Attachment 3

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State and Local Area Integrated Telephone Survey (SLAITS)

Attachment 3

OMB: 0920-0406

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Attachment 3:



2007

Survey of Adult Transition and Health (SATH)

Instrument


OMB Number 0920-0406

Expiration date 11/30/07


According to the Paperwork Reduction Act (PRA) of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 0920-0406. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments about the accuracy of the time estimate(s) or suggestions for improving this form please write to: CDC Reports Clearance Officer, 1600 Clifton Road, MS-D74, Atlanta, GA 30333; call 404-639-4604; or send an email to [email protected].


The Public Health Service Act is Volume 42 of the US Code, Section 242k. The collection of information in this survey is authorized by Section 306 of this Act. The confidentiality of your responses is assured by Section 308d of this Act, and by the Confidential Information Protection and Statistical Efficiency Act.


Data collection is conducted under contract to the CDC by the National Opinion Research Center (NORC) at the University of Chicago.




State and Local Area Integrated Telephone Survey (SLAITS)l

Survey of Adult Transition and Health (SATH)

Spring & Summer 2007


DRAFT SPECIFICATIONS

March 1, 2007






SECTION 2: HEALTH AND FUNCTIONAL STATUS


Subdomain 1. General health status


F2Q11 In general, how would you describe your health? Would you say your health is excellent, very good, good, fair, or poor?


(1) Excellent

(2) Very good

(3) Good

(4) Fair

(5) Poor

(7) DON’T KNOW

(9) REFUSED


F2Q12 About 6 years ago, your parent or guardian told us about your health. Compared with 6 years ago, would you say your health now is better, worse, or about the same?


(1) Better

(2) Worse

(3) About the same

(7) DON’T KNOW

(9) REFUSED


F2Q13 Do you consider yourself to have any kind of disability?


(1) Yes

(2) No

(7) Don’t know

(9) Refused


F2Q14 A person with special health care needs is someone who needs special health care services because of a medical, mental health, or other health condition. People with special health care needs might need medicine, therapy, or specialty care on a regular basis – stuff other people don’t typically need or only need once in a while. Do you consider yourself to have a special health care need?


(1) Yes

(2) No

(7) Don’t know

(9) Refused


Subdomain 2. Activity limitations – daily living


F2Q21 Because of a physical, mental, or emotional problem, do you need the help of other persons with PERSONAL CARE NEEDS, such as eating, bathing, dressing, or getting around inside your home?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F2Q22 Because of a physical, mental, or emotional problem, do you need the help of other persons in handling ROUTINE NEEDS, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F2Q23 Does a physical, mental, or emotional problem interfere with your ability to participate in social, religious, or recreation activities like sports, clubs, parties, or church?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED




Subdomain 3. Activity limitations – work


F2Q30 What were you doing most of the past 12 months: Working at a job or business, looking for work, taking care of your house or family, going to school, or something else?


(1) Working at a job or business [SKIP TO F2Q32]

(2) Looking for work [SKIP TO F2Q31]

(3) Taking care of house or family [SKIP TO F2Q31]

(4) Going to school [SKIP TO F2Q31]

(5) Something else

(7) DON’T KNOW [SKIP TO F2Q31]

(9) REFUSED [SKIP TO F2Q31]


F2Q30A What were you doing most of the past 12 months?


TEXT FIELD: _______________________________________________________


F2Q31 Did you have a job or business at any time in the past 12 months?


(1) YES

(2) NO [SKIP TO Q37]

(7) DON’T KNOW [SKIP TO Q37]

(9) REFUSED [SKIP TO Q37]


F2Q32 In the past 12 months, how often has your health affected your ability to work at a job or business? Would you say:


(1) Never [SKIP TO Q34]

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW [SKIP TO Q34]

(9) REFUSED [SKIP TO Q34]


F2Q33 Does your health affect your ability to work a great deal, some, or very little?


(1) A great deal

(2) Some, or

(3) Very little?

(7) DON’T KNOW

(9) REFUSED


F2Q34 Because of your health, did you need any services, accommodations, or other assistance to help you do your job better?


(1) YES [SKIP TO Q35]

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F2Q35 Did your job(s) or business(es) provide any services, accommodations, or other assistance to help you do your best there?


(1) YES [SKIP TO Q36]

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F2Q36 Did you ask or apply for any services, accommodations, or other assistance from your job or business?


(1) YES [SKIP TO NEXT SUBDOMAIN]

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F2Q37 Did you want to have a job or business at any time in the past 12 months?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F2Q38 Do you have plans to have a job or business in the next 12 months?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F2Q39 Does your health affect your ability to have a job or business?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


Subdomain 4. Activity limitations – school


IF F2Q30 = 4 (MAIN ACTIVITY IS SCHOOL), SKIP TO F2Q42.


F2Q41 In the past 12 months, did you attend any type of school?


(1) YES

(2) NO [SKIP TO Q47]

(7) DON’T KNOW [SKIP TO Q47]

(9) REFUSED [SKIP TO Q47]


F2Q42 In the past 12 months, how often has your health affected your ability to attend school? Would you say:


(1) Never [SKIP TO Q44]

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW [SKIP TO Q44]

(9) REFUSED [SKIP TO Q44]


F2Q43 Does your health affect your ability to attend school a great deal, some, or very little?


(1) A great deal

(2) Some, or

(3) Very little?

(7) DON’T KNOW

(9) REFUSED


F2Q44 Because of your health, did you need any services, accommodations, or other assistance to help you attend school or do your best there?


(1) YES [SKIP TO Q45]

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F2Q45 Did the school(s) you attended provide any services, accommodations, or other assistance to help you do your best there?


(1) YES [SKIP TO Q46]

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F2Q46 Did you ask or apply for any services, accommodations, or other assistance from your school?


