riiFiii

I

ITEM.

I❑ Available (N2)I

NISP Statua 2 ❑ Callback required (Household page)

3 ❑ Noninterview (Section Z)

ITEM~

Refer to Hispanic origin in 4e and f on page 2 and 3 of ~I ❑ Hispanic/English Supp. interview ( ?a)

N2 HIS- 1 and expected language for this supplement.2 n Hispanic/Spaniah Supp. intewiew (lb)

Is ❑ Other (Section 0)

I I

Read to respondant:~

I’m going to be asking questions that ara ralatad to haalth concarna, such as smoking, sating practices, vitamin use and so forth.Bafore I ask thasa quastions I would Iika to ask a faw quastions about tha Ianguaga you usa most oftan.

I

1a. Do you spaak any Spanish?I

1•l Yea (2)I 2 ❑ No (4)

--- —-——--—-—————————-———------—-— ————--- L————————————————-—---- ————_______ ———-—Read to respondent: m

I’m going to ba asking quastions that ara ralatad to haalth concams, such as smoking, sating practicas, vitamin usa and so forth.Bafora I ask thasa quastions I would Iika to ask a faw quastions about tha Ianguaga you usa most oftan.

b. Do you spaak any English?

I1•l Yes (2)

I2 ❑ No (4)

I

z. Would you say that you spaak mostly Spanish, mostly English, ~ , ❑ ~05tly Spanish ~

or do you spaak Spanish and English about the sama? I2 ❑ Mostly English

I 3 ❑ Both about the same

a. What Ianguaga do you prafar: Spanish only, mostly Spanish, ; , ❑ Speni5h only ~

mostly English, English only, or Spanish and English aboutsqually? 2 ❑ Mostly Spanish

Mark only one.3 ❑ Mostly English4 ❑ English only

I5 ❑ Spanish and English equally

I

a. Can you raad Spanish? I ~I El Yes

I 20No1

s. Can you raad English? [ ~1❑ Yes

I 20No

Ask if “Yes” to both 4 and 5; otherwise skip to 7. I ~

6. In which Ianguaga do you raad battar?I ❑ Spenish

I2❑ English

I 3❑ Both the same

T. Can you writa in Spanish?tI ~

I ❑ Yesi 20No

8. Can you writa in English?I ~

1 ❑ YesI 20No

Ask if “Yes” to both 7 and 8; otherwise skip to 10.I ~

I ❑ Soanish

!3. In which Ianguaga do you writa battar? : 2❑ English3 ❑ Both the same

I1

HAND CARD B. Read categories if telephone interview. I01 ❑ Puerto Rican 07 ❑ Hismano

~

10. Which of thasa groups bast dascribas your national origin?i 02 ❑ Cuban 08❑ Other Latin American

Mark only one,03❑ Cuban American 09 ❑ Other Spanish or Hispanic

~ 04 ❑ Mexican/Mexicano 10❑ American05❑ Mexican American 11❑ Anglo American

I 06❑ Chicano se ❑ Other (Spacify)

11. Which of thasa groups bast dascribas your mothar’s Inational origin?

01 II Puerto Rican~

07❑ HispanoI 02❑ Cuban 08❑ Other Latin American

Mark only one. 03❑ Cuban American 09❑ Other Spaniah or HispanicI

04❑ Mexican/Mexicano 10❑ AmericanI 05❑ Mexican American 1I ❑ Anglo American

013❑ Chicano 1313❑ Other LSpacify)1

1 z. Which of thasa groups best dascribas your fathar’snational origin?

01•l Puerto Rican21-2:

07❑ Hispano02❑ Cuban os❑ Other Latin American

Mark only one. 03❑ Cuban Amarican 09 ❑ Other Spanish or Hispanic04 ❑ Mexican/Mexicano 10❑ American05 ❑ Mexican Americen 11 ❑ Anglo American

I 06 ❑ Chicano SE❑ Other (Specify)

age 4FORM HIS.2B [3+0

198

Section N – ACCULTURATION – Continued

13a. In what country ware you born?1I I ❑ U. S., except Puerto Rico (74) ~

2 ❑ Puerto RicoI3 ❑ Cuba

I

I}

(13b)4 ❑ Mexico

8 ❑ Other (Specify) ~

II

--------------------------------------------------------------------------------

b. Altogether, how many years hava you iivad inI

I ❑ Less than 1 yr. EEtimUnited States? I 2 ❑ 1 yr., less thsn 5

I3 ❑ 5 yrs., less thsn 10

I 4 ❑ 10 yrs., less then 15I

5 ❑ 15 yrs. or more; 9nDK

I a. In what country was your fathar born?I

I ❑ U. S., except Puerto Rico @I 2 ❑ Puerto Rico1

I 3 ❑ Cuba4 ❑ MexicoIs ❑ Other (Specify) ~

I

I9nDKI

I 5. k what country was your mother born? I 1❑ U. S., except Puerto Rico &

2 ❑ Puerto RicoI3 ❑ Cuba

I4 ❑ Mexico

I s ❑ Other (Specify) ~I

I

1 9CIDK

Uotes

MH13.2B[34921 Pege !

1a. Is there one particular clinic, haalth centar, doctor’s offica, or I

othar placa that YOUusually go to if you ate sick or naad advicaI ❑ Yes (3) +

about your haalth?I 20 No (2)

anThere is more then one (jb)(—--- ———-—————--- ———--—-- .--- ———-—————––––+––––––––––––––––-–--–––––––----–––––--

b. lstharaonaofthosaplaoasyougoto MOSTOFTENwhanyou ~m

arasickornaad advicaaboutyour haalth?tClYes(3)

I 20No (2)

HAND CARD 01. Read all categories if telephone interview. II ❑ I have two or more ueual doctore or places

za. Which ofthasaiatha MAINraasonyou donothavea patiicular \depending onwhatiswrong(2b)

placa or parson you usually go to? I 201 haven’t needed a doctor/Don’t heve e doctors❑ My previous doctor is no longer available

Mark only one.I

40 No care is available/Care is too far awayI SD I haven’t been able to find the right doctor

}

(Item 0?)

6❑ I don’t have insurance/Can’t afford it

s❑ Other reason

9nDK

______________ —————_--____ ——————____ +---------------------------------------b. lsthereonaofthosaplacesyougotomost&anwhenyouare ~

sick or naad advica about your haalth?lCiYes (3)

I 20No (Item 01)I

3. Whattypaofplace iait - a doctor’s offlca, a hospital, aI 9

clinic or some other place?I ❑ Doctor’s officeI2❑ Hoapitel emergency room

IF HOSPITAL: Do you usually go to an outpatient clinic or an I 3❑ Hospital outpatient clinicamargancy room? I An Health center

IF CLINIC: Isthisa public haalthcfirdc orsomaotharkind ~ 5❑ HMO (Health Maintenance Organization)of clinic? I 6DPublicheaIth clinic

IF NAME GIVEN, RECORD NAME: 8nOtherIIs this an HMO, a clinic, a doctor’s offica or I 9UDK

soma other Dlaca? 1

aa. About how long does it USUALLY taka you to traval to this I ~

(place in question 3)7{

I ❑ MinutesI 20 Hours

I NumberI ~3 ❑ It varies

i 999CIDK-- ——————------- —————---—-. —--- ——————-––--’l-––––-–––––--––––-––––------------–––––

b. Onceyou gettottislnlace inquestion 3), about howlongdoyou ~I {

-E@!10 Minutes

usually have to wait bafora you gat madical cara? 20 HoursI

I NumbarI msnlt varies

] 999CIDK1

!5. Istheracurrantly apa@icular person youseaatttisplaca?I ~

I ❑ IYesI

20NoI 9nDK

16. Whanwasthe lasttimayou wanttothisplace?

~I1 I ❑ Less than one year ago

201 to3yearsagoI

So More than 3 years agoI 9nDK

1 @

ITEM ;Refer to sex of SP.

lnMala (Sectiorr P)

01 I znFemale (7)

I ITa. When was tha last time you saw a gynecologist? I @

I ❑ Less than one year agoI 201 to3years ago }

(7b)

I saMora than 3 years agoAn Never

I}

(Section P)9nDK

—- ————--- ————------- ————- ——----— ————____________________________________________ --–.

b. Was this visit for a chack-up, for a spacific gynecological T-zI I ❑ Check-up

problam or for some other problam? 2DGynecological problemI3❑ Other Droblem

I enDK

Notes

200

I

ITEM❑ SPwashousehold repondentfor HIS-1 (Transcribe from

I

PIf?efar to /-//S- 7.

page 20–2 1, question 5, then Section Q)II

❑ SPwaa NOThousehold repondentfor HIS-1 (7)I

1. About how tall are you without shoes?II

@

FeetII

InchesI

2. About how much do you weigh without ehoes? I &

Note: If SP is pregnant, weight referred to is pre-pregnancy weight. [ Pounds

Notes

The next questione ere about certein kinds of medioel tests and examinations.

1

1a. Hava you aver had a tast for oral cancar in which tha doctor

}

I 5

/o ❑ I think so

or dantist pulls on your tongua, somatimas with gauze(lb)

wrappad around it, and faals undar the tongue and inside thaI El Yes

cheeks?I 20No

I 7❑ Refused

}

(5)9❑ DK, not sure

-----------------------------------------k--------------------------------------b. How meny timas have you baen checked for EEz

orei cencer in your Iifatime? Il— Times (2)

: 99CIDK(7C)_-_--_----------_----------------_-------L-------------------------------------- ----

c.lsitlassthan 10,10t020,0r morathan20timas? I k1❑ Less than 10

[ 2nloto20! 3❑ More thsn 20

9CIDKI

2a. When did you hava your most raoent oral cancar axam? I

Id~

E

I Year 1I

I OR If 3 years ago or E

I

I

{}

less (3)I ❑ Days ago2❑ Weeks ago if more thsn 3 yeara

Number 3❑ Months ago ago (5)

4 •l Years ago] 999nDK(2b)

-----------------------------------------+--------------------------------------b. Was it within tha past yaar, batwaan 1 and 3 yeara ago, or ovar I , ❑ within the ~a5t year ~3)

I

I

~-Tc.

3 years ago? 2 El 1to 3 years ago

! 3•l Over 3 yaara ago (5)9CIDK

I

a. What type of madical parson examined you when you had17

Iyour last chack-up for oral cancar?

1❑ Physician2❑ DentistI3❑ Dental hygenist

I a ❑ Other (Specify) ~II

; 90DK

HANDCARDQ l. Readcategoriea iftelephoneintervie w. I ~I ❑ Because of a specific oral problem

a. Whatwasthemainraasonyouhadthischeck-up?I 2❑ Follow-up to a pravious oral problemI

Mark only ona.3❑ Part of a routine physical exam4❑ Part of a routina dental examI

/a ❑ Other (Specify) ~

II

9CIDKI

HAND CARD Q2. Read categories if telephone interview. I 1sI❑ Spendingtoomuchtime inthesun

/5. Which of thesa do you think increasas a parson’s chances of ,

202❑ Excessive drinking of alcoholic beverages 21

gatting oral cancar, that is cancer of tha lip, mouth, tongue, I 3❑ Excessive coffee drinkingor throat?

