ASTHMA CHILD Questionnaire 2018.docx

BRFSS/ASTHMA SURVEY

CHILD QUESTIONNAIRE - 2018

CATI SPECIFICATIONS

Section Subject Page

Section 1 Introduction……

Section 2 Informed Consent

Section 3 Recent History.............….................................……. 04

Section 4 History of Asthma (Symptoms & Episodes)............… 06

Section 5 Health Care Utilization

Section 6 Knowledge of Asthma/Management Plan

Section 7 Modifications to Environment

Section 8 Medications........................... ........................................… 20

Section 9 Cost of Care...................................................................… 31

Section 10 School Related Asthma ………………………………… 33

Section 11 Complimentary and Alternative Therapy …………… 38

Section 12 Additional Child Demographics …………………...…… 40

Appendix C: Coding Notes and Pronunciation Guide. ….……

[CATI: IF INTERVIEW BREAKS OFF AT ANY POINT LEAVE REMAINING FIELDS BLANK. DO NOT FILL WITH ANY VALUE.]

MISDIAGNOSIS NOTE: If, during the survey, the interviewer discovers that the respondent never really had asthma because it was a misdiagnosis, then assign disposition code “4471 Respondent was misdiagnosed; never had asthma” as a final code and terminate the interview.

{Read the statement below ONLY if you’re conducting the survey via a cellphone} Is this a safe time to talk with you now or are you driving? (STATES HAVE THE OPTION OF INCLUDING THIS TEXT HERE OR AT THE END OF THE SURVEY INTRO BELOW.)

Section 1. Introduction For states identifying the Most Knowledgeable Person/Parent (MKP) at the BRFSS interview use language in Appendix A.

For states identifying the Most Knowledgeable Person/Parent (MKP) at the Asthma Call-Back use language in Appendix B.

Section 2. Informed Consent For states identifying the Most Knowledgeable Person/Parent (MKP) at the BRFSS interview use language in Appendix A.

For states identifying the Most Knowledgeable Person/Parent (MKP) at the Asthma Call-Back use language in Appendix B.

Section 3. Recent History

AGEDX (3.1) How old was {child’s name} when a doctor or other health professional first said {he/she} had asthma

[INTERVIEWER: ENTER 888 IF LESS THAN ONE YEARS OLD]

__ __ __(ENTER AGE IN YEARS)

[RANGE CHECK: IS 001-018, 777, 888, 999]

(777) DON’T KNOW

(888) Under 1 year old

(999) REFUSED

[CATI CHECK: IF RESPONSE = 77, 99, 88 VERIFY THAT 777, 888, 999 WERE NOT THE INTENT]

INCIDNT (3.2) How long ago was that? Was it...

READ CATEGORIES

(1) Within the past 12 months

(2) 1-5 years ago

(3) more than 5 years ago

(7) DON’T KNOW

(9) REFUSED

LAST_MD (3.3) How long has it been since you last talked to a doctor or other health professional about {child’s name} asthma? This could have been in a doctor’s office, the hospital, an emergency room or urgent care center.

[INTERVIEWER: READ RESPONSE OPTIONS IF NECESSARY]

(88) NEVER

(04) WITHIN THE PAST YEAR

(05) 1 YEAR TO LESS THAN 3 YEARS AGO

(06) 3 YEARS TO 5 YEARS AGO

(07) MORE THAN 5 YEARS AGO

(77) DON’T KNOW

(99) REFUSED

LAST_MED (3.4) How long has it been since {he/she} last took asthma medication?

(88) NEVER

(01) LESS THAN ONE DAY AGO

(02) 1-6 DAYS AGO

(03) 1 WEEK TO LESS THAN 3 MONTHS AGO

(04) 3 MONTHS TO LESS THAN 1 YEAR AGO

(05) 1 YEAR TO LESS THAN 3 YEARS AGO

(06) 3 YEARS TO 5 YEARS AGO

(07) MORE THAN 5 YEARS AGO

(77) DON’T KNOW

(99) REFUSED

INTRODUCTION FOR LASTSYMP:

READ: Symptoms of asthma include coughing, wheezing, shortness of breath, chest tightness or phlegm production when {child’s name} did not have a cold or respiratory infection.

LASTSYMP (3.5) How long has it been since {he/she} last had any symptoms of asthma?

(88) NEVER

(01) LESS THAN ONE DAY AGO

(02) 1-6 DAYS AGO

(03) 1 WEEK TO LESS THAN 3 MONTHS AGO

(04) 3 MONTHS TO LESS THAN 1 YEAR AGO

(05) 1 YEAR TO LESS THAN 3 YEARS AGO

(06) 3 YEARS TO 5 YEARS AGO

(07) MORE THAN 5 YEARS AGO

Section 4. History of Asthma (Symptoms & Episodes in past year) IF LAST SYMPTOMS (LASTSYMP 3.5) WERE WITHIN THE PAST 3 MONTHS (1, 2 OR 3) CONTINUE. IF LAST SYMPTOMS (LASTSYMP 3.5) WERE 3 MONTHS TO 1 YEAR AGO (4), SKIP TO EPISODE INTRODUCTION (EPIS_INT - BETWEEN 4.4 AND 4.5); IF LAST SYMPTOMS (LASTSYMP 3.5) WERE 1-5+ YEARS AGO (05, 06 OR 07), SKIP TO SECTION 5; IF NEVER HAD SYMPTOMS (88), SKIP TO SECTION 5, IF DK/REF (77, 99) CONTINUE.

IF LASTSYMP = 1, 2, 3 then continue IF LASTSYMP = 4 SKIP TO EPIS_INT (between 4.4 and 4.5) IF LASTSYMP = 88, 5, 6, 7 SKIP TO INS1 (Section 5) IF LASTSYMP = 77, 99 then continue

SYMP_30D (4.1) During the past 30 days, on how many days did {child’s name} have any symptoms of asthma?

