***REACT***

(Rapid Early Action for Coronary Treatment)

**COMMUNITY SURVEY TELEPHONE INTERVIEW**

  -------- --------------------------- ---- ---- ---- ---- ---- ---- ---- ----
           RESPONDENT ID:                                            \-   

  -------- --------------------------- ---- ---- ---- ---- ---- ---- ---- ----

  --------- ------------- ------- -- ---- ---- -- -- -- -- -- ----- ---- -- -- -- -- -- ------ ---- -- -- -- --- -- --- -- ---
            DATE:                                                                                                          

                                                                                                                           

                          MONTH                               DAY                       YEAR                               
  --------- ------------- ------- -- ---- ---- -- -- -- -- -- ----- ---- -- -- -- -- -- ------ ---- -- -- -- --- -- --- -- ---

  ---------- ----------------------------------- ----- ----- ----- ---- ----
             INTERVIEWER ID:                                            

  ---------- ----------------------------------- ----- ----- ----- ---- ----

  ------- ------------------ --- --- ------- --- --- --------- -- ---------- -- --
          START TIME:                **:**           1\. AM       2\. PM        

  ------- ------------------ --- --- ------- --- --- --------- -- ---------- -- --

+-----------------------------------------------------------------------+
| READ TO ALL RESPONDENTS TO BE INTERVIEWED BY TELEPHONE                |
|                                                                       |
| I am calling on behalf of \[University\]. The University is           |
| participating in a study to learn more about people with chest pain   |
| or similar symptoms who seek medical care.                            |
|                                                                       |
| Before we begin, let me remind you that your participation is         |
| voluntary and will help us learn more about the treatment of heart    |
| disease. You may ask to stop the interview at any time. If there is a |
| question that you cannot or do not wish to answer, please tell me and |
| I will go on to the next question.                                    |
|                                                                       |
| Any information that you provide is strictly confidential. Only       |
| members of an independent research staff will see or hear your        |
| responses.                                                            |
|                                                                       |
| **If you have any questions or concerns about the survey, you may     |
| call the Principal Investigator at \[UNIVERSITY\] \[PI NAME AND       |
| NUMBER\], or the Institutional Review Board at the New England        |
| Research Institutes. IF THE RESPONDENT EXPRESSES DESIRE TO DO SO,     |
| STATE: The toll free number for NERI is 1-800-775-6374. There will be |
| absolutely no charge to you.**                                        |
+-----------------------------------------------------------------------+
| I, THE INTERVIEWER HAVE READ THIS STATEMENT TO THE RESPONDENT         |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_INITIALS OF THE INTERVIEWER     |
+-----------------------------------------------------------------------+

SECTION C: EXPOSURE, INFORMATION, SOURCES

The first few questions are about the media and health.

C1. Newspapers, radio and television often carry information about
health. In your opinion, do you think the amount of information on
health in the media has increased, decreased, or stayed about the same
during the [past year]{.underline}?

1\. INCREASED

2\. DECREASED

3\. SAME

-8. DON'T KNOW

-2. REFUSED

C2. Thinking back now over the [past month]{.underline}, what kinds of
messages about health do you recall in the media or from other sources
such as people you talk with?

> \[PROBE: PROBE FOR UP TO FIVE MESSAGES.\]
>
> \[ENTER TEXT AND CODE MESSAGES FROM "CODES FOR EVALUATION SURVEY."\]

**TEXT** **CODE**

  ---------------- ----- ------------------------------ ------ ------ ------
                   a\.                                                

  ---------------- ----- ------------------------------ ------ ------ ------

  ---------------- ----- ------------------------------ ------ ------ ------
                   b\.                                                

  ---------------- ----- ------------------------------ ------ ------ ------

  ---------------- ----- ------------------------------ ------ ------ ------
                   c\.                                                

  ---------------- ----- ------------------------------ ------ ------ ------

  ---------------- ----- ------------------------------ ------ ------ ------
                   d\.                                                

  ---------------- ----- ------------------------------ ------ ------ ------

  ---------------- ----- ------------------------------ ------ ------ ------
                   e\.                                                

  ---------------- ----- ------------------------------ ------ ------ ------

> CODES FOR EVALUATION SURVEY

+-----------------------------------------------------------------------+
| 1\. Aids, other STDs                                                  |
+-----------------------------------------------------------------------+
| 2\. Blood pressure, general                                           |
+-----------------------------------------------------------------------+
| 3\. Cancer (general, specific cancers, prevention, etc.)              |
+-----------------------------------------------------------------------+
| 4\. Cholesterol, saturated fat                                        |
+-----------------------------------------------------------------------+
| 5\. Nutrition, general, food                                          |
+-----------------------------------------------------------------------+
| 6\. Physical activity, exercise                                       |
+-----------------------------------------------------------------------+
| 7\. REACT, Specific mention of program name or slogan                 |
+-----------------------------------------------------------------------+
| 8\. Smoking, drugs, alcohol, other substance abuse                    |
+-----------------------------------------------------------------------+
| 9\. Weight, obesity                                                   |
+-----------------------------------------------------------------------+
| 11\. NONE                                                             |
+-----------------------------------------------------------------------+
| 12\. Heart disease, heart problems general                            |
+-----------------------------------------------------------------------+
| 13\. Heart attacks, general                                           |
+-----------------------------------------------------------------------+
| 14\. heart attack symptoms, specific                                  |
+-----------------------------------------------------------------------+
| 15\. Heart attacks, getting medical care rapidly                      |
+-----------------------------------------------------------------------+
| 16\. Heart attacks, calling 911/EMS                                   |
+-----------------------------------------------------------------------+
| 17\. Heart attacks, rehearsing a plan of action                       |
+-----------------------------------------------------------------------+
| 18\. Diabetes                                                         |
+-----------------------------------------------------------------------+
| 19\. Environmental problems                                           |
+-----------------------------------------------------------------------+
| 20\. General response: everything                                     |
+-----------------------------------------------------------------------+
| 21\. Health care costs, health insurance, access to care              |
+-----------------------------------------------------------------------+
| 22\. Mental Health, stress                                            |
+-----------------------------------------------------------------------+
| 23\. New medications or other medical advances                        |
|                                                                       |
| \[e.g. treatments, surgery, genetics\]                                |
+-----------------------------------------------------------------------+
| 24\. Violence                                                         |
+-----------------------------------------------------------------------+
| 25\. Wellness, holistic health, alternative medical treatments        |
+-----------------------------------------------------------------------+
| 26\. Other                                                            |
+-----------------------------------------------------------------------+