224 ❑ Smoking cigarettes, cigars, or a pipe

I 23

(Pleese give me the numbers from tha card.)5❑ Use of chewing tobacco or snuff 24

I 7❑ Refused 26Mark each that applies. I s ❑ Something else (Specify) ~

1

I 9nDK E

Notas

ige 8 FORM H13.2B [349:

202

Section Q - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued

6a. Hava you avar had your skin chacked for cancer either by aI I 27

I ❑ Yes (6b)darmatolog[st or some other kind of doctor? I 20No

I 7 ❑ Refused

I }

(lo)9UDK

._-_-----____._--____---__-..__----------L-------------------------------------- ----b. Howmanytimeshavayouhadyourskin checkedforcancerin / *

your Ilfatima? I — Times

I 99 CIDK

T#t. When did you have your most recent skin exam?I I30-33II ~x!--

1Month Year

I ORIf 3 years ago or M

{1

I ❑ Days ago less (8)

I 2❑ Weeks ago If more than 3 years

Number 3 ❑ Months ago ago (10)

~ 999 ❑ DK (7b) 4 ❑ Years ago

___________----------__---___---___--____k-------------------------------------- –––-b. Was It within tha paat year, batwean 1 and 3 I I ❑ Within the past year

I

I

I

/

T.-3L

years ago, or ovar 3 yeara ago7(8)

2 •l 1to 3 years ago3❑ Over 3 years ago (lo)9nDK

8. What kind of doctor cltackad your akin for cancar the lastI

I ❑ General practitioner I 38

timeyouhadaskin exam? ; 2❑ DermatologistI 8 ❑ Other (Specify) ~

I

I 9DDK

HAND CARD (23. Read categories if telephone intervie w.1

I I ❑ Because of a specific ekin problem I 39

g. Whatwasthamainraasonyouhadthisskin exam? I 2❑ Follow-up to a previous skin problem3 ❑ Part of a routine physical exam/ As a screening exam

IMark oniy ona. a ❑ Other (Specify) ~

I

I9cl DK

II

10. lfyouwsratogooutsideonaverysunnydayforMORE40

Ithanonehour - !

a. How likely ara you to waar protactiva clothing such as wida I ❑ Very likelyIbrimmed hats or long sleeved shirts? Would you say vary likely, \ zDSomewhat Iikalysomowhatlikely, orunlikaly? 3DUnlikely

-—___--——__——___—____— ___________________ L__–––___–––_––––__–––___–––--–––__–-– ----

b. Howiikelyarayoutoavoidthe sunbystayingintheshade;very \ lDVe~like\Y kIikaly, somawhat likely, or unlikely? I 2❑ Somewhat likely

I3 ❑ Unlikely

-—___ -- —___ —_____________________________ ;-------- ————————-——————————-————-——-—— ---

C. How[ikelyara youtousesunscreen orsunblock lotion; veW I I ❑ Very likely T2?-Iikaly, somawhet likely, or unlikaly?

I 2❑ Somewhat likely

30 Unlikely1

HAND CARD Q4. Read categories if telephone intertdew.II I ❑ Getasevere sunburn with blisters

~

I11a. Aftar sevaral months of not baing in tha sun, if you THEN I 2❑ A severe sunburn for a few days with peeling

want out in the sun without sunscraan or protective clothing 3❑ Mildly burned with some tanning

for an hour, which one of these would happen to your skin?I

4❑ Turning darker without sunburnI

(Plaase give ma a number from the card.)5❑ Nothing would happen in an hour

I s ❑ Other (Specify) ~

Mark only one.I

I9CIDK

1________________________________________________________________________________HAND CARD Q5. Read categories if telephone interview. [ 1 ❑ Very dark and deeply tanned m

b.lfyou wamoutinthe aunfora longtime repeatedly, which one ~ 3DMildly tanned2❑ Moderately tanned

of thasa things would happen to your skin? I 4❑ Only freckled or no suntan at all

(Ptaasa giva ma a number from the card.) I 5❑ Repeated sunburnsI

Mark only one..9❑ Other (Specify) ~

;

9nDK

!2. lnyouropinlon, howaanaitiveisyour aMntosuntight; isit I ❑ Extremely sensitive&

axtrsmaly sansitiva, moderately sensitive, mildly sensitive, or 2❑ Moderately sensitivenot sansitiva at all? 30 MilrJlyserwitive

40 Notsansitive at all9CIDK

... ,,,. . . ,. . .“, m-—- .lnl .K1..., .-.., rage Y

203

Sac*inn Q — CANCER SCREENING KNOWLEDGE AND PRACTICE — Continued---.. -.. — —----- —--——--——-—--——---———————1

ITEM I I❑ Male, under 40 (Section R)46

QIRefer to age and sex. 2 ❑ Ma[a, 40+ (31)1

3 ❑ Female (73)1

I Sa. Have you ever had a Pap smaar tast? I I ❑ Yes (73b)47

Read if neceaaary: A Pap ●maar is a routine gynacologic test in \ 20 NO (16)

which tha doctor axamines the cervix and I 7 ❑ Refusedsends a cell sample to the lab. }

(Item Q2)eaDK

——————-— —.. -- —- —- ——-— ———--— ————- ————____; ––––– ___. __________ ———-- —--------------

b. How many Pap smaar teats hava you evar hadT

--—I 4a

I ❑ Less than 10in your Iifetima? Less than 10,10 to 20, or I 2clloto20more than 207

/3 ❑ Mora than 209nDK

14a. When did you hava your most recent Pap smaar teat?I49-52

~LMonth Year

OR If 3 years agoorless(15) =

{}

1❑ Days ago if mora than 3 years ego (16)2 ❑ Weeks ago

Number3 ❑ Months ago4 El Yeara ago

9e9 ❑ DK (14b)_________________ ——-------------------------- *–––––_––--- _—— —--__ --_____ -—-- __--- ——-—

b. Was it within the past yaar, batwsan 1 and 3 I

I /

E

yaars ago, or ovar 3 yaars ago7I ❑ Within the past yeer (71j)2 •l 1 to 3 years ago

/ 3 ❑ Over 3 years ago (76)9CIDK

HAND CARD Q6. Read categories if telephona interview. ! I ❑ Because of a specific gynecological problem (1 5b)67

15a.What was the main reason you had this Pap smaar tast72 ❑ Follow-up to a previous gynecological problem

I3 ❑ Part of a routine physicai ( or pragnancy) exam

Mark only one.I s ❑ Other (Specify) ~

I

i}

(17)

9nDK________ ---- __-__________________ ------- L --------------------------------------- –~8– -

b. What was the probiem? ; I H Blaeding

I

I

I

I

III

E

59

Mark all mentionad, do not probe.2 ❑ Pain 603 ❑ Discharga al

i4 ❑ itching 625❑ Burning6 ❑ infection (17)

s ❑ Other (Specify) ~

E63

9CIDK

; ;1

16. What is the most important reason why you have [nevar had Ia6

a Pap amaar taatlnot had a Pap smaar tast in tha past fawyears]?

o ❑ No reason/Never thought about it/ Didn’t know I shouldI I ❑ Not needed/Haven’t had any problemsI

Mark only one.2❑ Put it off/Laziness3 ❑ Costs too much/No insuranceI4 ❑ Doctor didn’t recommend it

; 5 ❑ Don’t go to or don’t like doctors

I 6 ❑ Had a hysterectomya ❑ Other (Specify) ~

!

I 9EIDK

1h. What is tha racommanded age a woman should START1I

W

having Pap smears? Yeara old OR

95 ❑ When aha starts having perioda96❑ When she starts having sexI97❑ Rafused

I913❑ Other (Spacify)

/ 9en DK---------------------------------------------------------------------------- ----

b. At what ago do women no Iongar naari to hava Pap smears or I ,E

is thara no age limit? _ Years old ORI

I es❑ When menstrual perioda stop (naturally or artificially)96 •l No age limit

/ 97 ❑ Refusad9s❑ Other (Specify)Is90 DK

I .,.”.. ,,,. . . ,. . .)ge 10

,U”hl “la-’. ,.-.4

204

Section Q – CANCER SCREENING KNOWLEDGE AND PRACTICE – Continued,

ITEM II ❑ BOX 6, Had a hysterectomy (Item Q3)

Q2Refer to age and question 16 for hysterectomy status. / 2 ❑ 60+ (19)

Ie ❑ Other (78)

1

18a. Do you have menstruel periods? II

1 ❑ Yes (Item Q3)z ❑ NO (f8b)

I3 ❑ Never had periods (78c)

I 7 ❑ Refused (/tern Q3)

.--------- .-----------------------------L----------------------------------------b. Did they stop due to surgery, such as e hysterectomy? I ❑ Yes

I20No }

(Item Q3)

1 3 ❑ Never had periods (78c)--------------------------------------------------------------------------------

c. Was this due to surgery, such es a hysterectomy?I

1EI YesI 20No

ITEM1I

Refer to age.1 ❑ lJnder30 (.Section/?)I

(L3 I 2 ❑ 30 and over (19)

I%. A mammogram is an x-ray takan only of tha breasts by a IlDYes (19b)

machine that presses the braast against a plate. Have you Iaver heard of a mammogram?

20NoII 70 Refused

I }

(26)9cl DK

----------------------------------------t----------------------------------------b. Hava you evar had a mammogram? I I ❑ IYea (79c)

I 20No (24)1 70 RefusedI

9CIDK }(25)

——____——___——___________—_________—____— k–––-––––––––___–––_–––___–––__––––__––_.C.Abouthow many mammograms haveyouavar hadinyour

lifetime?Il—

Mammograms

99CIDKI

?oa, When did you have your (most recent) mammo9ram? I

~M_-1Month Yaar

I

IOR

I

{1

If 3 years agoorIesa(21)I ❑ Daya ago2 ❑ Weeks ago If more than 3 years ago (i

I Number30 Months ago40 Years ago

I 9990 DK (20b)________________________________________________________________________________ .

Ib. Was it within the past year, betwaan 1 and 3 yaars ago, or I

II 1Inwithin the past year (27)

ovar 3 years ago? 20 1 t03 years3❑ Over 3 years ago

I}

(24)9nDK

1

!1. Wherewasthis mammogram done -inadoctor’soffice,a I

clinic,ahospital, anx-rayorradiology Iab,orsomaotharI I ❑ Doctor’s office (private or HMO)I

placa? 20 ClinicI3 ❑ Hospital

[ 4 ❑ X-ray or radiology lab

I 5 ❑ Mammogram van

en Other (Specify) ~IIII

9CIDK

HAND CARD Q7. Read categories if telephone interview. II ❑ Because ofaspecific breast problem (22b)

!Ztl. What was tha main reason you had this mammogram?I 20 Follow-up toaprevioua breast problem

I 30 Baseline mammogramMark only one. 4D Part ofaroutine physical exam/As a screening test

I

I a ❑ Other (Specify) ~

II

sDDK }—____ ---_ -— ——___________________________

b. What was the problem?

;_–– -_ -— ————————————_— —————————-— ———————

I 1❑ Sorenesa

Mark all mentioned. Do not probe.20 Pain3 ❑ Swelling4 ❑ Lumps

50 Fibrocystic breast disease

a ❑ Other [Spacify) ~

! 9D DK II

,.,. . . .. . .,,

71

72

T———

73

T-—-

74

75

76

T———

77

——-7a-79

]80-83

j a4-aa

24)

T—-—

87

1 88

1 89

(23)

909192as9495

ae

Page 11

205

S%etinn n — CANCER SCREENING KNOWLEDGE AND PRACTICE — Continued

:

Zge 12 . . .

