Attachment 4 - New Jersey Behavioral Risk Factor Survey.docx

DRAFT

New Jersey Behavioral Risk Factor Surveillance System Questionnaire

Imported & Hidden Sample Variables – 2026

[ASK ALL]

SAMPTYPE. Imported Sample Variable: Sample Type

1 Landline 2 Cell Phone

[ASK ALL]

STATE. Imported Sample Variable: State

NJ New Jersey

[SET HEALTHDEPT = STATE]

HEALTHDEPT. Hidden Variable for Piping: Health Department Name

NJ New Jersey Department of Health

[SET DEPTPHONE = STATE]

DEPTPHONE. Hidden Variable for Piping: Department Phone Number

NJ 1-855-530-5785

[SET LENGTH = STATE]

LENGTH. Hidden Variable for Piping: Interview Length

NJ 27

[ASK ALL]

ASGCNTY. Imported Sample Variable: County by State 001 001 003 003 005 005 007 007 009 009 011 011 013 013 015 015 017 017 019 019 021 021 023 023 025 025 027 027

[ASK ALL]

HGENDER. Hidden variable for storing last provided gender response entered at SEX2, ASKGENDR, ASKGENDR2. Used for logic and piping throughout.

1 male 2 female

CDAY. System variable - Current day [NUMBER BOX] RANGE 1-31

CWEEKDAY. System variable - Current weekday

1 Sunday 2 Monday 3 Tuesday 4 Wednesday 5 Thursday 6 Friday 7 Saturday

CMONTH. System variable - Current month

01 January 02 February 03 March 04 April 05 May 06 June 07 July 08 August 09 September 10 October 11 November 12 December

CYEAR. System variable - Current year RANGE 2025-2027 [NUMBER BOX] WIDTH=4

MONTH. Imported Sample Variable – Sample month

01 January 02 February 03 March 04 April 05 May 06 June 07 July 08 August 09 September 10 October 11 November 12 December

CDC NOTE: Items in parentheses at any place in the questions or response DO NOT need to be read.

2026 BRFSS Questionnaire/Draft

Behavioral Risk Factor Surveillance System 2026 Questionnaire Table of Contents

Interviewer’s Script Landline

Form Approved OMB No. 0920-1061 Exp. Date: 04/30/2028

Public reporting burden of this collection of information is estimated to average 27 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 aspect 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, Georgia 30333; ATTN: PRA (0920-1061).

NOTE: Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Marquisette Glass Lewis at grp2@cdc.gov.

ANSWERING MACHINE MESSAGE TEXT:

AM_TEXT. TO BE LEFT ON 1ST, 4TH, AND 9TH ATTEMPTS THAT RESULT IN ANSWERING MACHINE.

1 Hello, I am calling on behalf of the [HEALTHDEPT] to conduct an important study on the health of US residents. We will call again in the next few days to conduct the interview. If you have any questions, please call us toll free at [DEPTPHONE] at your convenience. Thank you.

PRIVACY MANAGER MESSAGE TEXT:

PM_TEXT. TO BE LEFT ON THE 1ST, 4TH, 9TH ATTEMPT THAT RESULTS IN A PRIVACY MANAGER

1 (NAME) calling on behalf of the [HEALTHDEPT]

[ASK IF (SELFLAG NE 1 OR GETADULT=1)]

INT01. Hello, I am calling for the [HEALTHDEPT]. My name is ________. We are gathering information about the health of US residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices. This call may be monitored or recorded for quality control.

[IF SAMPTYPE=1 INSERT “Is this $N?”; IF SAMPTYPE=2 NH INSERT “Is this a safe time to talk with you?”]

INTERVIEWER NOTE: If Respondent objects to being contacted by a state where they never lived, say: “This survey is conducted by all states and your information will be forwarded to the correct state of residence.”

[ASK IF SELFLAG=1 AND NOT(GETADULT=1)]

INT02. Hello, my name is ______ and I am calling back on behalf of the [HEALTHDEPT]. We recently spoke to an adult in your household about an important health survey.

[IF SAMPTYPE=1 INSERT: “When we called previously the person with the most recent birthday was selected to be interviewed.

May I please speak to“] [IF INT02_CB = 01 AND SAMPTYPE=1 insert “[INT02_CB]?”; IF SAMPTYPE=1 AND INT02_CB NE 01 INSERT “them”] [IF SAMPTYPE=1 insert “to finish the survey now?

INTERVIEWER NOTE: If person on the phone is not the selected respondent, read the following after transferring to the selected respondent.

Hello, my name is ______ and I am calling back on behalf of the [HEALTHDEPT] about an important health survey.”] [IF SAMPTYPE=1 INSERT: “When we last called, you were selected to complete the interview and we would like to finish the survey now.”][IF SAMPTYPE=2 INSERT: “When we called previously we were unable to complete the interview. We would like to finish the survey with the same adult we spoke to previously. May I please speak to“] [IF SAMPTYPE=2 insert “them?”]