FOR EACH MESSAGE LISTED ABOVE:

C2a. You mentioned \[MESSAGE a.\]. Where did you hear, read or see this?

\[CIRCLE "1" NO OR "2" YES FOR ALL SOURCES OR TYPES OF MEDIA THAT APPLY
BELOW.\]

\[PROBE: Where else did you get this information in the last month?\]

  ------- -------------------------------------------------- -------- -------
          SOURCE                                             NO       YES

  1\.     Billboards                                         1        2

  2\.     Book                                               1        2

  3\.     church                                             1        2

  4\.     civic organization                                 1        2

  5\.     Doctor                                             1        2

  6\.     Family member                                      1        2

  7\.     Friend, co-worker                                  1        2

  8\.     HOSPITAL                                           1        2

  9\.     Mailing                                            1        2

  10\.    Magazine                                           1        2

  11\.    Mall Event                                         1        2

  12\.    Newspaper                                          1        2

  13\.    Other Health Professional                          1        2

  14\.    Other Healthcare organization                      1        2

  15\.    Pamphlet                                           1        2

  16\.    Pharmacy Poster/Flier                              1        2

  17\.    Poster                                             1        2

  18\.    Radio                                              1        2

  19\.    School, class, lecture                             1        2

  20\.    Self-help clinic or group                          1        2

  21\.    Signs                                              1        2

  22\.    Social, recreation group                           1        2

  23\.    Television                                         1        2

  24\.    Other                                              1        2
          (SPECIFY):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            
  ------- -------------------------------------------------- -------- -------

C2b. You mentioned \[MESSAGE b.\]. Where did you hear, read or see this?

\[CIRCLE "1" NO OR "2" YES FOR ALL SOURCES OR TYPES OF MEDIA THAT APPLY
BELOW.\]

\[PROBE: Where else did you get this information in the last month?\]

  ------- -------------------------------------------------- -------- -------
          SOURCE                                             NO       YES

  1\.     Billboards                                         1        2

  2\.     Book                                               1        2

  3\.     church                                             1        2

  4\.     civic organization                                 1        2

  5\.     Doctor                                             1        2

  6\.     Family member                                      1        2

  7\.     Friend, co-worker                                  1        2

  8\.     HOSPITAL                                           1        2

  9\.     Mailing                                            1        2

  10\.    Magazine                                           1        2

  11\.    Mall Event                                         1        2

  12\.    Newspaper                                          1        2

  13\.    Other Health Professional                          1        2

  14\.    Other Healthcare organization                      1        2

  15\.    Pamphlet                                           1        2

  16\.    Pharmacy Poster/Flier                              1        2

  17\.    Poster                                             1        2

  18\.    Radio                                              1        2

  19\.    School, class, lecture                             1        2

  20\.    Self-help clinic or group                          1        2

  21\.    Signs                                              1        2

  22\.    Social, recreation group                           1        2

  23\.    Television                                         1        2

  24\.    Other                                              1        2
          (SPECIFY):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            
  ------- -------------------------------------------------- -------- -------

C2c. You mentioned \[MESSAGE c.\]. Where did you hear, read or see this?

\[CIRCLE "1" NO OR "2" YES FOR ALL SOURCES OR TYPES OF MEDIA THAT APPLY
BELOW.\]

\[PROBE: Where else did you get this information in the last month?\]

  ------- -------------------------------------------------- -------- -------
          SOURCE                                             NO       YES

  1\.     Billboards                                         1        2

  2\.     Book                                               1        2

  3\.     church                                             1        2

  4\.     civic organization                                 1        2

  5\.     Doctor                                             1        2

  6\.     Family member                                      1        2

  7\.     Friend, co-worker                                  1        2

  8\.     HOSPITAL                                           1        2

  9\.     Mailing                                            1        2

  10\.    Magazine                                           1        2

  11\.    Mall Event                                         1        2

  12\.    Newspaper                                          1        2

  13\.    Other Health Professional                          1        2

  14\.    Other Healthcare organization                      1        2

  15\.    Pamphlet                                           1        2

  16\.    Pharmacy Poster/Flier                              1        2

  17\.    Poster                                             1        2

  18\.    Radio                                              1        2

  19\.    School, class, lecture                             1        2

  20\.    Self-help clinic or group                          1        2

  21\.    Signs                                              1        2

  22\.    Social, recreation group                           1        2

  23\.    Television                                         1        2

  24\.    Other                                              1        2
          (SPECIFY):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            
  ------- -------------------------------------------------- -------- -------

C2d. You mentioned \[MESSAGE d.\]. Where did you hear, read or see this?

\[CIRCLE "1" NO OR "2" YES FOR ALL SOURCES OR TYPES OF MEDIA THAT APPLY
BELOW.\]

\[PROBE: Where else did you get this information in the last month?\]

