Form CMS-R-204 Second Generation Social HMO Organization Demonstration

C ase ID: | | | | | | | | |

MPR Reference No.: | | | | | |

OMB APPROVAL NUMBER: 0938-0709

EXPIRATION DATE: 02/28/2007

Second Generation Social Health Maintenance Organization Demonstration

Initial Interview

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0709. The time required to complete this information collection is estimated to average 12 minutes per response, including the time to review instructions, search existing data resources, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this interview, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

March, 2004 Mathematica Policy Research

INTRODUCTION

I1. Hello, my name is INTERVIEWER’ FULL NAME. I am calling on behalf of Senior Dimensions. May I please speak to SAMPLE MEMBER?

SPEAKING TO SAMPLE

MEMBER (GO TO I4) 1

PERSON WHO ANSWERED

WANTS TO KNOW WHAT THE

CALL IS ABOUT (GO TO I2) 2

SAMPLE MEMBER BUSY, UNAVAILABLE, NOT HOME,

NOT FEELING WELL, OR TEMPORARILY OUT OF THE

AREA (ASK FOR BEST DAY AND TIME

TIME TO CALL BACK AND

SCHEDULE AN APPOINTMENT) 3

WHEN SAMPLE MEMBER COMES

TO THE PHONE (GO TO I3) 4

SAMPLE MEMBER PHYSICALLY OR

MENTALLY UNABLE TO RESPOND

ON THE TELEPHONE (GO TO I7) 5

SAMPLE MEMBER HAS A SPEECH

OR HEARING PROBLEM (GO TO I7) 6

SAMPLE MEMBER IN A COMA (GO TO I10) 7

SAMPLE MEMBER DECEASED (GO TO I12) 8

SAMPLE MEMBER IN THE

HOSPITAL (GO TO I13) 9

SAMPLE MEMBER IN A NURSING

HOME (GO TO I16) 10

SAMPLE MEMBER MOVED (GO TO I24) 11

SAMPLE MEMBER ONLY SPEAKS

SPANISH . . . . . . . . . . (GO TO SPANISH VERSION) 12

SAMPLE MEMBER DOES NOT

SPEAK ENGLISH OR SPANISH (GO TO I10) 13

I2. SAMPLE MEMBER should have received a letter explaining that we would be calling about the health care of Medicare beneficiaries who are enrolled in Senior Dimensions. We are (calling/visiting) people who are members of Senior Dimensions to (conduct our annual ) interview (them) [over the telephone]. [We interviewed SAMPLE MEMBER about one year ago and would like to talk to (her/him) again about (her/his) health and how (she/he) gets along day-to-day.] When is a good time to call SAMPLE MEMBER?

WHEN SAMPLE MEMBER COMES

TO THE PHONE (GO TO I3) 1

SAMPLE MEMBER BUSY, UNAVAILABLE, NOT HOME,

NOT FEELING WELL, OR TEMPORARILY OUT OF THE

AREA (ASK FOR BEST DAY AND TIME

TIME TO CALL BACK AND

SCHEDULE AN APPOINTMENT) 2

PERSON REFUSED FOR

SAMPLE MEMBER (SKIP TO CALL BACK) 3

SAMPLE MEMBER PHYSICALLY OR

MENTALLY UNABLE TO RESPOND

ON THE TELEPHONE (GO TO I8) 4

SAMPLE MEMBER HAS A SPEECH OR

HEARING IMPAIRMENT (GO TO I8) 5

SAMPLE MEMBER IN A COMA (GO TO I11) 6

SAMPLE MEMBER DECEASED (GO TO I12) 7

SAMPLE MEMBER IN THE

HOSPITAL (GO TO I13) 8

SAMPLE MEMBER IN A NURSING

HOME (GO TO I16) 9

SAMPLE MEMBER MOVED (GO TO I24) 10

SAMPLE MEMBER ONLY SPEAKS

SPANISH (GO TO SPANISH VERSION) 11

SAMPLE MEMBER DOES NOT SPEAK

SPANISH OR ENGLISH (GO TO I11) 12

I3. Hello, my name is INTERVIEWER'S FULL NAME. I am calling on behalf of (PRIMARY CARE PHYSICIAN/CLINIC NAME) of PLAN. CONTINUE TO I4.

I4. You should have received a letter explaining that we are calling to conduct (an/our annual) (telephone) interview about the health care of Medicare beneficiaries who are enrolled in Senior Dimensions. (You may recall that we interviewed you about one year ago.) The questions I will be asking are about your health and how you get along day-to-day. The information will become part of your medical record and be used to help Senior Dimensions plan for your needs and to study the Medicare program. Your participation is voluntary and all of your answers will be held in strict confidence. The interview only takes about ten minutes. I would like to begin the interview now.

BEGIN INTERVIEW (GO TO I32) 1

NOT A GOOD TIME (SCHEDULE APPOINTMENT

AND SKIP TO CALL BACK) 2

DID NOT RECEIVE OR DOES

NOT RECALL THE LETTER 3

I5. The letter explained that we would be calling because you are a member of Senior Dimensions. We are calling all members of Senior Dimensions to collect information about their health. The information will become part of your medical record and be used to help Senior Dimensions plan for your needs and to study the Medicare program. I would like to begin the interview now.

BEGIN INTERVIEW (GO TO I31) 1

NOT A GOOD TIME (SCHEDULE APPOINTMENT

AND SKIP TO CALL BACK) 2

WANTS ANOTHER LETTER 3

I6. To what address would you like the letter sent?

PROBE: Is there an apartment number?

STREET ADDRESS: APT.#:

CITY: STATE: ZIP CODE:

SKIP TO CALL BACK

I7. SAMPLE MEMBER should have received a letter explaining that we are calling about the health care of Medicare beneficiaries who are enrolled in Senior Dimensions. We are asking people who are enrolled in Senior Dimensions to complete (a telephone/an) interview about their health and how they get along day-to-day. This information will become part of SAMPLE MEMBER’s medical record and be used to help Senior Dimensions plan for (her/his) needs and to study the Medicare program. CONTINUE TO I8.