16

w“”.. -.. - . . . . . . . . . ------------ ----- --——— _—-. ..—

1

?3. Who made the decision that YOUshould hava this I

I

I

I

I

I 1’

97I ❑ I decided on my own

mammogram? 2 ❑ My doctor ordered it

Mark only one. 3 ❑ Both my doctor end I agreed on ita ❑ Other (Specify) ~ (25)

9aDK

24. What is the most important raason why you have [never,I

98

had a mammogram/not had a mammogram in the pasto ❑ No reaaon/Nevar thought about itioidn’t know I should

faw yaarsl? I I ❑ Not needed/Haven’t had any problems2 ❑ Put it off/LazinessI

Mark only one. 3 ❑ Coats too much/No insuranceI

4 ❑ Doctor didn’t racommand itI 5 ❑ Don’t go to or don’t like doctors

6 ❑ Not old enoughI8 ❑ Other

I 9CIDK

~s. What is the age doctors racommand a woman should start, I 99-1oo

having mammograms? / Years old

i OR96 ❑ When she starts having periods

I e7 ❑ Refusad9s •l Other (Specify) ~

I

I

99 CIDKI I RT 88

A braast physical exam is when the breast is fait for lumps I ~

by a doctor or medical assistant. /I ❑ Yes (26b)

26a. Have you aver had a braast physical axam dona by a I DC20Nodoctor or medical assistant? I 7 ❑ Refused

}

(30)eHDK

——---— ———---— ———---- ————-- —————--— ———--–L–––--––––––-––––--–-––--–––––---––----–

b. How many breast physical exams have you evar had in your /

~

tifetima? Was it lass than 10,10 to 20, or mora than 20?I ❑ Less than 10

I 2nloto20

I 3 ❑ Mora than 209EIDK

I

ZTZI. VixhemTdidyou have your most recant breast physicalI ~

I~E_

I mMonth Year

IOR If 3 years ago or less (28)

/

{1

1❑ Days ago

2 ❑ Weeks ago If more than 3 years ago (29)I 3 ❑ Months agoI Number 4 •l Years ago

I 999 ❑ DK (27b)——————-— —————----— ————————————--— ——————- ~–––– —————-—-— ——---—-- ————------ —------—

b. Was it within the past yaar, bstwaan 1 and 3 years ago, or

I I

EI ❑ Within tha past year (28)

ovar 3 years ago? 2 ❑ 1 to 3 years ago

3 El Ovar 3 years ago(29)

eaDK

Notes

, FORMHIS.2B 13-4.

Section Q — CANCER SCREENING KNOWLEDGE AND PRACTICE — Continued1

HAND CARD Q8. Read categories if telephone interview. I~

I ❑ Because of a specific breaat problem (28b)

28a. VJxJ;,wastha main raason you had this braast physicalI 2 ❑ Follow-up to a previous braast problem

3 ❑ Part of a routine physical (or pregnancy) axamI

Merk only one.

8 ❑ Other (Specify) ~II

I

I

(29)

9CIDK

——_ -- —----------------------------------

b. What was tha problam?

;–––––––––-–– ——————--— ———————————-— ————— _——II

I

I

I

E

16I El Soreness 17

Mark ell mentionad, do not probe. 2 ❑ Pain 183 II Swelling 19

4 ❑ Lumps 20s ❑ Fibrocystic breast disease 21a ❑ Other (Specify) ~

III

I 9EIDK ECI

29. At what age do doctors racommand that a woman should ~I

start having braast physical axama? _ Years old

OR

85 ❑ When she starts developing breasts56 ❑ When she starts having periods97 ❑ Refused

I9a ❑ Other (Specify) ~

I

I

99 CIDKI

Sotl. Do you know how to axamina your own breasts for lumps?&

II I ❑ Yes (30b)

20NoI

7 H RefusedI }

(Itam Q4)

--------------------------------------------------------------------------------

b. About how oftan do you axamina your braasts for lumps? I

I

I

I

{

T-zm1 ❑ Day

_ per 2 ❑ Week

Times 3 ❑ Month4 ❑ Year

IOR

000❑ NeverIam ❑ Other (Specify) ~

II

I99sn DK

ITEM I ~Refer to age.

1 ❑ Under 40 (Section R)

Q4 I 2 ❑ 40 and over (31)I

31 lt. Hava you aver had a chast x-ray?I ~

t ❑ Yes (31b)I 20NoI

9nDK }(34)

——__-___ —_______________________________ :––––– —————-— ———————- ———————————————————

b. How many chast x-rays have you avar had in your Iifetima? I 1❑ Less than 10 m

Was It lass than 10,10 to 20, or morn than 20? 2clloto20II 3 ❑ More than 20

9CIDKI

laa. Whsn did you hava your most recant chest x-ray? I ~

I

~N--- mI Month YearI

ORIf 3 yeara ago or lass (33)

II

{}

I ❑ Daya ago

2 ❑ Weeks ago If more than 3 yaars ago (34)

I 3 ❑ Months agoNumber 4 II Years ago

I999 ❑ DK (32b)

_______________ ------_ ---_ --____________ ;_______________________________________ --–.

b. Was k within tha past yaar, batwaen 1 and 3 yaars ago, or I I ❑ Within th6 past year

I1

I

I

E

over 3 yaars ago? 2 ❑ 1 to 3 years ago [33)

3 ❑ Over 3 years ago9CIDK (34)

I. . . . . . . . --

207

Section Q - CANCER SCREENING KNOWLEDGE AND PRACTICE - ContinuedHAND CARD 09. Read categories if telephone interview. I ~

I ❑ Because of a sDecific chest E.roblem (33b)1

33a. What was tha main raason you had this chast x-ray? 2 ❑ Follow-up to a “previous chest problem:

Mark only one.

3 ❑ Part of a routine physical exem/As a screening test

I 4 ❑ For employment reasons

; 5 ❑ Because of hospitalization8 ❑ Other (Specify) ~

I

\

(34)

1

I sDDK )I-------------------------------------------------------------------------------- ——-

b. What was the problam? I

I

I

I

E

41

Mark all mantioned, do not probe.1 •l Coughing

42

2 ❑ Chest pain43

;3 •l Pneumonia

44

4 ❑ Bronchitis45

5 ❑ Emphysema4e

6 ❑ Shortness of breath47

T •l Injury48

Is ❑ Other (Specify)

/ 9 ❑ DK/Refusadm

kla. A proctoscopic exam ia whan a tuba is insertad in tha rectumI &

/to check for problems. Have you evar heard of a proctoscopic ,I ❑ Yes (34b)

exam?20No

I 7 ❑ Refused

I 1(37)9UDK

—-—-——————---——---- ———-—--—---- —-——--————L__ ——— —_ ——L——__— —--__ -———_--— —-- ——---— —

b. Have you ever had a proctoscopic exam? EI ❑ Yes (34c)

i 2DN0

I 7 ❑ Refused

I }

(37)9CIDK

-----------------------------------------t------------------------------------------C. Howmanyproctoscopic axamshavayou everhadin I&E

your Iifetima? i_ Proctoscopic exams

; 99 CIDK1

]Sa, Whan did you have your (most racant) proctoscopic axam? I &

,19 \I ~—

I Month Year mI OR1

I

{1

1❑ Days agoIf 3 yaara ago or Iaaa (36)

2 ❑ Weeka ago If mora than 3 years ago (37)

Number 3 ❑ Montha ago4 ❑ Years ago

! 999n DK(35b)-------------____----___------__----___--L______________________________________

b. Was it within the past year, betwaan 1 and 3 yaara ago, I 1 ❑ within the peat year

}

mor over 3 years ago? (36)

201 to3yearsago

/ 30 0ver3 years ego

}(37)

enDK1

HAND CARD Q1O. Readcategorfea iftelephone intewiaw.1

; I ❑ Because ofaspecific health problem (36fJ)~

36a. What was the main reason you had this proctoscopic exam? ] 2 ❑ Follow-up to a previous health problem3 ❑ Part of a routine physical exam/Aa a screening test

Mark only ona.I

a ❑ Other (Specify) ~I

\

(371

i

I----- _- ——— — — _____________________________

b. What was the problom?:–

Mark all mentioned, do not probe. i

I

II

9CIDK)

—---- ——--— —---- ——-—--— —--- —- ———---— ——~_g3-

I ❑ Bleeding20 Pain

3 II Constipation

4 ❑ Bowal trouble

5 ❑ Blood in stoolE

64666a

67

68

s ❑ Other (Spacify)9CIDK E

Votes

Ige 14 FORM H13-2B (3-4.

208

Section Q – CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued

3ra. A digitai rectai exam ia when a finger is insertad in tha70

ractum to chack for probiama. Haveyouavar haard of thisaxam? I ❑ Yes (37b)

20No7 ❑ Refused

9CIDKI 1(41)

___________ ———____ ---- ———--______ —————---- L–––––--–––––__–––––---––––-_–––––-____ –-–.

b. Have you ever had a digital ractal exam? T.-.?LI I ❑ Yes (37c)

2DN0 (40)I

7D RefusedI 9nDK 1(41)

———-—-— ----- ———————--- ——————-— —-- ——————-— L______________________________________ ____

C, Howmrmydigital ractalexams haveyou everhadinyour TJl-fifatima? Was it iessthan 10,10 to 20, or morathan 20?

I I ❑ Lessthen 102clloto20

r3D More than20

I 9nDK

ISa. Whandid youhavayour moatracant digitairactalexam?I [ 73-76I

; &2L

I Year E

I OR

{1

If 3 years ago or less 139)I ❑ Days ago2 ❑ Weeks ago If more than 3 years ago (40)

I

I Number 3n Months ago4C! Years ago

[ 999DDK (38b)————----- ————-- —--- —- ————- ——————_––––_L_-L–____–––––_–____________________–_____ ____

b. Wasitwithintha pastyaarrbatwaan land3 I

I

I

/

U!_.yaara ago, or ovar 3 years ago? I Hwithinthe past year (39)

2CI 1 to3 years ago3 ❑ Over 3 years ago (40)9i3DK

,

HAND CARD Q 10. Read categories if telephone interview. II ❑ Because ofaspecific health probiem(39b)

61

39a. Whatwaatha mainraason youhadtMsfigitai ractalaxam? [20 Follow-up toaprevious health problem3D Part of aroutine physical exam/As a screening test

Mark only one. ; en Other (Specify)v

II

}

(41)

9ci DK———_------ —_____ --__ —————-_— ————_________

b. What was tha problam?~_____–––––– _———————-____——-—————— _____I ,

I

I

IE

—-—-

01 ❑ Blood in stool82-83

020 Pain84-a5

Mark all mentioned, do not probe.03 ❑ Constipation

86-a7

o.tnBoweltrouble88-89

/ 05D Difficulty urinating90-91

060 Prostate enlargement92-93

07 ❑ BiaedingI (41)

I oaaHemorrhoids

090 Diverticulitis

I E

94-9596-97~ 9a E10ther(Specify)~

/98-as

100-101

I 99 ❑ DK/RefusedI 1

E!EE

LO. Whatistha moatimportant reason whyyouhava[navar I 104

had a digital ractai axam/not had a digital ractal axam inon Noreason/Never thought about it/Didn’t know iahould

tha past faw yaarsl?I I ❑ Notneeded/Haven’t hadanyprobiems

1 2D Putit off/Laziness3 ❑ Costs too much/No insurance

IMark only one.