  ------- -------------------------------------------------- -------- -------
          SOURCE                                             NO       YES

  1\.     Billboards                                         1        2

  2\.     Book                                               1        2

  3\.     church                                             1        2

  4\.     civic organization                                 1        2

  5\.     Doctor                                             1        2

  6\.     Family member                                      1        2

  7\.     Friend, co-worker                                  1        2

  8\.     HOSPITAL                                           1        2

  9\.     Mailing                                            1        2

  10\.    Magazine                                           1        2

  11\.    Mall Event                                         1        2

  12\.    Newspaper                                          1        2

  13\.    Other Health Professional                          1        2

  14\.    Other Healthcare organization                      1        2

  15\.    Pamphlet                                           1        2

  16\.    Pharmacy Poster/Flier                              1        2

  17\.    Poster                                             1        2

  18\.    Radio                                              1        2

  19\.    School, class, lecture                             1        2

  20\.    Self-help clinic or group                          1        2

  21\.    Signs                                              1        2

  22\.    Social, recreation group                           1        2

  23\.    Television                                         1        2

  24\.    Other                                              1        2
          (SPECIFY):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            
  ------- -------------------------------------------------- -------- -------

C2e. You mentioned \[MESSAGE e.\]. Where did you hear, read or see this?

\[CIRCLE "1" NO OR "2" YES FOR ALL SOURCES OR TYPES OF MEDIA THAT APPLY
BELOW.\]

\[PROBE: Where else did you get this information in the last month?\]

  ------- -------------------------------------------------- -------- -------
          SOURCE                                             NO       YES

  1\.     Billboards                                         1        2

  2\.     Book                                               1        2

  3\.     church                                             1        2

  4\.     civic organization                                 1        2

  5\.     Doctor                                             1        2

  6\.     Family member                                      1        2

  7\.     Friend, co-worker                                  1        2

  8\.     HOSPITAL                                           1        2

  9\.     Mailing                                            1        2

  10\.    Magazine                                           1        2

  11\.    Mall Event                                         1        2

  12\.    Newspaper                                          1        2

  13\.    Other Health Professional                          1        2

  14\.    Other Healthcare organization                      1        2

  15\.    Pamphlet                                           1        2

  16\.    Pharmacy Poster/Flier                              1        2

  17\.    Poster                                             1        2

  18\.    Radio                                              1        2

  19\.    School, class, lecture                             1        2

  20\.    Self-help clinic or group                          1        2

  21\.    Signs                                              1        2

  22\.    Social, recreation group                           1        2

  23\.    Television                                         1        2

  24\.    Other                                              1        2
          (SPECIFY):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            
  ------- -------------------------------------------------- -------- -------

SECTION D: PERSONAL HEALTH CONCERNS AND BEHAVIORAL INTENTIONS

Now I\'d like to ask you questions about some health situations.

D1. What one health condition or health problem is of greatest concern
to you personally right now?

\[ASK FOR ONLY [ONE]{.underline} RESPONSE. IF MORE THAN ONE RESPONSE,
PROBE BY ASKING WHICH IS HIS/HER GREATEST CONCERN. ENTER TEXT AND CODE
RESPONSE.\]

+-----------------------------------------------------------------------+
| 1\. Aids, other STDs                                                  |
+-----------------------------------------------------------------------+
| 2\. Blood pressure, general                                           |
+-----------------------------------------------------------------------+
| 3\. Cancer (general, specific cancers, prevention, etc.)              |
+-----------------------------------------------------------------------+
| 4\. Cholesterol, saturated fat                                        |
+-----------------------------------------------------------------------+
| 5\. Nutrition, general, food                                          |
+-----------------------------------------------------------------------+
| 6\. Physical activity, exercise                                       |
+-----------------------------------------------------------------------+
| 7\. REACT, Specified mention of program name or slogan                |
+-----------------------------------------------------------------------+
| 8\. Smoking, drugs, alcohol, other substance abuse                    |
+-----------------------------------------------------------------------+
| 9\. Weight, obesity                                                   |
+-----------------------------------------------------------------------+
| 11\. NONE                                                             |
+-----------------------------------------------------------------------+
| 12\. Heart disease, heart problems general                            |
+-----------------------------------------------------------------------+
| 13\. Heart attacks, general                                           |
+-----------------------------------------------------------------------+
| 14\. heart attack symptoms, specific                                  |
+-----------------------------------------------------------------------+
| 15\. Heart attacks, getting medical care rapidly                      |
+-----------------------------------------------------------------------+
| 16\. Heart attacks, calling 911/EMS                                   |
+-----------------------------------------------------------------------+
| 17\. Heart attacks, rehearsing a plan of action                       |
+-----------------------------------------------------------------------+
| 18\. Diabetes                                                         |
+-----------------------------------------------------------------------+
| 19\. Environmental problems                                           |
+-----------------------------------------------------------------------+
| 20\. General response : everything                                    |
+-----------------------------------------------------------------------+
| 21\. Health care costs, health insurance, access to care              |
+-----------------------------------------------------------------------+
| 22\. Mental Health, stress                                            |
+-----------------------------------------------------------------------+
| 23\. New medications or other medical advances                        |
|                                                                       |
| \[e.g. treatments, surgery, genetics\]                                |
+-----------------------------------------------------------------------+
| 24\. Violence                                                         |
+-----------------------------------------------------------------------+
| 25\. Wellness, holistic health, alternative medical treatments        |
+-----------------------------------------------------------------------+
| 26\. Other                                                            |
+-----------------------------------------------------------------------+

**TEXT** **CODE**

  ---------------- ----- ------------------------------ ------ ------ ------
                   a\.                                                

  ---------------- ----- ------------------------------ ------ ------ ------

D2. If you thought someone was having a heart attack, what would you do?