I8. Will SAMPLE MEMBER be able to talk (on the telephone) if I (call/come) back next week?

YES 1

NO (GO TO I11) 0

NOT SURE d

I9. When would be a good time to (call/visit) to see if (he/she) is up to it?

DATE: |___|___| / |___|___| / |___|___|

MONTH DAY YEAR

TIME: |___|___| : |___|___| AM 1

PM 2

SKIP TO CALL BACK

I10. SAMPLE MEMBER should have received a letter explaining that we are calling about the health care of Medicare beneficiaries who are enrolled in Senior Dimensions. We are asking people who are members of Senior Dimensions to complete (a telephone/an) interview. The information will become part of SAMPLE MEMBER’s medical record and be used to help Senior Dimensions plan for (her/his) needs and to study the Medicare program. CONTINUE TO I11.

I11. Perhaps there is someone who could answer the questions on behalf of SAMPLE MEMBER. Is there a family member or friend who is knowledgeable about (her/his) health and the care (she/he) receives?

YES, SPEAKING TO PROXY,

BEGIN INTERVIEW (GO TO I31) 1

YES, BUT NOT A GOOD TIME OR PROXY

NOT AVAILABLE (ASK FOR PROXY’S NAME AND

SCHEDULE APPOINTMENT) 2

PROXY LIVES AT DIFFERENT

ADDRESS (GO TO I19) 3

NO PROXY AVAILABLE 4

PROXY REFUSAL r

SKIP TO CALL BACK

I12. I am very sorry to hear that (she/he) passed away. I am calling about a study we are conducting for the Medicare program concerning the health care of beneficiaries who are enrolled in Senior Dimensions. A letter explaining why we are calling was recently sent to SAMPLE MEMBER.

When did SAMPLE MEMBER pass away?

|___|___| / |___|___| / |___|___|

MONTH DAY YEAR

Thank you. Please accept my condolences. Goodbye.

END OF INTERVIEW

I13. SAMPLE MEMBER should have received a letter explaining that we are calling about the health care of Medicare beneficiaries who are members of Senior Dimensions. Do you expect SAMPLE MEMBER to come home from the hospital within a day or two?

YES 1

NO (GO TO I15) 0

DOES NOT KNOW d

I14. I would like to talk to SAMPLE MEMBER (over the telephone) about (her/his) health and how (she/he) gets along day-to-day. The information will become part of SAMPLE MEMBER’s medical record and be used to help Senior Dimensions plan for (her/his) needs and to study the Medicare program. When would be a good time to call back?

APPOINTMENT MADE (ENTER APPOINTMENT

DATE AND TIME) 1

PATIENT UNABLE TO RESPOND OVER THE TELEPHONE 2

I15. Perhaps there is someone who could answer the questions on behalf of SAMPLE MEMBER. Is there a family member or friend who is knowledgeable about (her/his) health and the health care (she/he) receives?

YES, SPEAKING TO PROXY,

BEING INTERVIEW (GO TO I31) 1

YES, BUT NOT A GOOD TIME

OR PROXY NOT HOME (ASK FOR PROXY’S NAME AND

SCHEDULE APPOINTMENT) 2

PROXY LIVES AT DIFFERENT

ADDRESS (GO TO I19) 3

NO PROXY AVAILABLE 4

PROXY REFUSAL r

SKIP TO CALL BACK

I16. I am (calling/visiting) about an interview we would like to conduct with SAMPLE MEMBER concerning the health care of Medicare beneficiaries who are enrolled in Senior Dimensions. A letter explaining why we are calling was recently sent to SAMPLE MEMBER. The information will become part of SAMPLE MEMBER’s medical record and be used to help Senior Dimensions plan for (her/his) needs and to study the Medicare program.

Do you expect (her/him) to come home from the nursing home in the next few weeks?

YES 1

NO (GO TO I28) 0

DOES NOT KNOW (GO TO I28) 9

I17. I would like to talk to SAMPLE MEMBER (over the telephone) about (her/his) health and how (she/he) gets along day-to-day. When would be a good time to call back?

APPOINTMENT MADE (ENTER APPOINTMENT

DATE AND TIME) 1

PATIENT UNABLE TO RESPOND OVER THE TELEPHONE 2

I18. Perhaps there is someone who could answer the questions on behalf of SAMPLE MEMBER. Is there a family member or friend who is knowledgeable about (her/his) health and the care (she/he) receives?

YES, SPEAKING TO PROXY,

BEGIN INTERVIEW (GO TO I31) 1

YES, BUT NOT A GOOD TIME OR PROXY

NOT AVAILABLE (ASK FOR PROXY’S NAME AND

SCHEDULE APPOINTMENT) 2

PROXY LIVES AT DIFFERENT

ADDRESS (GO TO I19) 3

NO PROXY AVAILABLE (GO TO I28) 4

PROXY REFUSAL (GO TO I28) 5

SKIP TO CALL BACK

I19. May I please have (her/his) name?

NAME:

I20. May I please have (her/his) telephone number?

TELEPHONE NUMBER:________ - ________ - __________________

I21. And (her/his) address?

PROBE: Is there an apartment number?

STREET ADDRESS: APT.#:

CITY: STATE: ZIP CODE:

I22. How is (she/he) related to SAMPLE MEMBER?

RELATIONSHIP:

I23. Thank you very much for your time.

SKIP TO CALL BACK

I24. SAMPLE MEMBER should have recently received a letter explaining that we are calling about the health care of Medicare beneficiaries who are enrolled in Senior Dimensions.

Do you know how we can reach SAMPLE MEMBER?

