| Order | Question Text | Prompt | Case Report Form Completion Instructions | Type | Collection Variable | Tabulation Target | Mapping Instructions | Controlled Terminology CodeList Name | Permissible Values | Pre-Populated Value |
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| 2 | What is the subject's education level? | Education Level | ndicate Indicate the subject's education level. | Text | EDLEVEL_SCORRES | SCORRES; | SCORRES WHERE SCTESTCD = "EDLEVEL" |
| Did not complete Secondary School or Less than High School; Some Secondary School or High School Education; High School or Secondary School Degree Complete; Associate’s or Technical Degree Complete; College or Baccalaureate Degree Complete; Doctoral or Postgraduate Education | LAST ATTEMPTED USE WITH THIS MEDICATION |
| 3 | What is the subject’s employment status? | Employment Status | Indicate the subject's employment status. | Text | JOBCLAS_SCORRES | SCORRES | SCORRES WHERE SCTESTCD = "JOBCLAS" | (EMPSTAT) | Full-time; Part-time; Not employed |
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| 4 | What is the subject's income? | Income | Indicate the subject's income. | Text | INCOME_SCORRES | SCORRES | SCORRES WHERE SCTESTCD = "INCOME" |
| <100% poverty guideline.;100-200% poverty guidelines; >200% poverty guidelines; |
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| 5 | What is the subject's marital status? | Marital Status | Indicate the subject's marital status. | Text | MARISTAT_SCORRES | SCORRES | SCORRES WHERE SCTESTCD = "MARISTAT" | (MARISTAT) | Never Married; Married; Legally Separated; Divorced; Widowed |
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| 6 | NATORIG_SCORRES | What is the subject's national origin status? | National Origin | Indicate the subject's national origin | NATORIG_SCORRES | SCORRES | SCORRES WHERE SCTESTCD = "NATORIG" |
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| 7 | MILTSTAT_SCORRES | What is the subject’s military status? | Military Status | Indicate the subject's military status. | MILTSTAT_SCORRES | SCORRES | SCORRES WHERE SCTESTCD = "MILTSTAT" |
| NO MILITARY SEVICE; ACTIVE SERVICE; VETERAN; |
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| 8 | SHSMEXST_SCORRES | Was the subject exposed to second hand smoke? | Second Hand Smoke Exposure Status | Indicate the subject's exposure to second hand smoke | SHSMEXST_SCORRES | SCORRES | SCORRES WHERE SCTESTCD = "SHSMEXST" |
| No Exposure to Second Hand smoke; Exposure at Home only; Exposure at work only; Exposure at Work and Home; |
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| 9 | AGESTSMK__SCORRES | What was the age of the subject when they started smoking? | Age Started Smoking | Record the Age Category when the subject started smoking | AGESTSMK__SCORRES | SCORRES | SCORRES WHERE SCTESTCD = "AGESTSMK" |
| 16-24 years; 25-34 years; 45–64 years; 65 years and older |
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| 10 | TBCESSCO__SCORRES | Did the subject have any tobacco cessation counseling? | Tobacco Cessation Counseling | Indicate whether the subject had previous tobacco cessation counseling. | TBCESSCO__SCORRES | SCORRES | SCORRES WHERE SCTESTCD = "TBCESSCO" | (NY) | Yes; No |
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| 11 | LDURABS__SCORRES | What is the longest duration of previous abstinence from tobacco use? | Longest Duration of Abstinence | Record the longest duration of tobacco abstinence | LDURABS__SCORRES | SCORRES | SCORRES WHERE SCTESTCD = "LDURABS" |
| ≤7 days; 8–28 days;1–6 months; >6 months |
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