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Attachment M.2: The Obesity & Type II Diabetes Risk Assessment Adult Survey Follow-up
If you require information to be presented in an accessible format or reasonable accommodations to
participate in this study, please contact us with any specific requests by calling XXX-XXX-XXXX or
emailing XXXX@XXXX.XXX. If you require language assistance to participate in this study, please
contact us with any specific language assistance requests or needs.
Paperwork Reduction Act Burden Statement
This collection of information is voluntary and will be used to evaluate the US Department of Housing
and Urban Development’s Community Choice Demonstration. Public reporting burden for this collection
of information is estimated to average 70 minutes per response, including the time for reviewing
instructions, gathering and maintaining the data needed, 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. The OMB number for this collection is OMB
2528-0337 which expires on XX/XX/XXXX. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to NAME at
XXXX@XXXXX.XXX or call XXX-XXX-XXXX.
Privacy Act Statement
Authority: Section 502 of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12
U.S.C. §§ 1701z-1; 1701z-2(d) and (g)).
Purpose: Evaluation of the Community Choice Demonstration (CCD).
Routine Use: The information will be used for the purpose set forth above and may be provided to
Congress or other Federal, state, and local agencies, when determined necessary.
Disclosure: Records will be used for research and statistical analysis and will not be used to make
decisions that affect the rights, benefits, or privileges of specific individuals.
SORN ID: Community Choice Demonstration Evaluation Data Files, HUD/PDR-09
Note: Some study activities are being funded by the National Institute of Diabetes and Digestive and
Kidney Diseases.
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MOVED ADULT Follow-Up SURVEY
Introduction
This survey will cover a wide range of topics that will help us understand how neighborhoods
may impact adult health outcomes, like diabetes and depression. Some of the questions we ask
will be about you, some will be about your household, and others will be about your
neighborhood. It should take about 70 minutes to complete the survey. Are you ready to begin?
SECTION A. NEIGHBORHOOD
Let’s start by talking about your neighborhood. In this part of the survey, we will ask questions
about the food choices in your neighborhood, opportunities to walk around your neighborhood,
neighborhood safety, police presence in your neighborhood, and what you think about your
neighbors and friends.
GENERAL NEIGHBORHOOD SATISFACTION
The first two questions are about neighborhood satisfaction.
A1. Which of the following statements best describes how satisfied you are with your current
neighborhood?
Very satisfied
Somewhat satisfied
In the middle
Somewhat dissatisfied
Very dissatisfied
Don’t know
Prefer not to answer
A2. Do you agree or disagree with this statement: “The neighborhood conditions where I live
make it harder to be the parent I want to be for my children”?
Strongly disagree
Disagree
Agree somewhat
Agree
Strongly Agree
Don’t know
Prefer not to answer
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The next question are about specific features of your current neighborhood.
A3. How satisfied are you with …
a.
b.
c.
d.
e.
f.
The friendliness of neighbors in your neighborhood?
The racial and ethnic mix of your neighborhood?
How near your neighborhood is to your job?
Your neighborhood’s access to public transportation?
The appearance of your neighborhood (cleanliness, lack of graffiti)?
The amenities of your neighborhood (parks, access to shops, places of worship,
schools, dining)?
g. How near your neighborhood is to your family and friends?
h. The size of your home?
i. The quality of your home?
1. Very Satisfied
2. Satisfied
3. Neither satisfied nor dissatisfied
4. Dissatisfied
5. Very Dissatisfied
6. Not applicable (for item c, only)
7. Don't know
8. Prefer not to answer
A4. Which of the following are located in or near your current neighborhood? (Check all that
apply) [Respondent needs to check either Yes, No, or Not Applicable for items A– K., unless L.
Prefer not to answer is checked.]
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
One or more of my children’s childcare providers
One or more of my children’s after-school activities
My job or the job of another person in the household
Other family members who do not live with me
Close friends who do not live with me
My church or place of worship
Other community groups I or my family is involved with
My primary care doctor
The primary care doctor of one or more of my children
Other medical services that I or others in the household use regularly
Other important services (specify)
Prefer not to answer
NEIGHBORHOOD FOOD ENVIRONMENT
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We would like to find out about the way that you think about the food choices in your
neighborhood. Please answer these questions thinking about the food stores in the
neighborhood near where you live. I will read three statements about the food choices in your
neighborhood. Please tell me whether you agree or disagree with each statement [provide card
with response options to the participant]. [if asked: you can define your neighborhood how you
define your neighborhood.]
[Source: Green, S. & Glanz, K. (2015). Development of the Perceived Nutrition Environment
Measures Survey. American Journal of Preventative Medicine.]
A5. It is easy to buy fresh fruits and vegetables in my neighborhood.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
A6. The fresh produce in my neighborhood is of high quality.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
A7. Fresh fruit and vegetables in my neighborhood are expensive.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
NEIGHBORHOOD WALKABILITY
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The next questions are about walking around your neighborhood. I will read four statements.
Please tell me the extent to which you agree or disagree with each statement
A8. There are many places to go within walking distance of my home.
[Source: https://www.ipenproject.org/documents/publications_docs/NEWS%20and%20NEWSA.pdf]
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
A9. My neighborhood offers many opportunities to be physically active.
[Source: https://academic.oup.com/aje/article/165/8/858/185012]
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
A10. It is pleasant to walk in my neighborhood.
[Source: https://academic.oup.com/aje/article/165/8/858/185012]
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
A11. I often see other people walking in my neighborhood.
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[Source: https://academic.oup.com/aje/article/165/8/858/185012]
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
NEIGHBORHOOD SAFETY
The next three questions are about neighborhood safety.
A12. How safe are the streets near your home during the day? Would you say very safe, safe,
somewhat unsafe, unsafe, or very unsafe?
Very safe
Safe
Somewhat unsafe
Unsafe
Very unsafe
Don’t know
Prefer not to answer
A13. How safe are the streets near your home at night? (Would you say very safe, safe, somewhat
unsafe, unsafe, or very unsafe?)
Very safe
Safe
Somewhat unsafe
Unsafe
Very unsafe
Don’t know
Prefer not to answer
A14. How often are you worried about gun violence in your neighborhood? Would you say:
None of the time
A little of the time
Some of the time
Most of the time
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All of the time
Don’t know
Prefer not to answer
A15. Please tell me if any of the following things have happened to you or anyone who lives with
you in the past 6 months.
a.
b.
c.
d.
e.
Was anyone's purse, wallet, or jewelry snatched from them?
Was anyone threatened with a knife or gun?