YES (GO TO I25) 1

NO, SPECIAL SEARCH NEEDED 0

SKIP TO CALL BACK

I25. May I please have (her/his) telephone number?

TELEPHONE NUMBER:________ - ________ - __________________

I26. May I please have (her/his) address?

PROBE: Is there an apartment number?

STREET ADDRESS: APT.#:

CITY: STATE: ZIP CODE:

I27. Thank you very much for your time.

SKIP TO CALL BACK

I28. What is the name of the nursing home?

NURSING HOME NAME:

I29. What is the address and telephone number of the nursing home?

PROBE: In what town or city is it located?

STREET ADDRESS:

CITY: STATE: ZIP CODE:

TELEPHONE NUMBER:________ - ________ - __________________

I30. Thank you very much for your time.

SKIP TO CALL BACK

I31. I want to assure you that your answers will be held in strict confidence.

I32. INTERVIEWER: RECORD IF KNOWN, OR ASK: Before we begin the interview, could you please tell me if (you are/SAMPLE MEMBER is) male or female?

FEMALE 1

MALE 2

DOES NOT KNOW d

REFUSED r

I33. According to our records, you live at ADDRESS, is that correct?

YES (GO TO A1) 1

NO 0

DOES NOT KNOW d

REFUSED r

I34. What is your present address?

PROBE: Is there an apartment number?

STREET ADDRESS: APT.#:

CITY: STATE: ZIP CODE:

CONTINUE TO QUESTION A1

SECTION A: SAMPLE MEMBER CHARACTERISTICS AND HEALTH SERVICE

UTILIZATION

A1. First I want to be sure we have (your/SAMPLE MEMBER’S) name spelled correctly. According to our records (your/her/his) name is SPELL SAMPLE MEMBER’S NAME, is that correct?

YES (GO TO A3) 1

NO 0

DOES NOT KNOW (GO TO A3) d

REFUSED (GO TO A3) r

A2. What is the correct spelling of (your/her/his) name?

A3. What is (your/her/his) date of birth?

|___|___| / |___|___| / |___|___|

MONTH DAY YEAR

DOES NOT KNOW d

REFUSED r

A3a. INTERVIEWER: IS THIS THE RIGHT PERSON? DOES THE NAME AND DATE OF BIRTH MATCH THE CONTACT SHEET?

YES (GO TO A4) 1

NO 0

A3b. What is your Social Security number?

|___|___|___|-|___||___|-|___|___||___|___|

DOES NOT KNOW d

REFUSED r

A3c. INTERVIEWER: IS THIS THE RIGHT PERSON? DOES THE SOCIAL SECURITY NUMBER MATCH THE CONTACT SHEET?

YES (GO TO A4) 1

NO 0

A3d. I am sorry we must have reached the wrong person. Do you know how I can reach SAMPLE MEMBER who was born on BIRTH DATE?

YES 1

NO (GO TO A3f) 0

A3e. RECORD LOCATING INFORMATION THEN TERMINATE INTERVIEW.

ADDRESS: APT.#:

CITY: STATE: ZIP CODE:

TELEPHONE NUMBER:________ - ________ - __________________

A3f. Thank you for your time and cooperation. END OF INTERVIEW.

A4. INTERVIEWER: IS THE SAMPLE MEMBER IN A COMA? DOES QUESTION I1=06 OR I2=05?

YES (GO TO A7) 1

NO 0

A5. The next questions are about (your/SAMPLE MEMBER’S) health. In general, compared to other people (your/her/his) age, would you say (your/her/his) health is excellent, very good, good, fair, or poor?

EXCELLENT 1

VERY GOOD 2

GOOD 3

FAIR 4

POOR 5

DOES NOT KNOW d

REFUSED r

A6. Compared to one year ago, would you say (your/SAMPLE MEMBERs) health is much better, somewhat better, about the same, somewhat worse, or much worse than one year ago?

MUCH BETTER 1

SOMEWHAT BETTER 2

ABOUT THE SAME 3

SOMEWHAT WORSE 4

MUCH WORSE 5

DOES NOT KNOW d

REFUSED r

A7. The next questions are about health care (you/SAMPLE MEMBER) may have received during the past 12 months.

During the past 12 months, did (you/she/he) visit a physician or clinic?

PROBE: Did (you/she/he) see a doctor?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

A8. During the past 12 months, (have you/has SAMPLE MEMBER) stayed overnight as a patient in a hospital?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

A9. During the past 12 months, did (you/SAMPLE MEMBER) go to an emergency room for medical care? Please do not include visits to an urgent care center.

PROBE: Please include times (you/SAMPLE MEMBER) went to the emergency room, when (you/she/he) received a brief exam, but were sent elsewhere.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

A10. During the past 12 months, (were you/was SAMPLE MEMBER) admitted to a nursing home and stayed overnight?

PROBE: Nursing homes are places where licensed nurses are on staff.

PROBE: Include skilled nursing facilities, intermediate care facilities, long-term care rooms in wards or buildings on the grounds of hospitals, long-term care rooms or nursing wings of congregate housing facilities, and sub-acute rehabilitation facilities.

PROBE: Exclude rest or retirement homes that do not have nurses on staff.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

A11. INTERVIEWER: CHECK QUESTION A7. DID THE SAMPLE MEMBER VISIT A PHYSICIAN OR CLINIC? DOES QUESTION A7=“YES”?

YES 1

NO (GO TO A13) 0

A12. You mentioned that (you/SAMPLE MEMBER) visited a physician. How many times did (you/she/he) visit a physician or clinic in the past 12 months? (Please do not count physician visits while (you were/she was/he was) an [overnight patient in a hospital/(or)(,) in a hospital emergency room/(or)(,) in a nursing home]).

PROBE: Your best estimate would be fine.

PROBE: Include osteopathic doctors and psychiatrists.

PROBE: Include outpatient visits.

PROBE: Include visits by physicians in your home.