__ __DAYS

[RANGE CHECK: (01-30, 77, 88, 99)]

CLARIFICATION: [1-29, 77, 99] [SKIP TO 4.3 ASLEEP30]

(88) NO SYMPTOMS IN THE PAST 30 DAYS [SKIP TO EPIS_INT]

(30) EVERY DAY [CONTINUE]

(77) DON’T KNOW [SKIP TO 4.3 ASLEEP30]

(99) REFUSED [SKIP TO 4.3 ASLEEP30]

DUR_30D (4.2) Does { he/she } have symptoms all the time? "All the time” means symptoms that continue throughout the day. It does not mean symptoms for a little while each day.

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

ASLEEP30 (4.3) During the past 30 days, on how many days did symptoms of asthma make it difficult for { him/her } to stay asleep?

__ __ DAYS/NIGHTS

[RANGE CHECK: (01-30, 77, 88, 99)]

(88) NONE

(30) Every day

(77) DON’T KNOW

(99) REFUSED

SYMPFREE (4.4) During the past two weeks, on how many days was {child’s name} completely symptom-free, that is no coughing, wheezing, or other symptoms of asthma?

__ __ Number of days

[RANGE CHECK: (01-14, 77, 88, 99)

(88) NONE

EPIS_INT IF LAST SYMPTOMS WAS 3 MONTHS TO 1 YEAR AGO (LASTSYMP = 4) PICK UP HERE, SYMPTOMS WITHIN THE PAST 3 MONTHS PLUS DK AND REFUSED (LASTSYMP (3.5) = 1, 2, 3, 77, 99) CONTINUE HERE AS WELL

READ: Asthma attacks, sometimes called episodes, refer to periods of worsening asthma symptoms that make you limit your activity more than you usually do, or make you seek medical care.

EPIS_12M (4.5) During the past 12 months’ has {child’s name} had an episode of asthma or an asthma attack?

(1) YES

(2) NO [SKIP TO INS1 in Section 5]

(7) DON’T KNOW [SKIP TO INS1 in Section 5]

(9) REFUSED [SKIP TO INS1 in Section 5]

EPIS_TP (4.6) During the past three months, how many asthma episodes or attacks has { he/she } had?

[RANGE CHECK: (001-100, 777, 888, 999)]

(888) NONE

(777) DON’T KNOW

(999) REFUSED

[CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888 AND 999 WERE NOT THE INTENT]

DUR_ASTH (4.7) How long did {his/her} MOST RECENT asthma episode or attack last?

Interviewer note:

If answer is #.5 to #.99 round up

COMPASTH (4.8) Compared with other episodes or attacks, was this most recent attack shorter, longer, or about the same?

(1) SHORTER

(2) LONGER

(3) ABOUT THE SAME

(4) THE MOST RECENT ATTACK WAS ACTUALLY THE FIRST ATTACK

Section 5. Health Care Utilization

All respondents continue here:

INS1 (5.1) Does {child’s name} have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare or Medicaid?

INS_TYP (5.2) What kind of health care coverage does {he/she} have? Is it paid for through the parent’s employer, or is it Medicaid, Medicare, Children's Health Insurance Program (CHIP), or some other type of insurance?

(1) parent’s employer

(2) medicaid/medicare

(3) CHIP {replace with state specific name}

(4) Other

INS2 (5.3) During the past 12 months was there any time that { he/she } did not have any health insurance or coverage?

(2) NO

FLU_SHOT (5.4) A flu shot is an influenza vaccine injected in your arm. During the past 12 months, did {CHILD’S NAME} have a flu shot?

FLU_SPRAY (5.5) A flu vaccine that is sprayed in the nose is called FluMistTM. During the past 12 months, did {he/she} have a flu vaccine that was sprayed in his/her nose?

The best known value for whether or not the child “still has asthma” is used in the skip below. It can be the previously answered BRFSS module value or the answer to CUR_ASTH (2.2) if this question is asked in this call back survey If the respondent confirms in the “Informed Consent” question that the previously answered BRFSS module value is correct then the value from the BRFSS module question (BRFSS M2.2) is used. If the respondent does not agree with the previous BRFSS module value in “Informed Consent” then the question REPEAT (2.0) was asked (REPEAT = 1) then the value for CUR_ASTH (2.2) “Do you still have asthma?” is used.

IF respondent agrees (1. Yes) with “Informed Consent”:

IF BRFSS module value for M2.2, “Does the child still have asthma?” = 2 (No), 7 (DK), or 9 (Refused)

AND

(LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LASTSYMP (3.5) = 88 (Never) or 05, 06, 07, 77 or 99) THEN SKIP TO Section 6; otherwise continue with Section 5.

The above “if” statement can also be restated in different words as:

AND

( (LAST_MD = 4) OR

(LAST_MED = 1, 2, 3 or 4) OR (LASTSYMP = 1, 2, 3 or 4) THEN Continue with Section 5 otherwise skip to Section 6)

IF BRFSS module value for M2.2, “Does the child still have asthma?” = 1 (Yes), continue to Section 5.

IF respondent DOES NOT agree 2 (No) with “Informed Consent” REPEAT = 1:

IF CUR_ASTH (2.2) = 2 (No), 7 (DK), or 9 (Refused) AND (LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND

THEN SKIP TO Section 6; otherwise continue with Section 5.

The above “if” statement can also be restated in different words as:

IF CUR_ASTH (2.2) = 2 (No), 7 (DK), or 9 (Refused) AND

( (LAST_MD = 4) OR

(LAST_MED = 1, 2, 3 or 4) OR (LASTSYMP = 1, 2, 3 or 4) THEN Continue with Section 5; otherwise skip to Section 6)

IF CUR_ASTH (2.2) = 1 (Yes) continue with section 5.

ACT_DAYS30 (5.6) During just the past 30 days, would you say {child’s name} limited {his/her} usual activities due to asthma not at all, a little, a moderate amount, or a lot?