[IF SAMPTYPE=2 INSERT “INTERVIEWER NOTE: If person on the phone is not the previously selected respondent, wait for the previous respondent to come to the phone and then proceed to ask, “Is this a safe time to talk with you?” If respondent is the previously selected respondent then proceed to ask, “Is this a safe time to talk with you?”

If the selected respondent is on the line and says this is a safe time to talk please select option 01 “Selected on the line” to proceed further.

Is this a safe time to talk with you?”]

[ASK IF INT01=02]

TERM1. Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time.

1 Continue [ASSIGN DISPO U1] [NON-CLEANING SKIP]

[ASK IF INT01=01 AND SAMPTYPE=1]

HS1. Is this a private residence?

READ IF NECESSARY: By private residence, we mean someplace like a house or apartment.

INTERVIEWER DO NOT READ: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.

INTERVIEWER NOTE: Business numbers which are also used for personal communication are eligible.

[ASK IF HS1=3]

BUS. Thank you very much but we are only interviewing persons on residential phones at this time.

1 Continue [ASSIGN DISPO M8]

[ASK IF HS1=2]

COLLEGE. Do you live in college housing?

READ IF NECESSARY: By college housing we mean dormitory, graduate student, or visiting faculty housing, or other housing arrangement provided by a college or university.

INTERVIEWER NOTE: IF NO, PROBE TO FIND OUT IF BUSINESS OR GROUP HOME.

[ASK IF COLLEGE=2,3,7,9]

X2. Thank you very much, but we are only interviewing persons who live in a private residence or college housing at this time.

1 Continue [ASSIGN DISPO M8]

[ASK IF SAMPTYPE=1]

STRES. Do you currently live in [STATE]?

[ASK IF STRES=2,7,9]

X3. Thank you very much, but we are only interviewing persons who live in [STATE] at this time.

1 Continue [ASSIGN DISPO M7]

[ASK IF HS1=1 or COLLEGE=1] HS2. Is this a cell phone?

READ IF NECESSARY: By cell phone we mean a telephone that is mobile and usable outside your neighborhood.

INTERVIEWER DO NOT READ: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).

[ASK IF HS2=1]

HS2X. Thank you very much, but we are only interviewing by landline telephones in private residences or college housing at this time.

1 Continue [ASSIGN DISPO M3]

[ASK IF HS2=2]

ADULT. Are you 18 years of age or older?

[ASK IF HS1=1 AND HS2=2]

ADULTS. I need to randomly select one adult who lives in your household to be interviewed. Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older?

INTERVIEWER: If respondent questions why any specific individual was chosen, emphasize that the selection is random and is not limited to any certain age group or sex.

RANGE 0-18 [NUMBER BOX]

[ASK IF (ADULT=2 AND ADULTS=0) OR (HS1=1 AND HS2=2 AND ADULTS=0)]

XX3. Thank you very much, but we are only interviewing persons aged 18 or older at this time.

1 Continue [ASSIGN DISPO M6]

[ASK IF ADULTS=1 AND ADULT=1]

ONEADULT. Are you that adult?

[ASK IF ONEADULT=2 OR (ADULT=2 AND ADULTS=1)]

GETADULT. May I speak with the adult in the household that is 18 years of age or older?

[ASK IF ONEADULT=1 OR (COLLEGE=1 AND ADULT=1 )]

YOU. Then you are the person I need to speak with.

1 Continue

[ASK IF ONEADULT=1 OR (COLLEGE=1 AND HS2=2 AND ADULT=1)]

ASKGENDR. Are you male or female?

READ IF NECESSARY: We ask this question to determine which health related questions apply to each respondent. For example, males might be asked about prostate health issues.

9 REFUSED

[ASK IF ASKGENDR=9]

XX5. Thank you for your time, your number may be selected for another survey in the future

1 Continue [ASSIGN DISPO R3]

[IF ASKGENDR=1 SET HGENDER=1 (Male); IF ASKGENDR =2 SET HGENDER=2 (Female)]

[ASK IF (ADULTS>1 OR (ADULT=2 AND ADULTS=2-18)) AND SAMPTYPE=1]

RESPSLCT. The person in your household that I need to speak with is the adult with the most recent birthday. Are you the adult with the most recent birthday?

INTERVIEWER: If respondent questions why any specific individual was chosen, emphasize that the selection is random and is not limited to any certain age group or sex.

[INTERVIEWER: PLEASE CHOOSE A RESPONSE. DO NOT USE QUIT]

[INTERVIEWER: IF PERSON ON THE PHONE IS NOT THE SELECTED ADULT SAY: “May I speak with the adult with the most recent birthday?]

[INTERVIEWER: WHEN NEW ADULT COMES TO THE PHONE READ: Hello, I am calling for the [HEALTHDEPT]. My name is _____. We are gathering information about the health of US residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices. This call may be monitored or recorded for quality control.]

