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[p. 175]

Section Q. VITAMIN AND MINERAL INTAKE - CHILD

Sample Person Number ____

Q1
Refer to Table A, Cover page

[] Children 2-6 in family (Enter sample person number and name, THEN 1)
First name ____
[] No children 2-6 in family (Next SP)

HAND CALENDAR
Read to respondent:
The following questions concern (name) use of vitamin and mineral products.

1. During the past 2 weeks, (that is, the 2 weeks outlined in red on the calendar), beginning Monday (date) and ending this past Sunday (date), did -- take any vitamin, mineral, or fluoride products?

1 [] Yes
2 [] No (Next SP)
9 [] DK (Next SP)


2. How many different vitamin, mineral, or fluoride products did -- take during the past 2 weeks?

Number of different products ____
99 [] DK


3. May I see the container(s)/Would you please bring to the telephone the container(s) for (ALL) the vitamin or mineral product(s) -- took during the past 2 weeks, including any fluoride or vitamin fluoride product(s)?

Record from the product label. If no container available and for the telephone, ask 4 for each product.

PRODUCT 1

4a. What is the (first) product name? ____

b. What is the manufacturer's or distributor's name? ____

Q2
Refer to FLASHCARD Q.

(card Q not found)

1 [] Both names NOT on card, container available and legible (6)
2 [] Both names NOT on card, container not available and illegible (6)
3 [] Both names on card (Enter code ____, THEN 6)

5. Nutrients

Vitamins
01 [] Vitamin A

Quantity ____
Units ____


02 [] Vitamin D

Quantity ____
Units ____


03 [] Vitamin E (Tocopherol)

Quantity ____
Units ____


04 [] Vitamin C

Quantity ____
Units ____


05 [] Folic Acid (Folacin)

Quantity ____
Units ____


06 [] Thiamine (B1)

Quantity ____
Units ____


07 [] Riboflavin (B2)

Quantity ____
Units ____


08 [] Niacin (Niacinamide)

Quantity ____
Units ____


09 [] Vitamin B6 (Pyridoxine)

Quantity ____
Units ____


10 [] Vitamin B12 (Cyanocobalamin)

Quantity ____
Units ____


11 [] Biotin

Quantity ____
Units ____


12 [] Pantothenic Acid (Pantothenate)

Quantity ____
Units ____

Minerals

13 [] Calcium

Compound ____
Quantity ____
Units ____


14 [] Phosphorus

Compound ____
Quantity ____
Units ____


15 [] Iodine

Compound ____
Quantity ____
Units ____


16 [] Iron (Ferrous/Feric)

Compound ____
Quantity ____
Units ____


17 [] Magnesium

Compound ____
Quantity ____
Units ____


18 [] Copper (Cuprous/Cupric)

Compound ____
Quantity ____
Units ____


19 [] Zinc

Compound ____
Quantity ____
Units ____


20 [] Potassium

Compound ____
Quantity ____
Units ____


21 [] Chromium

Compound ____
Quantity ____
Units ____


22 [] Manganese

Compound ____
Quantity ____
Units ____


23 [] Selenium (Selenate)

Compound ____
Quantity ____
Units ____


24 [] Fluoride

Compound ____
Quantity ____
Units ____


25 [] Non-listed nutrient ____

LIST OF COMPOUNDS FOR ITEM 5

1 -- Aluminum citrate
2 -- Aspartate
3 -- Bitartrate
4 -- Carbonate
5 -- Chloride
6 -- Citrate
7 -- Fumarate
8 -- Gluconate
9 -- Glycerophosphate
10 -- Hydroxide
11 -- Iodate
12 -- Iodine
13 -- Lactate
14 -- Oxide
15 -- Phosphate
16 -- Pyrophosphate
17 -- Sodium
18 -- Sulfate


Circle if known, otherwise ask:
6a. In what form did -- take this product?

1 [] Capsules, tablets or pills?
2 [] Wafers?
3 [] Teaspoon(s)?
4 [] Tablespoon(s)?
5 [] Drops/Droppers?
8 [] Some other form? (Specify) ____
9 [] DK

Record from label, ask if telephone interview:
b. How many (entry in 6a) must -- take to obtain the amount of nutrients listed on the label? ____

99 [] DK


7a. During the past 2 weeks, how many days did -- take (product name in 4a)/the vitamin or mineral?

14 [] Every day
Number of days ____
99 [] DK

b. On the day(s) when -- took ((product name in 4a)/ the vitamin or mineral), how many (entry in 6a) did -- take per day?