(1) NOT AT ALL

(2) A LITTLE

(3) A MODERATE AMOUNT

(4) A LOT

NER_TIME (5.7) [IF LAST_MD= 88, 05, 06, 07; SKIP TO Section 6 {renamed from NR_Times} (have not seen a doctor in the past 12 months)]

During the past 12 months how many times did {he/she} see a doctor or other health professional for a routine checkup for {his/her} asthma?

__ __ __ ENTER NUMBER

[RANGE CHECK: (001-365, 777, 888, 999)] [Verify any value >50]

[CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888, AND 999 WERE NOT THE INTENT]

(888) NONE

(777) DON’T KNOW

ER_VISIT (5.8) An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment. During the past 12 months, has {child’s name} had to visit an emergency room or urgent care center because of {his/her} asthma?

(2) NO [SKIP TO URG_TIME]

ER_TIMES (5.9) During the past 12 months, how many times did{ he/she } visit an emergency room or urgent care center because of {his/her} asthma?

__ __ __ ENTER NUMBER

[RANGE CHECK: (001-365, 777, 999)] [Verify any entry >50]

(888) ZERO (skip back to 5.8)

(777) DON’T KNOW

(999) REFUSED

[CATI CHECK: IF RESPONSE = 77, 99 VERIFY THAT 777 AND 999 WERE NOT THE INTENT]

[CATI CHECK: IF RESPONSE TO 5.8 IS “YES” AND RESPONDENT SAYS NONE OR ZERO TO 5.9 ALLOW LOOPING BACK TO CORRECT 5.8 TO “NO”]

[HELP SCREEN: An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment.]

URG_TIME (5.10) [IF ONE OR MORE ER VISITS (ER_VISIT (5.8) = 1) INSERT “Besides those emergency room or urgent care center visits,”]

During the past 12 months, how many times did {child’s name} see a doctor or other health professional for urgent treatment of worsening asthma symptoms or an asthma episode or attack?

__ __ __ ENTER NUMBER

[RANGE CHECK: (001-365, 777, 888, 999)] [Verify any entry >50]

(888) NONE

(777) DON’T KNOW

(999) REFUSED

[CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888 AND 999 WERE NOT THE INTENT]

[HELP SCREEN: An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment.]

HOSP_VST (5.11) [IF LASTSYMP > 5 AND < 7, SKIP TO Section 6 IF LASTSYMP=88 (NEVER), SKIP TO Section 6]

During the past 12 months, that is since [1 YEAR AGO TODAY], has {child’s name} had to stay overnight in a hospital because of {his/her} asthma? Do not include an overnight stay in the emergency room.

(1) YES

(2) NO [SKIP TO Section 6]

(7) DON’T KNOW [SKIP TO Section 6]

(9) REFUSED [SKIP TO Section 6]

HOSPTIME (5.12) During the past 12 months, how many different times did {he/she} stay in any hospital overnight or longer because of {his/her} asthma?

__ __ __ TIMES

[RANGE CHECK: (001-365, 777, 999)] [Verify any entry >50]

(777) DON’T KNOW

(999) REFUSED

[CATI CHECK: IF RESPONSE = 77, 99 VERIFY THAT 777 AND 999 WERE NOT THE INTENT]

[CATI CHECK: IF RESPONSE TO 5.11 IS “YES” AND RESPONDENT SAYS NONE OR ZERO TO 5.12 ALLOW LOOPING BACK TO CORRECT 5.11 TO “NO”]

HOSPPLAN (5.13) The last time {he/she} left the hospital, did a health professional TALK with you or {child’s name} about how to prevent serious attacks in the future?

(1) YES

(2) NO

(7) DON’T KNOW

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators. This should not be coded yes if the respondent only received a pamphlet or instructions to view a website or video since the question clearly states “talk with you”. ]

Section 6. Knowledge of Asthma/Management Plan

TCH_SIGN (6.1) Has a doctor or other health professional ever taught you or {child’s name}...

a. How to recognize early signs or symptoms of an asthma episode?

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]

(1) YES

(2) NO

TCH_RESP (6.2) Has a doctor or other health professional ever taught you or {child’s name}...

b. What to do during an asthma episode or attack?

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]

(1) YES

(2) NO

TCH_MON (6.3) A peak flow meter is a hand held device that measures how quickly you can blow air out of your lungs. Has a doctor or other health professional ever taught you or {child’s name}...

c. How to use a peak flow meter to adjust his/her daily medications?

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]

(1) YES

(2) NO

MGT_PLAN (6.4) An asthma action plan, or asthma management plan, is a form with instructions about when to change the amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room.

Has a doctor or other health professional EVER given you or {child’s name}....an asthma action plan?

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]

(1) YES

(2) NO

MGT_CLAS (6.5) Have you or {child’s name} ever taken a course or class on how to manage {his/her} asthma?

(2) NO

Section 7. Modifications to Environment

HH_INT READ: The following questions are about {child’s name} household and living environment. I will be asking about various things that may be related to experiencing symptoms of asthma.

AIRCLEANER (7.1) An air cleaner or air purifier can filter out pollutants like dust, pollen, mold and chemicals. It can be attached to the furnace or free standing. It is not, however, the same as a normal furnace filter.

Is an air cleaner or purifier regularly used inside {child’s name} home?

(1) YES

(2) NO

DEHUMID (7.2) A dehumidifier is a small, portable appliance which removes moisture from the air.

Is a dehumidifier regularly used to reduce moisture inside {his/her} home?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

KITC_FAN (7.3) Is an exhaust fan that vents to the outside used regularly when cooking in the kitchen in {his/her} home?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

COOK_GAS (7.4) Is gas used for cooking in {his/her} home?

(1) Yes

(2) NO

(7) DON’T KNOW

(9) REFUSED

ENV_MOLD (7.5) In the past 30 days, has anyone seen or smelled mold or a musty odor inside in {his/her} home? Do not include mold on food.

(1) YES

(2) NO

ENV_PETS (7.6) Does {child’s name} home have pets such as dogs, cats, hamsters, birds or other feathered or furry pets that spend time indoors?