Was anyone beaten or assaulted?
Was anyone stabbed or shot?
Did anyone try to break into your home?
1. Yes
2. No
3. Don't know
4. Prefer not to answer
NEIGHBORHOOD POLICING
The next three questions are about policing in your neighborhood. How much do you agree or
disagree with the following statements.
A16. Excessive policing is a problem in my neighborhood.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
A17. I am worried that my children will be targeted by the police in my neighborhood.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
A18. The police do a good job in responding to people in the neighborhood after being victims
of crime.
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Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
Adapted from Project on Human Development in Chicago Neighborhoods Community Survey (Boehme et al, 2020)
NEIGHBORHOOD SOCIAL ENVIRONMENT
Now I am going to read some statements about things that people in your neighborhood may or
may not do. Please tell me how much you agree with each of the following statements [provide
card with response options]:
[Source: Collective Efficacy Short Form – 10]
A19. People around here are willing to help their neighbors.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
A20. This is a close-knit neighborhood.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
A21. People in this neighborhood can be trusted.
Strongly disagree
Somewhat disagree
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Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
A22. People in this neighborhood generally don’t get along with each other.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
A23. People in this neighborhood do not share the same values.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Don’t know
Prefer not to answer
COLLECTIVE EFFICACY
Could your neighbors be counted on to intervene if…[provide response card with options]:
[Source: Collective Efficacy Short Form – 10]
A24. Children are skipping school and hanging out on a street corner. Would you say it is very
likely, likely, neither likely nor unlikely, unlikely, or very unlikely that your neighbors would
intervene?
Very likely
Likely
Neither likely nor unlikely
Unlikely
Very unlikely
Don’t know
Prefer not to answer
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A25. Children are spray-painting graffiti on a local building. [Would you say it is very likely, likely,
neither likely nor unlikely, unlikely, or very unlikely that your neighbors would intervene?]
Very likely
Likely
Neither likely nor unlikely
Unlikely
Very unlikely
Don’t know
Prefer not to answer
A26. Children are showing disrespect to an adult. [Would you say it is very likely, likely, neither
likely nor unlikely, unlikely, or very unlikely that your neighbors would intervene?]
Very likely
Likely
Neither likely nor unlikely
Unlikely
Very unlikely
Don’t know
Prefer not to answer
A27. A fight broke out in front of their house. [Would you say it is very likely, likely, neither likely
nor unlikely, unlikely, or very unlikely that your neighbors would intervene?]
Very likely
Likely
Neither likely nor unlikely
Unlikely
Very unlikely
Don’t know
Prefer not to answer
A28. The fire station closest to their home was threatened with budget cuts. [Would you say it is
very likely, likely, neither likely nor unlikely, unlikely, or very unlikely that your neighbors would
intervene?]
Very likely
Likely
Neither likely nor unlikely
Unlikely
Very unlikely
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Don’t know
Prefer not to answer
INSTRUMENTAL SUPPORT FROM NEIGHBORS
Now I am going to ask you about people in your neighborhood. Please think about people
outside your immediate household and who are not part of your family. Tell me if you know
people in the neighborhood who…
[Source: Mobilizing Social Capital;
https://www.tandfonline.com/doi/abs/10.1080/02673037.2016.1140724?journalCode=chos20]
A29. You could borrow a car from, if you needed it.
Yes
No
Don’t know
Prefer not to answer
A30. Could give you a ride, if you needed it.
Yes
No
Don’t know
Prefer not to answer
A31. Could babysit for your children, if you needed it.
Yes
No
Don’t know
Prefer not to answer
A32. Could help you with a computer, if you needed it.
Yes
No
Don’t know
Prefer not to answer
A33. Are active in community organizations.
Yes
No
Don’t know
Prefer not to answer
A34. Could give you advice about job opportunities, if you asked for it.
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Yes
No
Don’t know
Prefer not to answer
A35. Could bring you food or medicine, if you get sick.
Yes
No
Don’t know
Prefer not to answer
A36. You could discuss personal matters with, if you wanted to.
Yes
No
Don’t know
Prefer not to answer
A37. Would lend you $100, if you needed it.
Yes
No
Don’t know
Prefer not to answer
A38. You could have a meal with, if you wanted to.
Yes
No
Don’t know
Prefer not to answer
BRIDGING SOCIAL CAPITAL
The next questions are about your friends. Please tell me if the following statements describe
nearly all, most, some, a few, or none of your friends [provide response options on a card].
[Source: New question, adapted from prior survey, Schwartz (2014);
onhttps://www.sciencedirect.com/science/article/pii/S0277953613005479?via%3Dihub]
A39. My friends live in the neighborhood. Would you say:
All
Most
Some
None
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Don’t know
Prefer not to answer
A40. My friends have graduated from college.
All
Most
Some
None
Don’t know
Prefer not to answer
A41. My friends are different races or ethnicities than me.
All
Most
Some
None
Don’t know
Prefer not to answer
SECTION B. HOME AND HOUSEHOLD
In this next part of the survey, we are interested in learning more about your home and your
household.
B1. Where do you currently live?
In an apartment, home, or room that you rent or sublet
In a home or apartment that you own
In an apartment, home, or room that friends or extended family rents where you
contribute to part of the rent
With friends or family, where you do not pay any rent
Homeless or in a group shelter
Other housing arrangement:
Don't know
Prefer not to answer
B2. Do you agree or disagree with this statement: “The size or physical condition of my home
makes it harder to be the parent I want to be for my children”?
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
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Strongly agree
Don’t know
Prefer not to answer
B3. Where you live now, how much of a problem are rats, mice, cockroaches or other vermin?
Big problem
Small problem
No problem at all
Don't know
Prefer not to answer
SOCIAL SERVICE PARTICIPATION
I would like to ask you about different sources of income or assistance you or people in your
family living with you now may receive. Your responses to these questions will not affect your
family’s eligibility for housing assistance or other types of assistance. By family, I mean the
people you told us about at enrollment who live with you now and who would move with you if
you moved. Remember your responses will remain confidential and you can skip any question
you don’t feel comfortable answering.
B4. At any time in the last 12 months did any family members living here receive SNAP or food
stamp benefits?
Yes
No [SKIP TO B6]
Don’t know [SKIP TO B6]
Prefer not to answer [SKIP TO B6]
[Source: National Health Interview Survey]
B5. Did any family members living here receive SNAP or food stamp benefits in the LAST 30
days?
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
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B6. At any time in the last 12 months did any family members living here receive benefits from
the WIC program, that is, the Women, Infants, and Children program?