> \[CIRCLE "1" NO OR "2" YES FOR ALL ACTIONS THAT APPLY BELOW.\]
>
> \[IF RESPONSE "a. GET HELP" IS GIVEN, PROBE: Could you be more
> specific?\]
>
> \[PROBE: Anything else?\]

  -------- ---------------------------------------------- -------- --------
                                                          NO       YES

  1\.      Administer CPR                                 1        2

  2\.      Advise them to get to hospital                 1        2

  3\.      Advise them to call their physician            1        2

  4\.      Advise them to lie down                        1        2

  5\.      Advise them to take aspirin or other medicine  1        2

  6\.      Call 911/or ambulance                          1        2

  7\.      Call spouse/family member                      1        2

  8\.      Call their doctor, clinic                      1        2

  9\.      Drive them to hospital                         1        2

  10\.     Get help                                       1        2

  11\.     MAKE THEM COMFORTABLE                          1        2

  12\.     Other (SPECIFY):\_\_\_\_\_\_\_\_\_\_\_\_\_\_   1        2
  -------- ---------------------------------------------- -------- --------

D3. How sure are you that you would call an ambulance or dial 911, if
you thought someone was having\
a heart attack? Are you [very sure]{.underline}, [pretty
sure]{.underline}, [a little sure]{.underline} or [not at all
sure]{.underline}?

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Very Sure   Pretty Sure A Little    Not At All  DK/NO       REFUSED
                          Sure        Sure        OPINION     
  ----------- ----------- ----------- ----------- ----------- -----------

D3a. \[IF NOT AT ALL SURE\] Why not?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

D4. If someone asked you not to call an ambulance or 911, how sure are
you that you would still call if you thought that person was having a
heart attack? Are you [very sure]{.underline}, p[retty
sure]{.underline}, [a little sure]{.underline} or [not at all
sure]{.underline}?

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Very Sure   Pretty Sure A Little    Not At All  DK/NO       REFUSED
                          Sure        Sure        OPINION     
  ----------- ----------- ----------- ----------- ----------- -----------

SECTION E: Self -efficacy

E1. How sure are you that you could recognize the signs and symptoms of
a heart attack in someone else? Are you [very sure]{.underline}, p[retty
sure]{.underline}, [a little sure]{.underline} or [not at all
sure]{.underline}?

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Very Sure   Pretty Sure A Little    Not At All  DK/No       REFUSED
                          Sure        Sure        opinion     
  ----------- ----------- ----------- ----------- ----------- -----------

E2. How sure are you that you could recognize the signs and symptoms of
a heart attack in yourself?\
Are you [very sure]{.underline}, p[retty sure]{.underline}, [a little
sure]{.underline} or [not at all sure]{.underline}?

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Very Sure   Pretty Sure A Little    Not At All  DK/No       REFUSED
                          Sure        Sure        opinion     
  ----------- ----------- ----------- ----------- ----------- -----------

E3. How sure are you that you could tell the difference between the
signs or symptoms of a heart attack\
and other medical problems? Are you [very sure]{.underline}, p[retty
sure]{.underline}, [a little sure]{.underline} or [not at all
sure]{.underline}?

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Very Sure   Pretty Sure A Little    Not At All  DK/No       REFUSED
                          Sure        Sure        opinion     
  ----------- ----------- ----------- ----------- ----------- -----------

E4. How sure are you that you could get help for someone if you thought
they were having a heart\
attack? Are you [very sure]{.underline}, p[retty sure]{.underline}, [a
little sure]{.underline} or [not at all sure]{.underline}?

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Very Sure   Pretty Sure A Little    Not At All  DK/No       REFUSED
                          Sure        Sure        opinion     
  ----------- ----------- ----------- ----------- ----------- -----------

E5. How sure are you that you could get help for yourself if you thought
you were having a heart attack?\
Are you [very sure]{.underline}, p[retty sure]{.underline}, [a little
sure]{.underline} or [not at all sure]{.underline}?

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Very Sure   Pretty Sure A Little    Not At All  DK/No       REFUSED
                          Sure        Sure        opinion     
  ----------- ----------- ----------- ----------- ----------- -----------

SECTION F: Personal Risk Perception

F1. Compared to other \[INSERT Women OR Men DEPENDING ON THEIR GENDER\]
your age, how\
likely do you think it is that you could have a heart attack in the next
five years? Would that be [much\
]{.underline} [less likely]{.underline}, [somewhat less
likely]{.underline}, [about the same]{.underline}, [somewhat more
likely]{.underline} , or [much more]{.underline} likely than\
other \[INSERT Women OR Men DEPENDING ON THEIR GENDER\] your age?

  ---------- ---------- ---------- ---------- ---------- ---------- ----------
  1          2          3          4          5          -8         -2

  Much Less  Somewhat   About the  Somewhat   Much More  DK         REFUSED
  Likely     Less       Same       More       Likely                
             Likely                Likely                           
  ---------- ---------- ---------- ---------- ---------- ---------- ----------

SECTION G: Behavioral Rehearsal/interpersonal Discussion

G1. Have you ever talked with anyone about planning what to do in case
you were having a heart attack?

