DMQ 2011 DEMOGRAPHICS (DMQ)

[Pages:7]DMQ 2011

DEMOGRAPHICS (DMQ)

SPID#:_____________

Date:______________ Interviewer#:_____________

Next I will be asking about your background. This includes your education, marital status, race and ancestry, and other things that can sometimes be associated with people's health.

Date (mm/dd/yyy) __ __/__ __/ __ __ __ __

Begin time of questionnaire __ __ : _:

__ am ____pm

Audio taping started ___ yes ___no

_ __

DMQ.010. What is the highest grade or level of school you completed or the highest

degree you received? [HAND CARD]

DMQ010

FMT_EDUCATION.

Never Attended/Kindergarten Only

0

1st Grade

1

2nd Grade

2

3rd Grade

3

4th Grade

4

5th Grade

5

6th Grade

6

7th Grade

7

8th Grade

8

9th Grade

9

10th Grade

10

11th Grade

11

12th Grade, No Diploma

12

High School Graduate

13

GED or Equivalent

14

Some College, No Degree

15

Associate Degree: Occupational,

Technical, Or Vocational Program

16

Associate Degree: Academic Program

17

Bachelor's Degree (i.e., BA, AB, BS, BBA)

18

Master's Degree (i.e., MA, MS, MEng, MEd, MBA) 19

Professional Degree (i.e., MD, DDS, DVM, JD) 20

Doctoral Degree (i.e., PhD, EdD)

21

Don't Know

(d)

Refused

(r)

DMQ.020. Are you now going to school to obtain a degree?

DMQ020

FMT_YES_NO.

Yes

1

No

2

Don't Know

(d)

Refused

(r)

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DMQ 2011

SPID#:_____________

DEMOGRAPHICS (DMQ) Date:______________ Interviewer#:_____________

DMQ.030. Did you ever serve in the Armed Forces of the United States?

DMQ030

FMT_YES_NO.

Yes

1

No

2

Don't Know

(d)

Refused

(r)

DMQ.040. What is your marital status?

DMQ040

FMT_MARITAL_STATUS.

Married

1

Widowed

2

Divorced

3

Separated

4

Never married

5

Living with partner 6

Don't Know

(d)

Refused

(r)

DMQ.050. Are you Hispanic or Latino?

DMQ050

FMT_YES_NO.

Yes

1

No

2

Don't Know

(d)

Refused

(r)

DMQ.060. Which one or more of the following would you say is your race? [Enter all that

apply. HAND CARD]

DMQ060_A

FMT_RACE.

DMQ060_B

FMT_RACE.

DMQ060_C

FMT_RACE.

DMQ060_D

FMT_RACE.

DMQ060_E

FMT_RACE.

DMQ060_F

FMT_RACE.

DMQ060_OTHER

$FMT_CHAR.

White

1

Black or African American

2

Asian

3

Native Hawaiian or Pacific Islander

4

American Indian or Alaska Native

5

Other (Specify: ___________________________) 6

Don't Know

(d)

Refused

(r)

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DMQ 2011

SPID#:_____________

DEMOGRAPHICS (DMQ) Date:______________ Interviewer#:_____________

BIRTH PLACE and NATIONALITY OF ANCESTORS and ACCULTURATION

Many people in the U.S. come from other countries, or have ancestors who came from another country. Sometimes our ancestry plays an important role in our health and it would be very helpful to this survey to know about this information. Examples of a person's ancestry could be Irish, Mexican, African, Ethiopian, Swedish, German, Hmong, Vietnamese, and so on.

DMQ.065. What is your ancestry or ethnic origin? [Enter as many as apply.

DMQ065

$FMT_CHAR.

Enter _____ ______________________

___________________________________________________________

Don't Know

(d)

Refused

(r)

Information about citizenship and place of birth is being asked by SHOW as it may help us understand risks to health. Providing this information is voluntary and is protected by a certificate of confidentiality. It will not be shared with any other agency or with the government.

DMQ.070. Are you a citizen of the United States by either birth or naturalization?

DMQ070

FMT_CITIZEN.

Yes, by birth

1

Yes, by naturalization

2 (Skip to DMQ.072)

No, not a citizen of the United States

3 (Skip to DMQ.072)

Don't Know

(d)

Refused

(r)

DMQ.071. In what state or US territory were you born? [CAPI: drop down box / PAPI: HAND

CARD]

DMQ071

FMT_STATE.

Enter ____ ______

(Skip to DMQ.074)

In foreign country (FC) to parents who were US citizens FC

Don't Know Refused

(d) (Skip to DMQ.074) (r) (Skip to DMQ.074)

DMQ.072. In what country were you born? [CAPI: drop down box / PAPI: HAND CARD]

DMQ072

$FMT_CHAR.

Enter name of country _________ ______

Don't Know

(d)

Refused

(r)

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DMQ 2011

DEMOGRAPHICS (DMQ)

SPID#:_____________

Date:______________ Interviewer#:_____________

DMQ.073. In what month and year did you come to the United States to stay?

DMQ073_M

FMT_NUMCAT.