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
B7. At any time in the last 12 months, did any child in your family receive free or reduced-cost
breakfasts or lunches at school through the National School Lunch Program?
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
FOOD SECURITY
These six questions are about your household’s food situation. I’m going to read you several
statements that people have made about their food situation. For these statements, please tell
me whether the statement was often true, sometimes true, or never true for your household in
the last 12 months – that is, since last [NAME OF CURRENT MONTH].
[if needed: Some people may find the next few questions personal. Please remember you can
choose not to answer any question.]
[Source: NHANES; https://www.ers.usda.gov/media/8282/short2012.pdf]
B8. The first statement is, “The food that we bought just didn’t last, and we didn’t have money
to get more.” Was this often, sometimes, or never true for your household?
Often true
Sometimes true
Never true
Don’t know
Prefer not to answer
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B9. “We couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for
your household in the last 12 months?
Often true
Sometimes true
Never true
Don’t know
Prefer not to answer
B10. In the last 12 months, since last [NAME OF CURRENT MONTH] did you or other adults in
your household ever cut the size of your meals or skip meals because there wasn’t enough
money for food?
Yes
No (SKIP TO B12)
Don’t know (SKIP TO B12)
Prefer not to answer (SKIP TO B12)
B11. [IF B10=Yes] How often did this happen – almost every month, some months but not every
month, or in only 1 or 2 months?
Almost every month
Some months but not every month
Only 1 or 2 months
Don’t know
Prefer not to answer
B12. In the last 12 months, did you ever eat less than you felt you should because there wasn’t
enough money for food?
Yes
No
Don’t know
Prefer not to answer
B13. In the last 12 months, were you ever hungry but didn’t eat because there wasn’t enough
money for food?
Yes
No
Don’t know
Prefer not to answer
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The next three questions are about characteristics of your household that may affect your
future plans.
PREDICTABILITY
B14. Sometimes things happen that completely throw your plans off course or mess things
up. How likely or unlikely is it that something like that will happen to you or your family in the
next 12 months? Would you say…
Very likely
likely
Neither likely nor unlikely
unlikely
Very unlikely
Don’t know
Prefer not to answer
PET OWNERSHIP
Having pets can impact how much time you spend outdoors and getting around.
B15. Does your household currently have a dog?
Yes
No
Don’t know
Prefer not to answer
HEALTH LIMITING MOVING
B16. Would the health of anyone in your household make it more challenging for you to move
to a new neighborhood?
Yes
No
Don’t know
Prefer not to answer
[Source: New question]
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SECTION C. INDIVIDUAL
[only if respondent is not completing child survey] The rest of the questions I’m going to ask are
all about you as an individual. First, I have some questions about your habits, behaviors, and
experiences. Then I will ask about your mood, thoughts, and feelings. Next, I’ll ask about your
health and healthcare. Lastly, I’ll ask some questions about your background.
We’ll start by talking about your habits and behaviors.
[If respondent is completing the child survey] The next set of questions I’m going to ask are all
about you as an individual. First, I have some questions about your habits, behaviors, and
experiences. Then I will ask about your mood, thoughts and feelings. Next, I’ll ask about your
health and healthcare. Lastly, I’ll ask some questions about your background. Once we are all
done asking questions about you, we will ask you some questions about your child.
We’ll start by talking about your habits and behaviors.
PHYSICAL ACTIVITY
The first set of questions asks about different types of activities you do and where you do them.
[Source: International Physical Activity Questionnaire - Short Form; https://youthrex.com/wpcontent/uploads/2019/10/IPAQ-TM.pdf]
Sitting
Think about the time you spent sitting on weekdays during the last 7 days. Include time spent at
work, at home, while doing course work and during leisure time. This may include time spent
sitting at a desk, visiting friends, reading, or sitting or lying down to watch television.
[interviewer instructions: respondent may use either hours or minutes per day. Please record
either but not both]
C1. During the last 7 days, how much time did you spend sitting on a weekday?
X hours per day________________
X minutes per day_______________
Don’t know/not sure
Prefer not to answer
Walking
Think about the time you spent walking in the last 7 days. This includes at work and at home,
walking to travel from place to place, and any other walking that you have done solely for
recreation, sport, exercise, or leisure.
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C2. During the last 7 days, on how many days did you walk for at least 10 minutes at a time?
# of days per week ___________
No walking [SKIP FOLLOWING QUESTION]
Don’t know/not sure [SKIP TO FOLLOWING QUESTION]
Prefer not to answer [SKIP TO FOLLOWING QUESTION]
C3. How much time did you usually spend walking on one of those days?
X hours per day____________
X minutes per day___________
Don’t know/not sure
Prefer not to answer
Vigorous activity
Think about all the vigorous activities that you did in the last 7 days. Vigorous physical activities
refer to activities that take hard physical effort and make you breathe much harder than normal.
Think only about those physical activities that you did for at least 10 minutes at a time.
C4. During the last 7 days, on how many days did you do vigorous physical activities like heavy
lifting, digging, aerobics, or fast bicycling if at all?
# of days per week__________
No vigorous physical activity [SKIP TO MODERATE ACTIVITY]
Don’t know/not sure [SKIP TO MODERACTE ACTIVITY]
Prefer not to answer [SKIP TO MODERATE ACTIVITY]
C5. [IF AT LEAST 1 DAY PER WEEK] How much time did you usually spend doing vigorous physical
activities on one of those days?
X hours per day _____________
X minutes per day_____________
Don’t know/not sure
Prefer not to answer
Moderate activity
Think about all the moderate activities that you did in the last 7 days. Moderate activities refer
to activities that take moderate physical effort and make you breathe somewhat harder than
normal. Think only about those physical activities that you did for at least 10 minutes at a time.
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C6. During the last 7 days, on how many days did you do moderate physical activities like
carrying light loads, bicycling at a regular pace, or doubles tennis if at all? Do not include
walking.
# of days per week _____________
No moderate physical activity [SKIP FOLLOWING QUESTION]
Don’t know/not sure [SKIP FOLLOWING QUESTION]
Prefer not to answer [SKIP FOLLOWING QUESTION]
C7. [IF AT LEAST 1 DAY PER WEEK] How much time did you usually spend doing moderate
physical activities on one of those days?