1 Yes

[ASK IF RESPSLCT=1]

ASKGENDR2. Are you male or female?

READ IF NECESSARY: We ask this question to determine which health related questions apply to each respondent. For example, males might be asked about prostate health issues.

9 REFUSED

[ASK IF ASKGENDR2=9]

XX9. Thank you for your time, your number may be selected for another survey in the future.

1 Continue [ASSIGN DISPO R3]

[IF ASKGENDR2=1 SET HGENDER=1 (Male); IF ASKGENDR2 =2 SET HGENDER=2 (Female)]

[ASK IF SAMPTYPE=1]

YOURTHE1. I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call [DEPTPHONE].

INTERVIEWER NOTE: The interview takes on average [LENGTH] minutes depending on your answers.

Interviewer’s Script Cell Phone

[ASK IF INT01=01 AND SAMPTYPE=2]

PHONE. Is this $N?

INTERVIEWER NOTE: PLEASE CONFIRM NEGATIVE RESPONSES TO ENSURE THAT RESPONDENT HAS HEARD AND UNDERSTOOD CORRECTLY.

[ASK IF PHONE=2]

XPHONE. Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time.

1 Continue [CODE AS U1]

[ASK IF PHONE=1]

CELLFON2. Is this a cell phone?

[ASK IF CELLFON2=2]

NOTCELL1. Thank you very much, but we are only interviewing persons on cell phones at this time.

1 Continue [ASSIGN DISPO M2]

[ASK IF PHONE=7,9 OR CELLFON2=7,9]

NOTCELL2. Thank you for your time.

1 Continue [ASSIGN DISPO M2]

[ASK IF CELLFON2=1]

CADULT. Are you 18 years of age or older?

[ASK IF CADULT=2]

NOTOLD. Thank you very much, but we are only interviewing persons aged 18 or older at this time.

1 Continue [ASSIGN DISPO M6]

[ASK IF CADULT=1]

SEX2. Are you male or female?

READ IF NECESSARY: We ask this question to determine which health related questions apply to each respondent. For example, males might be asked about prostate health issues.

9 REFUSED

[ASK IF SEX2=9]

XX6. Thank you for your time, your number may be selected for another survey in the future.

1 Continue [ASSIGN DISPO R3]

[IF SEX2=1 SET HGENDER=1 (Male); IF SEX2 =2 SET HGENDER=2 (Female)]

[ASK IF CADULT=1]

PVTRESD2. Do you live in a private residence?

READ ONLY IF NECESSARY: By private residence we mean someplace like a house or apartment.

INTERVIEWER NOTE: PRIVATE RESIDENCE INCLUDES ANY HOME WHERE THE RESPONDENT SPENDS AT LEAST 30 DAYS INCLUDING VACATION HOMES, RV’S OR OTHER LOCATIONS IN WHICH THE RESPONDENT LIVES FOR PORTIONS OF THE YEAR.

[ASK IF PVTRESD2=2]

COLLEGE2. Do you live in college housing?

READ ONLY IF NECESSARY: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.

INTERVIEWER NOTE: IF NO, PROBE TO FIND OUT IF BUSINESS OR GROUP HOME.

[ASK IF COLLEGE2=2,3,7,9 OR PVTRESD2=7,9]

NOTARES. Thank you very much, but we are only interviewing persons who live in a private residence or college housing at this time.

1 Continue [ASSIGN DISPO M8]

[ASK IF PVTRESD2=1 OR COLLEGE2=1]

CSTATE. Do you currently live in [STATE]?

[ASK IF CSTATE=7,9]

X5. Thank you very much for your time.

1 Continue [ASSIGN DISPO M7]

[ASK IF CSTATE=2]

RSPSTATE. In what state do you currently live?

[ASK IF CSTATE=2 AND (STATE=NJ AND RSPSTATE=NJ)]

STATEVER. I’m sorry, I previously recorded that you did not live in [STATE]. I need to go back and correct this inconsistency.

1 Continue [GO BACK TO CSTATE]

[ASK IF RSPSTATE=99]

REFSTATE. I’m sorry, but our data is compiled by state. In order to qualify for the interview we need to know which state you live in. Thank you for your time.

1 Continue [ASSIGN DISPO M7]

[ASK IF RSPSTATE=77]

REFSTATE2. Thank you very much, but we are only interviewing persons who live in the United States.

1 Continue [ASSIGN DISPO M7]

[ASK IF CSTATE=2]

RSPSTATE_CHK. Just to confirm, you said you currently live in [RSPSTATE], is that correct?

[ASK IF SAMPTYPE=2]

LANDLINE. Do you also have a landline telephone in your home that is used to make and receive calls?

READ ONLY IF NECESSARY: By landline telephone, we mean a regular telephone in your home that is used for making or receiving calls. Please include landline phones used for both business and personal use.

[ASK IF PVTRESD2=1]

NUMADULT. How many members of your household, including yourself, are 18 years of age or older?

