1 on the next page
Female

D17. Have you smoked at least 100 cigarettes in your
entire life?
Yes
No

GO TO D21 below

E2. Has a doctor ever told you that you could
choose whether or not to have the Pap test?

GO TO D19 in the next column

Yes
No

D18. How often do you now smoke cigarettes?
Everyday
Some days
Not at all

6

E3. How long ago did you have your most recent
Pap test to check for cervical cancer?

F2. There are a few different tests to check for colon
cancer. These tests include:

A year ago or less
More than 1, up to 2 years ago
More than 2, up to 3 years ago
More than 3, up to 5 years ago
More than 5 years ago
I have never had a Pap test

A colonoscopy – For this test, a tube is
inserted into your rectum and you are given
medication that may make you feel sleepy. After
the procedure, you need someone to drive you
home.
A sigmoidoscopy – For this test, you are
awake when the tube is inserted into your
rectum. After the test you can drive yourself
home.

E4. A mammogram is an x-ray of each breast to look
for cancer.

A stool blood test – For this test, you collect a
stool sample at home, and then provide it to a
doctor or lab for testing.

Has a doctor ever told you that you could
choose whether or not to have a mammogram?
Yes
No

Has a doctor ever told you that you could
choose whether or not to have a test for colon
cancer?

E5. When did you have your most recent
mammogram to check for breast cancer, if ever?

Yes
No

A year ago or less
More than 1, up to 2 years ago
More than 2, up to 3 years ago
More than 3, up to 5 years ago
More than 5 years ago
I have never had a mammogram

F3. Have you ever had a test to check for colon
cancer?
Yes
No

F4. (Females GO TO G1 on the next page. Males
continue with F4.) The following questions are
about discussions doctors or other health care
professionals may have with their patients about
the PSA test that is used to look for prostate
cancer.

F: Screening for Cancer
F1. A vaccine to prevent HPV infection is available
and is called the HPV shot, cervical cancer
vaccine, GARDASIL®, or Cervarix®.

Has a doctor ever told you that you could
choose whether or not to have the PSA test?

Has a doctor or other health care professional
ever talked with you about the HPV shot or
vaccine?

Yes
No

F5. Have you ever had a PSA test?

Yes
No

Yes
No
Not sure

F6. Has a doctor or other health care professional
ever told you that some doctors recommend the
PSA test and others do not?
Yes
No
Not sure
7

X
F7. Has a doctor or other health care professional
ever told you that no one is sure if using the
PSA test actually saves lives?

G4. How much do you agree or disagree with each
of the following statements?

Yes
No
Not sure

a. It seems like everything causes
cancer ........................................
b. There’s not much you can do to
lower your chances of getting
cancer ........................................

G: Beliefs About Cancer

c.

Think about cancer in general when answering
the questions in this section.

There are so many different
recommendations about
preventing cancer, it's hard to
know which ones to follow .........

G1. How likely are you to get cancer in your lifetime?
Very unlikely
Unlikely
Neither unlikely nor likely
Likely
Very likely

H: Your Cancer History
H1. Have you ever been diagnosed as having
cancer?
Yes
No

G2. Compared to other people your age, how likely
are you to get cancer in your lifetime?
Very unlikely
Unlikely
Neither unlikely nor likely
Likely
Very likely

GO TO H4 on the next page

H2. What type of cancer did you have?
Mark

all that apply.

Bladder cancer
Bone cancer
Breast cancer
Cervical cancer (cancer of the cervix)
Colon cancer
Endometrial cancer (cancer of the uterus)
Head and neck cancer
Hodgkin's lymphoma
Leukemia/Blood cancer
Liver cancer
Lung cancer
Melanoma
Non-Hodgkin lymphoma
Oral cancer
Ovarian cancer
Pancreatic cancer
Pharyngeal (throat) cancer
Prostate cancer
Rectal cancer
Renal (kidney) cancer
Skin cancer, non-melanoma
Stomach cancer
Other-Specify

G3. How worried are you about getting cancer?
Not at all
Slightly
Somewhat
Moderately
Extremely

8

H3. At what age were you first told that you had
cancer?

I4.

Do you agree or disagree with
the following statements:

Age

a. Information about the risks of over
the-counter drugs is easy to
understand .......................................

H4. Have any of your family members ever had
cancer?

b. Information about the risks of over
the-counter drugs helps me decide
whether to buy a drug ......................

Yes
No
Not sure

c.

I5.

I: Looking for Information about Food and
Medical Products

I1.

Information about foods is easy to
understand .......................................

b.

Information about foods helps me
make the right food choices .............

c.

I can easily find information about
the foods I eat ..................................

I6.

I3.

I7.

Do you buy any over-the-counter drugs (you
don’t need a doctor’s prescription) for yourself or
someone else?
Yes
No

Do you agree or disagree with
the following statements:

a. Ads for over-the-counter drugs tell
me enough about the benefits of
using the drugs ................................