Number of days ____
99 [] DK


8. For how long has -- been taking this type of product?

_____
Number
1 [] Days
2 [] Weeks
3 [] Months
4 [] Years


9. Did -- have a doctor's prescription to obtain this product?

1 [] Yes
2 [] No
9 [] DK

(Next product)

[p. 176]

Section Q. VITAMIN AND MINERAL INTAKE - ADULT

Sample Person Number ____

Q1
First name ____

PRODUCT 6

4a. What is the (sixth) product name? ____

b. What is the manufacturer's or distributor's name? ____

Q2
Refer to FLASHCARD Q.

1 [] Both names NOT on card, container available and legible (6)
2 [] Both names NOT on card, container not available and illegible (6)
3 [] Both names on card (Enter code ____, THEN 6)


5. Nutrients

Vitamins
01 [] Vitamin A

Quantity ____
Units ____

02 [] Vitamin D

Quantity ____
Units ____

03 [] Vitamin E (Tocopherol)

Quantity ____
Units ____


04 [] Vitamin C

Quantity ____
Units ____

05 [] Folic Acid (Folacin)

Quantity ____
Units ____


06 [] Thiamine (B1)

Quantity ____
Units ____


07 [] Riboflavin (B2)

Quantity ____
Units ____


08 [] Niacin (Niacinamide)

Quantity ____
Units ____


09 [] Vitamin B6 (Pyridoxine)

Quantity ____
Units ____


10 [] Vitamin B12 (Cyanocobalamin)

Quantity ____
Units ____

11 [] Biotin

Quantity ____
Units ____

12 [] Pantothenic Acid (Pantothenate)

Quantity ____
Units ____

Minerals Compound Quantity Units
13 [] Calcium

Compound ____
Quantity ____
Units ____

14 [] Phosphorus

Compound ____
Quantity ____
Units ____

15 [] Iodine

Compound ____
Quantity ____
Units ____

16 [] Iron (Ferrous/Feric)

Compound ____
Quantity ____
Units ____

17 [] Magnesium

Compound ____
Quantity ____
Units ____

18 [] Copper (Cuprous/Cupric)

Compound ____
Quantity ____
Units ____

19 [] Zinc

Compound ____
Quantity ____
Units ____

20 [] Potassium

Compound ____
Quantity ____
Units ____

21 [] Chromium

Compound ____
Quantity ____
Units ____

22 [] Manganese

Compound ____
Quantity ____
Units ____

23 [] Selenium (Selenate)

Compound ____
Quantity ____
Units ____

24 [] Fluoride

Compound ____
Quantity ____
Units ____

25 [] Non-listed nutrient ____

LIST OF COMPOUNDS FOR ITEM 5

1 -- Aluminum citrate
2 -- Aspartate
3 -- Bitartrate
4 -- Carbonate
5 -- Chloride
6 -- Citrate
7 -- Fumarate
8 -- Gluconate
9 -- Glycerophospate
10 -- Hydroxide
11 -- Iodate
12 -- Iodide
13 -- Lactate
14 -- Oxide
15 -- Phospate
16 -- Pyrophospate
17 -- Sodium
18 -- Sulfate

Circle if known, otherwise ask:
6a. In what form did you take this product -

1 [] Capsules, tablets or pills?
2 [] Wafers?
3 [] Teaspoon(s)?
4 [] Tablespoon(s)?
5 [] Drops/Droppers?
8 [] Some other form? (Specify) ____
9 [] DK

Record from label, ask if telephone interview:
b. How many (entry in 6a) must you take to obtain the amount of nutrients listed on the label? [75-76]

Number ____
99 [] DK

7a. During the past 2 weeks, how many days did you take (product name in 4a)/the vitamin or mineral?

14 [] Every day
99 [] DK
Number of days ____

b. On the day(s) when you took ((product name in 4a)/ the vitamin or mineral), how many (entry in 6a) did you take per day?

Number of days ____
99 [] DK

8. For how long have you been taking this type of product?

1 [] Days ____
2 [] Weeks ____
3 [] Months ____
4 [] Years ____

9. Did you have a doctor's prescription to obtain this product?

1 [] Yes
2 [] No
9 [] DK

(Next product)


Q3
Refer to age and sex on Household Composition Page.

1 [] Sample Person is female 18-44 (10)
9 [] Other (Cover page)

It is important to know about vitamin and mineral use or nonuse by women who were pregnant or were breastfeeding a baby during the past 2 weeks.

10a. Were you pregnant during the past 2 weeks?

1 [] Yes
2 [] No
9 [] DK

b. Were you breastfeeding a baby during the past 2 weeks?

1 [] Yes
2 [] No
9 [] DK