40 Doctor didn’t recommend itI 5U Don’tgo toordon’t like doctora

I s ❑ Other

90DKI1

Jotes

.-IMHIS.26[3.4.92) Page It

209

pimrSbmtinn Q - CANCER SCREENING KNOWLEDGE AND PRACTICE – Continued ~------- .— —-.---—------—— ----- —---——--—————–—–

1

ala. A blood stool testis when the stool is examined to6

determine whether it contains blood. Heve you ever heard i I ❑ Yes (47b)

of a blood stool tast?20No

I 7❑ RefusedI }

(Section R)9CIDK

-- ——————. ..- —————----— ————---- —- —————---- ~_–––– -_ ——————----- ——----— -- ——---— —————

b. Have you ever had a blood stool tast? I EI lZYes (47c)

I 2 ❑ NO (46)

/}

~ ~ ~~d (Section R)

I-----------------------------------------------------------------------------c. About how many blood stool tasts have you avar had in

---

I Eyour tifetima? _ Blood stool tests

II 99n DK

H?a. Whan did you have your (moat recent) blood stool taat?I ~

I d=

: Yeer EOR

{1

If 3 years ago or less (43)1 ❑ Days ago2❑ Weeks ago if more than 3 years ago (46)

Number 3❑ Months ego4❑ Years ego] 999❑ DK (42b)

————————-------- ———————- —- ———-—-..— ————————b. Wasitwithin tha pest year, batwaen 1 and 3 years ago,

~___–––––––_________ ––________I H Within the psst year

I

i

Eor over 3 yeara ago~

(43)2 •l 1 to 3 years ago

/3❑ Over 3 years ago (46)91JDK

ks. Oid you parform this blood stool test yoursalf or was it done I I ❑ Self-tested~

by a doctor or other medical parson? I 2❑ Doctor/medical person9nDKI

HAND CARD Q 10. Read categories if telephone interview.II 1 ❑ Because of a specific health problem (44b)

~

a&l. What was the main reason you had this blood stool tast? 2❑ Follow-up to a previous health problemI3❑ Part of a routina physical exam/As a screening test

Mark only one.I s ❑ Other (Specify) ~I

I

}

(45)

9EIDK_________________________________________;______________________________________ -78-.

b. What waa the problem? I I ❑ Hemorrhoids2 ❑ Pain

I

I

E

20

Mark all mentioned, do not probe.3❑ Bleeding

21

4 •l Constipation22

; 5❑ Bowel trouble23

6❑ Blood in stool2426

7 •l Ulcers

s ❑ Other (Specify) ~26

Is ❑ DK/Refused E

45. Who made the decision that you should hava this blood I &

stool tast? I 1❑ I decided on my own

I2 ❑ My doctor ordered it

Mark only one.3 ❑ Both my doctor and I agreed on it

I a ❑ Other (Specify) ~

I

I

I II

(Saction R)

9CIDK

46. What is the moat important reason why you hava [navar 2s

had a blood stool tesffnot had a blood stool test in the past; o ❑ No reason/Never thought about it /Oidn’t know I should

faw yaarsl? I ❑ Not needed/Haven’t had any problemsI2 ❑ Put it off/Lazinees

I 3❑ Costs too much/No insuranceMark only one. I 4❑ Doctor didn’t recommend it

s ❑ Don’t go to or don’t like doctorsIs ❑ Other

: 9EIDK

Notes

. . . .. . .. . . ,. . .ige 16 ,.J.nl“1=.. .. . . .

210

riiF6ii

1. Haa a medical doctor ever told you that you had cancer of any II ❑ Yes (2) L-L

kind (including any cancar You have already mentioned)? I 2 ❑ No (Section S)

2. How many diffarant kinds of cancer have you had?II

~

,I

1}

— ‘umber ‘f Cancera If 1 cancer (3)9nDK If 2 or more cancers (4)

I

aa. What kind of cancw was it?1I ~

I

I 799n DK.---. -- —----- ———————- —————————————————___

b. What part of tha body waa affected?;–-_–– —————————————————___— ——————-— ———— ——.

I TE!z

1

1 990 DK-— ——-— ———---- ——--— —————————————————-— .—— —&_-– ————-- ————————. ————- ————- ——-— ———— ——-

C. In what yaar was this cancar first diagnosad? I TEE1 _ Year (3e)

I 99❑ DK (3d)———----------- ——————--— ————————————-— ————L–_______–_______ –_____ –– ______________ ____

d. How old ware you when this cancer was first diagnosed? II&N1l—

Age

99n DK—----- —- —----- ——————-— —————————————- —————HAND CARD G 1. Read categories if telephone interview.

;__––– ———————————————————————————-— ————

I

~

I ❑ Ihadnosymptoma anditwas detacted duringa

r3. (Pleasa lookatthia cardandtall ma)howwasyour cancar I routine check-upfirst datected? I ZO Inoticed something waswrong andwentto a doctor

1Mark only one.

30 Inoticed something waswrong butdidnottalk to a doctorabout it until my regular physical examI

s ❑ It was detected in some other way (Specify) ~IIII 9nDKII

ITEM Refertoqueation 3cor3d for when the cancer

~

I ❑ Morethan 10years ago (Section S)I

RIwas FIRST DIAGNOSED. I 20 100rfewer years ago(6)

1 1

aa. What kind of cancar was diagnosad first? I ~

I

I 799n DK_----___-----___-----__-_---_____---____-L-------------------------------------- –-–-

b.Whatpartoftha bcdywasaffacted? TEzII

I 99UDK--------------------------__-------------L-------------------------------------- –-–-

C.Whatyaarwas thiscancarfirat diagnoaed? I E%?!II _ Year {4e)

~ 99DDK (4d)---------------------------_------_-_____+______________________ __

d. Hawoldwareyou whenthiscancerwas firstdiagnosad? I IzEz!!_ Aga

I99CIDK

----—---—____—_______——_____———_____———__ L––––--–––––––––––––––––––_–––––––__–-– –-–.

HAND CARD G 1. Read categories if telephone interview. kI I ❑ lhadnosymptoms anditwas detected duringaO.(Plaaselook atthiscard andtellma) howwastie fcancarin4a) i routine check-up

first datectad? z ❑ I noticed something was wrong and went to a doctorI

Mark only one.3❑ I noticed something was wrong but did not talk to a doctor

I about it until my regular physical exam

I s ❑ It was detected in some other way (sPf?CifY)~

I

t 90DK

Notes

!M HIS2B [34921 Page 17

211

Section R – CANCER SURVIVORSHIP – Continued

5a. What kind of cancar was diagnosed most racantly? I ~

/, 799n DK

—————————----- ———————--- ————————————---__ L ______________________________________ ---

b. What part of the body was affeated? @I

I

] 99 CIDK

-----------------------------------------k--------------------------------------c. In what yaar was this cancar first diagnosed? T&z

I_ Year (R2)

: 990DK (5d)-----------------------------------------t-------------------------------------- ---

d. Howoldwarayou whanthiscancarwas firstdiagnosad? &I _ Age

I 990 DKII

ITEM Refer to q“estjon 5Gor 5d for when the most

~

1 I ❑ More than 10 years ago (Section S)

R2 recent cancer was FIRST DIAGNOSED. 2 ❑ 10 or fewer years ago (6)I

The following quastions refer only to theI 3a

a or 560.1 ❑ Internist, general practitioner

I 39

HAND CARD G2. Read each category if telephone interviaw.2 •l Cancer specialist (oncologist) 40

I

6. Whattypesofdoctorsdidyousaaforyourdiagnosis3 ❑ General surgeon 41

Iandtraatmant?

4 ❑ Cancer surgeon 42

5 ❑ Plastic surgeon/Reconstructive surgeonIMark each that applies.

43

6 H Radiologist 44I B ❑ other apecialiat (SpeCifY} ~

I

I9CIDK

I EI

7a. Didyougatmora thanonaopinionabout tha~

typaoftraatmant youshouldhava?I EIYesI20No

I 9CIDK——————————---------———————————--------——— ~––––––-- ---——.———-—-—--———————— -------

HAND CARD G3. Read each category if telaphone interview. I

I

I

I

I E

_— -

I ❑ Surgery toremovethetumor47

2 ❑ Radiation48

b. What typas of traatmant did you raceive for this cancar? 3 ❑ Chemotherapy40

4 •l Special diata50

Mark each that applies. 5 ❑ Self healing techniques, including imaging51

a ❑ Other (Specify) ~62

I

I 91JDK E

8. After yourcancerwasdiagnossd, didyouracaivaanyI

I ❑ Yes (10)@

counseling or join any support groups to halp you cope? I2 ❑ No (9)

I 90 DK (10)

HAND CARD G4. Read categories if telephone interview. I1 ❑ ldidn’t know itwasavailable (9b)

p

I9a. What was tha main raason you did not gat counsafing?

20 Ididn’t wantit3 ❑ I didn’t think I needed it, )

Mark only one. i s ❑ Some other reason (Specify) ~\ (10)

I

i 9Ei DKJ-_____________________-------------------L-------------------------------------- ---

b. Would youhavahan intarastd inr=aiving oounsafingifyou / L!?!!hadknownabout ft?

1•l YeaI 20NoI

9CIDK,

10. Didadoctor,nuraa,orsooiaiworkargivayouwrittan&

!information about your cancar or its traatmant?

lfNO,ASK–I

Evanthoughno onagavayouany writtaninformation didyou ;lUYes (17)

piokanyuponyour own? 2 ❑ No, no information givenI

If Yes, mark box 3.3 ❑ No, but I picked it up myself

}

(12)

If No, mark box 2.9CIDK

/

Notes

~ge 18 FORMH12-28[2-4

212

Section R – CANCER SURVIVORSHIP – Continued

HAND CARD G5. Read each category if telephone interview. I I ❑ General information about cancer58

11a. What subjects did the materials cover? (Anything alsa?) I 2 ❑ Information about your specific type of cancer59

I 3 ❑ Cancer treatment options60

Mark each that applies. I 4 ❑ Coping with the physical side effects of cancer treatment61

5 ❑ Coping with the emotional effects of cancer62

I

I 8 ❑ Other (Specify) ~63

III 9EIDK

E._______-_._----_-.--------------------.-L--------------------------------------

b. [Was thisiMfara any of thesal malarial helpful? I EEI •l YesI2DN0

I 90DK

HAND CARD G6. Read 12b categories if telephone interview.I ~

lZa. Aftaryouwerediagnosadwith cancer,didyoucontactanyof / 1❑ Yea (12b)thase cancer organizations? I 2UN0 (13)--------------------------------------------------------------------------------

b. Which cancer organizations did you contact? (Any others?)———

II ❑ American Cancer Society 67

I z ❑ National Cancer Institute68

Mark each that applies. 3UThel-800–4-CANCER HOTLINE 69I

8 ❑ Other 70I 9 ❑ Don’t know 71

13. Did you participate in a raseerch study or clinical trial as a part of I 1❑ Yes~

your cancertrtratmant? I 20No91JDK,

1aa. Not counting Medicare or Medicaid, did you hava healthI

I ❑ Yes (74b) 73

insuranca that paid for all or part of your treetment? I 20No

}(15)

9nDK————__--_-—----——_--___————__—————-————-_ ;_––-_ ———————————————————--—————--———-—

HANDCARDG7. Readallcategories iftelephoneintervie w, I 1 ❑ Yea — Coet to me increased FI

b. Did your haakh insurance change in any of these ways becausa ~2❑ Yes — My insurance was cancelledor not renewed

of your cancar?8❑ Yes – Other change (Specify) ~

I

Mark only one. Io ❑ No — Did not change

,15a.Were you EVER deniad health or Iifa insurance coveraga because I I ❑ Yes

~

ofyourcancar? 20NoI9CIDK

——————----—-—--————-___—————_——————————-— ;–––-_b. Ware vou EVERaskad to waiva covarage of your cancer in order I

———-————————————————-——————————-—..