GO TO I7 in the next column

b. Ads for over-the-counter drugs tell
me enough about their negative
side-effects ......................................

Do you agree or disagree with
the following statements:

a. Information about the benefits of
over-the-counter drugs is easy to
understand .......................................

I8.

b. Information about the benefits of
over-the-counter drugs helps me
decide whether to buy a drug ..........
c.

“The directions and warnings label on over-thecounter drugs is easy to understand.” Do you...
Agree,
Disagree, or
Have no opinion?

The next few questions are about over-thecounter drugs.
I2.

When you first buy over-the-counter drugs, how
often do you read the directions and warnings
label?
Always
Often
Sometimes
Rarely
Never

Do you agree or disagree with
the following statements:

a.

I can easily find information about
the risks of the over-the-counter
drugs I may buy ...............................

Do you agree or disagree with
the following statements:

a. Over-the-counter drugs are safer
than prescription drugs ....................

I can easily find information about
the benefits of the over-the-counter
drugs I may buy. ..............................

b. Over-the-counter drugs are less
effective than prescription drugs .....

9

The next few questions are about prescription
drugs.
I9.

I14. Do you agree or disagree with
the following statements:

Do you buy any prescription drugs for yourself or
anyone else?
Yes
No

a. Ads for prescription drugs tell me
enough about the benefits of using
the drugs .........................................

GO TO I13 below

b. Ads for prescription drugs tell me
enough about their negative sideeffects ..............................................

I10. When you first buy drugs that a doctor
prescribes, how often do you read the directions
and warnings that come with the drug?

The next few questions are about medical
products.

Always
Often
Sometimes
Rarely
Never

I15. At any time in the last 12 months, have you
purchased any common household medical
product for yourself or for someone else in your
household, such as bandages (e.g., Band-Aids®),
a thermometer, an electronic toothbrush or a
pregnancy test kit?

I11. What would you do if a prescription drug you
purchased for yourself or someone else was
recalled? Would you:
Yes

Yes
No

No

I16. At any time in the last 12 months have you
purchased a medical product for yourself or for
someone else in your household to help care for
a chronic condition, such as a walker, blood
glucose kit, hearing aid, blood pressure cuff,
contact lenses or prescription eye glasses?

a. Stop taking it at once ...............................
b. Keep using the drug ................................
c.

Pay no attention to the recall ...................

d. Be on guard .............................................

Yes
No

e. Go on the manufacturer’s website ...........
f.

Contact the manufacturer ........................

g. Contact the doctor/nurse/other medical
professional .............................................

I17. At any time in the last 12 months have you
purchased any other type of medical product for
yourself or for someone else in your household,
such as a powered wheelchair, motorized
scooter, or hospital bed?

h. Talk to the pharmacist .............................
i.

!

Unsure .....................................................

Yes
No

I12. IfWould
you do “yes”
anything
if aorprescription
you answered
to I15else
or I16
I17 then
drug you
for page.
yourself or someone
continue
to purchased
I18 on the next
else was recalled?
If you answered “no” to all 3 questions then
GO TO
Yes-Specify
Question I20 on the next page.
No

I13. “The directions and warnings that come with
prescription drugs are easy to understand.” Do
you...
Agree,
Disagree, or
Have no opinion?

10

X
I18. When you first buy a medical product, how
frequently do you read the directions and
warnings that come with it?

I22. Would you do anything else if a medical product
that you or someone you love depended on was
recalled?
Yes-Specify
No

By medical product, we mean the kinds of
medical products you included when answering
I15, I16 and I17.
Always
Often
Sometimes
Rarely
Never

I23. Did you ever visit the Food and Drug
Administration’s website (www.FDA.gov)?
Yes
No

I24. Why haven’t you visited the FDA website?

I19. “Directions and warnings that come with medical
products are easy to understand.” Do you...

Mark

Agree,
Disagree, or
Have no opinion?

a. Ads for common medical products
tell me enough about the benefits of
using these products .........................

I25. Is there any other reason you have not visited
the FDA website?

b. Ads for common medical products
tell me enough about the risks of
using these products .........................

Yes-Specify
No

I21. You may have heard about some recent recalls
on medical products. Examples of products that
have recently been recalled are stents,
pacemakers, infant apnea monitors, and
automated external defibrillators (AEDs).

GO TO J1 on the next page

I26. On your most recent visit, did you find the
information you were looking for?

What would you do if any medical product that
you or someone you love depended on was
recalled? Would you....
Yes

Yes
No

I27. How easy or hard was it to find the information
you were looking for?

No

a. Have it removed/stop using it ................

Very easy
Easy
Neither easy nor hard
Hard
Very hard

b. Contact the doctor .................................
Go on the manufacturer’s website/
Contact the manufacturer .....................

d. Have it replaced/Find a substitute .........
e. Keep using it/Keep it .............................
f.

all that apply.

