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N12 Landline Questionnaire

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N12 Landline Questionnaire Macro International, Inc. INTRODUCTION/SCREENER Fieldwork Subcontractor for INTRO1 Alcohol Research Group Hello, my name is ______. I am calling as a part of a research study funded by the National Institutes National Alcohol Research Center of Health. [IF AN ADDRESS WAS AVAILABLE TO SEND AN INTRODUCTORY LETTER SAY: We PUBLIC HEALTH INSTITUTE may have sent a letter to your household describing the study.] 6475 Christie Ave., Suite 400 Emeryville, CA 94608 It will take just a minute to see who in your household is eligible to participate. (IF NECESSARY: This is a purely scientific study sponsored by the National Institute of Health with 2009-10 NATIONAL ALCOHOL SURVEY funding to the Public Health Institute. We are not trying to sell anything or conduct any sort of business (N12) MAIN QUESTIONNAIRE with you. Your opinions are very important to us.") Is this (phone number) ? Work on this project was supported by Center Grant P30 AA05595 from the If "no," U.S. National Institute on Alcohol Abuse and Alcoholism Thank you very much, but I seem to have dialed the wrong number. It's possible that your to the Alcohol Research Group number may be called at a later time. STOP National Alcohol Research Center on the Epidemiology of Alcohol Problems 6475 Christie Ave., Suite 400, Emeryville CA 94608 USA HS1 Is this a private residence? Thomas K Greenfield, PI, [email protected] If "no," Karen Trocki, Study Director [email protected] Thank you very much, but we are only interviewing private residences. STOP Jason Bond, Senior Biostatistician [email protected] Yu Ye, Biostatistician [email protected] HS2 NOTES: Is this a cellular telephone? 1. This is a draft version of N12. Since the final version of N12 will be in a CATI format, we are using Read only if necessary: "By cellular telephone we mean a telephone that is mobile and usable this draft version for development. Skip pattern may need refinements.. outside of your neighborhood." 2. We have tried to maintain the same question numbers as N10. Where new items have been inserted, they will have a code like BN instead of B to indicate these are new variables. In addition, BC If "yes," or BNC would be a variable in the B series that has been changed in some way. This version of the Thank you very much, but we are only interviewing land line telephones and private residences. questionnaire is not always in alphabetic and numeric order because of rearranging some sections and STOP moving some items. ADULTS I need to randomly select one adult who lives in your household to be interviewed. How many members of your household, including yourself, are 18 years of age or older? __ Number of adults If "1," ONEADULT. Are you the adult? If "yes," Then you are the person I need to speak with. Enter 1 man or 1 woman below (Ask gender if necessary). Go to "YOURTHE1". If "no," GETADULT. May I speak with (him/her)? Go to "NEWADULT" on the next page. 1 2 Page Page MEN ASK OF ALL How many of these adults are men? PMQA2 In what state, territory, or country were you born? __ Number of men 01 Gave Response WOMEN 02 Other Country (specify) How many of these adults are women? 97 Don’t Know 99 Refused __ Number of women ASK IF PMQA2=01 ASKFOR 01 Alabama 21 Louisiana 41 Oregon The person in your household that I need to speak with is . 02 Alaska 22 Maine 42 Pennsylvania If "you," go to "CONSENT" 03 American Samoa 23 Maryland 43 North Carolina NEWADULT: Hello, my name is ______. I am calling as a part of a research study funded by the National Institutes 04 Arizona 24 Massachusetts 44 Rhode Island of Health. My computer has randomly selected you from among the adult members of your household to participate in this study, we cannot substitute any other person. 05 Arkansas 25 Michigan 45 South Carolina YOURTHE1: 06 California 26 Minnesota 46 South Dakota Participation in the study involves answering questions about health related issues such as the experience of injuries, violence, and some background questions such as your age and marital status. 07 Colorado 27 Mississippi 47 Tennessee We are also interested in your attitudes, opinions and use of alcohol and drugs even if you do not drink alcoholic beverages or use drugs. Your participation provides important information for treatment and 08 Connecticut 28 Missouri 48 Texas policy on health-related issues. Participation is voluntary. If any questions make you uncomfortable just tell me and we can move on to the next one; you can postpone or end the interview at any time. 09 Delaware 29 Montana 49 Utah All of your answers to questions will be confidential. Your answers will be grouped with those of all the other participants. Any answers given cannot be linked with any personal identifying information.The 10 District of Columbia 30 Nebraska 50 Vermont survey takes about 20-45 minutes. Portions of this call may be monitored and recorded for quality control purposes. 