I lJYes Eto gat health insurance? I 20NoI

9UDK

16a. Werayouworting atajoborbusiness immetiataly BEFORE your ~77

1 a Ye8 (16b)diagnosis of cancer? I zONO (77).—— —--- ———---— ———-— ————————————————————-—

b. Were you self-amployad?L––__––––– _______________________ –––__– ––-1 IxLI 1❑ Ye8 (77)I 20No (76c)

-— ———_— ———________ ——____— ——__— ——__— ——————;––––– ———-—-— ——-— —————. . ..- ———..- ————---------C. Didyour amployerhava along-term disability plan I EI ❑ Yes

that covered cancery I20NoI

1 1(18)9UDK

17a. Hava you workad at e job for pay AFTER your IlD Yes (77b)

@

cancar was diagnosed? I 20 No (Section S)________________________________________________________________________________

b. Ware vou salf-employad?I EI ❑ IYes(Section S)I 20 NO (18)

18. Somepaopla haveproblems withamploymant becauseof I ~

cancer. Have you EVER. . . Ia. Facadon-th~Job problamefrom youremployer orsupewisor I ❑ Yes

directly relatad to your cancar?II 20No

_——___— —________________ ———__— ———_— ——————!––––––––– _––––––––– ––____-–___________– –––

I U%1❑ IYasb. Baen fbad or laid off from your job because of your cancer? ! 20No

-—-—————----—-———-——___—————_———————————— ~———-_———— ————————————————-—————-————-—I EI ❑ IYes

C. Faltyou couldnrt change jobs becausaof yourcancer? 20No-—-————----—-———---———--————-——————————-— L________––_____–––––__–––____________ ---

d, Faltyoucouldn’t takeanawjobbecausa ofachangainTJ?!LI I UYes

Insuranca ralated to your cencer? 20No-———__--.--_--____—_______—___———_———___— ~____–––__––– ——.———————————-————-————-—

I Ee. Refrainedfromapplying forenewjobbecauseyoudidn’twent I •l Yes

your madical racords made public? ; 20NoI

. . ...- . .

213

1.

1 L

Now, I’m going to ask your opinion about cartain haalth problams. IFor thasa quastions, if you ara not sura, faal fraa to tall ma that.

I ❑ Heart diaease

I 2CI AIDS

HAND CARD S 1. Read categories if telephone interview.30 Diabetes

/ 40 Cancer

Of thase four diseasas, which ONE do you think is the country’s70 Refused

[most sarious haalth problem? 9nDK

/Mark only one. I

IREFER TO CARDS 1. Read categories if telephone intarview.

[z. Tothebastof yourknowladge, which TWOofthasadiaaasaa \ 3DDiabetes

caused the moat daaths in the United Stataa in tha PAST YEAR? , 4 ❑ CancerI

Mark only two.7 •l Refused

I 9CIDKI

s. Have you evar haard of – I YES NO Refused DK @

a. the American Cancar Sociaty? la. lCl 20 70 9n.---.-..---.-----------------------------L-------------------------------------- -––

b. thaCancer information Sarvice? /b.lUL-L

20 70 90-----------------------------.--------.--L-------------------------------------- -–-

Ll!_C. tha National Cancar Instituta? Ic.in 20 70 90

-------------------------_--------_______L______________________________________ ---

d.tha l-800-4-Cancer Hotline?w

ld.lCl 20 70 90

c%. In your opinion, how much progress has baan made overall in I p

tha fight againat cancar in the past twanty years? Would youI ❑ A great deal

say a graat deal of progress, soma prograss, very little / 2 ❑ Some progress

progress, or no progress? 3ClVerylittleI4 ❑ No progress

I 5 ❑ Depends on type of cancer

I 7 ❑ Refused9nDK

I

HANDCARDS2.I p

5. Please tell me which of these You think causas more cancer in ~1❑ A, personal

the United States.2 ❑ B, environment

I3 ❑ Both

A. Personal behaviors, such as smoking or eating habita.I 7 ❑ Refused

OR 8 ❑ Neither/other (Specify) ~

B. Factora you have little control ovar, such as environmentalpollutionorfamily history.

I 9CIDK1

ITEMI ~

SIRefer to sex of SP

In Female (6)I

2 ❑ Male (8)

HANDCARDS3.I

I6. {If cancer of the (bed

fair pO~ror you=~~v ‘arly, whati52r

GOOD FAIR POOR REFUSED DK/NOTSURE

p!rsonschanceo survwing?WouIdyousaygood, I,

I Ea. braast Ia.l Cl 20 30 70 90

-------------------------------------------------------------------------------- –––

b.cewix?b

lb.lEl 20 30 70 90-----------------------------------------f______________________________________ ---

I.JzC. colon or rectum? Ic.in 20 30 70 90

_______________________________________________________________________ - —-------I

d. !ung? ~d.ltltz!i

20 30 70 90---------------------------------------------------------------------------------

(3. fivar? EIe.in 20 30 70 90

Notea

214

Section S - GENERAL KNOWLEDGE AND ATTITUDES - Continued

HAND CARD S4. Read each category if telephone interview.I 20

0 ❑ None of these -.I

7a. Which of these things do You think increases a woman’sI ❑ Increasing age

II H

-.

2 ❑ High fat diet22

chanca of gatting cancar of tha braast? 3 ❑ Low fiber diet23. .

(Plaase giva me tha numbara from tha card.)I 4 ❑ SmokingIII

I

u

Z*

5 ❑ Family history 25

Mark each that appliea. e ❑ Having multiple sexual partners 26

7 ❑ Refused 27

9nDK 2a_-----_____--_---_---___---__-----_----_-;----.---__---___-----_..-__-----____--T_r__

REFER TO CARD S4. Read each category if te/eDhone interview. ! o ❑ None of these

b. Which of thaaa things do you think increeses a women’schance of gatting cancer of tha carvix?

I I ❑ Increasing ageI 20 High fat diet, 3 ❑ Low fiber diet

(Plaasa giva ma tha numbars from tha card.)I 4 ❑ Smoking

50 Family historyIMark each that applies. I en Having multiple aexual partners

7 ❑ RefusedI 9nDK 4

2s303132333435362.7

____________________ ___________ ;__________ —_____ ———____—————————------ J

REFER TO CARD S4. Read each catagory if telephone interview.

———

I o ❑ None of these

III

I

I

I

)

38

I ❑ increasing age39

C. Which ofthasathings doyouthink incraasasawoman’s 2❑ High fat diet40

chanca of getting cancar of tha colon or ractum? 3 ❑ Low fiber diet 41

(Piaase giva ma tha numbars from the card.)4 II Smoking (Item S2) 42

5 ❑ Family hlatory 43

Mark aach that applies. 6 ❑ Having muitipte SeXUal pattnerS 447 ❑ Refused 45

I 9CIDK 4a

I

HAND CARD S3.I

8. {If cancar of the (body part) is datacted early, what is a GOOD FAIR POOR REFUSED DK/NOT SURE

person’s chance of surviving? Would you say good, 1

fair, poor or you ara not sura?}III Sa E

a. prostata ia.liJ 20 30 70—- —------- —--- ———---— ——-— —- ——-— —- —- —————- !––––-–––– -–––––––––– ––––––-––– ––-–––– -- –––-

b. coion or rectum?,~ Lxlb.lCl 20 30 70

_--.-------------------------------------&-------------------------------------- –––-s~ k

c. lung? IC.in 2n 30 7D_––––__L–––_– _________________________________ ____

CI. liver?,~ IU!L

ld.lCl 20 30 70

HANDCARDS4. Readeachcatagory iftelephoneinterview.I 51I o ❑ None of theseI I ❑ Increasing age

62

9a. Whichofthesethingsdoyouthink increasesa man’schance I 2D High fat diet5’3

of gatting cancar of tha prostate? I 3DLowfiber diet54

(Plaasa give ma the numbers from the card.)4ElSmoking 55

IsD Family history 56

Mark each that applies. I 60 Having multiple sexual partners 57

70 Refused 58I

9CIDK 69

-----------------------------------------F-------------------------------------- 80REFER TO CARD S4. Read each category if telephone interview.

———

on None of theseI al

I ❑ Increasing ageb. Which of these things doyouthink incraaaaa aman'schanca ~ ~DHighfattiet 62

of gatting cancer of the coion or rectum? I 3nLowfiberdiet63

(Plaase giva ma tha numbars from tha card.) 4ClSmoidng64

I5DF8mily history

65

Mark each that applies.I 60 Having multiple sexual partners 66

I 70 Refused 67

9nDK 68I1

ITEM Refer to Question I in Section R on page 17 toI

69in’’Yes’’markedinl (Section J)

S2 determine if SP reported having cancer. I 2❑ Ail other (70)

10. Howconcernad arayouaboutgatting cancarinthafutura? \ lo Very concernedE

WouldyousayyouaravaWconcarnad, somawhatconcarnad, Ior not at ail concerned?

zD Somewhat concerned30 Notat ail concernedI7 ❑ Refused

I 9nDK

Iotea

MHIS.2B {3491} Page 21

215

These next questions are about cigerette smoking. I ~I •l Yes (2)

1. Heva You smoked et least 100 cigarattqa in your entira life? I 20No

If asked: approximately 5 packsII }

(Section W)9UDK

z. How old were you whan you first started smoking cigarettes I6-7

fairly ragularly? I _ Age

;, 00 ❑ Never smoked regularlyI 99CIDK

3. Do you smoke cigarettes now?I 8

I ❑ Yes (4)I

2❑ No (5)I

4. Do you now amoka cigarettes avary day or some days? I 9I ❑ Every day (6)

I 2❑ Some days (7)

I

5. Do you now smoka cigarattas “not at all” or “some days”?I ~

I ❑ Not at all (Section V)I

2❑ Some days (7)I

6. On the average, how many cigarettes do you now smoke a day? /I

I

}

~

_ Cigarettes a day

(Number)(Section U)

[ 99n DK

T& On how many of the past 30 days did you smoke cigarettes?1I

@

~ 00 ❑ None (Section V)

I_ Days

I (Number)I

}

(7b)

I 99CIDK——— ——— ——— ——— ——- --- ——— ——— ——— —-— .— -

b. On tha avaraga, whan you smoked, about how many cigarettes ,lr_–––– ——— ——— —-- ——— ——— ——— —-- ——— ——

I

}

Edid you smoka a day?

— Ggarettes a day (Section u)(Number)

/\ 99 CIDK

Notea

age 22FORMHIS.2B[3.4.9

216

ITEM Refer to question 4, page 22, Section T to

UI determine if SP no w smokes every day.

II I ❑ Every day in 4 (4)I

2 ❑ All others (1)I

. .

I1. Hava you EVER smoked cigaraties every day for at I

I ❑ Yes (2)~

least 6 months? II 20NoI 190lx“2)I

Za. About how long has it been since you last smokedII I ❑ Days

~

cigarettes every day? I

II

{1

(3)2 ❑ Weeks

Number 3 ❑ Month If 1 year or 12 months ago, go to 2b;

4 ❑ Years otherwise go to 3.