I don’t own a computer (no Internet access)
I don’t have a reason to visit the site
I prefer other sites
I didn’t know about the FDA site
I don’t trust government websites
I don’t trust the FDA
It’s too hard to find information on the FDA
website

I20. Do you agree or disagree with
the following statements:

c.

GO TO I26 below

Make no change ...................................

g. Unsure/Don’t know ................................
11

X
J5. Have you ever kept information from your health
care provider because you were concerned
about the privacy or security of your medical
record?

J: Medical Research and Medical Records
J1. As far as you know, do any of your doctors or
other health care providers maintain your
medical information in a computerized system?

Yes
No

Yes
No

J6. If your medical information is sent by fax from
one health care provider to another, how
concerned are you that an unauthorized person
would see it?

J2. Please indicate how important each of the
following statements is to you.

Very concerned
Somewhat concerned
Not concerned
a. Doctors and other health care
providers should be able to share
your medical information with each
other electronically ............................

J7. If your medical information is sent electronically
from one health care provider to another, how
concerned are you that an unauthorized person
would see it? (Electronically means from
computer to computer, instead of by telephone,
mail, or fax machine).

b. You should be able to get to your
own medical information
electronically ......................................

Very concerned
Somewhat concerned
Not concerned

J3. How confident are you that safeguards
(including the use of technology) are in place to
protect your medical records from being seen by
people who aren’t permitted to see them?
Having safeguards (including the use of
technology) in place has to do with the security
of your medical records.

K: You and Your Household

Very confident
Somewhat confident
Not confident

K1. What is your age?
Years old

J4.

How confident are you that you have some say
in who is allowed to collect, use and share your
medical information?

K2. What is your current occupational status?
Mark

Having a say in who can collect, use and share
your medical information has to do with the
privacy of your records

only one.

Employed
Unemployed
Homemaker
Student
Retired
Disabled
Other-Specify

Very confident
Somewhat confident
Not confident

12

K3. Have you ever served on active duty in the U.S.
Armed Forces, military Reserves or National
Guard? Active duty does not include training in
the Reserves or National Guard, but DOES
include activation, for example, for the Persian
Gulf War.

K8. How comfortable do you feel speaking English?
Completely comfortable
Very comfortable
Somewhat comfortable
A little comfortable
Not at all comfortable

Yes, now on active duty
Yes, on active duty in the last 12 months but
not now
Yes, on active duty in the past, but not in the
last 12 months
No, training for Reserves or
National Guard only
GO TO K4
No, never served in the military

K9. Are you Hispanic or Latino?
Yes
No

K10. Which one or more of the following would you
say is your race?

X

K3a. In the past 12 months, have you received some or all
of your health care from a VA hospital or clinic?
Yes, all my health care
Yes, some of my health care
No, no VA health care received

Mark

American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White

K4. What is your marital status?
Married
Living as married
Divorced
Widowed
Separated
Single, never been married

K11. Including yourself, how many people live in your
household?
Number of people

K12. Including yourself, please mark the gender, and
write in the age and month of birth for each adult
18 years of age or older living at this address.

K5. What is the highest grade or level of schooling
you completed?

Month Born

Less than 8 years
8 through 11 years
12 years or completed high school
Post high school training other than college
(vocational or technical)
Some college
College graduate
Postgraduate

Gender

K6. Were you born in the United States?
Yes
No

one or more boxes.

Adult 1

Male
Female

Adult 2

Male
Female

Adult 3

Male
Female

Adult 4

Male
Female

Adult 5

Male
Female

GO TO K8 in the next column

K7. In what year did you come to live in the
United States?
Year

13

Age

(01-12)

X
K13. How many children under the age of 18 live in
your household?

K18. Did you complete this survey all in one sitting, or
did you do it in more than one sitting?
I completed the survey all in one sitting.
I completed the survey in more than one sitting.

Number of children under 18

K14. Do you currently rent or own your home?

K19. Did anyone help you complete this survey?

Own
Rent
Occupied without paying monetary rent

Yes
No

K20. About how long did it take you to complete the
survey?

K15. Does anyone in your family have a working cell
phone?

Write a number in one box below.

Yes
No

Minutes

K16. Is there at least one telephone inside your home
that is currently working and is not a cell phone?

Hours

K21. At which of the following types of addresses
does your household currently receive
residential mail?

Yes
No

Mark
K17. Thinking about members of your family living in
this household, what is your combined annual
income, meaning the total pre-tax income from
all sources earned in the past year?

all that apply.

A street address with a house or building number
An address with a rural route number
A U.S. post office box (P.O. Box)
A commercial mail box establishment (such as
Mailboxes R Us, and Mailboxes Etc.)

$0 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $199,999
$200,000 or more

Thank you!
Please return this questionnaire in the postage-paid envelope at your earliest convenience.

If you have lost the envelope, mail the completed questionnaire to:
HINTS Study, TC 1046F
Westat
1600 Research Boulevard
Rockville, MD 20850
14