RANGE 1-18 [NUMBER BOX]

77 DON’T KNOW/NOT SURE

99 REFUSED

[ASK IF SAMPTYPE=2]

SVINTRO. I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call [DEPTPHONE].

INTERVIEWER NOTE: The interview takes on average [LENGTH] minutes depending on your answers.

9 REFUSED [GO TO TERM SCREEN]

Core Sections

Section 1: Health Status

[ASK ALL]

S1Q1. Section 1: Health Status

Would you say that in general your health is —

PLEASE READ

DO NOT READ

Section 2: Healthy Days

[ASK ALL]

S2Q1. Section 2: Healthy Days

Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

INTERVIEWER: 88 may be coded if respondent says “never” or “none”. It is not necessary to ask respondents to provide a number if they indicate that this never occurs.

RANGE 1-30 [NUMBER BOX] Number of days

88 None

[ASK ALL]

S2Q2. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

INTERVIEWER: 88 may be coded if respondent says “never” or “none”. It is not necessary to ask respondents to provide a number if they indicate that this never occurs.

RANGE 1-30 [NUMBER BOX] Number of days

88 None

[ASK IF S2Q1 NE 88 OR S2Q2 NE 88]

S2Q3. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

INTERVIEWER: 88 may be coded if respondent says “never” or “none”. It is not necessary to ask respondents to provide a number if they indicate that this never occurs.

RANGE 1-30 [NUMBER BOX] Number of days

88 None

Section 3: Healthcare Access

[ASK ALL]

S3Q1. Section 3: Healthcare Access

What is the current primary source of your health care coverage?

Interviewer: If respondent has multiple sources of insurance, ask for the one used most often.

Interviewer: If respondents give the name of a health plan rather than the type of coverage, ask whether this is insurance purchased independently, through their employer, or whether it is through Medicaid or CHIP.

READ IF NECESSARY:

DO NOT READ

[ASK ALL]

S3Q2. Do you have one person (or a group of doctors) that you think of as your personal health care provider?

If no, read: “Is there more than one, or is there no person who you think of as your personal doctor or health care provider?”

INTERVIEWER NOTE: if the respondent had multiple doctor groups then it would be more than one - but if they had more than one doctor in the same group it would be one.

[ASK ALL]

S3Q3. Was there a time in the past 12 months when you needed to see a doctor but could not because you could not afford it?

[ASK ALL]

S3Q4. About how long has it been since you last visited a doctor for a routine checkup?

READ IF NECESSARY: A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.

READ IF NECESSARY

DO NOT READ

Section 4: Exercise

S4Q1. Section 4: Exercise

During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

INTERVIEWER NOTE DO NOT READ: If respondent does not have a regular job or is retired, they may count the physical activity or exercise they spend the most time doing in a regular month.

INTERVIEWER NOTE: Physical activity done at a work gym during the workday would count

Section 5: Oral Health

S5Q1. Section 5: Oral Health

Including all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists, how long has it been since you last visited a dentist or a dental clinic for any reason?

READ IF NECESSARY:

DO NOT READ:

[ASK ALL]

S5Q2. Not including teeth lost for injury or orthodontics, how many of your permanent teeth have been removed because of tooth decay or gum disease?

READ IF NECESSARY: If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth.

READ IF NECESSARY:

DO NOT READ:

Section 6: Chronic Health Conditions

S6Q1. Section 6: Chronic Health Conditions

Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You’re Not Sure.

Ever told you that you had a heart attack also called a myocardial infarction?

[ASK ALL]

S6Q2. (Ever told) (you had) angina or coronary heart disease?

[ASK ALL]

S6Q3. (Ever told) (you had) a stroke?

[ASK ALL]

S6Q4. (Ever told) (you had) asthma?

[ASK IF S6Q4=1]

S6Q5. Do you still have asthma?

[ASK ALL]

S6Q6. (Ever told) (you had) skin cancer that is not melanoma?

[ASK ALL]

S6Q7. (Ever told) (you had) melanoma or any other types of cancer?

[ASK ALL]

S6Q8. (Ever told) (you had) C.O.P.D. (chronic obstructive pulmonary disease), emphysema or chronic bronchitis?

S6Q9. (Ever told) (you had) a depressive disorder (including depression, major depression, dysthymia, or minor depression)?

Read if necessary: Dysthymia, renamed persistent depressive disorder, characterized by depressed mood occurring for most of the day, for more days than not, over a minimum duration of two years. It is distinguished from major depressive disorder by its chronicity and typically less severe but more persistent symptom presentation. Individuals with dysthymia may also experience superimposed episodes of major depression (historically termed "double depression").

[ASK ALL]

S6Q10. Not including kidney stones, bladder infection or incontinence, were you ever told you had kidney disease?

READ IF NECESSARY: Incontinence is not being able to control urine flow.

[ASK ALL]

S6Q11. (Ever told) (you had) some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?