I 999 ❑ DK (2b)____; _–––––––––– ————.——————————————.

b. Was it within the past year or a year or more ago? I--------=

1❑ Within the past yearII 20 1 year or more

9CIDKI

aa, On tha average, how many cigarattee did you smoke a day I ~

witan you last smokad every day? II Cigarettes a dayI Number

I 99n DK————--- ———————————--— —————————. _ ;____________––––––__________––—––-––––– –––6

b. Whatisthetotalnumberofyaarsyou smokedeveryday?Do / k

not include any time you stayed off cigarettes for at least 600❑ None or less than one year

Imonths or longer? I

YearsII }

(12)

99 CIDKII

a, Whatisthetotal number ofyearsyou havesmoked everyday? Ib

Donotinclude anytime youstayed offcigaretias foratleaat6 I00❑ None or less than one year

months or Iongar. IYears

199n DK

SIL ~n:e;~ EVER stopped smoking for one day or I ~

I 1 ❑ Yes (5b)I 20NoII

},D DK ’12)

———————----- ————————————————————————————+––––––––– –_––––––_– ––––––_––– –––___–––– –-–.

b. In your whole life how many times hava you stopped @

smoking for one day or longer, including the last tima?III TimesI Number

I 99 CIDKII

6a. During the PAST 12 MONTHS, have you stoppedI ~

smoking for one day or longer?I 1❑ Yes (6b)II 20NoI

}, ❑ DK ‘6”

—-----—-----————————— ------------------- +--------------------------------------- -––-b. How many times during the pact 12 months have you I *

stopped smoking for one day or longer? II Times

1 Number \(7)

I 99n DKI J

-----———————————————————————————————————+.–––– _———————____——————___—————————————-C. Howlongagowasthelasttimayou stoppedsmokingfor I UC

onadayorlonger? I I ❑ l—5yearsI 20 6—10yearsII 30 10yeara or moreI 9nDKI

7. Howlongdid youactually steyoffcigereties the Iasttimeyou jI 36-38

stopped smoking? I

I

I {

ID Days2 ❑ Weeks

Number 30 Month

4 ❑ Years

999 CIDKI

HAND CARD U1. I 3940

8. The iasttime you stopped smoking did you stop onI I ❑ I stopped on purpose 41

purposa, wereyou sick, or wae there soma other reason 2 ❑ I could not smoke becauee i was sickIyou couldn’t smoke?

42s ❑ I could not smoke for some other reason

I

Mark all that apply.9nDK

I

IM H13.2E {3.4.921 Page 2<

217

Section U – CURRENT SMOKER - Continued.-

ITEMU2

Refer to question 8.

II ❑ Box 2, Stopped for sickness ONLY (7 7)

I2 ❑ All othere (9)

IHAND CARD U2. Read each category if telephone intewiew. I ❑ Concern about my future health

I

I

I

E

.-

145

9. The last tima you stoppad smoking, what were the reasons ~2 ❑ Concern about my health at the time 463 ‘d Pressure from family and friends

you stoppad?47

4 El Cost of cigarettes 48

Mark each that applies. 5 ❑ Pregnancy 498 ❑ Some other reaaon (sp.!?Cify) 50

9CIDK

10. The LAST TIME you stoppad smoking, did you - IYes No DK

(1) Stop smoking along with friends or relatives who were also !trying to quit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :(1) In 20 90 m

(2) Use a prescription chewing gum called “Nicorette”? . . . ...(2) In 20 90 EE

(3) Follow instructions in a pamphlet or book? . . . . . . . . . . . . ~(3) 1❑ 20 90 E

(4) Use a stop-smoking clinic or program? . . . . . . . . . . . . . . ..~(4) In 20 90 E

(5) Stop all at once, or stop “cold turkey”? . . . . . . . . . . . . ...1(5) In 20 90 IIzE

[6) Use any other mathod?I

. . . . . . . . . . . . . . . . . . . . . . . . . . . I {6) 1❑ Specify ~ 20 90 EIII

I

11. When trying to stop smoking, have you EVER - I ~

a. gradually dacreasad tha number of cigarettesYes No DK

Iyou smokad in a day? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In 20 90

I----------------------------------------k--------------------------------------- ~

b. switched to lowar tsr or nicotine cigarettes? . . . . . . . . . . . . . . . . 1❑/ 20 90

1 z. Do you think that your smoking affects your haalth now?I &

1❑ YesI 20No

9nDKI

13. How likely do you think it is that you will have serious healthp

problams from smoking if you continua to smoke? Do you I ❑ Unlikely

think it is unlikely, somewhat Iikaly, or vary Iikaly? 2 ❑ Somewhat likely3 H Very likely

I Ask for each “Yes” in 14a.

14fL In the past yaar have you saen a – / b. During the past year, didI any. . . advise you to stop

smoking?t

I 1I

IYes No DK Yes No DK

I

(1) Medical doctor? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In 20 ‘n d 10 2D go EI

(2) Dentist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 20 9D l--=--l In 2D SD E

I

ITEM Refer to q“esfion 14b(l) and 14b(2) to deterrnineif ~

U31❑ Yes in 14b[l) or14b(2) (76)

medical doctor or dentist adviaed the 5P to stop smoking. I 2 ❑ All others (15)

E

I I

15. Has a medical doctor or dantiat EVER advisad you to stopI ~

smoking? ; 1❑ Yes20No

I 9DDK1

16a. Are you seriously considering stopping within theII ~

naxt 6 months? 1❑ Yes (76b)I 2nNo(f7)

I 90 DK (76b)1-———__-————____————____ ———______________

b. Are you planning to stop within the naxt 30 days?~___-–– ------ ———-— ————---- ——-- —---------1

~

I ❑ Yes

I 20No9nDKI

1 ~. About how oftan in the past 12 months has anyona asked Io❑ Never

I

\

Eyou not to smoke when you were smoking or were about tosmoke? Never, once or twica, several times, or many times? I 1•l Once or twice (Section W)

2 ❑ Several timesI 3❑ Many times )I

ige 24 FORM HIS.2B [3.44

218

1. Have you EVER smoked cigarattaa every day for at I I ❑ Yes (3) I_Z!?_least 6 months? 20NoI

I }, ❑ DK ‘2)

z. How long has it been since you completely stopped I ~I ‘d Days

●moklrsg cigarettaa? I

I

I {}

2 ❑ Weeks

(Number) SD Months ‘7)4 ‘d Yesrs

I 999 ❑ DK (7)I

Sa. About how long hes it bean since you Ieat smoked II

II {1

I ❑ Days~

clgerettee every day?(4)

2 ❑ Weeke(Number) 3 ❑ Months If 1 year or 12 months ago, go to 3b;

4 ‘d Yesrs otherwise go to 4.

I 999❑ DK (3b);–––––––. —————————————.————————.

b. Was it within tha paat yaar or a year or more ago? I ------ ’-EI ❑ Within the past year/. 2❑ 1year or moreI 9CIDKI

4, On tha averaga, how meny cigarattas did you smoke a day when ~~

you last smokad evary day? I Cigarettes per dayI (Number)I

99n DKI

5. What is tha totai numbar of years you smokad evary day?,I k

Do not include any tima you stayed off cigarattea for at00❑ None or less then one yearI

Iaast 6 months or longer. II

YesrsI

6. 1ssyour whole life, how many timaa hava you atopped&

Ismoking for one day or Iongar, including tha last Timestime? I (Number)

I 99 CIDK

HAND CARD U1. I 84I 85

7. Whan You stoppad smoking comislataly,did Youstop on purpose, ~I ❑ I stopped on purpose 86

wara you sick, or was there soma other raason you couldn’t 2 ❑ I could not smoke because I was sick

smoke?87

a ❑ Icould not smoke for some other reason

Mark each that applies.9nDK

ITEMVI

Refer to question 7.

II ❑ Box 2, Stopped for sickness ONLY (10)

I 2❑ All others (8)I I

HAND CARD U2. Read each category if telephone interview.I 69

I ❑ Concern about my future healthI

eo

8, When You stoppad smoking complataly, what wera tha 2❑ Concern 8bout my health 8t the time 91raasons you stoppad? 3 ❑ Pressure from family and friends 92

Merk each that applies.4 ❑ Cost of cigarettes 935 ❑ Pregnancy

Ie4

E ❑ some other reason (Specify) ~

I

IenDK 95

I

g. When You stoppad smoking cigarettes compiataiy, did you – ~ Yes No DKI I

(1) Stop smoking along with friands or ralatives who wera also Itrying to quit? \(l)lcl 20 90

3

96. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(2) Usa a prescription chewing gum callad “Nicorette”? . . . . . ;(2)10 20 90 e7

(3) Foliow instructions in a pamphlat or book? . . . . . . . . . . . . ! (3) I ❑ 20 90 98

I

(4) Use a stop-smoking clinic or program? . . ‘(4)10. . . . . . . . . . . . . . 20 90 m

(5) Stop all at onca, or stop “’cold turkey”’? . . . . . . . . . . . . . . . ~ (5) I ❑ 20

(6) Use any othar mathod?

90

I~

100

~ (6) I ❑ Specify ~ 20 90 101. . . . . . . . . . . . . . . . . . . . . . . . . . .

I

10. When trying to stop smoking, did you EVER –I

Yes No DK 102

a. gradualiy decrease tha numbar of cigarettaa youI

smokad in a day?I

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In 20 90

I J

______ ----- __-__ ._______________________ L _______________________________________ _lz=

b. switch to lower tar or nicotine cigarattas? . . . . . . . . . . . . . . . . . ~ I ❑ 20 90

ORMHIS-29[S4921 Page 25

219

IJLThese next questions are about other tobacco products. I

1a.Hava you aver smoked a pipa?I I ❑ Yes (lb)

20NoI}so DK ‘2’

-———————————_——_________________________ ,b. Havayousmokad apipaat least 50timesinyour entire hfe? I

~-–––– ——-____ -— — ________________________

uI lJYes(lc)20No

/ 1,DDK ‘2)

----------------------------------------t--------------------------------------- ----C. Doyousmokeapipanow? LL-

1 10Yes (Id)I 20No (2)

-———________________-——-———_____________d. On tha average, how many days par month do you

+___________ _--_____________________——__I IxE

smokeapipe?00❑ Less than one dsy a month

II

Days per monthi

30❑ Every dayI 99n DK

Za. Have you evar smoked cigars?1I

&lCIYes (2b)

I 20No

}eaDK ‘3)_---——-—————____________________________ ‘

b. Have you smoked at Iaast 50 cigars in your entira life?

~–––__ “——--——————————— --------—— ---------1 E

I ❑ Yes (2c)1I

I }

20No,DDK ‘3)

----------------------------------------t--------------------------------------- --–-C. Doyousmokecigarsnow? b

I In Yes (2d)20No(3)

————____________________________________ ______________________________ ____

d. On the averaga, how many days par month do you 00❑ Less than one day a month m

smoke cigars? 1I Days per month

I 30❑ Every day99CIDK1

sa. Haveyouavar usedsnuff,suchas SkoaI,Skoal ~

Bandits, orCopanhagan? / lDYes(3b)

20NoI

},DI)K ‘4)----------------------------------------i-------:_______________________________ ----

b. Have you used snuff at least 20 times in your entire life? lJ!!-1 lCl Yes(3c)

20NoI 1,DDK ‘4)——————__________________________________

C. Howoldwara youwhan you first usadsnuff?+–- ———————————————————————____________

I E

I Age

99nDK---—————— _______________________________

d. Doyouusesnuff now?;–––_ ----————————————--—————— ___________I =I ❑ Yes

; 20No----------------------------------------&--------------------------------------- ----

@. Altogether,abouthowlong [haveyouusedkfidyouusalsnuff? ~ *000❑ Less than one monthI

I

{

I ❑ Months2❑ Years

f.

I

I 999 CIDK——______________________________________ +__–––– ———————————----— _________________

Ontheaverage,howmanydays permonth[dokiid]youuseit? I w00❑ Less than one day a month1

I Days per monthI

30 ❑ Evary day/ 99n DK

----------------------------------------t--------------------------------------- ---g. Onthadaysthat youuse(d)snuff, howmanytimes -@z!

