Attachment J.1 Screener_NSFG_2020.docx

Attachment J. 1

NSFG SCREENER QUESTIONNAIRE

Proposed for Year 1 of Next NSFG Contract

Notes:

- The final questions included on the screener will depend on the final sample design with respect to oversampling by race and Hispanic origin (see C.4.4. Sample Design) and other aspects of sample design.

- The italicized language below will be updated and provided by NCHS NSFG staff.

THIS ITALICIZED TEXT MUST APPEAR ON THE SCREEN, IN COMPLIANCE WITH OMB GUIDELINES.

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; ATTN: PRA (OMB No. 0920-0314) Assurance of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347). By law, every employee as well as every agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

CONFIRMA

Interviewer checkpoint:

This is sample ID [Sample ID preload]. You are at:

[Address number preload], [Street name preload] [Apartment number preload, if app] [City name preload], [State where Interview is being conducted preload], [Zip code preload]

If you have entered the wrong sample line, please suspend this case by pressing [Alt+X]

Please re-enter the numeric portion of the address to continue

INFORMANT

Interviewer checkpoint:

Who are you talking to now?

1. Household Member

5. Proxy Reporter DK Don’t Know RF Refused

HHPerson[1].NAME I would like the name (or initials) of the people who usually live here.

Please include any unmarried children away from home living in a dormitory, fraternity or sorority.

Remember that this interview is completely voluntary and confidential.

If there is any question that you do not wish to answer, please let me know and we can move on to the next question.

Let's start with you, what is your name?

ENTER Name

HHPerson[1].SEX If necessary, ask: (Is [Name of nth person in household] male or female?)

1. Male

2. Female

HHPerson[1].AGE_X How old are you?

If necessary, ask: (How old were you on your last birthday?)

Age probes: Is the household member

14 or under? If yes, enter [14]. If no, continue;

15-17? If yes, enter [16]. If no, continue;

18-19? If yes, enter [18]. If no, continue;

20-49? If yes, enter [32]. If no, continue;

50 or older? If yes, enter [50].

ENTER [0] if less than 1 year

HHPerson[1].HISP

[F1]--Help

Do you consider yourself to be Hispanic or Latino?

1. Yes

5. No

HHPerson[1].RACE [Only if HHPerson[1].HISP = 5] [F1]--Help

What race do you consider yourself to be?

READ list:

1. American Indian or Alaska Native

2. Asian

3. Native Hawaiian or other Pacific Islander

4. Black or African-American

5. White

HHPerson[1].DORMRES [Only if HHPerson[1].AGE_X = 17-22] Do you live in a college or university dormitory, fraternity, or sorority during the school year?

1. Yes

5. No

EndRoster Before we finish, are there any other members of this household who are currently living in a college or university dormitory, fraternity, or sorority?

If Informant says there are no others, enter [1] to continue

Otherwise, if Informant has more people to describe, press the [Up-arrow] to return to the roster screen and enter additional household information

VERROSTER

To ensure I have entered all the information correctly, I would like to review the list of household members with you. Please let me know if any of this information is incorrect.

Currently I have the following information about this household:

You're [Name of the nth person in the household] and you’re [Age of the nth person in the household] years old and consider yourself to be [Hispanic or Latino/American Indian or Alaska Native/Asian/Native Hawaiian or Other Pacific Islander/Black or African-American/White/F/M]

If there is incorrect information, step back to the roster screen, by pressing the [Up] arrow, and enter additional household information

ASK if necessary: (What should be changed?)

ENTER [1] once all information has been verified to be correct

EXITSCR1 [If informant is selected] You have been selected for the study. May we begin the interview now?

(My home office may be calling you to verify that I was at the correct address and spoke with a household member.

For these reasons, may I have your telephone number?)

1. Yes

5. No

EXITSCR2 [If another member of household is selected] [Name of the nth person in the household] has been selected to provide additional information for this study. May I speak to [Name of the nth person in the household] now?

(My home office may be calling you to verify that I was at the correct address and spoke with a household member.

For these reasons, may I have your telephone number?)

1. Yes

5. No

LANG

Interviewer checkpoint:

Please enter the likely interview language.

1. English

2. Spanish

3. Unknown

4. Other

SCComplete Interviewer checkpoint:

You have reached the end of the NSFG Screener

ENTER [1] to exit interview

EXITAGE [Would occur after VERROSTER only if no household member is between the ages of 15 and 49]

Thank you. In this study, we are only interviewing men and women between the ages of 15 and 49. So, these are all the questions I have for you now. On behalf of [contractor name], the US Public Health Service, and the US Department of Health and Human Services, I thank you for taking the time to help with this survey.

(My home office may be calling you to verify that I was at the correct address and spoke with a household member. For these reasons, may I have your telephone number?)

ENTER [1] to exit interview