INTERVIEWER DO NOT READ: Arthritis diagnoses include: rheumatism, polymyalgia rheumatic, osteoarthritis (not osteoporosis), tendonitis, bursitis, bunion, tennis elbow, carpal tunnel syndrome, tarsal tunnel syndrome, joint infection, Reiter’s syndrome, ankylosing spondylitis; spondylosis, rotator cuff syndrome, connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome, vasculitis, giant cell arteritis, Henoch-Schonlein purpura, Wegener’s granulomatosis, polyarteritis nodosa)

[ASK ALL]

S6Q12. (Ever told) (you had) diabetes?

INTERVIEWER: If yes and respondent is female, ask: was this only when you were pregnant? If respondent says pre-diabetes or borderline diabetes, use response code 4.

[ASK IF HGENDER=1 AND S6Q12=2]

S6Q12A. INTERVIEWER: You recorded that the respondent was told by a doctor during pregnancy that she had diabetes. Are you sure? The respondent selected was male.

You have to go back and correct this INCONSISTENCY ERROR.

01 GO BACK [GO TO S6Q12]

Module 1: Prediabetes

[ASK IF S6Q12 NE 1 AND CSTATE NE 2]

MOD1_1. Module 1: Prediabetes

When was the last time you had a blood test for high blood sugar or diabetes by a doctor, nurse, or other health professional?

[ASK IF S6Q12 NE 1,4 AND CSTATE NE 2]

MOD1_2. Has a doctor or other health professional ever told you that you had prediabetes or borderline diabetes?

INTERVIEWER NOTE: If Yes and respondent is female, ask: Was this only when you were pregnant?

[ASK IF HGENDER=1 AND MOD1_2=2]

MOD1_2A. INTERVIEWER: You recorded that the respondent was told by a doctor during pregnancy that she had pre-diabetes or borderline diabetes. Are you sure? The respondent selected was male.

You have to go back and correct this INCONSISTENCY ERROR.

1 Go Back [GO BACK TO MOD1_2]

[ASK IF S6Q12=1]

S6Q13. How old were you when you were first told you had diabetes?

INTERVIEWER: 97 = 97 or older

RANGE 1-97 [NUMBER BOX] Code age in years

Module 2: Diabetes

[ASK IF S6Q12=1 AND CSTATE NE 2]

MOD2_1. Module 2: Diabetes

According to your doctor or other health professional, what type of diabetes do you have?

[ASK IF S6Q12=1 AND CSTATE NE 2]

MOD2_2. Insulin can be taken by shot or pump. Are you now taking insulin?

[ASK IF S6Q12=1 AND CSTATE NE 2]

MOD2_3. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for A-one-C?

READ IF NECESSARY: A test for A-one-C measures the average level of blood sugar over the past three months.

INTERVIEWER: 76 = 76 or more

RANGE 1-76 [NUMBER BOX]

[ASK IF S6Q12=1 AND CSTATE NE 2]

MOD2_4. When was the last time you had an eye exam in which the pupils were dilated, making you temporarily sensitive to bright light?

READ IF NECESSARY

DO NOT READ

[ASK IF S6Q12=1 AND CSTATE NE 2]

MOD2_5. When was the last time a doctor, nurse or other health professional took a photo of the back of your eye with a specialized camera?

READ IF NECESSARY

DO NOT READ

[ASK IF S6Q12=1 AND CSTATE NE 2]

MOD2_6. When was the last time you took a course or class in how to manage your diabetes yourself?

READ IF NECESSARY

DO NOT READ

[ASK IF S6Q12=1 AND CSTATE NE 2]

MOD2_7. Have you ever had any sores or irritations on your feet that took more than four weeks to heal?

Section 7: Demographics

[ASK ALL]

S7Q1. Section 7: Demographics

What is your age?

RANGE 18-99 [NUMBER BOX] Code age in years

[ASK IF S6Q13>S7Q1 AND S7Q1 NE 07,09 AND S6Q13 NE 98,99]

S7Q1CHK. You said you are [S7Q1] years of age and told you had diabetes at age [S6Q13]. I must correct this inconsistency.

1 GO BACK [GO TO S7Q1]

[ASK IF MOD4_2>S7Q1 AND S7Q1 NE 07,09 AND MOD4_2 NE 98,99]

S7Q1CHK2. You said you are [S7Q1] years of age and told you had cancer at age [MOD4_2]. I must correct this inconsistency.

1 GO BACK [GO TO S7Q1]

[ASK ALL]

S7Q2. Are you Hispanic, Latino/a, or Spanish origin?

[ASK IF S7Q2=2]

[MUL=4]

S7Q2B. Are you…

INTERVIEWER NOTE: One or more categories may be selected.

PLEASE READ

DO NOT READ

[MUL=6]

S7Q3. Which one or more of the following would you say is your race?

INTERVIEWER NOTE: Select all that apply.

INTERVIEWER NOTE: If respondent indicates that they are Hispanic for race, please read the race choices.