[dolcfidlyouusait?I 00❑ Less than one time per day

ITime(a)perday

[9snDK

----------____________________________--;--------------------------------------- ----h.[Do/Did]youuse snuffbysniffingit orbyplacingit UL-

in your mouth? I ❑ ISniffing

2 ❑ Mouth

Mark only one. 3 ❑ Both

Page 26 FORM H13.2B (3+9

220

Section W – OTHER TOBACCO USE – Continued1

3i. Hava you EVER been advised to stop using snuff by a -I Yes No DK

I

(1)Madical doctor? . . . . . . . . . . . . I. . . . . . . . . . . . . . . . . . . . In 2U 90

I E28

(2) Dantist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In 20 9029

I,

Aa. Hava you ever used chewing tobacco, such es Redman, I@

Lavi Garrett, or Beechnut?I ❑ Yes (4b)

I 20No

I 1QD Dl( ‘5).—————————________ ——_———————___—————————

b. Hava you usad chewing tobacco at least 20 times in your

~–––––––– ———————————I

I II Yes (4c)antira Iifa? I 20No

I 1soDK ‘5’

.————————————————————-LE

----------------------------------------L--------------------------------------- –––-

C. How old were you when you first used chewing tobacco? =I Age

I 99n DK-------------------------------------------------------------------------

d. Do you use chewing tobacco now?I

-------mI ❑ Yes

I20No

—————-------———------————————---———————— L–––––––––_________________________––___ --–.

f). Altogether, about how long [have you used/ did you use] &I

chawingtobacco?000❑ Less than one month

I

I{

I ❑ Months2❑ Years

I999n DK

-_______________________________________L_______________________________________ –––.f. On tha average, how many days per month [do/did] YOUuse it? j Ix@

00❑ Less than one day a monthIII Days per month

I 30❑ Every day990DKI

----------------------------------------k--------------------------------------- -——-

$Onthadaysthatyouuse(d) chewingtobacco, howmanytimes ~ I!Wll

[doldidl You use it?00❑ Less than one time per day

III Time(s) per day

99CIDK--_-------------------------------------;____________________________________________

h. HaveyouEVER beenedvisedtostop using Ichewingtobecco bya-

Yes No DK

,(1) Madical doctor? I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 20 90 E42

(2) Dantist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I ID 20 90 43

& Nowlamgoingtoreada listofstatamentsaboutcigaretiesmoMng. Afterlreadeachone,pleasetall mewhetheryouagree,disagrae, or have no opinion.

I

I AGREE/YES DISAGREE/NO NO OPINION/DK&i.So many things cause cencer that it doesn’t

really mattar if you smoke la. ID 20 90 F—————-------————————————————————————————

b. Smoking by a pregnant woman may harm tha baby

;––––– ——————————————————————--——————————————-I b. ID 20 90 E

------------------------------------------------------------------------------------ -C. Thesmokefrom otherpeople’s cigarettesisharmful toyou I c. In 20 9CI E

I------------------------------------------------------------------------------------ -

d. Most daaths from LUNG CANCER are caused byclgaratte smoking id, In 20 90 E-------------------------------------------------------------------------------------

I0. Smoking should not be allowad in indoor public placas I e. 10 20 9CI E

__--------__---________---------_-------L____________________________________________

f. Evan if a parson has smoked for more than 20 years, there is a ~haakh banafit to quitting If. 10 20 90 E

Jotes

IM HIS.2B 13+921 Page 2

221

Section W – OTHER TOBACCO USE — Continued

6a. Do You think smoking is a habit, an addiction, neither, or both? ~ I ❑ HabitI 2 ❑ Addiction

3 ❑ NeitherI4 ❑ Both

I enDKI----------------------------------------t--------------------------------------- –––-

b. In generel, would You say that the smoke from other people’s I Lcigarettesisnotatallannoying toyou,somewhatannoyingto I o ❑ Not annoying at all

you, or very annoying to you7 1❑ Somewhat annoyingI

2 •l Very annoyingI 9CIDK

I

ITEM Refer to question 3, page 22, Section T, to

52

I I ❑ Smokes cigarettes now (7)

WIdetermine if SP smokes cigarettes no w. I a ❑ All other (8)

HAND CARD W. Read categories if telephone interview.~

I ❑ Light up a cigarette and smoke if you wish

7. Whenyouara inside apublicplace thathasnorules about20 Look around toseeif others aresmoking andthen light up

Ismoking, what ara you most likely to do?

s ❑ Ask if others would mindI

4 ❑ Just not smoke

Mark only one.I a ❑ Do something else (Specify) ~

1I

I 9DDK

8. Whenyou areinsidea public placathathas norulesabout I &

smoking and someone else lights up a cigarette, what ere you ~1❑ Ask person not to smoke

most likely to do — ask the person not to smoke, move eway, 2 ❑ Move awayI

do nothing, or something else? 3 ❑ Do nothingI a ❑ Do something else (Specify) ~

I

I9nDK

9. Does ANYONE smoke cigarettes, cigars, or pipes I ~

ANYWHERE INSIDE this home?1❑ Yes (70)

I 20NoI

}(Section X)9nDK

I

10. On an average waak day, how many people smoka anywhere ~~

msida this home? II Number of smokers

I9nDKI

11. On the average, about how many days par week is there I ~

smoking ANYWHERE INSIDE this homa? I o ❑ Less than one day per week/RarelyI 7 ❑ Every dayI

II Days per weekI (Number)I

9DDKI

Jotes

(a.. ,. 4.Page 28

FORMHl&.. ,.,---

222

ITEMI

xlRefer to SP’S “Wa/Wb” boxes in Cl on HIS-1.

I ❑ Wa or Wb box marked (kern X2)I

8 ❑ Other (Section Y)II,

ITEMI 59

Refar to SP’S 6g, page 44 or 45 on HIS- 1.I ❑ Entry of P, F, S, orL (1)

x2II 8 Q Other (SeCtiOn y)

1

These next questions are about smoking in the workplace. I ~1 I ❑ Yes (2)

1, Earlier [you told mrr/1was told] that you wara amployad during ~ 2 ❑ No (Section Y)

tha past two waaka. Is that corract? I 9❑ DK (2)

Za. Altogether, does your amployar have 50 or mora amployaes? ~ I ❑ Yes (2b) m

I

I }; : &; (2C)

——. .._ ———--—___________ . .. ——————————————

b. Doss your amployar hava 50 or more employeas at tha

+––––– ————————___— —______ ———___— ————————

I mbuilding or location whare you work?

I ❑ Yes (3)

I1 1::~;(2C)

----------------------------------------+---------------------------------------C. Does your employer hava 5 or more amployaes at the building f FI •l Yes

or location whara you work? I 20No9DDKI

I

3.

HAND CARD X 1. Read ALL categories if telephone interview.I

IWhich of thase best describes the area in which You workmost of tha timer? I

Mark only one.I

I

I

I

1I

I

I

I

01 ❑ Private enclosed office with doorIS&?!!

02❑ Enclosed office with door shared with one or more other persons03UCubicle04 ❑ Open area05 ❑ Classroom06 ❑ Hospital (not an office)oTalnahomeOfinlnonebuikiing, butnoregular work areaog❑ Mainly work outdoors

1

(5)

I o ❑ Travel to clifferent buildings or sitesII ❑ Ina motor vehicle (7)

98 ❑ Other (SpeCi@) ~

99DDK

aa. During the past 2 weeks, has anyone smokad in yourI

I ❑ Yes (4b)~

IMMEDIATE work area? II 20No

a❑ Did not work in past 2 weeksI J

(5)

I 9 ❑ DK (4b)

———_— ————————————————————————___— ———____b. During tha past 2 waaks, have you avar been bothered by

;–––– ———————————————————————————————————P

cigarette smoke in your immediata work area? / I ❑ Yes20No

I 9nDK

Si3. Does your employer hava an official policy that restrictsI ~

●rooking in any way? I ❑ Yes (5b)I20No

I 1~DDK(/tern X3)

I

---------_____________________--________L--------------------------------------- ____HAND CARD X2. Read ALL categories if telephone intarview. k

I I ❑ Notallowed in ANYindoor orcommon public areas

b. Which of thesa baat describes your amployar’a smoking I 2 ❑ Allowed in SOME public areas, including designated smoking areaspolicy for indoor public or common areas, such as lobbies,rest rooms, and lunch rooms?

3 ❑ Allowed in ALL indoor or common public areasI

Mark only one.4 ❑ Not applicable, no policy for these areas

I 9nDKI

-— —--- __-___ -— —____________ ————————____—HAND CARD X3. Raad ALL categories if telephone interview.

+–––––– —————————————————————————————————I E

1 ❑ Notallowed in ANY work areas(6)C, Which ofthaae bestdescribes youramployer’s emoking I

policy for work araas?2❑ Allowed in SOME work areaa (5d)

I 3 ❑ Allowed in ALL work areas (Item X3)

Mark only one. I 40 Nonapplicable, nopolicy fortheae areas9nDKI 1(5d)

—————————_______________________________d. lssmoking allowed in YOURimmetfiate workarea?

+––––––

1❑ IYes(/tern X3) m-

20No

}~nDK ‘6)

IMH18.2Ei[3.4-92) Page 2!

223

Section X – WORKPLACE TOBACCO SMOKE - Continued1

6a. Are there ever customers or clients in your work area, that is, I I ❑ Yes (6b)~

people who do not work for your employer? 20NoI

}

(Item X3)9nDK

———————--- —------------- —-- —------- —-— ——b. Are these people ellowed to smoke in your work area?

;----- _—— ———______ _________________

I I ❑ Yes m

20NoI9EIDK

I

7. Doas your amployar offar a stop smoking program or anyII I ❑ Yes (Item X3)

~

othar halp to amployeas who want to quit smoking? 20NoI 1(Section Y)9CIDK

/

ITEM Refer to question 3, pege 22, Section T,I I ❑ “Yes,” current smoker (8)

x3 to determine if SP IS e current smoker. I 2❑ “No,” former smoker (g)8 ❑ Other (Section Y)I

8a. Do you evar smoke during the tima you are at work?1 ~/ I ❑ Yes (8b)

20NoI

}sDI)K ‘8C)----------------------------------------L--------------------------------------- –––-HAND CARD X4. I I ❑ In my work area

E

77

b. Where?2❑ In a public area, such as a restroom, lunchroom, lobby,

7a

or other smoking area 79

Mark all that apply. 3❑ Outside the buildingao

4❑ Not applicable — 1work outside or at different sitesal

I 9nDK---------- ————————------ —————————————————————————————___________ ——————————-- ———— ——.