(2) NO (SKIP TO 7.8)

PETBEDRM (7. 7) Is the pet allowed in {his/her} bedroom?

[SKIP THIS QUESTION IF ENV_PETS = 2, 7, 9]

(1) YES

(2) NO

(3) SOME ARE/SOME AREN’T

(7) DON’T KNOW

(9) REFUSED

C_ROACH (7.8) In the past 30 days, has anyone seen cockroaches inside {child’s name} home?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: Studies have shown that cockroaches may be a cause of asthma. Cockroach droppings and carcasses can also cause symptoms of asthma.]

C_RODENT (7.9) In the past 30 days, has anyone seen mice or rats inside {his/her} home? Do not include mice or rats kept as pets.

(1) YES

(2) NO

(7) DON’T KNOW

[HELP SCREEN: Studies have shown that rodents may be a cause of asthma.]

WOOD_STOVE (7.10) Is a wood burning fireplace or wood burning stove used in {child’s name} home?

(2) NO

(7) DON’T KNOW

(9) REFUSED

HELP SCREEN: OCCASIONAL USE SHOULD BE CODED AS “YES”.

GAS_STOVE (7.11) Are unvented gas logs, unvented gas fireplaces, or unvented gas stoves used in {his/her} home?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: “Unvented” means no chimney or the chimney flue is kept closed during operation.]

S_INSIDE (7.12) In the past week, has anyone smoked inside {his/her} home?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

HELP SCREEN: “The intent of this question is to measure smoke resulting from tobacco products (cigarettes, cigars, pipes) or illicit drugs (cannabis, marijuana) delivered by smoking (inhaling intentionally). Do not include things like smoke from incense, candles, or fireplaces, etc.”

MOD_ENV (7.13) INTERVIEWER READ: Now, back to questions specifically about {child’s name}.

Has a health professional ever advised you to change things in {his/her} home, school, or work to improve his/her asthma?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]

MATTRESS (7.14) Does {he/she} use a mattress cover that is made especially for controlling dust mites?

[INTERVIEWER: If needed: This does not include normal mattress covers used for padding or sanitation (wetting). These covers are for the purpose of controlling allergens (like dust mites) from inhabiting the mattress. They are made of special fabric, entirely enclose the mattress, and have zippers.]

(1) YES

(2) NO

E_PILLOW (7.15) Does {he/she} use a pillow cover that is made especially for controlling dust mites?

[INTERVIEWER: If needed: This does not include normal pillow covers used for fabric protection. These covers are for the purpose of controlling allergens (like dust mites) from inhabiting the pillow. They are made of special fabric, entirely enclose the pillow, and have zippers.]

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

CARPET (7.16) Does {child’s name} have carpeting or rugs in {his/her} bedroom? This does not include throw rugs small enough to be laundered.

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

HOTWATER (7.17) Are {his/her} sheets and pillowcases washed in cold, warm, or hot water?

(1) COLD

(2) WARM

(3) HOT

DO NOT READ

(4) VARIES

(7) DON’T KNOW

(9) REFUSED

BATH_FAN (7.18) In {child’s name} bathroom, does {he/she} regularly use an exhaust fan that vents to the outside?

(1) YES

(2) NO OR “NO FAN”

(7) DON’T KNOW

HELP SCREEN: IF RESPONDENT INDICATES THEY HAVE MORE THAN ONE BATHROOM, THIS QUESTION REFERS TO THE BATHROOM THE CHILD USES MOST FREQUENTLY FOR SHOWERING AND BATHING.

Section 8. Medications

OTC (8.1) [IF LAST_MED = 88 (NEVER), SKIP TO SECTION 9. ELSE, CONTINUE.]

The next set of questions is about medications for asthma. The first few questions are very general, but later questions are very specific to {child’s name} medication use.

Over-the-counter medication can be bought without a doctor’s order. Has {child’s name} ever used over-the-counter medication for {his/her} asthma?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

INHALERE (8.2) Has {he/she} ever used a prescription inhaler?

(1) YES

(2) NO [SKIP TO SCR_MED1]

INHALERH (8.3) Did a health professional show {him/her} how to use the inhaler?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]

INHALERW (8.4) Did a doctor or other health professional watch { him/her } use the inhaler?

(1) YES

(2) NO

SCR_MED1 (8.5) [IF LAST_MED = 4, 5, 6, 7, 77, or 99, SKIP TO SECTION 9]

Now I am going to ask questions about specific prescription medications {child’s name} may have taken for asthma in the past 3 months. I will be asking for the names, amount, and how often {he/she} takes each medicine. I will ask separately about medication taken in various forms: pill or syrup, inhaler, and Nebulizer.

It will help to get {child’s name} medicines so you can read the labels.

Can you please go get the asthma medicines while I wait on the phone?

(1) YES

SCR_MED3 (8.7) [when Respondent returns to phone:] Do you have all the medications?

[INTERVIEWER: Read if necessary]

(1) YES I HAVE ALL THE MEDICATIONS

(2) YES I HAVE SOME OF THE MEDICATIONS BUT NOT ALL

(3) NO

(7) DON’T KNOW

(9) REFUSED

[IF INHALERE (8.2) = 2 (NO) SKIP TO PILLS]

INH_SCR (8.8) In the past 3 months has {child’s name} taken prescription asthma medicine using an inhaler?

(1) YES

(2) NO [SKIP TO PILLS]

(7) DON’T KNOW [SKIP TO PILLS]

(9) REFUSED [SKIP TO PILLS]

INH_MEDS (8.9)

For the following inhalers the respondent can choose up to eight medications; however, each medication can only be used once (in the past, errors such as 030303 were submitted in the data file). When 66 (Other) is selected as a response, the series of questions ILP03 (8.13) to ILP10 (8.19) is not asked for that response.