X hours per day______________
X minutes per day______________
Don’t know/not sure
Prefer not to answer
Location of physical activity
C8. In the past month, where have you gone for physical activity? Please let us know all of the
places you’ve gone.[Respondent may select multiple options]
Park
Trail or another walking/running path
Gym/recreation center
Your own home
Home of a family member or a friend
Work
Retail outlets (malls)
Streets/sidewalks
Physical therapy or rehabilitation
Other (please specify type of place)
I don't engage in physical activity
I don't know
Prefer not to answer
[Source: RAND Corporation’s PHRESH Survey (Pittsburgh Hill/Homewood Research On
Neighborhood Change and Health]
C9. In the past month, how often did you walk to places in your neighborhood for exercise,
pleasure, or to get somewhere you needed to go?
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At least once a day in the past month
3-6 times a week in the past month
Once or twice a week in the past month
2-3 times in the past month
Once in the past month
Never in the past month
Don't know
Prefer not to answer
[Source: RAND Corporation’s PHRESH Survey (Pittsburgh Hill/Homewood Research On
Neighborhood Change and Health]
DIET
The next set of questions are about the different kinds of foods you ate or drank during the past
month, that is, the past 30 days. When answering, please include meals and snacks eaten at
home, at work or school, in restaurants, and anyplace else.
[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-innhanes-09-10-interviewer-administered-english-version.pdf]
C10. During the past month, how often did you eat hot or cold cereals? You can tell me per day,
per week, or per month.
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never [SKIP TO C12]
Don’t know [SKIP TO C12]
Prefer not to answer [SKIP TO C12]
C11. [SKIP IF C10=Never, Don’t know or prefer not to answer] During the past month, what kind
of cereal did you usually eat?
[OPEN RESPONSE]___________________________________
Don’t Know
Prefer not to answer
C12. During the past month, how often did you drink regular soda or pop that contains sugar?
Do not include diet soda. You can tell me per day, per week, or per month.
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
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C13. During the past month, how often did you drink 100% pure fruit juices such as orange,
mango, apple, grape and pineapple juices? Do not include fruit-flavored drinks with added sugar
or fruit juice you made at home and added sugar to. (You can tell me per day, per week, or per
month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C14. (During the past month), how often did you drink coffee or tea that had
sugar or honey added to it? Include coffee and tea you sweetened yourself and presweetened
tea and coffee drinks such as Arizona Iced Tea and Frappuccino. Do
not include artificially sweetened coffee or diet tea. (You can tell me per day, per week, or per
month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C15. (During the past month), how often did you drink sweetened fruit drinks, sports or energy
drinks, such as Kool-Aid, lemonade, Hi-C, cranberry drink, Gatorade, Red Bull, or Vitamin Water?
Include fruit juices you made at home and added sugar to. Do not include diet drinks or
artificially sweetened drinks. (You can tell me per day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C16. (During the past month), how often did you eat fruit? Include fresh, frozen or canned fruit.
Do not include juices. (You can tell me per day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
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C17. (During the past month), how often did you eat a green leafy or lettuce salad, with or
without other vegetables? (You can tell me per day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C18. (During the past month), how often did you eat any kind of fried potatoes, including french
fries, home fries, or hash brown potatoes? (You can tell me per day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C19. (During the past month), how often did you eat any kind of potatoes, such as baked,
boiled, mashed potatoes, sweet potatoes, or potato salad? (You can tell me per day, per week,
or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C20. (During the past month), how often did you eat refried beans, baked beans, beans in soup,
pork and beans or any other type of cooked dried beans? Do not include green beans. (You can
tell me per day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C21. (During the past month), how often did you eat brown rice or other cooked whole grains,
such as bulgur, cracked wheat or millet? Do not include white rice. (You can tell me per day, per
week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
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C22. (During the past month), not including what you just told me about--green salads,
potatoes, cooked dried beans--how often did you eat other vegetables? (You can tell me per
day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C23. (During the past month), how often did you have Mexican-type salsa made with tomato?
(You can tell me per day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C24. (During the past month), how often did you eat pizza? Include frozen pizza, fast food pizza,
and homemade pizza. (You can tell me per day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C25. (During the past month), how often did you have tomato sauces such as with spaghetti or
noodles or mixed into foods such as lasagna? Do not include tomato sauce on pizza. (You can
tell me per day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C26. (During the past month), how often did you eat any kind of cheese? Include cheese as a
snack, cheese on burger, sandwiches, and cheese in foods such as lasagna, quesadillas, or
casseroles. Do not include cheese on pizza. (You can tell me per day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
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C27. Please look at this card, during the past month, how often did you eat red meat such as
beef, pork, ham, or sausage? Do not include chicken, turkey or seafood. (You can tell me per
day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C28. Please look at this card, (during the past month), how often did you eat any processed
meat, such as bacon, lunch meats, or hot dogs? (You can tell me per day, per week, or per
month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C29. (During the past month), how often did you eat whole grain bread including toast, rolls and
in sandwiches? Whole grain breads include whole wheat, rye, oatmeal and pumpernickel. Do
not include white bread. (You can tell me per day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C30. During the past month, how often did you eat chocolate or any other types of candy? Do
not include sugar-free candy.
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C31. (During the past month), how often did you eat doughnuts, sweet rolls, Danish, muffins,
pan dulce, or pop-tarts? Do not include sugar-free items. (You can tell me per day, per week, or
per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
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Don’t know
Prefer not to answer
C32. (During the past month), how often did you eat cookies, cake, pie, or brownies? Do not
include sugar-free kinds. (You can tell me per day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C33. (During the past month), how often did you eat ice cream or other frozen desserts? Do not
include sugar-free kinds. (You can tell me per day, per week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
C34. (During the past month), how often did you eat popcorn? (You can tell me per day, per
week, or per month.)
___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS
Never
Don’t know
Prefer not to answer
EATING OUT
C35. Next I'm going to ask you about meals. By meal, I mean breakfast, lunch and dinner. During
the past 7 days, how many meals did you get that were prepared away from home in places
such as restaurants, fast food places, food stands, grocery stores, or from vending machines?
None [SKIP TO NEXT SECTION]
[ENTER NUMBER 1-21]_________
More than 21 times
Don’t know [SKIP TO NEXT SECTION]
Prefer not to answer [SKIP TO NEXT SECTION]
[Source: Frequency of Eating Out and Cooking At Home (NHANES)]
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C36. [ASK IF C35 = >than 1] How many of those meals did you get from a fast-food or pizza
place?
[ENTER NUMBER 1-21]________
None
More than 21 times
Don’t know
Prefer not to answer
[Source: Frequency of Eating Out and Cooking At Home (NHANES)]
FOOD PURCHASING
The next three questions are about where you buy your food.