PROBE: Include physician visits in urgent care centers.

PROBE: Exclude dentist visits, chiropractor visits, and telephone calls to doctors.

PHYSICIAN VISITS |___|___|

DOES NOT KNOW d

REFUSED r

A13. INTERVIEWER: CHECK QUESTION A8. WAS THE SAMPLE MEMBER HOSPITALIZED? DOES QUESTION A8=“YES”?

YES 1

NO (GO TO A15) 0

A14. You (also) mentioned that (you were/SAMPLE MEMBER was) hospitalized. How many times (have you/has she/has he) been admitted to, and stayed overnight, as a patient in the hospital in the past twelve months?

PROBE: Please count each time (you were/she was/he was) admitted to a hospital and stayed overnight.

PROBE: Please do not count the total nights spent in the hospital.

HOSPITALIZATIONS |___|___|

DOES NOT KNOW d

REFUSED r

A15. INTERVIEWER: CHECK QUESTION A9. DID THE SAMPLE MEMBER GO TO AN EMERGENCY ROOM? DOES QUESTION A9=“YES”?

YES 1

NO (GO TO A17) 0

A16. You (also) mentioned that (you/SAMPLE MEMBER) went to an emergency room. How many times did (you/she/he) go to an emergency room for medical care in the past 12 months?

PROBE: Please count all visits to emergency rooms, including visits where (you/she/ he) received a brief examination, but were sent elsewhere, as well as visits that resulted in admission to the hospital.

PROBE: Please do not count visits to urgent care centers.

EMERGENCY ROOM VISITS |___|___|

DOES NOT KNOW d

REFUSED r

A17. INTERVIEWER: CHECK QUESTION A10. WAS THE SAMPLE MEMBER ADMITTED TO A NURSING HOME? DOES QUESTION A10=“YES”?

YES 1

NO (GO TO A19) 0

A18. You (also) mentioned that (you were/SAMPLE MEMBER was) admitted to a nursing home. How many times (have you/has she/has he) been admitted to a nursing home in the past 12 months?

PROBE: Nursing homes are places where licensed nurses are on staff.

PROBE: Include skilled nursing facilities, intermediate care facilities, long-term care rooms in wards or buildings on the grounds of hospitals, long term care rooms or nursing wings of congregate housing facilities, and sub-acute rehabilitation facilities.

PROBE: Exclude “rest” or “retirement” homes that do not have nurses on staff.

NURSING HOME ADMISSIONS |____|____|

DOES NOT KNOW d

REFUSED r

A19. (Are you/Is SAMPLE MEMBER) currently receiving health care in (your/her/his) home? Please include care provided by a visiting nurse, home health aide, therapist, or other health care professional.

PROBE: Please do not include nursing services received in a nursing home.

PROBE: Please include care provided by friends or relatives only if they are paid to help (you/her/him).

YES 1

NO (GO TO A21) 0

DOES NOT KNOW (GO TO A21) d

REFUSED (GO TO A21) r

A20. What is the name of the agency or organization that provides the home health care?

DOES NOT KNOW d

REFUSED r

A21. Did (you/SAMPLE MEMBER) take prescription or non-prescription medication yesterday?

YES 1

NO (GO TO A24) 0

DOES NOT KNOW (GO TO A24) d

REFUSED (GO TO A24) r

A22. How many different medications, prescribed by a doctor, did (you/she/he) take yesterday? Please also include prescribed over-the-counter medications.

PROBE IF MORE THAN THREE: Is that different medications or the number of pills taken yesterday?

PROBE: Please include vitamins if they were prescribed by a doctor.

PROBE: Please do not include dietary supplements such as Sustacal or Ensure.

PRESCRIPTION MEDICATIONS |____|____|

DOES NOT KNOW d

REFUSED r

A23. How many different medications, not prescribed by a doctor, did (you/she/he) take yesterday?

PROBE IF MORE THAN THREE: Is that the number different medications or the number of pills taken yesterday?

PROBE: Please do not include dietary supplements such as Sustacal or Ensure.

NON-PRESCRIPTION MEDICATIONS |____|____|

DOES NOT KNOW d

REFUSED r

A24. During the past 12 months, (have you/has SAMPLE MEMBER) had a flu shot?

PROBE: This shot is usually given in the fall and protects against influenza for the flu season.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

A25. (Have you/Has she/Has he) ever had a shot for pneumonia?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

A26. INTERVIEWER: IS THE SAMPLE MEMBER FEMALE? DOES QUESTION I32=“1”?

YES 1

NO (GO TO B1) 0

A27. (Have you/Has she) had a PAP smear in the past two years?

PROBE: A PAP smear is a test for cancer of the cervix where a scraping is taken during a vaginal exam.

YES 1

N0 0

DO NOT KNOW d

REFUSED r

A28. Have you had a mammogram in the past two years?

PROBE: A mammogram is an x-ray taken only of the breasts by a machine that presses against the breast.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

SECTION B: HEALTH CONDITIONS

B1. The next questions are about health conditions (you/SAMPLE MEMBER) may have. Did a doctor ever tell (you/him/her) that (you/she/he) had hypertension or high blood pressure?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B2. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had a myocardial infarction or a heart attack?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B3. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had angina pectoris or coronary heart disease?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B4. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had other heart problems, such as congestive heart failure, problems with the valves in (your/her/his) heart, or problems with the rhythm of (your/her/his) heartbeat?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B5. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had any kind of cancer, malignancy, or tumor, except skin cancer?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B6. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had diabetes, high blood sugar, or sugar in (your/her/his) urine?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B7. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had mental retardation?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B8. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had Alzheimer’s Disease or dementia?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B9. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had a mental or psychiatric disorder other than Alzheimer's disease or dementia?