In the past 3 months, what prescription asthma medications did {he/she} take by inhaler? [MARK ALL THAT APPLY. PROBE: Any other prescription asthma inhaler medications?]

[INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION.]

Note: The top ten items (in bold below) should be highlighted in the CATI system if possible so they can be found more easily.

[IF RESPONDENT SELECTS ANY ANSWER <66, SKIP TO ILP03]

(88) NO PRESCRIPTION INHALERS [SKIP TO PILLS]

[100 ALPHANUMERIC CHARACTER LIMIT FOR 66]

OTH_I1 (8.10) ENTER OTHER MEDICATION FROM (8.9) IN TEXT FIELD

IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE.

CATI programmers note that the text for 66 (other) should be checked to make sure one of the medication names above was not entered. If the medication entered is on the list above, then an error message should be shown.

[LOOP BACK TO ILP03 AS NECESSARY TO ADMINSTER QUESTIONS ILP03 THRU ILP10 FOR EACH MEDICINE 01-44 REPORTED IN INH_MEDS, BUT NOT FOR 66 (OTHER).]

[FOR FILL [MEDICINE FROM INH_MEDS SERIES] FOR QUESTIONS ILP03 THROUGH ILP10]

SKIP before ILP03 IF [MEDICINE FROM INH_MEDS SERIES] IS ADVAIR (01) OR FLOVENT ROTADISK (15) OR MOMETASONE FUROATE (39) OR ASMANEX (40) OR FORADIL (34) OR MAXAIR (20) OR PULMICORT (25) OR SEREVENT (27) OR SYMBICORT (42) SKIP TO 8.14

ILP03 (8.13) A spacer is a small attachment for an inhaler that makes it easier to use. Does {he/she} use a spacer with [MEDICINE FROM INH_MEDS SERIES]?

(2) NO

(3) Medication is a dry powder inhaler or disk inhaler, not a canister inhaler

(4) Medication has a built-in spacer/does not need a spacer

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: A spacer is a device that attaches to a metered dose inhaler. It holds the medicine in its chamber long enough for you to inhale it in one or two slow, deep breaths. The spacer makes it easy to take the medicines the right way.]

[HELP SCREEN: The response category 3 (disk or dry powder) and 4 (built in spacer) are primarily intended for medications Beclomethosone (7) Beclovent (08), Budesonide (11) and QVAR (36), which are known to come in disk or breathe activated inhalers (which do not use a spacer). However, new medications may come on the market that will need either category, so 3 or 4 can be used for other medications as well.]

ILP04 (8.14) In the past 3 months, did {child’s name} take [MEDICINE FROM INH_MEDS SERIES] when he/she had an asthma episode or attack?

(1) YES

(2) NO

(3) NO ATTACK IN PAST 3 MONTHS

ILP05 (8.15) In the past 3 months, did {he/she} take [MEDICINE FROM INH_MEDS SERIES] before exercising?

(2) NO

(3) DIDN’T EXERCISE IN PAST 3 MONTHS

(7) DON’T KNOW

(9) REFUSED

ILP06 (8.16) In the past 3 months, did {he/she} take [MEDICINE FROM INH_MEDS SERIES] on a regular schedule everyday?

(1) YES

(2) NO

(7) DON’T KNOW

ILP08 (8.18) How many times per day or per week did {he/she} use [MEDICINE FROM INH_MEDS SERIES]?

[RANGE CHECK: 301-399, 401-499, 555, 666, 777, 999]

[ASK ILP10 ONLY IF INH_MEDS = 3, 4, 9, 10, 20, 21, 23, 24, 28, 30, 33, 37, 38, 41 OTHERWISE SKIP TO PILLS (8.20)]

ILP10 (8.19) How many canisters of [MEDICINE FROM INH_MEDS SERIES] has {child’s name} used in the past 3 months?

[INTERVIEWER: IF RESPONDENT USED LESS THAN ONE FULL CANISTER IN THE PAST THREE MONTHS, CODE IT AS ‘88’]

___ CANISTERS

(77) DON’T KNOW

(88) NONE

(99) REFUSED

[RANGE CHECK: (01-76, 77, 88, 99)]

[HELP SCREEN: IF RESPONDENT INDICATES THAT <CHILD> HAS MULTIPLE CANISTERS, (I.E., ONE IN THE CAR, ONE AT SCHOOL, ETC.) ASK THE RESPONDENT TO ESTIMATE HOW MANY FULL CANISTERS HE/SHE USED. THE INTENT IS TO ESTIMATE HOW MUCH MEDICATION IS USED, NOT HOW MANY DIFFERNT INHALERS.]

PILLS (8.20) In the past 3 months, has {he/she} taken any PRESCRIPTION medicine in pill form for his/her asthma?

(2) NO [SKIP TO SYRUP]

PILLS_MD (8.21) For the following pills the respondent can chose up to five medications; however, each medication can only be used once (in the past, errors such as 232723 were submitted in the data file).

What PRESCRIPTION asthma medications does {child’s name} take in pill form?

[MARK ALL THAT APPLY. PROBE: Any other PRESCRIPTION asthma pills?]

Note: The top ten items (in bold below) should be highlighted in the CATI system if possible so they can be found more easily.

[IF RESPONDENT SELECTS ANY ANSWER FROM 01-49, SKIP TO PILL01]

(88) NO PILLS [SKIP TO SYRUP]

[100 ALPHANUMERIC CHARACTER LIMIT FOR 66]

OTH_P1

ENTER OTHER MEDICATION IN TEXT FIELD

IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE.

CATI programmers note that the text for 66 (other) should be checked to make sure one of the medication names above was not entered. If the medication entered is on the list above, then an error message should be shown.

[REPEAT QUESTION PILL01 AS NECESSARY FOR EACH PILL 01-49 REPORTED IN PILLS_MD, BUT NOT FOR 66 (OTHER).]

FOR FILL [MEDICATION LISTED IN PILLS_MD] FOR QUESTION PILL01]

PILL01 (8.22) In the past 3 months, did {child’s name} take [MEDICATION LISTED IN PILLS_MD] on a regular schedule every day?