11 Florida 31 Nevada 51 Virginia 12 Georgia 32 New Hampshire 52 Virgin Islands [if needed] If you have any questions, I can provide a telephone number for you to call to get more information. [if needed] You can verify the legitimacy of the study and learn more information at 13 Guam 33 New Jersey 53 Washington www.nationalstudy12.org. 14 Hawaii 34 New Mexico 54 West Virginia ASK OF ALL TIMING SECTION 1 15 Idaho 35 New York 55 Wisconsin A1 16 Illinois 36 North Carolina 56 Wyoming A1 First, I’d like to ask you a few questions for background purposes. (RECORD R’S GENDER) 17 Indiana 37 North Dakota 95 OTHER COUNTRY-SPECIFY (IF NECESSARY, ASK: Are you male or female?) 18 Iowa 38 Northern Marianas Islands 97 DON’T KNOW 01 Male 02 Female 19 Kansas 39 Ohio 99 REFUSED 3 IF GENDER FROM A1 DOESN’T MATCH GENDER FROM SCREENER, INTERVIEWER MUST GO 4 BACK TO FIX THE INCONSISTENCY Page Page 20 Kentucky 40 Oklahoma ASK IF A4=03 OR 05, OR A5=04 ASK IF MQA2=95 A6 Which one of these groups best describes your own ethnic identification: MQA2O. ENTER OTHER MENTION 01 Puerto Rican (SKIP TO PH1) __________________________________ 02 Cuban (SKIP TO PH1) (STATE/TERRITORY/COUNTRY) 03 Cuban American (SKIP TO PH1) 04 Mexican (SKIP TO PH1) ASK IF PMQA2=02 05 Mexican American (SKIP TO PH1) 06 Latin American (ASK A6o) A3 How many years have you lived in the United States? 07 Other Spanish-Hispanic (ASK A6o) 08 Anglo American (SKIP TO PH1) __________________ RANGE 0-105 09 South American (ASK A6o) (YEARS) 10 Central American (ASK A6o) 997 Don’t Know 95 Some other group? (ASK A6o) 999 Refused ASK IF A6=06, 07, 09, 10, OR 95 ASK OF ALL A4. Which one of these groups best describes your family origin: A6o. What country is that? (ALL RESPONSES SKIP TO PH1) 01 Asian (SKIP TO A8) 01 Antigua and Barbuda 14 El Salvador 27 Saint Kitts and Nevis 02 Black, not of Hispanic origin. (skip to A7) 03 Black of Hispanic origin (that is, Latino, Mexican, Central or South American, or any other 02 Argentina 15 Grenada 28 Saint Lucia Hispanic Origin.) (SKIP TO A6) 04 White, not of Hispanic origin. (SKIP TO PH1) 03 Barbados 16 Guatemala 29 Saint Vincent and the 05 White of Hispanic origin (that is, Latino, Mexican, Central or South American, or any other Grenadines Hispanic Origin.) (SKIP TO A6) 06 American Indian or Alaskan Native (SKIP TO PH1) 04 Belize 17 Guyana 30 Spain 07 Pacific Islander (SKIP TO PH1) 08 Other origin? (ASK A4o) 97 DON’T KNOW (SKIP TO PH1) 05 Bolivia 18 Haiti 31 Suriname 99 REFUSED (SKIP TO PH1) ASK IF A4=08 06 Brazil 19 Honduras 32 Trinidad and Tobago A4o. What origin is that? (SPECIFY) ______________________ 07 Chile 20 Jamaica 33 Uruguay ASK IF A4=08 A5. Which one of these racial and ethnic groups best describes most of your ancestors: 08 Costa Rica 21 Mexico 34 Venezuela 01 Asian (SKIP TO A8) 09 Cuba 22 Nicaragua 35 United States/American 02 Black (SKIP TO A7) 03 White (SKIP TO PH1) 10 Colombia 23 Panama 95 Other 04 Hispanic (ASK A6) 05 American Indian or Alaskan Native, or (SKIP TO PH1) 06 Pacific Islander (SKIP TO PH1) 11 Dominica 24 Paraguay 97 DON’T KNOW 97 DON’T KNOW (SKIP TO PH1) 99 REFUSED (SKIP TO PH1) 12 Dominican Republic 25 Peru 99 REFUSED 13 Ecuador 26 Portugal 5 6 Page Page ASK IF A4=02 OR A5=02 11 Cambodian, (SKIP TO PH1) 12 A7 Which one of the following terms best fits how you would describe yourself: Burmese, or (SKIP TO PH1) 95 Some other group? (ASK A8o) 01 American, (SKIP TO PH1) 97 DON’T KNOW (SKIP TO PH1) 99 REFUSED 02 African-American, (SKIP TO PH1) (SKIP TO PH1) 03 African, (SKIP TO PH1) 04 Black, (SKIP TO PH1) ASK IF A8=95 05 Negro, (SKIP TO PH1) 06 Creole, (SKIP TO PH1) A8o. What country is that? [ALL RESPONSES SKIP TO PH1] 07 Colored, (SKIP TO PH1) 08 West Indian, or (SKIP TO PH1) 01 Mixture 02 Bangladesh 95 Some other group (ASK A7o) 03 Bhutan 97 DON’T KNOW (SKIP TO PH1) 04 Brunei 99 Refused (SKIP TO PH1) 05 Kazakhstan ASK IF A7=95 06 North Korea 07 South Korea A7o. IF NECESSARY: Which one of the following terms best fits how you would describe yourself: 08 Kyrgyzstan 09 Maldives 01 Mixture (SKIP TO PH1) 10 Mongolia 02 Caribbean (SKIP TO PH1) 11 Myanmar 95 12 Nepal Other (SKIP TO PH1) 13 Singapore 97 DON’T KNOW (SKIP TO PH1) 14 Sri Lanka 99 15 Taiwan REFUSED (SKIP TO PH1) 16 Tajikistan ASK IF A4=01 OR A5=01 17 Turkmenistan 18 Uzbekistan A8.
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