DMQ073_Y

FMT_NUMCAT.

|___|___| / |___|___|___|___|

mm

yyyy

Don't Know

(d)

Refused

(r)

DMQ.074. In what country was your birth mother born? [CAPI: drop down box / PAPI: HAND

CARD]

DMQ074

$FMT_CHAR.

Enter name of country _____ __________

Don't Know

(d)

Refused

(r)

DMQ.075. In what country was your birth father born? [CAPI: drop down box / PAPI: HAND

CARD]

DMQ075

$FMT_CHAR.

Enter name of country ________

Don't Know

(d)

Refused

(r)

DMQ.080. What language(s) do you usually speak at home? [ENTER ALL THAT APPLY]

DMQ080_A

FMT_LANGUAGE.

DMQ080_B

FMT_LANGUAGE.

DMQ080_C

FMT_LANGUAGE.

DMQ080_OTHER

$FMT_CHAR.

English

1

Spanish

8

Other (Specify Languages):

9

Other (Specify Languages):

9

Other (Specify Languages):

9

Don't Know

(d)

Refused

(r)

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DMQ 2011

SPID#:_____________

DEMOGRAPHICS (DMQ) Date:______________ Interviewer#:_____________

The next questions are about your income in the last 12 months. In the Unites States income has been associated with health status, ability to get insurance, and ability to follow screening and treatment recommendations. This information, like all the information you provide, will be kept confidential. When answering these questions, please remember that by income we mean income before taxes and from all sources. Here is a card with typical sources of income. [HAND SOURCES OF INCOME CARD] The response categories are broken down by yearly income and the monthly equivalent for that range and you give the associated letter to identify your income category.

INQ.100. Considering all the sources of income, can you tell me which letter on this card

best represents your individual income before taxes in the last 12 months or in

the last month? [HAND INCOME RANGE CARD]

INQ100

$FMT_INCOME.

INQ100 (hand card info)

Income for Year

Income for Month

A.

Less than $10,000

Less than $832

B.

$10,000 to $14,999

$833 to $1,249

C.

$15,000 to $19,999

$1,250 to $1,666

D.

$20,000 to $24,999

$1,667 to $2,083

E.

$25,000 to $29,999

$2,083 to $2,499

F.

$30,000 to $34,999

$2,500 to $2,916

G. $35,000 to $39,999

$2,917 to $3,333

H.

$40,000 to $44,999

$3,334 to $3,749

I.

$45,000 to $49,999

$3,750 to $4,166

J.

$50,000 to $59,999

$4,167 to $4,999

K

$60,000 to $74,999

$5,000 to $6,249

L.

$75,000 to $99,999

$6,250 to $8,333

M. $100,000 to $124,999

$8,334 to $10,416

N.

$125,000 to $149,999

$10,417 to $12,499

O. $150,000 to $199,999

$12,500 to $16,666

P.

$200,000 or more

$16,667 or more

Enter letter: _____________

Don't Know

(d)

Refused

(r)

INQ.200.

Now, considering all the sources of income, can you tell me which letter on this card best represents the combined family income before taxes in the last 12 months or in the last month? [HAND INCOME RANGE CARD]

INQ200

$FMT_INCOME.

INQ100 (hand card info)

A.

Income for Year Less than $10,000

Income for Month Less than $832

B.

$10,000 to $14,999

$833 to $1,249

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DMQ 2011

DEMOGRAPHICS (DMQ)

SPID#:_____________

Date:______________ Interviewer#:_____________

C.

$15,000 to $19,999

D.

$20,000 to $24,999

E.

$25,000 to $29,999

F.

$30,000 to $34,999

G. $35,000 to $39,999

H.

$40,000 to $44,999

I.

$45,000 to $49,999

J.

$50,000 to $59,999

K

$60,000 to $74,999

L.

$75,000 to $99,999

M. $100,000 to $124,999

N.

$125,000 to $149,999

O. $150,000 to $199,999

P.

$200,000 or more

Enter letter: _____________

Don't Know

(d)

Refused

(r)

$1,250 to $1,666 $1,667 to $2,083 $2,083 to $2,499 $2,500 to $2,916 $2,917 to $3,333 $3,334 to $3,749 $3,750 to $4,166 $4,167 to $4,999 $5,000 to $6,249 $6,250 to $8,333 $8,334 to $10,416 $10,417 to $12,499 $12,500 to $16,666 $16,667 or more

INQ.201. INQ201

How many people were supported by this combined family income in the last 12

months?

FMT_NUMCAT.

Enter number: |____|____| (enter number 1-20)

(If greater than 20, enter 66)

Don't Know

(d)

Refused

(r)

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DMQ 2011

DEMOGRAPHICS (DMQ)

SPID#:_____________

Date:______________ Interviewer#:_____________

NOTE: Income ranges will be preprogrammed so that if a family income falls in a range that may be close to the poverty level for that size family, the computer will generate an extra question to try to determine if household income is above or below the poverty line for that size family. The computer will insert the dollar amount * in the following question.

This question is not asked when done on paper.

INQ.205. INQ205

Is your income below or above $(variable*) per {year/month}? FMT_BELOW_ABOVE.

Below

1

Above

2

Don't Know

(d)

Refused

(r)

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