Number of Blaise fields: 47
Seq # | Var | Question | Data Type/Coding |
---|---|---|---|
1 | versiondate | Version Date | |
2 | formdescr | Form Description | |
3 | formno | Form Number | String[10] |
4 | version | Version Number | String[4] |
5 | projid | ^formdescr Form: ^formno Version: ^version (^versiondate) Enter project ID number. | String[8] |
6 | visit | Enter curent visit code from face sheet: CODE F/U Year CODE F/U Year CODE F/U Year CODE F/U Year 00 = Baseline 08 = 8th F/U 16 = 16th F/U 24 = 24th F/U 01 = 1st F/U 09 = 9th F/U 17 = 17th F/U 25 = 25th F/U 02 = 2nd F/U 10 = 10th F/U 18 = 18th F/U 26 = 26th F/U 03 = 3rd F/U 11 = 11th F/U 19 = 19th F/U 27 = 27th F/U 04 = 4th F/U 12 = 12th F/U 20 = 20th F/U 28 = 28th F/U 05 = 5th F/U 13 = 13th F/U 21 = 21th F/U 29 = 29th F/U 06 = 6th F/U 14 = 14th F/U 22 = 22th F/U 30 = 30th F/U 07 = 7th F/U 15 = 15th F/U 23 = 23th F/U | String[2] |
7 | baseyear | Enter year of baseline from face sheet: | 1993 .. 2025 |
8 | autodate | Automatic Date. | Date type |
9 | autotime | Automatic Time. | TimeType |
10 | autolog | Automatic Logged Date. | Date type |
11 | intid | INTERVIEWER ID | 100 .. 997 |
12 | compid | Laptop id | String[7] |
13 | dateint | Date of interview | Date type |
14 | gender | Enter participant's gender. | 1= Male 2= Female 3= Transgender |
15 | igender | Which gender do you identify with? | 1= Male 2= Female |
16 | evict | 1. Have you been evicted in the past five years? | 0= No 1= Yes |
17 | evictnum | 1a. If so, how many times? | 1 .. 10 |
18 | moves | 2. How many times have you moved from a place where you received mail, in the past five years? | 0 .. 15 |
19 | homeless | 3. Have you been homeless in the past five years? | 0= No 1= Yes |
20 | residence | 4. What type of residence do you live in? | 1= Single family home 2= Apartment/condominium 3= Shelter 4= Single room occupancy 5= Senior/Assisted Living |
21 | resown | 4a. Do you own this residence? | 0= No 1= Yes |
22 | reselse | 4b. Do you live with someone else? | 0= No 1= Yes |
23 | utilities | 5. Have any of your utilities ever been turned off? | 0= No 1= Yes |
24 | utiloften | 5a. If so, how many times in the past 5 years? | 0 .. 5 |
25 | homeown | 6. Have you ever owned a home? | 0= No 1= Yes |
26 | bank | 7. Do you have an active bank account? | 0= No 1= Yes |
27 | credit | 8. Do you have a credit card? | 0= No 1= Yes |
28 | homeph | 9. Do you have a home phone? | 0= No 1= Yes |
29 | cellph | 10. Do you own a cell phone? | 0= No 1= Yes |
30 | celloff | 10a. If so, has your phone been turned off in the past five years? | 0= No 1= Yes |
31 | celloffx | 10b. How many times? | 1 .. 10 |
32 | laidoff | 11. Have you been laid off in the past five years? | 0= No 1= Yes |
33 | violence | 12. Have you ever witnessed or been a victim of violence? | 0= No 1= Yes |
34 | policebrt | 13. Have you ever witnessed or been a victim of police brutality? | 0= No 1= Yes |
35 | safe | 14. Do you feel safe in your current neighborhood? | 0= No 1= Yes |
36 | physexam | 15. Have you had a physical exam in the past year? | 0= No 1= Yes |
37 | eyeex | 16. Have you had an eye exam in the past year? | 0= No 1= Yes |
38 | dentex | 17. Have you had a dental exam in the past year? | 0= No 1= Yes |
39 | hungry | 18. Have you gone hungry or without food for over 24 hours, in the past year? | 0= No 1= Yes |
40 | transport | 19. Did you have a hard time getting to your appointment because of transportation? | 0= No 1= Yes |
41 | formcode | Please enter status code. 11 = COMPLETE 13 = COMPLETE, portion with proxy 12 = INCOMPLETE, refused 14 = INCOMPLETE, too impaired 21 = INCOMPLETE interim, complete later 73 = NOT TESTED, out of town 31 = NOT TESTED, moved 33 = NOT TESTED, refused 75 = NOT TESTED, hospitalized 76 = NOT TESTED, other 42 = DECEASED 43 = WITHDRAWN 44 = WITHDRAWN, Autopsy OK | 11 .. 76 |
42 | formpart | Was participant reluctant, and/or does participant have special needs? | 1= Yes 2= No |
43 | formcomm | Please explain reluctance or any other factors which may have affected this data. [Press enter if no comment needed.] | String[120] |
44 | statid | Please enter you staff id. | 100 .. 997 |
45 | formch | Has the form been modified? | 1= Yes 2= No |
46 | revidate | Enter the date that the form was modified. | Date type |
47 | revintd | Enter your staff id number. | 100 .. 997 |