PLEASE READ

DO NOT READ

[ASK IF S7Q3=40]

[MUL=8]

S7Q3A. Is that …

INTERVIEWER NOTE: Select all that apply.

INTERVIEWER NOTE: If respondent indicates that they are Hispanic for race, please read the race choices.

PLEASE READ

DO NOT READ

[ASK IF S7Q3=50]

[MUL=4]

S7Q3PI. Is that…

INTERVIEWER NOTE: Select all that apply.

INTERVIEWER NOTE: If respondent indicates that they are Hispanic for race, please read the race choices.

PLEASE READ

DO NOT READ

Module 19: Sexual Orientation

[ASK IF HGENDER=1 AND CSTATE NE 2]

MOD19_1A. Module 19: Sexual Orientation

The next question is about sexual orientation.

Which of the following best represents how you think of yourself?

READ IF NECESSARY: We ask this question in order to better understand the health and health care needs of people with different sexual orientations.

INTERVIEWER NOTE: Please say the number before the text response. Respondent can answer with either the number or the text/word.

PLEASE READ:

DO NOT READ:

[ASK IF HGENDER=2 AND CSTATE NE 2]

MOD19_1B. The next question is about sexual orientation.

Which of the following best represents how you think of yourself?

READ IF NECESSARY: We ask this question in order to better understand the health and health care needs of people with different sexual orientations.

INTERVIEWER NOTE: Please say the number before the text response. Respondent can answer with either the number or the text/word.

PLEASE READ:

DO NOT READ:

NJ State Added Section 1: Where Born

[ASK IF STATE=NJ AND CSTATE NE 2]

NJ1_1. State Added Section 1: Where Born

Where were you born?

INTERVIEWER: Puerto Rico, Guam, and Virgin Islands should be included in “Outside U.S.”

1 In U.S.

2 Outside U.S.

[ASK IF STATE=NJ AND NJ1_1 = 2 AND CSTATE NE 2]

NJ1_1B. (Read if necessary: In what country were you born?)

INTERVIEWER: RECORD COUNTRY OF BIRTH

88 Other 99 Refused

[ASK IF STATE=NJ AND NJ1_1 = 2 AND NJ1_1B NE GQ, RQ, VQ AND CSTATE NE 2]

NJ1_2. Approximately how old were you when you came to live in the United States permanently?

INTERVIEWER: 97 = 97 and older

_ _ Range 0-97 [Number Box]

[ASK IF STATE=NJ AND NJ1_1=2 AND (S7Q1<NJ1_2) AND NJ1_2 NE 98,99 AND S7Q1 NE 07,09 AND CSTATE NE 2] NJ1_2ck. I would like to confirm some responses, you are [S7Q1] years old, but you came to live in the United States at age [NJ1_2]. Is this correct?

[ASK ALL]

S7Q4. Are you…?

PLEASE READ

DO NOT READ

9 REFUSED

[ASK ALL]

S7Q5. What is the highest grade or year of school you completed?

READ IF NECESSARY

DO NOT READ

9 REFUSED

S7Q6. Do you own or rent your home?

INTERVIEWER NOTE: Other arrangement may include group home, staying with friends or family without paying rent.

INTERVIEWER NOTE: Home is defined as the place where you live most of the time / the majority of the year.

INTERVIEWER READ IF NECESSARY: We ask this question in order to compare health indicators among people with different housing situations.

NJ State-Added Section: County

[ASK IF STATE=NJ AND CSTATE NE 2]

NJ_CNTY. State-Added Section: County

In what county do you currently live?

777 Don’t know / Not sure 999 Refused

[ASK IF CSTATE=2]

CNTY. In what county do you currently live?

1 Gave Response [TEXT BOX]

[ASK ALL]

S7Q8. What is the ZIP Code where you currently live?

RANGE 00001-99999 [NUMBER BOX]

[ASK IF STATE=NJ AND S7Q8 NE 07000-08999,99999,77777 AND CSTATE NE 2]

S7Q8CHK2. I am sorry, the zip code you have given me is not a valid New Jersey zip code. I must go back and correct this inconsistency.

1 Continue [GO BACK TO S7Q8]

NJ State-Added Section 2: City/Town

[ASK IF STATE=NJ AND CSTATE NE 2]

NJFILTER. State-Added Section: Town

What city or town do you live in?

INTERVIEWER NOTE: Please read the municipalities listed in the populated town list.

[INSERT SQL FILTER]

7777 DON’T KNOW / NOT SURE

9999 REFUSED

8888 INTERVIEWER: If City/Town is not listed, please record their verbatim response [TEXT BOX]

//Hidden question populated with corresponding town response coding selected at NJFILTER//

NJCITYC.

