Page 174 - QAP Manual 2020
P. 174
NCI™ ADULT IN-PERSON SURVEY (IPS) 2020-21
BI-20 When was the last time this person had an eye exam/vision screening?
□ 1. Within the past year (anytime less than 12 months ago)
□ 2. Within the past 2 years (more than 1 year ago but less than 2 years ago)
□ 3. Within the past 3 years (more than 2 years ago but less than 3 years ago)
□ 4. Within the past 5 years (more than 3 years ago but less than 5 years ago)
□ 5. 5 or more years ago
□ 6. Has never had a vision screening
□ 99. Don't know
BI-21 When was the last time this person had a hearing test?
□ 1. Within the past 5 years (anytime less than 5 years ago)
□ 2. 5 years ago or more
□ 3. Has never had a hearing test
□ 99. Don’t know
BI-22 During the past 12 months, has this person had a flu vaccination?
□ 1. No
□ 2. Yes
□ 99. Don’t know
BI-23 How much does this person weigh? ___ ___ ___ lbs.
BI-24 How tall is this person? ___feet ___ ___ inches
BI-25 Does this person use nicotine or tobacco products (e.g., cigarettes, e-cigarettes, chewing
tobacco, etc.)?
□ 1. No
□ 2. Yes
□ 99. Don’t know
BI-26 If female, when was her last Pap test screening? (A Pap test is used to check women for
cancer of the cervix.) Check ONE. Will be reported for females age 21 and over.
□ 98. Not applicable – individual is not female or individual is under age 21
□ 1. Within the past year (anytime less than 12 months ago)
□ 2. Within the past 2 years (more than 1 year ago but less than 2 years ago)
□ 3. Within the past 3 years (more than 2 years ago but less than 3 years ago)
□ 4. Within the past 5 years (more than 3 years ago but less than 5 years ago)
□ 5. 5 or more years ago
□ 6. Has never had a Pap test
□ 99. Don't know
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