[Source: Green, S. & Glanz, K. (2015). Development of the Perceived Nutrition Environment
Measures Survey. American Journal of Preventative Medicine.]
C37. What type of store is the store where you buy most of your food? [Note to interviewer:
Respondents may select more than one option].
Supermarket
Small grocery store
Corner store or convenience store
Supercenter (like Wal-Mart or Costco)
Other (please specify):
Don’t know
Prefer not to answer
C38. Thinking about the store where you buy most of your food, how do you usually travel to
this store?
Walk
Bicycle
Bus or other public transportation
Drive your own car
Get a ride
Other (please specify):
Don’t know
Prefer not to answer
C39. About how long does it take to get from your home to the store where you buy most of
your food?
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10 minutes or less
11 to 20 minutes
21 to 30 minutes
More than 30 minutes
Don’t know
Prefer not to answer
TRANSPORTATION
The next questions are about different ways people may get from place to place in your
neighborhood and how you get around.
[Source: Massey, Climbing Mount Laurel study]
C40. Do you or anyone in your household own or lease a motor vehicle?
Yes
No
Don’t know
Prefer not to answer
C41. [IF C40 NOT YES] Do you have reliable access to a vehicle?
Yes
No
Don’t know
Prefer not to answer
C42. How many days a week do you make use of public transportation, including buses, trains,
and subways?
1-7 days____________
I don’t use public transportation
Don’t know
Prefer not to answer
C43. How long would it take you to get to the nearby bus, train, or subway stop?
< 15mins
15 to 30 mins
31 to 45 mins
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46 min to 1 hour
> 1 hour
Don’t know
Prefer not to answer
C44. How good is the public transportation service in your neighborhood?
Very poor
Poor
Neither poor nor good
Good
Very good
Don’t know
Prefer not to answer
SLEEP
The next four questions relate to your sleep habits. When answering, think about your usual
sleep habits during the past month only. [note to interviewer, the following may be added: Your
answers should indicate the most accurate reply for the majority of days and nights in the past
month. ]
[Source: Sancho-Domingo, C., Carballo, J., Caloma-Carmona, A., & Buysse, D. (2021). Brief
version of the Pittsburgh Sleep Quality Index (B-PSQI) and measurement invariance across
gender sex and age in a population-based sample. Psychological Assessment.]
C45. During the past month, what time have you usually gone to bed at night?
Bedtime AM/PM: [OPEN RESPONSE]_________
Don’t know
Prefer not to answer
C46. During the past month, how long does it usually take you to fall asleep each night?
Number of:_______________minutes OR hours
Don’t know
Prefer not to answer
C47. During the past month, what time have you usually gotten up in the morning?
GETTING UP TIME: AM/PM__________________
Don’t know
Prefer not to answer
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C48. During the past month, how would you rate your sleep quality overall? Would you say…
Very good
Fairly good
Fairly bad
Very bad
Don’t know
Prefer not to answer
SUBSTANCE USE
Now I would like to ask you some questions about tobacco, alcohol, and weight control. We are
asking these questions of everyone in the study. Remember that the information you provide
will be kept private and your name will never be linked to your responses in reports. [IF
NEEDED: Some people may find the next few questions personal. Please remember you can
choose not to answer any question.]
Tobacco
The first few questions are about cigarette smoking.
C49. Have you smoked at least 100 cigarettes in your ENTIRE LIFE?
Yes
No [SKIP TO C52]
Don’t know [SKIP TO C52]
Prefer not to answer [SKIP TO C52]
[Source: National Health Interview Survey]
C50. [ASK IF C49=YES] Do you NOW smoke cigarettes every day, some days, or not at all?
Every day
Some days
Not at all
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
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C51. Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?
[Read if necessary: Snus [pronounced “snoos”] (Swedish for snuff) is a moist smokeless tobacco
usually sold in small pouches that are placed under the lip against the gum.)
Every day
Some days
Not at all
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C52. Do you currently use e-cigarettes or other electronic vaping products every day, some days,
or not at all? [Read if necessary: Electronic cigarettes (e-cigarettes) and other electronic vaping
products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These
products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or
candy. Brands you may have heard of are JUUL, NJOY, or blu. Interviewer note: These questions
concern electronic vaping products for nicotine use. The use of electronic vaping products for
marijuana use is not included in these questions.]
Every day
Some days
Not at all
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
Binge-drinking
This next question is about drinking alcohol.
C53. Over the past 2 weeks, how many occasions have you had [5 (male)/4 (female)] or more
drinks in a row?
None
Once
Twice
2 to 5 times
6 to 9 times
10 or more times
Don’t know
Prefer not to answer
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[Source: National Health Interview Survey]
DIET BEHAVIORS
The last several questions in this part are about behaviors you may use to control your weight or
what you eat.
C54. How often have you gone on a diet during the last year? By 'diet' I mean changing the way
you eat so you can lose weight. Dieting includes any changes, big or small, that you made to
lose weight.
Never
One to four times
Five to ten times
More than ten times
I am always dieting
Don’t know
Prefer not to answer
[Source: Dieting and disordered eating behaviors among adolescents; https://www-sciencedirectcom.proxy1.library.jhu.edu/science/article/pii/S0002822311004251
C55. Do you NOW take any of the following prescription medicines to lose weight or manage
diabetes? (Show card with weight loss medicines approved by the FDA.) (Prompt if needed:
These are medicines prescribed by a doctor or other health practitioner. )
Yes
No
Don’t know
Prefer not to answer
C56. Have you done any of the following things in order to lose weight or keep from gaining
weight during the past year including fasting, ate very little food, took diet pills, made yourself
vomit, used laxatives, used diuretics (water pills), used food substitute (powder or special
drinks), skipped meals, or smoked more cigarettes? [interview, please use list for items]
Yes
No
Don’t know
Prefer not to answer
[Source: Dieting and disordered eating behaviors among adolescents; https://www-sciencedirectcom.proxy1.library.jhu.edu/science/article/pii/S0002822311004251
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C57. In the past year, have you ever eaten so much food in a short period of time that you
would be embarrassed if others saw you (binge-eating)?
Yes
No [SKIP TO NEXT SECTION]
Don’t know [SKIP TO NEXT SECTION]
Prefer not to answer [SKIP TO NEXT SECTION]
[Source: https://www.sph.umn.edu/sph-2018/wp-content/uploads/2019/12/project-eat-gen2adolescent-survey.pdf]
C58. [if C57= YES] During the times when you ate this way, did you feel like you couldn’t stop
eating or control what or how much you were eating?