Variable to record town code (CITYC) recorded on NJFILTER

Full response list can be found in \\ICFI.icfconsulting.com\ORG\HESP\PHaSR\2_Active Projects\CDC\BRFSS\BRFSS24\NJ\Operations Files\Questionnaire\NJ TOWN Spreadsheets> NJ_ZipCodes_v3.xlsx

//Hidden question populated with corresponding town response selected at NJFILTER//

NJTOWN.

What city or town do you live in?

[ASK IF STATE=NJ AND CSTATE NE 2 AND NOT(S7Q8=77777,99999 AND NJ_CNTY=777,999 AND NJFILTER=7777,9999) NJTOWN_1CK. I just want to confirm, [IF S7Q8 NE 77777,99999 INSERT “your zip code is [S7Q8],”] [IF NJ_CNTY NE 777,999 INSERT “your county is [NJ_CNTY],”] [IF NJFILTER NE 7777,9999 INSERT “your town is [NJTOWN]”]. Is that correct?

1 Yes 2 No [Go BACK TO S7Q8]

[ASK IF SAMPTYPE=1]

S7Q9. Not including cell phones or numbers used for computers, fax machines or security systems, do you have more than one landline telephone number in your household?

[ASK IF S7Q9=1]

S7Q10. How many of these landline telephone numbers are residential numbers?

RANGE 1-5 [NUMBER BOX] Enter number

[ASK ALL]

S7Q11. How many cell phones do you have for your personal use?

READ IF NECESSARY: Include cell phones used for both business and personal use.

RANGE 1-5 [NUMBER BOX] Enter number

6 Six or more

[ASK ALL]

S7Q12. Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?

READ IF NECESSARY: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.

[ASK ALL]

S7Q13. Are you currently…?

INTERVIEWER NOTE: If more than one, say “Select the category which best describes you”.

PLEASE READ

DO NOT READ

9 REFUSED

[ASK ALL]

S7Q14. How many children less than 18 years of age live in your household?

RANGE 1-87 [NUMBER BOX] Number of children

[ASK IF S7Q14=1-87]

S7Q14CHK. INTERVIEWER DO NOT READ: you entered the respondent has [S7Q14] [IF S7Q14=1 INSERT “child”; IF S7Q14=2-87 INSERT “children”] under 18 living in their household. Is that correct?

9 REFUSED

S7Q15A. Is your annual household income from all sources –

Less than $35,000 ($25,000 to less than $35,000)?

INTERVIEWER NOTE: If respondent refuses at any income level, code ‘99’ (refused)

[ASK IF S7Q15A=01]

S7Q15B. Less than $25,000 ($20,000 to less than $25,000)?

READ ONLY IF NECESSARY: Is your annual household income from all sources—

[ASK IF S7Q15B=01]

S7Q15C. Less than $20,000 ($15,000 to less than $20,000)?

READ ONLY IF NECESSARY: Is your annual household income from all sources—

[ASK IF S7Q15C=01]

S7Q15D. Less than $15,000 ($10,000 to less than $15,000)?

READ ONLY IF NECESSARY: Is your annual household income from all sources—

[ASK IF S7Q15D=01]

S7Q15E. Less than $10,000?

READ ONLY IF NECESSARY: Is your annual household income from all sources—

[ASK IF S7Q15A=02]

S7Q15F. Less than $50,000 ($35,000 to less than $50,000)?

READ ONLY IF NECESSARY: Is your annual household income from all sources—

[ASK IF S7Q15F=02]

S7Q15G. Less than $75,000 ($50,000 to less than $75,000)?

READ ONLY IF NECESSARY: Is your annual household income from all sources—

[ASK IF S7Q15G=02]

S7Q15H. Less than $100,000 ($75,000 to less than $100,000)?

READ ONLY IF NECESSARY: Is your annual household income from all sources—

[ASK IF S7Q15H=02]

S7Q15I. Less than $150,000 ($100,000 to less than $150,000)?

READ ONLY IF NECESSARY: Is your annual household income from all sources—

[ASK IF S7Q15I=02]

S7Q15J. Less than $200,000 ($150,000 to less than $200,000)?

READ ONLY IF NECESSARY: Is your annual household income from all sources—

[ASK IF S7Q15J=02]

S7Q15K. $200,000 or more?

READ ONLY IF NECESSARY: Is your annual household income from all sources—

[ASK ALL]

S7Q15.

Aggregated response to income question

SET S7Q15=01 IF S7Q15E=01

SET S7Q15=02 IF S7Q15E=02

SET S7Q15=03 IF S7Q15D=02

SET S7Q15=04 IF S7Q15C=02

SET S7Q15=05 IF S7Q15B=02

SET S7Q15=06 IF S7Q15F=01

SET S7Q15=07 IF S7Q15G=01

SET S7Q15=08 IF S7Q15H=01

SET S7Q15=09 IF S7Q15I=01

SET S7Q15=10 IF S7Q15J=01 OR IF S7Q15K=02

SET S7Q15=11 IF S7Q15K=01

SET S7Q15=77 IF ANY S7Q15A-S7Q15K=77

SET S7Q15=99 IF ANY S7Q15A-S7Q15K=99

[ASK IF S7Q15 NE 77,99]

S7Q15AA. Your Annual Household Income is [S7Q15]. Is this Correct?

