Calculated Variable
VERSION	QDS Version	16

 	VERSION = QDS version

Calculated Variable
STTIME	START TIME	8

 	STTIME = Current time

Calculated Variable
TODAY		8

 	TODAY = Today's date

Calculated Variable
PAST30D	Date 30 days ago	128

 	PAST30D = LONGDATE(TODAY-30)

Info-DateTime.	(For Respondent) The date is recorded as [TODAY]  and the start time is recorded as [STTIME].

Q1.	Subject ID:
SUBJECT	Subject	3
	1 - 100	=	range

Q2.	SITE:
SITE	Site Code	1
	0	=	A
	1	=	B

Q3.	Enter Visit Code:
VISIT	Visit Code	1
	1	=	Baseline
	2	=	Followup

Sect-Demographics.

Demographics

Info-Welcome.	(For Respondent) Welcome to our Health Study.  Thank you for participating!

DEM1.	What is your gender?
GENDER	What is your gender?	1
	1	=	Male
	2	=	Female

DEM2.	How old are you?
AGE	How old are you?	2
	18 - 96	=	Years old

DEM3.	What is your current marital or partnership status?
STATUS	What is your current marital or partnership status?	1
	1	=	Legally married
	2	=	Never married
	3	=	Divorced
	4	=	Widowed
	5	=	Domestic partnership
	6	=	Other
	8	=	Refuse to Answer

Skip-1.	If ( STATUS ^= 6 ), Skip STATUS_S

DEM4.	Please specify other marital or partnership status:
STATUS_S	Please specify other marital or partnership status:	20
	0 - 20	=	length of response
	99	=	skipped

DEM5.	Which of the following best describe your race?
RACE	Which of the following best describe your race?	1
	0 - 6	=	number of selected items
	9	=	Don't Know
	7	=	Refuse to Answer
RACEA	Which of the following best describe your race?: White	1
	0	=	No
	1	=	Yes
	9	=	Don't Know
	7	=	Refuse to Answer

RACEB	Which of the following best describe your race?: Black or African American	1
	0	=	No
	1	=	Yes
	9	=	Don't Know
	7	=	Refuse to Answer

RACEC	Which of the following best describe your race?: Asian	1
	0	=	No
	1	=	Yes
	9	=	Don't Know
	7	=	Refuse to Answer

RACED	Which of the following best describe your race?: Native Hawaiian or Pacific Islander	1
	0	=	No
	1	=	Yes
	9	=	Don't Know
	7	=	Refuse to Answer

RACEE	Which of the following best describe your race?: American Indian or Alaska Native	1
	0	=	No
	1	=	Yes
	9	=	Don't Know
	7	=	Refuse to Answer

RACEF	Which of the following best describe your race?: Other	1
	0	=	No
	1	=	Yes
	9	=	Don't Know
	7	=	Refuse to Answer

Skip-2.	If ( RACEF ^= 1 ), Skip RACE_O

DEM5_o.	Please specify other race:
RACE_O	Please specify other race:	20
	0 - 20	=	length of response
	98	=	Refuse to Answer
	99	=	skipped

DEM6.	What is your date of birth?
DOB	What is your date of birth?	8
	1/1/1950 - Current	=	mm/dd/yyyy
DOBY	Year: What is your date of birth?	4
	1950 - Current	=	range
DOBM	Month: What is your date of birth?	2
	1 - 12	=	range
DOBD	Day: What is your date of birth?	2
	1 - 31	=	range

Sect-Health.	Health

Info-1.	(For Respondent) The next set of questions will ask about your health.

HLT1.	In the past year, has a health care provider recommended that you receive a flu vaccine?
FLU	In the past year, has a health care provider recommended that you receive a flu vaccine?	1
	0	=	No
	1	=	Yes
	7	=	Don't Know
	8	=	Refuse to Answer
	9	=	Not Applicable

HLT2.	Using the line as a guide, how would you rate your current state of health? Pick any number between 1 and 10.
HRATING	How would you rate your current state of health?	2
	1	=	Worst possible health
	2 - 9	=	unlabeled scale points
	10	=	Best possible health
	98	=	Refuse to Answer