Yes
No
Don’t know
Prefer not to answer
[Source: https://www.sph.umn.edu/sph-2018/wp-content/uploads/2019/12/project-eat-gen2adolescent-survey.pdf]
DISCRIMINATION AND SAFETY
We hope to better understand more about everyone in the study’s personal experiences. The
next few questions are about how you are treated in your everyday life. [if needed: if you feel
that these questions are too personal, you can choose not to answer them.]
Everyday Discrimination Scale
C59. In your day-to-day life how often have any of the following things happened to you?
Almost every day, at least once a week, a few times a month, a few times a year, less than once
a year, or never? [These are the response options for each question]
a.
b.
c.
d.
e.
You are treated with less courtesy or respect than other people. _______
You receive poorer service than other people at restaurants or stores. _______
People act as if they think you are not smart. ______
People act as if they are afraid of you. _____
You are threatened or harassed. _____
Almost every day
At least once a week
A few times a month
A few times a year
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Less than once a year
Never
Don’t know
Prefer not to answer
[Source: Everyday Discrimination Scale, Short Form;
https://scholar.harvard.edu/davidrwilliams/node/32397]
C60. [IF RESPONSE TO AT LEAST ONE QUESTION ABOVE IS “A FEW TIMES A YEAR” OR MORE]
What do you think is the main reason for this experience? [SELECT ALL THAT APPLY. This item is
asked only once and not for each time that a person reports discrimination]
Your Ancestry or National Origins
Your Gender Sex
Your Race
Your Age
Your Religion
Your Height
Your Weight
Some other Aspect of Your Physical Appearance
Your Sexual Orientation
Your Education or Income Level
Don’t know
Prefer not to answer
[Source: Everyday Discrimination Scale, Short Form;
https://scholar.harvard.edu/davidrwilliams/node/32397]
Experienced weight stigma
C61. Have you ever been [READ EACH BELOW] because of your weight? [If needed: this may be
because of over or underweight, as well as body shape].
a. Teased
b. Treated unfairly
c. Discriminated against
Yes
☐
☐
☐
No
☐
☐
☐
Don’t know
☐
☐
☐
[Source: Experienced Stigma Scale; https://pubmed-ncbi-nlm-nihgov.proxy1.library.jhu.edu/34061867/.]
MENTAL HEALTH
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Prefer not to answer
☐
☐
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Now that we’ve talked about your usual behaviors and experiences, I’d like to ask some
questions about your mood, thoughts, and feelings. Remember your responses are confidential
and you can skip any question you feel uncomfortable answering.
Body satisfaction
The first two questions are about how you feel about your body. We are asking these questions
of everyone and your responses will be kept private.
C62. On a scale from 1 to 10, where 1 is “Extremely Unsatisfied” and 10 is “Extremely Satisfied”,
how satisfied are you with your weight?
[Scale from 1 to 10] ______
Don’t know
Prefer not to answer
[Source: Does Body Satisfaction Matter?; https://pubmed.ncbi.nlm.nih.gov/16857537/]
C63. On a scale from 1 to 10, where 1 is “Extremely Unsatisfied” and 10 is “Extremely Satisfied”,
how satisfied are you with your body shape?
[Scale from 1 to 10]________
Don’t know
Prefer not to answer
[Source: Does Body Satisfaction Matter?; https://pubmed.ncbi.nlm.nih.gov/16857537/]
Eating to cope
The next few questions are about how you feel when you are eating. I will list five reasons
people may choose to eat. For each, please tell me whether this is never, rarely, sometimes,
often, or always true for you [give card with response options].
C64. In the past 12 months, how often have you eaten… [READ ANSWER CHOICES]
Never
a. Because you’re
depressed or sad
b. because you feel
worthless or inadequate
c. as a way to help you cope
d. as a way to comfort
yourself
Rarely
Sometimes
Often
Always
Don’t
know
Prefer not
to answer
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
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e. as a way to avoid
thinking about something
unpleasant and to distract
yourself
☐
☐
☐
☐
☐
☐
☒
[Source: Motivations to Eat subscale; Depression; https://www-sciencedirectcom.proxy1.library.jhu.edu/science/article/pii/S0092656602005743]
Depression and Anxiety
The next questions are about how you have been feeling.
C65. Thinking about the last 2 weeks, please tell me how often you have been bothered by each
[show card with response options].
a. Little interest or pleasure in
doing things
b. Feeling down, depressed, or
hopeless
c. Trouble falling or staying asleep
or sleeping too much
d. Feeling tired or having little
energy
e. Poor appetite or overeating.
f. Feeling bad about yourself – or
that you are a failure or have let
yourself or your family down
g. Trouble concentrating on
things, such as reading the
newspaper or watching television
h. Moving or speaking so slowly
that other people could have
noticed? Or the opposite – being
so fidgety or restless that you
have been moving around a lot
more than usual
i. Feeling nervous, anxious, or on
edge
j. Not being able to stop or
control worrying
Not at
all
Several
days
More
than half
the days
Nearly
every day
Don’t
know
Prefer
not to
answer
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
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[Source: Kroenke, K., Spitzer, R., & Williams, J. (2001). The PHQ-9: validity of a brief depression
severity measure. Journal of General Internal Medicine.]
[Source: Generalized Anxiety Disorder 2-item (GAD-2); https://www.hiv.uw.edu/page/mentalhealth-screening/gad-2]
Perceived stress
The next four questions are about stress you may have felt in the past month. Please tell me
how often you have felt each of these things on a scale from never to very often [show card
with response options].
[Source: Perceived Stress Scale (PSS-4); Wartig, S., Forshaw, M., … & White, A. (2013). New,
normative English-sample data for the Short Form Perceived Stress Scale (PSS-4). Journal of
Health Psychology.]
C66. In the last month, how often have you felt that you were unable to control the important
things in your life?
Never
Almost never
Sometimes
Fairly often
Very often
Don’t know
Prefer not to answer
C67. In the last month, how often have you felt confident about your ability to handle your
personal problems?
Never
Almost never
Sometimes
Fairly often
Very often
Don’t know
Prefer not to answer
C68. In the last month, how often have you felt that things were going your way?
Never
Almost never
Sometimes
Fairly often
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Very often
Don’t know
Prefer not to answer
C69. In the last month, how often have you felt difficulties were piling up so high that you could
not overcome them?
Never
Almost never
Sometimes
Fairly often
Very often
Don’t know
Prefer not to answer
C70. How often do you get the social and emotional support you need?