PROBE: Please include depression if it was diagnosed by a doctor.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B10. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had emphysema, asthma, or chronic obstructive pulmonary disease?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B11. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had vision problems, such as glaucoma or cataracts?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B12. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had hearing loss or other hearing problems?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B13. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had Parkinson's Disease?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B14. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had a stroke or partial or complete paralysis?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B15. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had arthritis, including rheumatoid arthritis?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B16. Did a doctor ever tell (you/SAMPLE MEMBER) that (you/she/he) had a broken hip?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

B17. (Have you/Has SAMPLE MEMBER) ever lost an arm or a leg?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

SECTION C: INSTRUMENTAL ACTIVITIES OF DAILY LIVING

C1. INTERVIEWER: IS THE SAMPLE MEMBER IN A COMA? DOES QUESTION I1=06 OR I2=05?

YES (GO TO D28) 1

NO 0

C2. Next, I would like to ask about some everyday activities and whether (you have/SAMPLE MEMBER has) difficulty doing them by (yourself/herself/himself). (Do you/Does she/Does he) have difficulty shopping for personal items such as toilet items or medicine?

YES 1

NO (GO TO C5) 0

DOES NOT SHOP 2

DOES NOT KNOW (GO TO C5) d

REFUSED (GO TO C5) r

C3. [You said that shopping is something that (you do/she does/he does) not do.] Is this because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C4. (Do you/Does she/Does he) receive help with shopping from another person?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C5. (Do you/Does she/Does he) have difficulty using the telephone?

YES 1

NO (GO TO C8) 0

DOES NOT USE THE TELEPHONE 2

DOES NOT KNOW (GO TO C8) d

REFUSED (GO TO C8) r

C6. [You said that using the telephone is something that (you do/she does/he does) not do.] Is this because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C7. (Do you/Does she/Does he) receive help with using the telephone from another person?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C8. (Do you/Does she/Does he) have difficulty doing light housework, such as washing the dishes?

YES 1

NO (GO TO C11) 0

DOES NOT DO LIGHT HOUSEWORK 2

DOES NOT KNOW (GO TO C11) d

REFUSED (GO TO C11) r

C9. [You said that light housework is something that (you do/she does/he does) not do.] Is this because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C10. (Do you/Does she/Does he) receive help with light housework from another person?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C11. (Do you/Does she/Does he) have difficulty preparing meals?

YES 1

NO (GO TO C14) 0

DOES NOT PREPARE MEALS 2

DOES NOT KNOW (GO TO C14) d

REFUSED (GO TO C14) r

C12. [You said that preparing meals is something that (you do/she does/he does) not do.] Is this because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C13. (Do you/Does she/Does he) receive help preparing meals from another person?

PROBE: Please include help provided by Meals-on-Wheels or a similar agency or organization.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C14. (Do you/Does she/Does he) have difficulty using public transportation or riding in a private automobile?

YES 1

NO (GO TO C17) 0

DOES NOT TRAVEL 2

DOES NOT KNOW (GO TO C17) d

REFUSED (GO TO C17) r

C15. [You said that using public transportation or riding in a private automobile is something that (you do/she does/he does) not do.] Is this because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C16. (Do you/Does she/Does he) receive help using public transportation or riding in a private automobile from another person?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C17. (Do you/Does she/Does he) have difficulty taking medications?

YES 1

NO (GO TO C20) 0

DOES NOT TAKE MEDICINE (GO TO C20) 2

DOES NOT KNOW (GO TO C20) d

REFUSED (GO TO C20) r

C18. Is this difficulty taking medications because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C19. (Do you/Does she/Does he) receive help taking medications from another person?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C20. (Do you/Does she/Does he) have difficulty managing finances or balancing a checkbook?

YES 1

NO (GO TO D1) 0

DOES NOT MANAGE FINANCES 2

DOES NOT KNOW (GO TO D1) d

REFUSED (GO TO D1) r

C21. [You mentioned that managing finances is something that (you do/she does/he does) not do.] Is this because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

C22. (Do you/Does she/Does he) receive help managing finances or balancing a checkbook from another person?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

SECTION D: ACTIVITIES OF DAILY LIVING

D1. Next, I would like to ask about some other everyday activities and whether (you have/SAMPLE MEMBER has) difficulty doing them by (yourself/herself/himself).

(Do you/Does she/Does he) have difficulty taking a bath or shower by (yourself/herself/himself)?

PROBE: Difficulty includes using safety rails, grab bars, transfer benches, shower chairs, hand held shower sprayers, or other special equipment to bathe.

YES 1

NO (GO TO D5) 0

DOES NOT KNOW (GO TO D5) d

REFUSED (GO TO D5) r

D2. Is this difficulty taking a bath or shower because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D3. (Do you/Does she/Does he) receive help taking a bath or shower from another person?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D4. (Do you/Does she/Does he) use special equipment to help (you/her/him) with taking a bath or shower?

PROBE: Please include safety rails, grab bars, transfer benches, shower chairs, and hand-held shower sprayers.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D5. (Do you/Does she/Does he) have difficulty dressing (yourself/herself/himself)?

PROBE: Difficulty includes using stocking aides, button holers, no tie shoe laces, or other special equipment to dress.

YES 1

NO (GO TO D9) 0

DOES NOT KNOW (GO TO D9) d

REFUSED (GO TO D9) r

D6. Is this difficulty dressing because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D7. (Do you/Does she/Does he) receive help with dressing from another person?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D8. (Do you/Does she/Does he) use special equipment to help (you/her/him) with dressing?

PROBE: Please include stocking aids, button holers, and no-tie-shoe laces.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D9. (Do you/Does she/Does he) have difficulty getting in or out of a bed or a chair by (yourself/herself/himself)?

PROBE: Difficulty includes using geriatric chairs, seat lift chairs, stairway lifts, patient lifters, Hoyer lifts, or other special equipment to get in or out of a bed or chair.