HLT3.	Using any number from 1 to 10, where 1 is the worst medical care possible and 10 is the best medical care possible, what number would you use to rate the medical care you received in the past 12 months?  (Please select the number on the line)
CARE	Medical care rating	2
	1	=	Worst Possible Care
	2 - 4	=	unlabeled scale points
	5	=	Moderate Care
	6 - 9	=	unlabeled scale points
	10	=	Best Possible Care
	98	=	Refuse to Answer
	99	=	Not Applicable

HLT4.	How long has it been since your last medical appointment?
APPT	How long since last medical appointment	5
	0 - 9999	=	 (Days)
	99997	=	Don't Know
	99998	=	Refuse to Answer
	99999	=	Not Applicable
APPTY	Years: How long since last medical appointment	3
	0 - 27	=	range
	997	=	Don't Know
	998	=	Refuse to Answer
	999	=	Not Applicable
APPTM	Months: How long since last medical appointment	3
	0 - 11	=	range
	997	=	Don't Know
	998	=	Refuse to Answer
	999	=	Not Applicable
APPTD	Days: How long since last medical appointment	3
	0 - 29	=	range
	997	=	Don't Know
	998	=	Refuse to Answer
	999	=	Not Applicable

HLT5.	In the last 2 weeks, how much were you distressed by:

Nervousness or shakiness inside
BSI1	Nervousness or shakiness inside	1
	0	=	Not at all
	1	=	A little bit
	2	=	Moderately
	3	=	Quite a bit
	4	=	Extremely
	8	=	Refuse to Answer

HLT6.	In the last 2 weeks, how much were you distressed by:

Faintness
BSI2	Faintness	1
	0	=	Not at all
	1	=	A little bit
	2	=	Moderately
	3	=	Quite a bit
	4	=	Extremely
	8	=	Refuse to Answer

HLT7.	What time do you usually wake up?
TIME12	What time do you usually wake up in the morning?	4
	01:00 - 12:00	=	hh:mm
	98	=	Refuse to Answer (Hour)
TIME12H	Hour: What time do you usually wake up in the morning?	2
	1 - 12	=	range
	98	=	Refuse to Answer
TIME12M	Minutes: What time do you usually wake up in the morning?	2
	0 - 59	=	range
	98	=	Refuse to Answer

HLT8.	What time do you usually go to sleep?
TIME24	What time do you usually go to sleep?	4
	01:00 - 23:00	=	hh:mm
	98	=	Refuse to Answer (Hour)
TIME24H	Hour: What time do you usually go to sleep?	2
	1 - 23	=	range
	98	=	Refuse to Answer
TIME24M	Minutes: What time do you usually go to sleep?	2
	0 - 59	=	range
	98	=	Refuse to Answer

Sect-Activities.	Activities

Info-2.	(For Respondent) The next set of questions will ask about recreational activities.

ACT1.	Please rank your top 3 favorite recreational activities:
ACTRANK	Favorite recreational activities	2
	3 - 3	=	number of ranked items
	97	=	Don't Know
	98	=	Refuse to Answer
ACTRANKA	Favorite recreational activities: Eating out	2
	0 - 3	=	range
	97	=	Don't Know
	98	=	Refuse to Answer

ACTRANKB	Favorite recreational activities: Movies or theatre	2
	0 - 3	=	range
	97	=	Don't Know
	98	=	Refuse to Answer

ACTRANKC	Favorite recreational activities: Dancing	2
	0 - 3	=	range
	97	=	Don't Know
	98	=	Refuse to Answer

ACTRANKD	Favorite recreational activities: Hiking	2
	0 - 3	=	range
	97	=	Don't Know
	98	=	Refuse to Answer

ACTRANKE	Favorite recreational activities: Exercising at the gym	2
	0 - 3	=	range
	97	=	Don't Know
	98	=	Refuse to Answer

ACTRANKF	Favorite recreational activities: Running	2
	0 - 3	=	range
	97	=	Don't Know
	98	=	Refuse to Answer

ACTRANKG	Favorite recreational activities: Playing sports	2
	0 - 3	=	range
	97	=	Don't Know
	98	=	Refuse to Answer

ACTRANKH	Favorite recreational activities: Watching sports	2
	0 - 3	=	range
	97	=	Don't Know
	98	=	Refuse to Answer

ACTRANKI	Favorite recreational activities: Other activity	2
	0 - 3	=	range
	97	=	Don't Know
	98	=	Refuse to Answer

Skip-Other Ranking Activities.