1\. NO  **GO TO H1** -8. DON\'T KNOW  **GO TO H1**

2\. YES -2. REFUSED  **GO TO H1**



G1a. Whom did you talk with?

\[RECORD IN COLUMN A "1" OR "2" FOR EACH RESPONSE.\]

G1b. Did you talk with them within the past 3 months?

\[RECORD IN COLUMN A "1" OR "2" FOR EACH RESPONSE.\]

  ------ ---------------------------------------------- -------- --------- -------- --------- -----------
                                                        **A**              **B**              

                                                        **NO**   **YES**   **NO**   **YES**   

  1\.    Co-worker/colleague                            1        2         1        2         

  2\.    Friend                                         1        2         1        2         

  3\.    health educator                                1        2         1        2         

  4\.    Neighbor                                       1        2         1        2         

  5\.    Nurse                                          1        2         1        2         

  6\.    Other family member                            1        2         1        2         
         (SPECIFY):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                         

  7\.    Other health professional                      1        2         1        2         

  8\.    Physician                                      1        2         1        2         

  9\.    Spouse                                         1        2         1        2         

  10\.   other (SPECIFY):\_\_\_\_\_\_\_\_\_\_           1        2         1        2         
  ------ ---------------------------------------------- -------- --------- -------- --------- -----------

SECTION H: Program Awareness/Name Recall

H1. In the past month, have you heard about any programs in your
community that encourage people to get immediate medical care if they
think they might be having a heart attack?

1\. NO  **GO TO H1c** -8. DON\'T KNOW  **GO TO H1c**

2\. YES -2. REFUSED  **GO TO H1c**



H1a. Where do you recall hearing about that program?

> \[CIRCLE "1" NO OR "2" YES FOR ALL SOURCES THAT APPLY BELOW.\]

  ------- ---------------------------------------------------- -------- ---------
          **SOURCE**                                           **NO**   **YES**

  1\.     Billboards                                           1        2

  2\.     Book                                                 1        2

  3\.     church                                               1        2

  4\.     civic organization                                   1        2

  5\.     Doctor                                               1        2

  6\.     Family member                                        1        2

  7\.     Friend, co-worker                                    1        2

  8\.     HOSPITAL                                             1        2

  9\.     Mailing                                              1        2

  10\.    Magazine                                             1        2

  11\.    Mall Event                                           1        2

  12\.    Newspaper                                            1        2

  13\.    Other Health Professional                            1        2

  14\.    Other Healthcare organization                        1        2

  15\.    Pamphlet                                             1        2

  16\.    Pharmacy Poster/Flier                                1        2

  17\.    Poster                                               1        2

  18\.    Radio                                                1        2

  19\.    School, class, lecture                               1        2

  20\.    Self-help clinic or group                            1        2

  21\.    Signs                                                1        2

  22\.    Social, recreation group                             1        2

  23\.    Television                                           1        2

  24\.    Other                                                1        2
          (SPECIFY):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            
  ------- ---------------------------------------------------- -------- ---------

H1b. Can you recall the name of the program?

> \[PROBE FOR NAME, SLOGAN\]

+---+-----------------+--------------+---+-------------+-------------+---+
| 1 | Heart Attack    | ** GO TO**  | - | DON'T KNOW  | ** GO TO** |   |
| \ | REACT           |              | 8 |             |             |   |
| . |                 | **SECTION    | . |             | **SECTION   |   |
|   |                 | I**          |   |             | I**         |   |
+---+-----------------+--------------+---+-------------+-------------+---+
|   |                 |              |   |             |             |   |
+---+-----------------+--------------+---+-------------+-------------+---+
| 2 | ANY OTHER NAME  |              | - | REFUSED     | ** GO TO** |   |
| \ |                 |              | 2 |             |             |   |
| . | (Specify):      |              | . |             | **SECTION   |   |
|   | \_\             |              |   |             | I**         |   |
|   | _\_\_\_\_\_\_\_ |              |   |             |             |   |
|   | \_\_\_\_\_\_\_\ |              |   |             |             |   |
|   | _\_\_\_\_\_\_\_ |              |   |             |             |   |
+---+-----------------+--------------+---+-------------+-------------+---+

3.  CAN'T RECALL



H1c. Here are three \[NAMES/SLOGANS\]. Do you recognize any of these?

  ------- ----------------------------------------------- -------- ---------
                                                          **NO**   **YES**

  1\.     COMMITT                                         1        2

  2\.     Heart Attack React                              1        2

  3\.     Heart Alert                                     1        2
  ------- ----------------------------------------------- -------- ---------

SECTION I: KNOWLEDGE

I1. Now I\'d like to read you some statements about heart health. Tell
me whether each of the following statements is true, false, or you don't
know:

  ----- -------------------------------------- ---------- ----------- -------- ---------
                                               **True**   **False**   **DK**   **REF**

  a\.   Heart disease is the most common cause 1          2           d        r
        of death in women in the United                                        
        States.                                                                

  b\.   Almost all heart attacks occur in      1          2           d        r
        people over age 65.                                                    

  c\.   Hospitals have drugs that reduce the   1          2           d        r
        damage done when a heart attack                                        
        occurs.                                                                

  d\.   Younger African Americans have a       1          2           d        r
        greater danger of heart attacks than                                   
        younger Whites.                                                        

  e\.   Younger Hispanic-Americans have a      1          2           d        r
        greater danger of heart attacks than                                   
        younger Whites.                                                        
  ----- -------------------------------------- ---------- ----------- -------- ---------

SECTION J: Beliefs

Now I will read you some statements of opinion. Please tell me how you
feel about each statement, do you strongly agree, agree, disagree, or
strongly disagree? Here's the first statement.

\[NOTE: IF RESPONDENT HAS DIFFICULTY, ASK: Do you [strongly
agree]{.underline} (agree, disagree, strongly disagree) that you would
be embarrassed, etc.\]

J1. Most people who think they\'re having a heart attack should drive
themselves to the hospital.