(2) NO

SYRUP (8.23) In the past 3 months, has {he/she} taken prescription medicine in syrup form?

(2) NO [SKIP TO NEB_SCR]

SYRUP_ID (8.24) For the following syrups the respondent can choose up to four medications; however, each medication can only be used once (in the past, errors such as 020202 were submitted in the data file).

What PRESCRIPTION asthma medications has {child’s name} taken as a syrup?

[MARK ALL THAT APPLY. PROBE: Any other PRESCRIPTION syrup medications for asthma?]

[IF RESPONDENT SELECTS ANY ANSWER FROM 01-10, SKIP TO NEB_SCR]

(88) NO PILLS [SKIP TO NEB_SCR]

[100 ALPHANUMERIC CHARACTER LIMIT FOR 66]

OTH_S1

ENTER OTHER MEDICATION.

IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE.

CATI programmers note that the text for 66 (other) should be checked to make sure one of the medication names above was not entered. If the medication entered is on the list above, then an error message should be shown.

NEB_SCR (8. 25) A nebulizer is a small machine with a tube and facemask or mouthpiece that you breathe through continuously. In the past 3 months, were any of {child’s name} PRESCRIPTION asthma medicines used with a nebulizer?

(1) YES

(2) NO [SKIP TO Section 9]

NEB_ID (8.27) For the following nebulizers, the respondent can chose up to five medications; however, each medication can only be used once (in the past, errors such as 0101 were submitted in the data file).

In the past 3 months, what prescription ASTHMA medications has {he/she} taken using a nebulizer?

[INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION.]

[MARK ALL THAT APPLY. PROBE: Has your child taken any other prescription ASTHMA medications with a nebulizer in the past 3 months?]

(88) NONE [SKIP TO Section 9]

OTH_N1

ENTER OTHER MEDICATION

IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE.

CATI programmers note that the text for 66 (other) should be checked to make sure one of the medication names above was not entered. If the medication entered is on the list above, then an error message should be shown.

[LOOP BACK TO NEB01 AS NECESSARY TO ADMINISTER QUESTIONS NEB01 THROUGH NEB03 FOR EACH MEDICINE 01 THROUGH 18 (NEB_01 to NEB_18) REPORTED IN NEB_ID, BUT NOT FOR 66 (OTHER).]

FOR FILL [MEDICATION LISTED IN NEB_ID] FOR QUESTION NEB01 to NEB03]

NEB01 (8.28) In the past 3 months, did {child’s name} take [MEDICINE FROM NEB_ID SERIES] when he/she had an asthma episode or attack?

(1) YES

(2) NO

(3) NO ATTACK IN PAST 3 MONTHS

(7) DON’T KNOW

(9) REFUSED

NEB02 (8.29) In the past 3 months, did he/she take [MEDICINE FROM NEB_ID SERIES] on a regular schedule every day?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

NEB03 (8.30) How many times per day or per week does he/she use [MEDICINE FROM NEB_ID SERIES]?

3__ __ DAYS

4__ __ WEEKS

(555) NEVER

(666) LESS OFTEN THAN ONCE A WEEK

(777) DON’T KNOW / NOT SURE

Section 9. Cost of Care

The best known value for whether or not the child “still has asthma” is used in the skip below. It can be the previously answered BRFSS module value or the answer to CUR_ASTH (2.2) if this question is asked in this call back survey If the respondent confirms in the “Informed Consent” question that the previously answered BRFSS module value is correct then the value from the BRFSS module question (BRFSS M2.2) is used. If the respondent does not agree with the previous BRFSS module value in “Informed Consent” then the question REPEAT (2.0) was asked (REPEAT = 1) then the value for CUR_ASTH (2.2) “Do you still have asthma?” is used.

IF respondent agrees 1 (Yes) with “Informed Consent”:

IF BRFSS module value for M2.2, “Does the child still have asthma?” = 1 (Yes), then continue with Section 9.

IF respondent DOES NOT agree 2 (No) with “Informed Consent” REPEAT = 1:

IF CUR_ASTH (2.2) = 2 (No), 7 (DK), or 9 (Refused)

AND

(LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND

AND

(LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND

THEN SKIP TO Section 10; otherwise continue with Section 9

(LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND

THEN SKIP TO Section 10; otherwise continue with Section 9.

IF CUR_ASTH (2.2) = 1 (Yes), then continue with Section 9.

ASMDCOST (9.1) Was there a time in the past 12 months when {child’s name} needed to see his/her primary care doctor for asthma but could not because of the cost?

(1) YES

(7) DON’T KNOW

ASSPCOST (9.2) Was there a time in the past 12 months when you were referred to a specialist for {his/her} asthma care but could not go because of the cost?

(1) YES

(7) DON’T KNOW

(9) REFUSED

ASRXCOST (9.3) Was there a time in the past 12 months when {he/she} needed medication for his/her asthma but you could not buy it because of the cost?

(1) YES

(7) DON’T KNOW

Section 10. School Related Asthma

SCH_STAT (10.1) Next, we are interested in things that might affect {child’s name} asthma when he/she is not at home.

Does {child’s name} currently go to school or pre school outside the home?

(1) YES [SKIP TO SCHGRADE]

(2) NO

NO_SCHL (10.2) What is the main reason {he/she} is not now in school? READ RESPONSE CATEGORIES

(7) DON'T KNOW

(9) REFUSED

SCHL_12 (10.3) Has {child’s name} gone to school in the past 12 months?

(1) YES

(2) NO [SKIP TO DAYCARE]

(88) PRE SCHOOL

(066) KINDERGARDEN

__ __ ENTER GRADE 1 TO 12

The best known value for whether or not the child “still has asthma” is used in the skip below. It can be the previously answered BRFSS module value or the answer to CUR_ASTH (2.2) if this question is asked in this call back survey If the respondent confirms in the “Informed Consent” question that the previously answered BRFSS module value is correct then the value from the BRFSS module question (BRFSS M2.2) is used. If the respondent does not agree with the previous BRFSS module value in “Informed Consent” then the question REPEAT (2.0) was asked (REPEAT = 1) then the value for CUR_ASTH (2.2) “Do you still have asthma?” is used.