If ( ACTRANKI= 0 OR ACTRANK = .DK OR ACTRANK= .REF ), Skip RANK_O

ACT2.	Describe your other favorite activity:
RANK_O	Other favorite activity:	200
	0 - 200	=	length of response
	997	=	Don't Know
	998	=	Refuse to Answer
	999	=	skipped

ACT3.	In the last 30 days, that is since [PAST30D], how many times have you gone to the movies?
TIMES	Times movies in the last 30 days	2
	0 - 96	=	range
	97	=	Don't Know
	98	=	Refuse to Answer

Skip-3.	If ( TIMES = 0 OR TIMES = .REF OR TIMES = .DK ), Skip TIME_3D

ACT4.	Of the [Response to ACT3] times you went to the movies, how many times did you watch in 3D?
TIME_3D	Times 3D movies in the last 30 days	2
	0 - 96	=	range
	97	=	Don't Know
	98	=	Refuse to Answer
	99	=	Not Applicable

Edit-LoopBack_Movie.

If ( TIME_3D > TIMES ), Loop back to question ACT4
Display message:  Number of times you saw a 3D movie cannot be greater than the number of movies you saw.  Please review your responses. 

Sect-TobaccoUse.

Tobacco Use

Info-3.	(For Respondent) The next set of questions will ask about tobacco use.

TOB1.	Have you ever smoked a cigarette?
CIG	Have you ever smoked a cigarette?	1
	0	=	No
	1	=	Yes
	7	=	Don't Know
	8	=	Refuse to Answer

Skip-EndTobacco.

If ( CIG ^= 1 ), Skip to question TOB8

TOB2.	How old were you the first time you smoked a cigarette?
CIG_AGE	How old were you the first time you smoked a cigarette	2
	1 - 96	=	range
	97	=	Don't Know
	98	=	Refuse to Answer
	99	=	skipped

TOB3.	During the past 7 days, how many cigarettes did you smoke?
CIG_WEEK	During the past 7 days, how many cigarettes did you smoke?	3
	0 - 500	=	range
	997	=	Don't Know
	998	=	Refuse to Answer
	999	=	skipped

Edit-EndTobacco.

If ( CIG_WEEK >= 1 ) is false, skip to question TOB8

TOB4.	How many cigarettes did you smoke yesterday?
CIG_YES	How many cigarettes did you smoke yesterday?	3
	0 - 500	=	range
	997	=	Don't Know
	998	=	Refuse to Answer
	999	=	skipped

Edit-LoopBack_Smoked7days.

If ( CIG_YES > CIG_WEEK ), Loop back to question TOB3
Display message:  You reported smoking more cigarettes yesterday ([Response to TOB4]) than in the past 7 days ([Response to TOB3]).  Please review your responses. 

TOB5.	When you smoke, how soon after you wake up do you have your first cigarette? Would you say….
CIG_WAKE	When you smoke, how soon after you wake up do you have your first cigarette?	1
	1	=	Within 5 minutes
	2	=	6-30 minutes
	3	=	31-60 minutes
	4	=	After 60 minutes
	7	=	Don't Know
	8	=	Refuse to Answer
	9	=	skipped

TOB6.	Have you ever tried to quit smoking?
CIG_QUIT	Have you ever tried to quit smoking?	1
	0	=	No
	1	=	Yes
	7	=	Don't Know
	8	=	Refuse to Answer
	9	=	skipped

TOB7.	Do you want to quit smoking cigarettes?
CIG_WANT	Do you want to quit smoking cigarettes?	1
	0	=	No
	1	=	Yes
	7	=	Don't Know
	8	=	Refuse to Answer
	9	=	skipped

TOB8.	Do you have any additional comments?  Select "Not Applicable" if none.
COMMENT	Do you have any additional comments?	200
	0 - 200	=	length of response
	999	=	Not Applicable

Info-End.	(For Respondent) You have completed the survey.  Thank you!

Calculated Variable
ENDTIME	ENDTIME	8

 	ENDTIME = Current time

Total variables:	60

Identifier variables

	Site:			SITE
	Subject:		SUBJECT
	Other IDs:		VISIT