[p. 175]
Section Q. VITAMIN AND MINERAL INTAKE - CHILD
Sample Person Number ____
Q1
Refer to Table A, Cover page
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?
2 [] No (Next SP)
9 [] DK (Next SP)
2. How many different vitamin, mineral, or fluoride products did -- take during the past 2 weeks?
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)
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
Units ____
Units ____
Units ____
Units ____
Units ____
Units ____
Units ____
Units ____
Units ____
10 [] Vitamin B12 (Cyanocobalamin)
Units ____
Units ____
12 [] Pantothenic Acid (Pantothenate)
Units ____
Quantity ____
Units ____
Quantity ____
Units ____
Quantity ____
Units ____
Quantity ____
Units ____
Quantity ____
Units ____
Quantity ____
Units ____
Quantity ____
Units ____
Quantity ____
Units ____
Quantity ____
Units ____
Quantity ____
Units ____
Quantity ____
Units ____
Quantity ____
Units ____
25 [] Non-listed nutrient ____
LIST OF COMPOUNDS FOR ITEM 5
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?
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? ____
7a. During the past 2 weeks, how many days did -- take (product name in 4a)/the vitamin or mineral?
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?
99 [] DK
8. For how long has -- been taking this type of product?
Number
2 [] Weeks
3 [] Months
4 [] Years
9. Did -- have a doctor's prescription to obtain this product?
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.
2 [] Both names NOT on card, container not available and illegible (6)
3 [] Both names on card (Enter code ____, THEN 6)
Vitamins
01 [] Vitamin A
Units ____
02 [] Vitamin D
Units ____
03 [] Vitamin E (Tocopherol)
Units ____
04 [] Vitamin C
Units ____
05 [] Folic Acid (Folacin)
Units ____
06 [] Thiamine (B1)
Units ____
07 [] Riboflavin (B2)
Units ____
08 [] Niacin (Niacinamide)
Units ____
09 [] Vitamin B6 (Pyridoxine)
Units ____
10 [] Vitamin B12 (Cyanocobalamin)
Units ____
11 [] Biotin
Units ____
12 [] Pantothenic Acid (Pantothenate)
Units ____
Minerals Compound Quantity Units
13 [] Calcium
Quantity ____
Units ____
14 [] Phosphorus
Quantity ____
Units ____
15 [] Iodine
Quantity ____
Units ____
16 [] Iron (Ferrous/Feric)
Quantity ____
Units ____
17 [] Magnesium
Quantity ____
Units ____
18 [] Copper (Cuprous/Cupric)
Quantity ____
Units ____
19 [] Zinc
Quantity ____
Units ____
20 [] Potassium
Quantity ____
Units ____
21 [] Chromium
Quantity ____
Units ____
22 [] Manganese
Quantity ____
Units ____
23 [] Selenium (Selenate)
Quantity ____
Units ____
24 [] Fluoride
Quantity ____
Units ____
25 [] Non-listed nutrient ____
LIST OF COMPOUNDS FOR ITEM 5
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 -
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]
99 [] DK
7a. During the past 2 weeks, how many days did you take (product name in 4a)/the vitamin or mineral?
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?
99 [] DK
8. For how long have you been taking this type of product?
2 [] Weeks ____
3 [] Months ____
4 [] Years ____
9. Did you have a doctor's prescription to obtain this product?
2 [] No
9 [] DK
(Next product)
Q3
Refer to age and sex on Household Composition Page.
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?
2 [] No
9 [] DK
b. Were you breastfeeding a baby during the past 2 weeks?
2 [] No
9 [] DK