YES 1

NO (GO TO D13) 0

DOES NOT KNOW (GO TO D13) d

REFUSED (GO TO D13) r

D10. Is this difficulty getting in or out of a bed or a chair because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D11. (Do you/Does she/Does he) receive help getting in or out of a bed or a chair from another person?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D12. (Do you/Does she/Does he) use special equipment to help (you/her/him) with getting in or out of a bed or chair?

PROBE: Please include geriatric chairs or “geri-chairs,” seat lift chairs, stairway lifts, and patient lifters or Hoyer lifts.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D13. (Do you/Does she/Does he) have difficulty eating by (yourself/herself/himself)?

PROBE: Difficulty includes using rocking utensils, built up utensils, adapted utensils with bigger handles, special adhering bowls, vacuum cups, electric feeders, food reachers, or other special equipment to eat.

YES 1

NO (GO TO D17) 0

DOES NOT KNOW (GO TO D17) d

REFUSED (GO TO D17) r

D14. Is this difficulty eating because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D15. (Do you/Does she/Does he) receive help eating from another person?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D16. (Do you/Does she/Does he) use special equipment to help (you/her/him) with eating?

PROBE: Please include rocking utensils, built-up utensils, adapted utensils with bigger handles, special adhering bowls, vacuum cups, electric feeders, and food reachers.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D17. (Do you/Does she/Does he) have difficulty walking by (yourself/herself/himself)?

PROBE: Difficulty includes using a cane, hemi-walker, folding walker, rigid walker, wheeled walker, wheel chair, or other special equipment to walk

YES 1

NO (GO TO D21) 0

DOES NOT KNOW (GO TO D21) d

REFUSED (GO TO D21) r

D18. Is this difficulty walking because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D19. (Do you/Does she/Does he) receive help with walking from another person?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D20. (Do you/Does she/Does he) use special equipment to help (you/her/him) with walking?

PROBE: Please include canes, hemi-walkers, folding walkers, rigid walkers, wheeled walkers, and wheel chairs.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D21. (Do you/Does she/Does he) have difficulty using the toilet by (yourself/herself/himself)?

PROBE: Difficulty includes using a toilet raiser, safety rail, grab bars, a commode, or other special equipment to use the toilet.

YES 1

NO (GO TO D25) 0

DOES NOT KNOW (GO TO D25) d

REFUSED (GO TO D25) r

D22. Is this difficulty using the toilet because of a health or physical problem?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D23. (Do you/Does she/Does he) receive help using the toilet from another person?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D24. (Do you/Does she/Does he) use special equipment to help (you/her/him) with using the toilet?

PROBE: Please include toilet raisers, safety rails, grab bars, and commodes.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

D25. INTERVIEWER: DOES THE SAMPLE MEMBER USE DURABLE MEDICAL EQUIPMENT? DOES D4, D8, D12, D16, D20, OR D24 EQUAL “YES”?

YES (GO TO D27) 1

NO 0

D26. (Are you/Is she/Is he) currently using special medical equipment in (your/her/his) home? Special medical equipment includes things like a hospital bed, floor trapeze, or oxygen equipment used in (your/her/his) home.

YES 1

NO (GO TO D28) 0

DOES NOT KNOW (GO TO D28) d

REFUSED (GO TO D28) r

D27. (Do you/Does she/Does he) own or rent the medical equipment (you use/she uses/he uses) in (your/her/his) home?

OWN (GO TO D28) 1

RENT 2

BOTH 3

DOES NOT USE DURABLE MEDICAL EQUIPMENT

USES WALLS OR FURNITURE TO MOVE AROUND 4

DOES NOT KNOW (GO TO D28) d

REFUSED (GO TO D28) r

D27a. From whom (do you/does she/does he) rent (your/her/his) durable medical equipment?

PROBE: From what company?

COMPANY NAME:

DOES NOT KNOW d

REFUSED r

D28. The next questions are about health problems that are much more common than people think.

During the past 12 months, (have you/has SAMPLE MEMBER) had accidents with (your/her/his) urine?

YES 1

NO (GO TO D30) 0

DOES NOT KNOW (GO TO D30) d

REFUSED (GO TO D30) r

D29. About how often did (you/she/he) have accidents with (your/her/his) urine in the past 12 months? Would you say only occasionally, two or three time a week, or more frequently than that?

OCCASIONALLY 1

FREQUENTLY (2 OR 3 TIMES A WEEK) 2

MULTIPLE DAILY ACCIDENTS OR NO CONTROL

OVER BLADDER 3

DOES NOT KNOW d

REFUSED r

D30. During the past 12 months, (have you/has SAMPLE MEMBER) had accidents with (your/ her/his) bowels?

YES 1

NO (GO TO D32) 0

DOES NOT KNOW (GO TO D32) d

REFUSED (GO TO D32) r

D31. About how often did (you/she/he) have accidents with (your/her/his) bowels in the past 12 months?

PROBE: Would you say only occasionally, two or three time a week, or more frequently than that?

OCCASIONALLY 1

FREQUENTLY (2 OR 3 TIMES A WEEK) 2

MULTIPLE DAILY ACCIDENTS OR NO CONTROL

OVER BOWELS 3

DOES NOT KNOW d

REFUSED r

D32. INTERVIEWER: CODE WITHOUT ASKING IF KNOWN, OR ASK: [You mentioned that (you receive/SAMPLE MEMBER receives) help performing some activities.] Who is the friend or relative who provides (you/her/him) with the most help?

PROBE: What is that person’s first name?

NAME:

NO INFORMAL CAREGIVER (GO TO D34) 0

DOES NOT KNOW d

REFUSED r

D33. INTERVIEWER: CODE WITHOUT ASKING IF KNOWN, OR ASK: How (is NAME/are you) related to (you/SAMPLE MEMBER)?