Do you:

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Strongly    Agree       Disagree    Strongly    DK          REFUSED
  Agree                               disagree                
  ----------- ----------- ----------- ----------- ----------- -----------

J2. Most people who have heart attacks have crushing, severe chest pain.
Do you:

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Strongly    Agree       Disagree    Strongly    DK          REFUSED
  Agree                               disagree                
  ----------- ----------- ----------- ----------- ----------- -----------

J3. Women rarely have heart attacks. Do you:

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Strongly    Agree       Disagree    Strongly    DK          REFUSED
  Agree                               disagree                
  ----------- ----------- ----------- ----------- ----------- -----------

J4. If I have chest pain that doesn\'t stop after 15 minutes, I should
get to the hospital as soon as possible. Do you:

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Strongly    Agree       Disagree    Strongly    DK          REFUSED
  Agree                               disagree                
  ----------- ----------- ----------- ----------- ----------- -----------

J5. I would be embarrassed to go to the hospital if I thought I was
having a heart attack but I wasn't. Do you:

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Strongly    Agree       Disagree    Strongly    DK          REFUSED
  Agree                               disagree                
  ----------- ----------- ----------- ----------- ----------- -----------

J6. If I thought I was having a heart attack, I would wait until I was
[very sure]{.underline} before going to the hospital. Do you:

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Strongly    Agree       Disagree    Strongly    DK          REFUSED
  Agree                               disagree                
  ----------- ----------- ----------- ----------- ----------- -----------

J7. If I thought I was having a heart attack, I would rather have
someone drive me to the hospital than have an ambulance come to my home.
Do you:

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Strongly    Agree       Disagree    Strongly    DK          REFUSED
  Agree                               disagree                
  ----------- ----------- ----------- ----------- ----------- -----------

J8. Because of the cost of medical care, I would want to be absolutely
sure I was having a heart attack before going to the hospital. Do you:

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Strongly    Agree       Disagree    Strongly    DK          REFUSED
  Agree                               disagree                
  ----------- ----------- ----------- ----------- ----------- -----------

J9. If I'm having chest pain and I'm not very sure if it's a heart
attack, I should go to the hospital. Do you:

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Strongly    Agree       Disagree    Strongly    DK          REFUSED
  Agree                               disagree                
  ----------- ----------- ----------- ----------- ----------- -----------

J10. If I thought I was having a heart attack, I would go to the
hospital right away. Do you:

  ----------- ----------- ----------- ----------- ----------- -----------
  1           2           3           4           -8          -2

  Strongly    Agree       Disagree    Strongly    DK          REFUSED
  Agree                               disagree                
  ----------- ----------- ----------- ----------- ----------- -----------

Now I'd like to ask you about the signs and symptoms of a heart attack.

J11. What would you say are the signs or symptoms that someone may be
having a heart attack? \[CIRCLE "1" OR "2" FOR ALL THAT APPLY BELOW.\]

\[PROBE: Anything else?\]

  ------ ------------------------------------------------------------------------ -------- ---------
                                                                                  **NO**   **YES**

  1\.    Abdominal Pain                                                           1        2

  2\.    ARM PAIN OR SHOULDER PAIN                                                1        2

  3\.    Back Pain                                                                1        2

  4\.    Chest Pain                                                               1        2

  5\.    Chest Pressure                                                           1        2

  6\.    Chest Tightness                                                          1        2

  7\.    Chest Discomfort \[HEAVINESS, BURNING, TENDERNESS\]                      1        2

  8\.    Cough                                                                    1        2

  9\.    DIZZINESS, LIGHTHEADEDNESS                                               1        2

  10\.   DON'T KNOW                                                               1        2

  11\.   feel lousy/general blahness                                              1        2

  12\.   HEADACHE                                                                 1        2

  13\.   HEARTBURN/INDIGESTION/stomach problem                                    1        2

  14\.   IMPENDING DOOM                                                           1        2

  15\.   JAW PAIN                                                                 1        2

  16\.   Loss of consciousness/fainting                                           1        2

  17\.   Nausea/vomiting                                                          1        2

  18\.   NECK pain                                                                1        2

  19\.   NUMBNESS/TINGLING IN ARM OR HAND                                         1        2

  25\.   PALE, ASHEN, LOSS/CHANGE OF COLOR                                        1        2

  20\.   Palpitations/RAPID HEART RATE                                            1        2

  21\.   SHORTNESS OF BREATH/difficulty breathing                                 1        2

  22\.   SWEATING                                                                 1        2

  23\.   Weakness/Fatigue/FAINTNESS                                               1        2

  24\.   Other                                                                    1        2
         (SPECIFY):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            
  ------ ------------------------------------------------------------------------ -------- ---------

J11a. Of the heart attack signs or symptoms you just mentioned, which
one would you say is the most

important?

  -------------- ------------------------------------------------------------------
  1\.            Abdominal Pain

  2\.            ARM PAIN OR SHOULDER PAIN

  3\.            Back Pain

  4\.            Chest Pain

  5\.            Chest Pressure

  6\.            Chest Tightness

  7\.            Chest Discomfort\
                 \[HEAVINESS, BURNING, TENDERNESS

  8\.            Cough

  9\.            DIZZINESS, LIGHTHEADEDNESS

  10\.           DON'T KNOW

  11\.           feel lousy/general blahness

  12\.           HEADACHE

  13\.           HEARTBURN/INDIGESTION/stomach problem

  14\.           IMPENDING DOOM

  15\.           JAW PAIN

  16\.           Loss of consciousness/fainting

  17\.           Nausea/vomiting

  18\.           NECK pain

  19\.           NUMBNESS/TINGLING IN ARM OR HAND

  20\.           Palpitations/RAPID HEART RATE

  21\.           SHORTNESS OF BREATH/difficulty breathing

  22\.           SWEATING

  23\.           Weakness/Fatigue/FAINTNESS

  24\.           Other
                 (SPECIFY):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  -2             REFUSED

  -8             DON'T KNOW
  -------------- ------------------------------------------------------------------

\[CODE THE NUMBER FROM THE ABOVE TABLE CORRESPONDING TO THE MOST\
IMPORTANT SYMPTOM STATED. CODE ONLY ONE NUMBER.\]

  ------------------------------------ ------------------------- ---------
                                       NUMBER CODE               

  ------------------------------------ ------------------------- ---------

SECTION K: Personal Health Status/History

The next few questions ask about your health.