[ASK IF HGENDER=2 AND S7Q1=18-49]

S7Q16. To your knowledge, are you now pregnant?

[ASK ALL]

PS7Q17. About how much do you weigh without shoes?

INTERVIEWER NOTE: ENTER “P” FOR WEIGHT GIVEN IN POUNDS OR ENTER “K” FOR WEIGHT GIVEN IN KILOGRAMS

[ASK IF PS7Q17=P]

S7Q17. About how much do you weigh without shoes?

INTERVIEWER NOTE: Round fractions up

RANGE 50-776 [NUMBER BOX] Weight

[ASK IF S7Q17=50-79 OR S7Q17=351-776]

S7Q17_A. INTERVIEWER DO NOT READ: You entered [S7Q17] pounds as the respondent’s weight. IS THIS CORRECT?

[ASK IF PS7Q17=K]

S7Q17M. About how much do you weigh without shoes?

INTERVIEWER NOTE: Round fractions up

RANGE 23-352 [NUMBER BOX] Weight

[ASK IF S7Q17M=23-352 AND PS7Q17=K]

S7Q17AM. INTERVIEWER DO NOT READ: You entered [S7Q17M] kilograms as the respondent’s weight. IS THIS CORRECT?

[ASK ALL]

PS7Q18. About how tall are you without shoes?

INTERVIEWER NOTE: ENTER “F” FOR HEIGHT GIVEN IN FEET OR ENTER “M” FOR HEIGHT GIVEN IN CENTIMETERS

[ASK IF PS7Q18=F]

S7Q18. About how tall are you without shoes?

INTERVIEWER NOTE: Round fractions down. Enter height in Feet and Inches Ex: 5 feet 9 inches would be entered as 509

RANGE 300-311, 400-411, 500-511, 600-611, 700-711 [NUMBER BOX] Height

[ASK IF S7Q18=300-407 OR S7Q18=609-711]

S7Q18A. INTERVIEWER DO NOT READ: You entered [S7Q18] FEET / INCHES TALL. IS THIS CORRECT?

[ASK IF PS7Q18=M]

S7Q18M. About how tall are you without shoes?

INTERVIEWER NOTE: Round fractions down. Enter height in centimeters. Ex: 2 meters 5 centimeters would be entered as 205

RANGE 90-254 [NUMBER BOX] Height

[ASK IF S7Q18M=90-254 AND PS7Q18=M]

S7Q18AM. INTERVIEWER DO NOT READ: You entered [S7Q18M] centimeters tall. IS THIS CORRECT?

Section 8: Disability

[ASK ALL]

S8Q1. Section 8: Disability

Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone.

Are you deaf or do you have serious difficulty hearing?

[ASK ALL]

S8Q2. Are you blind or do you have serious difficulty seeing, even when wearing glasses?

[ASK ALL]

S8Q3. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

[ASK ALL]

S8Q4. Do you have serious difficulty walking or climbing stairs?

[ASK ALL]

S8Q5. Do you have difficulty dressing or bathing?

[ASK ALL]

S8Q6. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

Section 9: Falls

[ASK IF S7Q1>44 OR S7Q1=07, 09]

S9Q1. Section 9: Falls

In the past 12 months, how many times have you fallen?

READ IF NECESSARY: By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.

INTERVIEWER NOTE: Code any number more than 76 as 76

RANGE 1-76 [NUMBER BOX]

[ASK IF S9Q1=1-76]

S9Q2. How many of these falls caused an injury that limited your regular activities for at least a day or caused you to go see a doctor?

READ IF NECESSARY: By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor.

INTERVIEWER NOTE: 76= 76 or more

RANGE 1-76 [NUMBER BOX]

[ASK IF S9Q2>S9Q1 AND S9Q2 NE 77,88,99]

S9Q2CHK. I'm sorry, you indicated you had [S9Q1] falls previously but just stated you had [S9Q2] falls that caused an injury that limited your regular activities. I must correct this inconsistency.

1 GO BACK [GO TO S9Q1]

Section 10: Breast and Cervical Cancer Screening

[ASK IF HGENDER=2]

S10Q1. Section 10: Breast and Cervical Cancer Screening

The next questions are about breast and cervical cancer.

Have you ever had a mammogram?

INTERVIEWER NOTE: A mammogram is an x-ray of each breast to look for breast cancer.

1 Yes 2 No

7 DON’T KNOW / NOT SURE

9 REFUSED

[ASK IF S10Q1=1]

S10Q2. How long has it been since you had your last mammogram?

READ IF NECESSARY

1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago

DO NOT READ

7 DON’T KNOW / NOT SURE

9 REFUSED

[ASK IF HGENDER=2]

S10Q3. There are two different kinds of…