IF BRFSS module value for M2.2, “Does the child still have asthma?” = 2 (No), 7 (DK), or 9 (Refused), AND

(LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LASTSYMP (3.5) = 88 (Never) or 05, 06, 07, 77 or 99) THEN SKIP TO 10.8; otherwise continue with 10.5

IF BRFSS module value for M2.2, “Does the child still have asthma?” = 1 (Yes) then continue with 10.5.

IF CUR_ASTH (2.2) = 2 (No), 7 (DK), or 9 (Refused)

AND

(LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LASTSYMP (3.5) = 88 (Never) or 05, 06, 07, 77 or 99) THEN SKIP TO 10.8; otherwise continue with 10.5

IF CUR_ASTH (2.2) = 1 (Yes), then continue with 10.5.

MISS_SCHL (10.5) During the past 12 months, about how many days of school did {he/she} miss because of {his/her} asthma?

__ __ __ENTER NUMBER DAYS

[3 NUMERIC-CHARACTER-FIELD, RANGE CHECK: (001-365, 777, 888, 999)] [Verify any entry >50]

[DISPLAY THE THREE POSSIBILITIES BELOW ON THE CATI SCREEN FOR THS QUESTION TO ASSIST THE INTERVIEWER]

(888) ZERO

(777) DON’T KNOW

[CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888 AND 999 WERE NOT THE INTENT]

[IF NO_SCHL = 2 (HOME SCHOOLED) SKIP TO SECTION 11]

[IF SCHL_12 (10.3) = 1 READ ‘PLEASE ANSWER THESE NEXT FEW QUESTIONS ABOUT THE SCHOOL {CHILD’S NAME} WENT TO LAST]

SCH_APL (10.6) Earlier I explained that an asthma action plan contains instructions about how to care for the child’s asthma.

Does {child’s name} have a written asthma action plan or asthma management plan on file at school?

(1) YES

(2) NO

SCH_MED (10.7) Does the school {he/she} goes to allow children with asthma to carry their medication with them while at school?

(2) NO

SCH_ANML (10.8) [IF NO_SCHL = 2 (HOME SCHOOLED) SKIP TO SECTION 11] added in 2011 Are there any pets such as dogs, cats, hamsters, birds or other feathered or furry pets in {his/her} CLASSROOM?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

SCH_MOLD (10.9) Are you aware of any mold problems in {child’s name} school?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

(1) YES [SKIP TO MISS_DCAR]

(2) NO

(7) DON’T KNOW [SKIP TO SECTION 11]

(9) REFUSED [SKIP TO SECTION 11]

DAYCARE1 (10.11) Has {he/she} gone to daycare in the past 12 months?

(1) YES

(2) NO [SKIP TO SECTION 11]

The best known value for whether or not the child “still has asthma” is used in the skip below. It can be the previously answered BRFSS module value or the answer to CUR_ASTH (2.2) if this question is asked in this call back survey If the respondent confirms in the “Informed Consent” question that the previously answered BRFSS module value is correct then the value from the BRFSS module question (BRFSS M2.2) is used. If the respondent does not agree with the previous BRFSS module value in “Informed Consent” then the question REPEAT (2.0) was asked (REPEAT = 1) then the value for CUR_ASTH (2.2) “Do you still have asthma?” is used.

IF BRFSS module value for M2.2, “Does the child still have asthma?” = 2 (No), 7 (DK), or 9 (Refused), AND

(LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LASTSYMP (3.5) = 88 (Never) or 05, 06, 07, 77 or 99) THEN SKIP TO 10.14; otherwise continue with 10.12

IF BRFSS module value for M2.2, “Does the child still have asthma?” = 1 (Yes), then continue with 10.12.

IF CUR_ASTH (2.2) = 2 (No), 7 (DK), or 9 (Refused) skip to Section 10.14

AND

(LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LASTSYMP (3.5) = 88 (Never) or 05, 06, 07, 77 or 99) THEN SKIP TO 10.14; otherwise continue with 10.12

IF CUR_ASTH (2.2) = 1 (Yes), then continue with 10.12.

MISS_DCAR (10.12) During the past 12 months, about how many days of daycare did {he/she} miss because of {his/her} asthma?

__ __ __ENTER NUMBER DAYS

[3 NUMERIC-CHARACTER-FIELD, RANGE CHECK: (001-365, 777, 888, 999)] [Verify any entry >50]

[DISPLAY THE THREE POSSIBILITIES BELOW ON THE CATI SCREEN FOR THS QUESTION TO ASSIST THE INTERVIEWER]

(888) ZERO

(777) DON’T KNOW

(999) REFUSED

[CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888 AND 999 WERE NOT THE INTENT]

DCARE_APL (10.13) [IF DAYCARE1 (10.11) = YES (1) THEN READ: “Please answer these next few questions about the daycare {child’s name} went to last. “

Does {child’s name} have a written asthma action plan or asthma management plan on file at daycare?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

DCARE_ANML(10.14) Are there any pets such as dogs, cats, hamsters, birds or other feathered or furry pets in {his/her} room at daycare?

(1) YES

(2) NO

DCARE_MLD (10.15) Are you aware of any mold problems in {his/her} daycare?

(1) YES

(2) NO

DCARE_SMK (10.16) Is smoking allowed at {his/her} daycare?

(1) YES

(2) NO

Section 11. Complimentary and Alternative Therapy

The best known value for whether or not the child “still has asthma” is used in the skip below. It can be the previously answered BRFSS module value or the answer to CUR_ASTH (2.2) if this question is asked in this call back survey If the respondent confirms in the “Informed Consent” question that the previously answered BRFSS module value is correct then the value from the BRFSS module question (BRFSS M2.2) is used. If the respondent does not agree with the previous BRFSS module value in “Informed Consent” then the question REPEAT (2.0) was asked (REPEAT = 1) then the value for CUR_ASTH (2.2) “Do you still have asthma?” is used.