K1. In general, would you say your health is:

  ----------- ---------- ---------- ---------- ---------- ---------- ----------
  1           2          3          4          5          -8         -2

  Excellent   Very Good  Good       Fair       Poor       DON'T KNOW REFUSED
  ----------- ---------- ---------- ---------- ---------- ---------- ----------

K2. Have you ever had a heart attack?

1\. NO -8. DON\'T KNOW

2\. YES -2. REFUSED

K3. Have your spouse, your parents, or a brother or sister ever had a
heart attack?

1\. NO -8. DON\'T KNOW

2\. YES -2. REFUSED

K4. Have any of your other relatives or close friends ever had a heart
attack?

1\. NO -8. DON\'T KNOW

2\. YES -2. REFUSED

K5. Have you ever been told by a doctor that you have a heart condition?

1\. NO -8. DON\'T KNOW

2\. YES -2. REFUSED

K6. Have you ever been told by a doctor that you have diabetes?

1\. NO -8. DON\'T KNOW

2\. YES

-2. REFUSED

K7. Have you ever been told by a doctor that you have high blood
pressure?

1\. NO -8. DON\'T KNOW

2\. YES -2. REFUSED

K8. Have you ever been told by a doctor that you have high blood
cholesterol?

1\. NO -8. DON\'T KNOW

2\. YES -2. REFUSED

K9. Have you **ever** smoked cigarettes?

1\. NO  **GO TO SECTION L** -8. DON\'T KNOW  **GO TO SECTION L**

2\. YES -2. REFUSED  **GO TO SECTION L**

K9a. Have you smoked a cigarette in the past week?

1\. NO -8. DON\'T KNOW

2\. YES -2. REFUSED

SECTION L: Demographics

I have a few final questions. Please bear with me, but I am required to
ask this:

L1. Could you please tell me if you are male or female?

Male 1

Female 2

  ------------------------ ---- ---- -- ---- ---- -- ---- ---- ----------------
  L2. What is your date of                                     **\[GO TO L3\]**
  birth?                                                       

  ------------------------ ---- ---- -- ---- ---- -- ---- ---- ----------------

> MM DD YY

L2a. \[IF WON\'T GIVE DATE OF BIRTH, ASK:\] In what age group are you?

18-24 1

25-34 2

35-44 3

45-54 4

55-64 5

65-74 6

75-84 7

85+ 8

L3. Do you consider yourself to be Hispanic or Latino?

\[PROBE: Of Spanish origin or descent?\]

NO 1

YES 2

L4. Please tell me which group best describes your racial background:

White 1

Black/African American 2

Native American 3

Asian/Pacific Islander 4

OTHER 5

(SPECIFY): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

L5. What is the highest grade or year of school that you have completed?

ENTER HIGHEST GRADE COMPLETED OR NUMBER OF YEARS OF SCHOOL

  ----- --------------------------------------------------- ------- -------
        COMPLETED IF LESS THAN HIGH SCHOOL                          

  ----- --------------------------------------------------- ------- -------

COMPLETED HIGH SCHOOL 12

SOME COLLEGE 13

COMPLETED COLLEGE 14

SOME GRADUATE SCHOOL 15

COMPLETED GRADUATE SCHOOL 16

SOME TECHNICAL SCHOOL 17

COMPLETED TECHNICAL SCHOOL 18

SOME PROFESSIONAL SCHOOL 19

COMPLETED PROFESSIONAL SCHOOL 20

OTHER 21

(SPECIFY):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

L6. Please tell me the category that describes your [total]{.underline}
household income, [before taxes]{.underline}, in the past year?

Less than \$10,000 1

\$10,000 - \$24,999 2

\$25,000 - \$39,999 3

\$40,000 - \$54,999 4

\$55,000 - \$69,999 5

\$70,000 or more 6

DON\'T KNOW -8

REFUSED -2

L7. How long have you lived in your community?

  ----------------------------------------------------- -------- --------
                                                                 

                                                        YEARS    
  ----------------------------------------------------- -------- --------

L8. What is your present marital status?

> \[PROBE: READ CATEGORIES 1-5.\]
>
> 1\. Married
>
> 2\. LIVING WITH SIGNIFICANT OTHER/SOMEONE OTHER THAN A
>
> ROOMMATE
>
> 3\. DIVORCED/Separated
>
> 4\. Single
>
> 5\. Widowed
>
> -8. DON'T KNOW
>
> -2. REFUSED

L9. Are you currently working for pay?

\[NOTE: INCLUDES SELF-EMPLOYED OR ON **TEMPORARY** DISABILITY LEAVE.\]

1\. NO -8. DON\'T KNOW

2\. YES  **GO TO L10** -2. REFUSED

L9a. Which of the following best describes you?

> \[CIRCLE ONE\]

1\. Homemaker

2\. Retired

3\. Disabled

4\. Student

5\. Not currently employed

-8. DON'T KNOW

-2. REFUSED

L10. Including yourself, how many people age 18 or older live in this
household?