PRIMARY INFORMAL CAREGIVER’S

RELATIONSHIP TO SAMPLE MEMBER IS:

SPOUSE 1

DAUGHTER 2

SON 3

SISTER 4

BROTHER 5

PARENT 6

DAUGHTER-IN-LAW 7

SON-IN-LAW 8

SISTER-IN-LAW 9

BROTHER-IN-LAW 10

GRANDCHILD 11

OTHER RELATIVE 12

FRIEND 13

NEIGHBOR 14

NO INFORMAL CAREGIVER 00

DOES N0T KNOW d

REFUSED r

D34. Is there a friend, relative, or neighbor who would take care of (you/her/him) for a few days, if needed? (Please include your spouse.)

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

SECTION E: FUNCTIONING

E1. INTERVIEWER: IS THE SAMPLE MEMBER IN A COMA? DOES QUESTION I1=07 OR I2=06?

YES (GO TO F1) 1

NO 0

E2. The next questions are about how (you get/SAMPLE MEMBER gets) along day to day. First, how much difficulty (do you/does she/does he) have lifting or carrying objects as heavy as 10 pounds, like a sack of potatoes? Would you say no difficulty at all, a little difficulty, some difficulty, a lot of difficulty, or (are you/is she/is he) not able to do this at all?

NO DIFFICULTY AT ALL 1

A LITTLE DIFFICULTY 2

SOME DIFFICULTY 3

A LOT OF DIFFICULTY 4

NOT ABLE TO DO THIS AT ALL 5

DOES NOT KNOW d

REFUSED r

E3. How much difficulty (do you/does she/does he) have walking a quarter of a mile, that is about two to three blocks? Would you say no difficulty at all, a little difficulty, some difficulty, a lot of difficulty, or (are you/is she/is he) not able to do this at all?

NO DIFFICULTY AT ALL 1

A LITTLE DIFFICULTY 2

SOME DIFFICULTY 3

A LOT OF DIFFICULTY 4

NOT ABLE TO DO THIS AT ALL 5

DOES NOT KNOW d

REFUSED r

E4. During the last month, (have you/has she/has he) fallen one or more times?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

E5. Without wanting to, (have you/has she/has he) gained or lost ten pounds or more in the past six months?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

E6. (Do you/Does she/Does he) smoke cigarettes?

PROBE: Please do not include cigars, pipes, or chewing tobacco.

YES 1

NO (GO TO E8) 0

DOES NOT KNOW (GO TO E8) d

REFUSED (GO TO E8) r

E7. How many cigarettes (do you/does she/does he) smoke, on average, each day? Would you say less than half a pack a day, about a pack a day, between one and two packs a day, or more than two packs a day?

LESS THAN HALF A PACK A DAY 1

ABOUT A PACK A DAY 2

BETWEEN ONE AND TWO PACKS A DAY 3

MORE THAN TWO PACKS A DAY 4

DOES NOT KNOW d

REFUSED r

E8. In the past month, (have you/has she/has he) had more than three glasses of alcoholic beverages, such as wine, beer, or hard liquor in any one day?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

E9. During the past month, how much (have you/has she/has he) been bothered by emotional problems, such as feeling unhappy, anxious, depressed, or irritable? Would you say not at all, slightly, moderately, quite a bit, or extremely bothered?

NOT AT ALL 0

SLIGHTLY 1

MODERATELY 2

QUITE A BIT 3

EXTREMELY OR ALL THE TIME 4

DOES NOT KNOW d

REFUSED r

E10. How much of the time, during the past month, (have you/has she/has he) felt downhearted and blue? Would you say all of the time, most of the time, a good bit of the time, some of the time, a little of the time, or none of the time?

ALL OF THE TIME 1

MOST OF THE TIME 2

A GOOD BIT OF THE TIME 3

SOME OF THE TIME 4

A LITTLE OF THE TIME 5

NONE OF THE TIME 0

DOES NOT KNOW d

REFUSED r

E11. During the past month, how much difficulty (have you/has she/has he) had remembering things?

PROBE: Would you say none, a little, some, or a lot of difficulty remembering things?

NONE 0

A LITTLE 1

SOME 2

A LOT 3

DOES NOT KNOW d

REFUSED r

E12. In the past month, (have you/has she/has he) been lost, or not known where (you were/she was/he was)?

YES 1

NO (GO TO E14) 0

DOES NOT KNOW (GO TO E14) d

REFUSED (GO TO E14) r

E13. How many times has this happened in the past month?

ONCE 1

2 OR 3 TIMES 2

MORE THAN 3 TIMES 3

DOES NOT KNOW d

REFUSED r

E14. During the past month, (have you/has she/has he) become more forgetful or confused?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

SECTION F: DEMOGRAPHIC CHARACTERISTICS

F1. (Are you/Is she/Is he) currently married, widowed, divorced, separated, or never married?

MARRIED 1

WIDOWED 2

DIVORCED 3

SEPARATED 4

NEVER MARRIED 5

DOES NOT KNOW d

REFUSED r

F2. Which of the following categories best describes (your/SAMPLE MEMBER’s) race? (Are you/Is she/Is he) American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, or White?

CIRCLE ALL THAT APPLY

AMERICAN INDIAN OR ALASKAN NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

WHITE 5

OTHER (SPECIFY) 6

DOES NOT KNOW d

REFUSED r

F3. (Are you/Is she/Is he) of Hispanic or Latino origin?

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

F4. INTERVIEWER: CODE WITHOUT ASKING IF KNOWN, OR ASK: (Are you/Is she/Is he) currently living:

INTERVIEWER: READ ALL RESPONSE CATEGORIES.

alone, (GO TO F7) 1

[with (your/her/his) spouse only

in (your/her/his) own home or

apartment,] (GO TO F7) 2

[with a spouse and other relatives,] (GO TO F6) 3

with children only, (GO TO F6) 4

with other relatives, (GO TO F6) 5

with non-relatives, (GO TO F6) 6

in a group home or board-and-care, or 7

in a nursing home? (GO TO F7) 8

OTHER (SPECIFY) (GO TO F6) 9

DOES NOT KNOW (GO TO F6) d

REFUSED (GO TO F6) r

F5. What is the name of that group home?