IF BRFSS module value for M2.2, “Does the child still have asthma?” = 2 (No), 7 (DK), or 9 (Refused), AND

(LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LASTSYMP (3.5) = 88 (Never) or 05, 06, 07, 77 or 99) THEN SKIP TO SECTION 12; otherwise continue with Section 11

IF BRFSS module value for M2.2, “Does the child still have asthma?” = 1 (Yes), then continue with section 11.

IF CUR_ASTH (2.2) = 2 (No), 7 (DK), or 9 (Refused) skip to Section 12

AND

(LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND

THEN SKIP TO SECTION 12; otherwise continue with Section 11

IF CUR_ASTH (2.2) = 1 (Yes), then continue with section 11.

READ: Sometimes people use methods other than prescription medications to help treat or control their asthma. These methods are called non-traditional, complementary, or alternative health care. I am going to read a list of these alternative methods. For each one I mention, please answer “yes” if {child’s name} has used it to control asthma in the past 12 months. Answer “no” if {he/she} has not used it in the past 12 months.

CAM_PRES (11.4) acupressure (1) YES (2) NO (7) DK (9) REF

CAM_AROM (11.5) aromatherapy (1) YES (2) NO (7) DK (9) REF

CAM_HOME (11.6) homeopathy (1) YES (2) NO (7) DK (9) REF

CAM_REFL (11.7) reflexology (1) YES (2) NO (7) DK (9) REF

CAM_YOGA (11.8) yoga (1) YES (2) NO (7) DK (9) REF

CAM_BR (11.9) breathing techniques (1) YES (2) NO (7) DK (9) REF

CAM_NATR (11.10) naturopathy (1) YES (2) NO (7) DK (9) REF

[INTERVIEWER: If respondent does not recognize the term “naturopathy” the response should be no”]

[HELP SCREEN: Naturopathy (nay-chur-o-PATH-ee) is an alternative treatment based on the principle that there is a healing power in the body that establishes, maintains, and restores health. Naturopaths prescribe treatments such as nutrition and lifestyle counseling, dietary supplements, medicinal plants, exercise, homeopathy, and treatments from traditional Chinese medicine.]

CAM_OTHR (11.11) Besides the types I have just asked about, has {child’s name} used any other type of alternative care for asthma in the past 12 months?

CAM_TEXT (11.13) What else has {he/she} used?

[100 ALPHANUMERIC CHARACTER LIMIT]

ENTER OTHER ALTERNATIVE MEDICINE IN TEXT FIELD

IF MORE THAN ONE IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE.

Section 12. Additional Child Demographics READ “I have just a few more questions about {child’s name}.”

HEIGHT1 (12.1) How tall is {child’s name}?

[INTERVIEWER: if needed: Ask the respondent to give their best guess.]

_ _ _ _ = Height (ft/inches) 7 7 7 7 = Don’t know/Not sure 9 9 9 9 = Refused

CATI Note: In the first space for the height (highlighted in yellow), if the respondent answers in feet/inches enter “0.” If respondent answers in metric, put “9” in the first space.

Examples:

6 feet = 600 (6 feet, zero inches) 5'3" = 503 (5 feet, 3 inches)

VALUES OF GREATER THAN 8 FEET 11 INCHES OR 250 CENTIMETERS SHOULD NOT BE ALLOWED, VALUE RANGE FOR INCHES 00-11.

HELP SCREEN: WE ARE INTERESTED IN LOOKING AT HOW HEIGHT AND WEIGHT MAY BE RELATED TO ASTHMA.

WEIGHT1 (12.2) How much does {he/she} weigh?

[INTERVIEWER: if needed: Ask the respondent to give their best guess.]

CATI Note: In the first space for the weight (highlighted in yellow), if the respondent answers in pounds, enter “0.” If respondent answers in kilograms, put “9” in the first space.

[VALUES OF GREATER THAN 500 POUNDS OR 230 KILOGRAMS SHOULD NOT BE ALLOWED]]

HELP SCREEN: WE ARE INTERESTED IN LOOKING AT HOW HEIGHT AND WEIGHT MAY BE RELATED TO ASTHMA.

BIRTHW1 (12.3) How much did {he/she} weigh at birth (in pounds)?

CATI note: If the respondent gives pounds and ounces: from left to right, positions one and two will hold “0 0”; positions three and four will hold the value of pounds from 0 to 30; and the last two positions will hold 00 to 15 ounces.

If the respondent gives kilograms and grams: from left to right, position one will hold “9”; positions two and three will hold the value of kilograms 1-30; and the last three positions will hold the number of grams.

[VALUES OF GREATER THAN 30 POUNDS OR 13.6 KILOGRAMS SHOULD NOT BE ALLOWED]

[IF BIRTH WEIGHT (12.3) IS DON’T KNOW OR REFUSED ASK BIRTHRF, ELSE SKIP TO CWEND.]

BIRTHRF (12.4) At birth, did {child’s name} weigh less than 5 ½ pounds?

[INTERVIEWER NOTE: 5 ½ pounds = 2500 GRAMS]

(1) YES

(2) NO

CWEND Those are all the questions I have. I’d like to thank you on behalf of the {STATE NAME} Health Department and the Centers for Disease Control and Prevention for the time and effort you’ve spent answering these questions. If you have any questions about this survey, you may call my supervisor toll-free at 1 – xxx-xxx-xxxx. If you have questions about your rights as a survey participant, you may call the chairman of the Institutional Review Board at 1800xxx-xxxx. Thanks again.

Appendix A:

Language for Identifying Most Knowledgeable Person during the BRFSS interview

Consent scripts for use during BRFSS 2011 Child asthma module when the most…