C. Do you fael that you smoka fewer cigarattas par day I •l Yes mbacause of your employar’s smoking policy? 20No

1ASK OR VERIFY: I I •l Yes

~

9. Hava you joinad any quit smoking programs at work in 20Nothe past yaar? 3❑ Quit more than 1 year ago

9CIDKI

Notes

ge 30 FORM HIS-2B (34-W

CARDB

01. Puerto Ricen

02. Cuben

03. Cuban Amarican

04. MexicanlMexicano

05. Mexican American

06. Chiceno

07. Hispano

08. Other Latin American

09. Othar Spanieh or Hispanic

10. American

11. Anglo American

88. Other (Specify)

. s,,1.,,,“,,,,, Pm,2

CARD F2

1. Eating more fiber

2. Eating Iaea sugar

3. Avoiding fooda with additives

4. Eating less fat

5. Eating less salt

6. Eating more fruit and vegetables

7. Taking vitamina

8. None of these changes would be helpful

.S.m,!!,,,,,!.,.”,, P,W,4

CARD H

A. What people eat or drink has little affecton whethar they will devalop majordiseasas.

OR

B. By eating the right kinds of foods,paople can reduce their chances ofdaveloping major diseases.

.

r>,.– –-–,

13

~[

$

PW,3-W, ,,”,, ,t.m$t

CARD GI

?2

01

,-------

,

i~

‘i

~j

,-

,

,

W8$?i ,!nz, ,,.1.,!, P,* ,5,

1. [ had no symptoms and it wasdetected during a routine chackup

2. 1noticed something was wrongand went to a doctor

3. I noticad somathing waswrong but did not talk to adoctor about it until my ragrdarphysical exam

8. It was detected in some otherway (Specify)

260

CARD G2

1. Internist, general practitioner

2. Cancer specialist (oncologist)

3. Generel Surgaon

4. Cancer Surgeon

5. Reconstructive Surgeon

6. Radiologist

8. Othar specialist (Specify)

,m..,!,!s!,4,!.!,,!, ,.,, ,,

CARD G4

1. I didn’t know it was evailabla

2. I didn’t want it

3. I didn’t think I naaded it

8. Some othar reason (Spec;fy)

,“,w,,,,,,,,!.,,,,, ,.O.,8

CARD G3

1. Surgary to remova the tumor

2. Radiation

3. Chemotherapy

4. Special diets

5. Salf haaling techniques,including imaging

8. Other (Specify)

.,

03,-------

!l,.,.

ii;S

-ml!!la.!loz.$,, P.,.t7

CARD G5

1. Ganaral information about cancer

2. Information about your specific typeof cancer

3. Cancar treatmant options

4. Coping with the physical side affectsof cancar treatment

5. Coping with the emotional effects ofcancer

8. Other (Specify)

.4

.s~.-.--

Ks;s;g

g-!4, ,,,,,,,!.,,,0 P.,.,, I*

261

CARD G6

1. American Cancer Sociaty

2. National Cancar Institute

3. The Cancer Information Sarvice:1 -800-4-CANCER

8. Othar

..-! .,,,,4!,>,,,,! ,+ 20

CARD JI

1. Employar

2. Union

3. Co-workers

4. Previoustraining/educetion

5. By resolingabout it

8. Other (Specify)

-la! !Wu,!!.,..!! m. 22

CARD G7

1. Yes - Cost to me increesed

2. Yes -My insurancewascencellador not renewed

8. Yes - Otherchange (Specify)

0. No - Did not chenge

ae

a7

,- . . . . .

~,n, ,,”.,,. -.!! ,.s.2, ~~

CARD J2

1. 8ecauseit doesn’twork properly

2. Beceuseit interfereswithjobperformance

3. Beceuseit isuncomfortable

4. BecauseI don’t know how to useit

5. Becauseit isnot needed

8. 8ome otherreason (Specify)

>,w-! ,,”. ,,.,,,!, ,’s. 2,.*

262

CARD KI

Television programs

Radio programs

Magazina articlas

Nawapaper articlas

Straat signs/billtroards

Stora displays/store distributedbrochuraa

Bus/straat car/subway displays

Haalth Dapartmant brochuras

Workplaca distributed brochuras

School rfistributad brochuras

Church distributed brochuras

Community organization

Friand/acquaintance

AIDS hotlina

Othar sourca (Specify)

Recaivad no AIDS information inthe past month

.,,,“,,,,,,,,,0,,,,, m, 2,

CARD K3

a. AZT can delay or slow down thasymptoms of AIDS virus infaction

b. AZT curas peopla with AIDS

c. AZT has no known sida affacta

d. AZT ia appropriate for a person with thaAIDS virus infaction ONLY at cartaintimes during the illness

e. There ara other drugs availabla to treatAIDS ralated illnassea

“’M,,,,,,,,!.,,,,, Paw28

.,CARD K2 ——

,_____

1. Very likely

2. Somewhat likely

3, Somawhat unlikely,

4. Very unlikely

5. Dafinitaly not possibla

;3p

I13

*W,,!”.,!.2..!! w. 26

CARD K4

a. You have hemophilia or another .s

blood clotting disorder and havareceived clotting factor

II.

concentrations einca 1977.-------

b. You ara a man who has had sex with ]another man at some time since1977, evan one time.

c. You have taken illagal druga by neadla+at any time sinca 1977.

d. You have had sax for money or drugsat any tima since 1977.

e. Sihce 1977, you ara or heve been ,-$

the aax partner of eny person who ,:could anawer “Yea” to any of the Xitems above on this cerd. j?

,$,

t

,

t

*W!,,”,!,!.,.,!, P,Q.27 ,

2ez

CARD 01

1. I havetwo or moreusueldoctorsorplacasdepanding on what iswrong

2. I havan’t naedtrda doctor/Don’t havaa doctor

3. My previousdoctor is no longeravailabla

4. No careisavailabla/Careistoo far away

5. ~~~’t beenablato find tha right

6. I don’t have insuranca/Can’t afford it

8, Othar reeson

**! ,,S!>,>l. -,!) M. 10

CARD Q2

1. Spanding too much time in the aun

2. Exceaeive drinking of elcoholic beveregea

3. Excessive coffee drinking

4. Smoking cigarettes, tigers, or * pipe

5. Uae of chewing tobacco or enuff

8. Something else (Specify)

9. Don’t know

mm,,,”,,,!.=,!) VW30

—

CARD QI

1. Beceuse of a specific oral problem

2. Follow-up to a previous oral problam

O*3. Part of a routine physical exam

al

~-- _____

4. Part of e routine dantal exam

8. Other (Specify)

j

~

13

,.sm,,,”,!,,.-. !, ,.W2s

CARD Q3

1. Because of a specific ekin problam

2. Follow-up to a previous skin problam

3. Part of a routine physical exam/As ascreening exam

a,

8. Othar (Specify) .3,.. ––---––

;2,5II:g~,!

,

-M!!!”,,,!.*,,, P* 31

264

CARD (I4

1. Get e severe sunburn withblisters

2. A severe sunburn for a fewdeys with peeling

3. Mildly burnad with comatanning

4. Turn darker without sunburn

5. W&g would happen in an

8, Other (Specify)

,,..,,,,,,,,!.,”,,, ,,,,32

CARD Q6

1. Because of a epecificgynecological problam

2. Follow-up to a praviousgynecological problem

3. Part of a routina physicel (orpregnancy) exam

8. Other (Specify)

“cm,,!,,,,,!.,.,,, ,.,03.

CARD Q5

1. Vary dark and daep[y tanned

2. Moderately tannad

3. Mildly tanned

4. Only frackled or no suntanat all

5. Rapeated sunburns m

as

8. Other (Specify)_...----

2:5:38~$

“MO!,,”>)>1.,..1! Ro..

CARD Q7

1. Becausa of a spacificbreaet problam

2. Follow-up to a previousbraast problam

3. 8aseihre mammogram

4. Part of a routina physicalaxam/As a scraening test

8. Othar (Specify)

as

a7

~-------

ii

ij

,-

mtd ,>SWcm.2..!, m. m(

I

265

CARD Q8

1. Because of a specificbreast problem

2. Follow-up to a previousbreast problem

3. Part of a routine physical (orpragntmcy) exam

8. Othar (Specify)

“sWii”mr!.>,m ,* .?4

CARD QI O

1. Because of a spacifichaalth problam

2. Follow-up to a pravioushaalth problam

3. Part of a routina physicalaxam/As a scraaning tast

8. Othar (Specify)

WHO!,!”1,,,.,,,1! ,.C.3,

CARD Q9

1. Bacause of a specificchest problem

2. Follow-up to a praviouschest problem

3. Part of a routine physicalexamlAs a scraening test

4. For employment raasons

5. 8acausa of hospitalization

8. Othar (Specify)

m

as,--------

:.K

~~

ia

,4s.37*IO, mm !!.*.,!

CARD S1

1. Heart disease

2. AIDS

3. Diabatae

4. Cancer

0,0

●1

~... -.. .

,I

:ZIS

X

g

,-

-IO! won !m.m,!, P.w as

,

266

CARD S2

A. Personal behaviors, such assmoking or eating habits.

OR

B. Factors you hava little controlover, such as anvironmantalpollution or family history.

.*M,,,,,,,,!.,.,,, w.40

CARD S4

1. Increasing aga

2. High fat diet

3. Low fibar diat

4. Smoking

5. Family history

6. Having multipla aaxualpartrrars

0. Nona of theaa

WW!,!”,,,!.,..i! P,,.42

CARD S3

1. Good

2. Fair

3. Poor

4. Don’t knowlNot sura

S*

s.

~...-.-_

-,,,”. ,!.-.>!m.,

CARD U1

1.1 stoppad on purpose

2. I could not smokebacause i was sick

S. I could not smoke forsoma other raasaon

s.

267

CARD U2

1. Concern about my futura health

2. Concern about my health at thetime

3. Pressure from family and friands

4. Cost of cigarettes

5. Pragnancy

8. Some other reason (Specify)

.$ IO,,,,,:, !,C.,,,,, Po$l 44

CARD Xl

01. Private enclosad office with door

02. Enclosed office with door sharedwith ona or more other persone

03. Cubicla

04. Open area

05. Classroom

06. Hospitel (not an offica)

07. In a home

08. In ona building, but no regularwork area

09. Mainly work outdoora

10. Traval to different buildings orsitas

11. In a motor vefricla

98. Other (Specify)

.,!0, ,,,,,, !!.,,,,, P,,. 46

CARD W

1. Light up a cigaratte andsmoke if you wish

2. Look around to sae if othersare smoking and than light up

3. Ask if othars would mind

4. Just not smoka

8. Something else (Specify)

“2

w~=. . . .

PW45 $H514, ,,,,,,,!*,*.!!

,1,~

CARD X2

1. Not allowad in ANY indoor orcommon public areas

2. Allowad in SOME publicaraas, including designatedsmoking araas

3. Allowed in ALL indoor orcommon public araas

4. Not applicable, no policy for ;3these areas IR

R~{

,

,

xl

*M, ,!”1,,!.,M!, %.,7

X*

268

CARD X3

1. Not allowad in ANY work areas

2. Allowed in SOME work areas

3. Allowed in ALL work areas

4. Not applicable, no policy forthasa areas

.,,,,,,,,,,,,.,,,,, W,48

MEDICARE

-m!,,,,1,,!.”.,!, P,,.50

Health @ ? Insurance

0 ., . ...0.... . . .“.., ., .,H,,,C*.”.loh. Q. wbl ‘c<LA!. . . ...” *EX

0<1<1-,1,34,1”0-), b,,, ,,E

,. .“,,,.,. TO .,,,.,,”. 0.,.

H“, p,,.1 ,.3”,,.., 7.,.M

Mod’, ,1 ,n, uranc. ,-1+0

.!..

.,”, o&L Q.@4&i

x,

CARD X4 x.. . . . . . .

1. In my work area

2. In a public area such as arastroom, lunchroom, lobby, orothar smoking area

3. Outside tha building

4. Not epplicabla -1 workoutside or at diffarant sitee

,-‘~;$j13

S-! ,!l$.!!.>.$!l ,.,..,

STATE NAMES FOR MEDICAID

MEDI – CAL

California

MEDI – KANM-—

Kansas pmum

~.......

HEALTH CARE COST CONTAINMENTSYSTEM (HCCCS)

Arizona

MEDICAL ASSISTANCE

All other States

~~~~

1$:3

t

,

I,

..m!,!$$,,rm.!.s!! ,.,0 ,!

●U.S.wm PrhtlngOftiw 1993- 301.019/80018269