DOES NOT KNOW d

REFUSED r

GO TO F7

F6. INTERVIEWER: CODE WITHOUT ASKING IF KNOWN, OR ASK:

How many people live in (your/her/his) household?

PROBE: Please include (yourself/SAMPLE MEMBER).

PEOPLE IN HOUSEHOLD |___|___|

DOES NOT KNOW d

REFUSED r

F7. How many years of school (have you/has she/has he) completed?

YEARS OF SCHOOL |___|___|

DOES NOT KNOW d

REFUSED r

F8. The next questions are about health insurance.

In addition to Medicare, (do you/does SAMPLE MEMBER) currently have health care coverage from (Medicaid/Medi-Cal/ACCESS)? (Medicaid/Medi-Cal/ACCESS) is a state program which provides health care to people who are poor or have very large medical bills.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

F9. Some people have insurance policies designed to cover health care costs not fully covered by Medicare. These policies are called Medicare supplemental or Medigap policies. (Do you/Does SAMPLE MEMBER) currently have Medicare supplemental insurance?

PROBE: Please include group policies and those (you/SAMPLE MEMBER) might have purchased individually.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

F10. (Do you/Does SAMPLE MEMBER) currently have any other form of health care coverage, such as through the military or Veterans Administration or VA? (Please do not include the Medigap coverage we already talked about.)

PROBE: Please include health care coverage provided through CHAMPUS, CHAMP-VA, TRICARE, and the Indian Health Service.

YES 1

NO (GO TO F12) 0

DOES NOT KNOW (GO TO F12) d

REFUSED (GO TO F12) r

F11. INTERVIEWER: ENTER TYPE OF COVERAGE, OR ASK: What type of health care coverage is that?

VETERANS ADMINISTRATION (VA) 1

CHAMPUS 2

CHAMP-VA 3

TRICARE 4

INDIAN HEALTH SERVICE 5

OTHER (SPECIFY) 6

F12. (Have you/Has SAMPLE MEMBER) ever signed a living will? A living will is a document that specifies the type of medical care persons want if they become too sick to tell their doctor personally.

PROBE: Please include an advance directive or durable power of attorney for health care.

YES 1

NO 0

DOES NOT KNOW d

REFUSED r

F13. Now, please think about income. What was the total income [you (and your spouse)/ SAMPLE MEMBER (and [her/his] spouse)] received during 2002? Please include all sources of income received during 2002.

PROBE: Your best estimate is fine.

$|___|,|___|___|___|,|___|___|___| (GO TO F17)

DOES NOT KNOW d

REFUSED r

F14. Could you please tell me if (your/SAMPLE MEMBER’s) [and (your/her/his) spouse’s] total income for 2002 was . . .

$10,000 or less, (GO TO F17) 1

$10,001 to $20,000, (GO TO F17) 2

$20,001 to $40,000, (GO TO F17) 3

$40,001 to $50,000, or (GO TO F17) 4

more than $50,000? (GO TO F17) 5

DOES NOT KNOW d

REFUSED (GO TO F17) r

F15. Perhaps you could estimate the income [you (and your spouse) receive/SAMPLE MEMBER (and [her/his] spouse) (receives/receive)] every month. What is the total income that (you/SAMPLE MEMBER) [and (your/her/his) spouse] receive(s) on a monthly basis? Please include wages, salaries, social security, pensions, and net rental income.

PROBE: Your best estimate is fine.

$|___|,|___|___|___|,|___|___|___| (GO TO F17)

DOES NOT KNOW d

REFUSED r

F16. Could you please tell me if (your/SAMPLE MEMBERs) monthly income is . . .

$833 or less, 1

$834 to $1,667, 2

$1,668 to $3,333, 3

$3,334 to $4,167, or 4

more than $4,167? 5

DOES NOT KNOW d

REFUSED r

F17. We will be calling (you/SAMPLE MEMBER) back in about one year to see how (you are/ she is/he is) getting along. At what address and telephone number will we be able to reach (you/her/him) one year from now?

PROBE: Is there an apartment number?

P.O. BOX OR STREET ADDRESS:

APT.#:

CITY: STATE: ZIP CODE:

TELEPHONE NUMBER: - -

SAME AS CURRENT ADDRESS 0

DOES NOT KNOW d

REFUSED r

F18. To help us locate and interview you next year, it would be very helpful if we could have the name, address, and telephone number of a close friend or relative who does not live with you who we could contact if you move.

PROBE: Is there an apartment number?

NAME:

P.O. BOX OR STREET ADDRESS:

APT.#:

CITY: STATE: ZIP CODE:

TELEPHONE NUMBER:________ - ________ - __________________

SAME AS F17 0

DOES NOT KNOW d

REFUSED r

F19. Those are all the questions I have. Thank you for your time. We appreciate your cooperation.

F20. INTERVIEWER: ENTER DATE INTERVIEW COMPLETED.

|___|___| / |___|___| / |___|___|

MONTH DAY YEAR

END OF INTERVIEW

SECTION G: INTERVIEWER OBSERVATIONS

G1. INTERVIEW MODE:

TELEPHONE INITIATED BY MPR 1

TELEPHONE CALL-IN 2

IN-PERSON 3

MAIL 4

G2. WAS THE INTERVIEW COMPLETED IN WHOLE OR IN PART WITH A PROXY?

YES 1

NO 0

G3. DID THE RESPONDENT HAVE DIFFICULTY UNDERSTANDING THE QUESTIONS?

YES 1

NO 0

G4. DID THE RESPONDENT HAVE DIFFICULTY COMMUNICATING?

YES 1

NO 0