Never
Almost never
Sometimes
Fairly often
Very often
Don’t know
Prefer not to answer
[modified from: https://www.cdc.gov/nchs/data/nhis/teen/NHIS-teen-surveyinstrument-508.pdf]
Perceived Constraints of Sense of Control
I have some more questions about your feelings.
C71. Please tell me whether you agree or disagree with each of the following five statements.
Strongly Disagree Neither
disagree
agree nor
disagree
a. Other people
determine most of
what I can and
cannot do
b. There is little I
can do to change
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Agree
Strongly
agree
Don’t Prefer
know not to
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many of the
important things in
my life
c. I often feel
helpless in dealing
with the problems
of life
d. What happens in
my life is often
beyond my control
e. There are many
things that
interfere with what
I want to do
[Source: Perceived Constraints on Sense of Control; https://psycnet.apa.org/record/1998-00299-016]
The next set of questions are about your health and healthcare.
HEALTH CONDITIONS
First, I have some questions about your health and health conditions that you may have.
Remember, we will keep your responses confidential.
Self-rated physical and mental health
C72. In general, how would you rate your overall health now? Is it…
Excellent
Very good
Good
Fair
Poor
Don’t know
Prefer not to answer
C73. We would like to know how good or bad your health is TODAY. On a scale of 0 to 100
where 100 means the best health you can imagine and 0 means the worst health you can
imagine, how is your health TODAY?
RANGE 0-100___________
Don’t know
Prefer not to answer
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[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]
C74. Taken all together, how would you say things are these days; would you say that you
are very happy, pretty happy, or not too happy?
Very happy
Pretty happy
Not too happy
Don’t know
Prefer not to answer
Physical health conditions
C75. [skip if male] Are you currently pregnant?
yes
no
not applicable
Don't know
prefer not to answer
C76. Have you EVER been told by a doctor or other health professional that you had
...Hypertension, also called high blood pressure?
Yes
No [SKIP TO C79]
Don’t know [SKIP TO C79]
Prefer not to answer [SKIP TO C79]
[Source: National Health Interview Survey]
C77. [ASK IF C76=YES] During the past 12 months, have you had hypertension or high blood
pressure?
Yes
No [SKIP TO C79]
Don’t know [SKIP TO C79]
Prefer not to answer [SKIP TO C79]
[Source: National Health Interview Survey]
C78. [ASK IF C77=YES] Are you now taking prescribed medicine for your high blood pressure?
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Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C79. Have you ever been told by a doctor or other health professional that you had asthma?
Yes
No [SKIP TO C84]
Don’t know [SKIP TO C84]
Prefer not to answer [SKIP TO C84]
[Source: National Health Interview Survey]
C80. [IF C79=YES] Do you still have asthma?
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C81. [IF C79=YES ] During the past 12 months, have you had an episode of asthma or an asthma
attack?
Yes
No [SKIP TO C83]
Don’t know [SKIP TO C83]
Prefer not to answer [SKIP TO C83]
[Source: National Health Interview Survey]
C82. [IF C81=YES] During the past 12 months, how many episodes of asthma or asthma attacks
did you have?
ENTER NUMBER OF ASTHMA ATTACKS _________
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
42
OMB Clearance Number: 2528-0337
Expires: XX/XX/XXXX
C83. [IFC79=YES] During the past 12 months, have you had to visit an emergency room or
urgent care center because of asthma?
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C84. Has a doctor or other health professional EVER told you that you had prediabetes or
borderline diabetes?
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C85. [SKIP IF MALE] Has a doctor or other health professional EVER told you that you had
gestational diabetes, a type of diabetes that occurs ONLY during pregnancy?
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C86. Has a doctor or other health professional EVER told you that you had diabetes?
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C87. [IF C86-YES] How old were you when a doctor or other health professional FIRST told you
that you had diabetes?
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OMB Clearance Number: 2528-0337
Expires: XX/XX/XXXX
[ENTER AGE]____________
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C88. [IF C84=YES, , OR C86-YES ] Are you NOW taking diabetic pills to lower your blood sugar?
These are sometimes called oral agents or oral hypoglycemic agents.
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C89. [IF C84=YES, , OR C86-YES ] Insulin can be taken by shot or pump. Are you NOW taking
insulin?
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C90. [C86-YES] According to your doctor or other health professional, what type of diabetes do
you have? Is it type 1, type 2, or some other type? If you don't remember or weren't told, that's
OK
Type-1
Type-2
Some other type
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
Mental Health Conditions
[IF NEEDED: Remember, your responses are confidential, and you can skip any question you feel
uncomfortable answering.
44
OMB Clearance Number: 2528-0337
Expires: XX/XX/XXXX
C91. Has a doctor or other health professional ever diagnosed you with one of the following
emotional or mental health conditions?
Anxiety or panic disorder
Depression
Other emotional or mental health condition
Yes
No
Don’t know
☐
☐
☐
☐
☐
☐
☐
☐
☐
Prefer not to
answer
☐
☐
☐
Other___________________________________
[Source: Local survey by Sabriya Linton on Baltimore HOPE VI redevelopment]
C92. In the past 12 months, have you ever received treatment from a doctor or other health
professional for an emotional or mental health condition?
Yes
No
Don’t know
Prefer not to answer
[Source: Local survey by Sabriya Linton on Baltimore HOPE VI redevelopment]
Health Questionnaire, EQ5D
Now Next, I will read some questions about activities that people experience in a typical day.
For each, please tell me whether each is not a problem for you, a slight problem, a moderate
problem, a severe problem, or if you’re unable to do it. Please think about what best describes
your health TODAY.
C93. First, I would like to ask you about MOBILITY. Would you say that: [card for no problems,
slight problems, moderate problems, severe problems, unable to]
You have no problems in walking about
You have slight problems in walking about
You have moderate problems in walking about
You have severe problems in walking about
You are unable to walk about
Don’t know
Prefer not to answer
[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]
45
OMB Clearance Number: 2528-0337
Expires: XX/XX/XXXX
C94. Next, I would like to ask you about SELF-CARE. Would you say that: [card for no problems,
slight problems, moderate problems, severe problems, unable to]
You have no problems washing or dressing yourself
You have slight problems washing or dressing yourself
You have moderate problems washing or dressing yourself
You have several problems washing or dressing yourself
You are unable to wash or dress yourself
Don’t know
Prefer not to answer
[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]
C95. Next I would like to ask you about USUAL ACTIVITIES, for example work, study, housework,
family or leisure activities. Would you say that: [card for no problems, slight problems,
moderate problems, severe problems, unable to]
You have no problems doing your usual activities
You have slight problems doing your usual activities
You have moderate problems doing your usual activities
You have severe problems doing your usual activities
You are unable to do your usual activities
Don’t know
Prefer not to answer
[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]
C96. Next, I would like to ask you about PAIN OR DISCOMFORT. Would you say that:
You have no pain or discomfort
You have slight pain or discomfort
You have moderate pain or discomfort
You have severe pain or discomfort
You have extreme pain or discomfort
Don’t know
Prefer not to answer
[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]
C97. Finally, I would like to ask you about ANXIETY OR DEPRESSION. Would you say that:
You are not anxious or depressed
You are slightly anxious or depressed
You are moderately anxious or depressed
You are severely anxious or depressed
You are extremely anxious or depressed
[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]
46
OMB Clearance Number: 2528-0337
Expires: XX/XX/XXXX
HEALTHCARE
The next questions are about your health insurance and health care.