  ------------------- --------------------------------- -------- --------
                      NUMBER OF PEOPLE:                          

  ------------------- --------------------------------- -------- --------

L11. Which of the following kinds of health insurance do you have now?

+---+----------------------------------+-----+-----+-----+------------+
|   |                                  | **N | *   | **D | *          |
|   |                                  | O** | *YE | K** | *REFUSED** |
|   |                                  |     | S** |     |            |
+---+----------------------------------+-----+-----+-----+------------+
| a | Medicare (the federal health     | 1   | 2   | -8  | -2         |
| \ | insurance for people 65 or older |     |     |     |            |
| . | or who are disabled)?            |     |     |     |            |
+---+----------------------------------+-----+-----+-----+------------+
| b | Medicare supplement (additional  | 1   | 2   | -8  | -2         |
| \ | insurance to Medicare that you   |     |     |     |            |
| . | buy yourself, such as Medex,     |     |     |     |            |
|   | Medigap, or AARP)?               |     |     |     |            |
+---+----------------------------------+-----+-----+-----+------------+
| c | Medicaid (the state program for  | 1   | 2   | -8  | -2         |
| \ | persons with incomes below a     |     |     |     |            |
| . | certain level)?                  |     |     |     |            |
+---+----------------------------------+-----+-----+-----+------------+
| d | Commercial or Private Insurance  | 1   | 2   | -8  | -2         |
| \ | (such as Blue Cross, Ætna,       |     |     |     |            |
| . | Prudential, or Hancock)?         |     |     |     |            |
+---+----------------------------------+-----+-----+-----+------------+
| e | An HMO (a Health Maintenance     | 1   | 2   | -8  | -2         |
| \ | Organization) or an IPA (an      |     |     |     |            |
| . | Individual Practice              |     |     |     |            |
|   | Association)?                    |     |     |     |            |
+---+----------------------------------+-----+-----+-----+------------+
| f | VA benefits, CHAMPUS?            | 1   | 2   | -8  | -2         |
| \ |                                  |     |     |     |            |
| . |                                  |     |     |     |            |
+---+----------------------------------+-----+-----+-----+------------+
| g | Student Health Plan?             | 1   | 2   | -8  | -2         |
| \ |                                  |     |     |     |            |
| . |                                  |     |     |     |            |
+---+----------------------------------+-----+-----+-----+------------+
| h | Other state medical assistance   | 1   | 2   | -8  | -2         |
| \ | or free care programs?           |     |     |     |            |
| . |                                  |     |     |     |            |
+---+----------------------------------+-----+-----+-----+------------+
| i | Or something else. What is it?   | 1   | 2   | -8  | -2         |
| \ |                                  |     |     |     |            |
| . | (SPECIFY):                       |     |     |     |            |
|   | \_\_\_\_\_\_\_\_                 |     |     |     |            |
|   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |     |     |     |            |
+---+----------------------------------+-----+-----+-----+------------+

L11a. Does your insurance plan pay part of the following:

  ----- ------------------------------ -------- --------- -------- -------------
                                       **NO**   **YES**   **DK**   **REFUSED**

  a\.   Ambulance Service              1        2         -8       -2

  b\.   Visits to the Emergency        1        2         -8       -2
        Department                                                 
  ----- ------------------------------ -------- --------- -------- -------------

L12. Do you have a regular doctor or group of doctors?

1\. NO  **GO TO L13** -8. DON\'T KNOW  **GO TO L13**

2\. YES -2. REFUSED  **GO TO L13**

L12a. Did you visit your doctor in the past year?

1\. NO -8. DON\'T KNOW

2\. YES -2. REFUSED

L13. Have you ever seen a cardiologist (a heart doctor)?

1\. NO  **GO TO L14** -8. DON\'T KNOW  **GO TO L14**

2\. YES -2. REFUSED  **GO TO L14**

> L13a. When was your most recent visit to this heart doctor?
>
> \[PROBE: Your best guess will do.\]

  ----------------- ----------------- -------- -------- --- -------- --------
                    DATE:                                            

  ----------------- ----------------- -------- -------- --- -------- --------

MM YY

L14. Besides the number I dialed, are there any other non-business
telephone numbers in this home?

1\. NO -8. DON\'T KNOW

2\. YES -2. REFUSED

**SECTION M: END OF SURVEY**

Thank you very much for your help. Good bye.

  ------- ------------------ ---- ---- --- ---- ---- --------- -- ---------- -- --
  M1.     END TIME:                    :             1\. AM       2\. PM        

  ------- ------------------ ---- ---- --- ---- ---- --------- -- ---------- -- --

**SECTION N: INTERVIEWER COMMENTS**

N1. Please rate how comfortable the Respondent was during the interview.

Not at all Very

comfortable comfortable

1 2 3 4 5

N2. Please rate how cooperative the Respondent was during the interview.

Not at all Very

cooperative cooperative

1 2 3 4 5

N 3. In general, how difficult was it for the Respondent to answer the
interview questions?

Not at all Very

difficult difficult

1 2 3 4 5

N4. Did the Respondent have difficulty answering any of the questions?

1\. NO 2. YES → Which ones? \_\_\_\_\_\_\_\_\_\_\_\_\_

N5. Do you feel that the Respondent gave inaccurate or misleading
information on any of the questions?

1\. NO 2. YES → Which ones? \_\_\_\_\_\_\_\_\_\_\_\_\_

N6. Were there any unusual circumstances at the time of the interview
(e.g., R had difficulty hearing, concentrating or there were frequent
interruptions, etc.)

1\. NO 2. YES → Describe \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

N7. Did the Respondent have a language or literacy problem?

1\. NO 2. YES → Which questions were affected?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_