Insurance
C98. Are you covered by any health insurance or some other kind of health care plan?
Yes
No [SKIP TO NEXT SECTION]
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C99. [IF C98=YES] What kinds of health insurance or health care coverage do you have?
Private health insurance
Medicare
Medigap
Medicaid(PA: Pennsylvania Medicaid Program, OH: MyCare OHIO, TN: TennCare)
Children's Health Insurance Program (CHIP) (PA: Pennsylvania CHIP, OH: Healthy Start,
TN: CoverKids)
Military related health care: TRICARE (CHAMPUS) / VA health care / CHAMPVA
Indian Health Service
State-sponsored health plan
Other government program
No coverage of any type
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
Usual source of care
C100. Is there a place that you usually go if you are sick and need health care?
Yes
No [SKIP TO NEXT SECTION]
Don’t know [SKIP TO NEXT SECTION]
Prefer not to answer [SKIP TO NEXT SECTION]
47
OMB Clearance Number: 2528-0337
Expires: XX/XX/XXXX
[Source: National Health Interview Survey]
C101. [IF C100=YES] What kind of place?
A doctor's office or health center
An urgent care center
A clinic in a drug store or grocery store
A hospital emergency room
A VA Medical Center or VA outpatient clinic
Some other place
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
Health care use
C102. During the past 12 months, have you been hospitalized overnight?
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
Preventative Medicine
C103. About how long has it been since you last saw a doctor or other health professional for a
wellness visit, physical, or general-purpose check-up?
Within the past year (any time less than 12 months ago)
Within the last 2 years (1 year but less than 2 years ago
Within the last 3 years (2 years but less than 3 years ago)
Within the last 5 years (5 years but less than 5 years ago)
Within the last 10 years (5 years but less than 10 years)
10 or more years ago
Don't know
Prefer not to answer
[Source: National Health Interview Survey]
48
OMB Clearance Number: 2528-0337
Expires: XX/XX/XXXX
C104. During the past 12 months, have you DELAYED getting medical care because of the cost?
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C105. During the past 12 months, was there any time when you needed medical care, but DID
NOT GET IT because of the cost?
Yes
No
Don’t know
Prefer not to answer
[Source: National Health Interview Survey]
C106. There are many other reasons people delay or do not get medical care. During the past
12 months, did you delay or not get medical care for any of the following reasons?
Reason
Yes
a...Because an appointment wasn't
available when you needed it?
b…Because you couldn't get to the
doctor's office or clinic when it was
open?
c…Because you had difficulty finding a
doctor, clinic, or hospital that would
accept your health insurance?
d…Because it takes too long to get to the
doctor's office or clinic from your house
or work?
e…Because you were too busy with work
or other commitments to take the time?
f...Because you didn't have
transportation
[Source: National Health Interview Survey]
49
No
Don’t
know
Prefer
not to
answer
OMB Clearance Number: 2528-0337
Expires: XX/XX/XXXX
C107. About how long has it been since you last had a dental examination or cleaning?
Within the past year (any time less than 12 months ago)
Within the last 2 years (1 year but less than 2 years ago
Within the last 3 years (2 years but less than 3 years ago)
Within the last 5 years (5 years but less than 5 years ago)
Within the last 10 years (5 years but less than 10 years)
10 or more years ago
Don't know
Prefer not to answer
[Source: National Health Interview Survey]
[only if respondent is not completing child survey] We are almost done with the survey.
DEMOGRAPHICS AND OTHER INFORMATION
Now I just have a few final questions about your household finances and work.
C108. In general, how do your household’s finances usually work out at the end of the month?
a.
b.
c.
d.
e.
There is some money left over
There is just enough to make ends meet
There is not enough money to make ends meet
Don't know
Prefer not to answer
C109. Are you currently working for pay?
Yes
No (SKIP TO end of survey)
Don’t know (SKIP TO end of survey)
Prefer not to answer (SKIP TO end of survey)
C110. About how many hours per week do you usually work? (Round the time to the
nearest whole hour. For example, if you work 22.5 hours per week, please record 23 hours.)
Hours
Don’t know
Prefer not to answer
50
OMB Clearance Number: 2528-0337
Expires: XX/XX/XXXX
[only if respondent is not completing child survey] Thank you very much for your time, that’s
the end of this questionnaire. SKIP TO INCENTIVE CONFIRMATION SCREEN
[if respondent is completing child survey] Now we are going to ask you some questions about
your child.
AFTER THE PARENT ON CHILD MODULE IS COMPLETE: SKIP TO INCENTIVE CONFIRMATION
SCREEN
INCENTIVE CONFIRMATION INTERVIEWER:
Now I’d like to confirm your contact information so that we can send you your electronic gift
card as a token of appreciation for your time.
I have your email address as: [EMAIL]. Is this correct?
Yes (SKIP TO if respondent is completing child survey)
No
Don’t know
Prefer not to answer
What is your email address?
_________________@______.________ (SKIP TO if respondent is completing child survey)
Do not have an email address
Don’t know
Prefer not to answer
If you do not have an email address, we will mail your gift card to you. First, I’ll need to confirm I
have the right address to send this to you. Is < ADDRESS> correct?
Yes (SKIP TO if respondent is completing child survey)
No
Don’t know
Prefer not to answer
What is your address?
Street Address________________________
Apartment #
Building Name:______________________
City___________________________ State_______ Zip _____________
Don’t know
Prefer not to answer
51
| File Type | application/pdf |
| File Title | Microsoft Word - Redline.Attachment M.2_The Obesity Type II Diabetes Risk Assessment_Survey_Follow-up.docx |
| Author | H03483 |
| File Modified | 2025-05-19 |
| File Created | 2025-05-19 |