(1) YES [SKIP TO NEXT SUBDOMAIN]

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F2Q47 Did you want to attend any type of school in the past 12 months?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

F2Q48 Do you have plans to enroll in any type of school in the next 12 months?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F2Q49 Does your health affect your ability to attend school or complete coursework?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


Subdomain 5. Activity limitations – taking care of house or family


IF F2Q30 = 3 (MAIN ACTIVITY IS TAKING CARE OF HOUSE OR FAMILY), ASK F2Q52. IF F2Q30 = (1,2,4,5,7,9), SKIP TO NEXT SUBDOMAIN.


F2Q52 In the past 12 months, how often has your health affected your ability to take care of your house or family? Would you say:


(1) Never [SKIP TO Q54]

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW [SKIP TO Q54]

(9) REFUSED [SKIP TO Q54]


F2Q53 Does your health affect your ability to take care of your house or family a great deal, some, or very little?


(1) A great deal

(2) Some, or

(3) Very little?

(7) DON’T KNOW

(9) REFUSED


F2Q54 Because of your health, did you need any services, accommodations, or other assistance to help you take care of your house or family?


(1) YES [SKIP TO Q55]

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F2Q55 Did you receive any services, accommodations, or other assistance to help you take care of your house or family?


(1) YES [SKIP TO Q56]

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F2Q56 Did you ask or apply for any services, accommodations, or other assistance to help you take care of your house or family?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


SECTION 3: MEDICAL HOME


Subdomain 1. Usual place for care


F3Q01 Is there a place that you USUALLY go when you are sick or you need advice about your health?


(01) YES

(02) THERE IS NO PLACE [SKIP TO Q03]

(03) THERE IS MORE THAN ONE PLACE

(77) DON’T KNOW [SKIP TO Q03]

(99) REFUSED [SKIP TO Q03]


F3Q02 When you are sick or you need advice about your health, what kind of place do you go to most often? Is it a doctor’s office, emergency room, hospital outpatient department, clinic, or some other place?


(01) Doctor’s office

(02) Hospital emergency room

(03) Hospital outpatient department

(04) Clinic or health center

(08) Some other place

(09) DOES NOT GO TO ONE PLACE MOST OFTEN

(77) DON’T KNOW

(99) REFUSED


F3Q03 Is there a place that you USUALLY go when you need routine preventive care, such as a physical examination or check-up?


(01) YES

(02) THERE IS NO PLACE [SKIP TO Q05]

(03) THERE IS MORE THAN ONE PLACE

(77) DON’T KNOW [SKIP TO Q05]

(99) REFUSED [SKIP TO Q05]


F3Q04 When you need routine preventive care, what kind of place do you go to most often? Is it a doctor’s office, emergency room, hospital outpatient department, clinic, or some other place?


(01) Doctor’s office

(02) Hospital emergency room

(03) Hospital outpatient department

(04) Clinic or health center

(08) Some other place

(09) DOES NOT GO TO ONE PLACE MOST OFTEN

(77) DON’T KNOW

(99) REFUSED


F3Q05 A personal doctor or nurse is a health professional who knows you well and is familiar with your health history. This can be a general doctor, a specialist doctor, a nurse practitioner, or a physician’s assistant. Do you have one or more persons you think of as your personal doctor or nurse?


(01) Yes, one person

(02) Yes, more than one person

(03) No

(77) Don’t Know

(99) Refused


Subdomain 2. Continuous screening


F3Q21 During the past 12 months, how many times have you seen a doctor, nurse, or other health care provider for preventive medical care such as a physical exam or checkup?


___ ___ ___ TIMES

(777) DON’T KNOW

(999) REFUSED


F3Q22 During the past 12 months, how many times did you see a dentist for preventive dental care, such as check-ups and dental cleanings?


___ ___ ___ TIMES

(777) DON’T KNOW

(999) REFUSED


IF F3Q21 ≥ 1 OR F3Q22 ≥ 1 THEN SKIP TO F3Q31. ELSE IF F3Q21 = (000,777,999) AND F3Q22 = (000,777,999) THEN ASK F3Q23.


F3Q23 During the past 12 months, did you see a doctor, nurse, or other health care provider for any kind of medical care?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

Subdomain 3. Foregone or delayed care


F3Q31 People often delay or do not get needed health care. Examples of needed health care include medical care as well as other types of care such as dental care, mental health services, and special types of therapies. In the past 12 months, have you delayed or gone without needed health care?


(1) YES

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F3Q32_INT There are many reasons people delay or do not get needed health care. Did you delay or did not get health care for yourself for any of the following reasons?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

F3Q32A You couldn’t get through to the health care provider’s office on the telephone.


F3Q32B You couldn’t get an appointment soon enough.


F3Q32C The clinic or doctor’s office was not open when you could get there.


F3Q32D Transportation was a problem.


F3Q32E You didn’t have enough money to pay the health care provider.


F3Q32F The type of care you needed was not available in your area.


F3Q32G The health care provider did not have the skills you needed.


F3Q32H The type of care was not covered by your health plan.


F3Q32I You could not get approval from your health plan or doctor.


F3Q32J Once you get there, you have to wait too long to see the health care provider.


F3Q32K You have language, communication, or cultural problems with the health care provider.


F3Q32L Going to appointments conflicts with other responsibilities at home, school, or at work.


Subdomain 4. Care coordination


F3Q40 Does anyone help you arrange or coordinate your care among the different doctors or services that you use?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F3Q41 During the past 12 months, have you felt that you could have used extra help arranging or coordinating your care among the different doctors or services?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F3Q42 During the past 12 months, did you need a referral to see any doctors or receive any services?


(1) YES

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F3Q43 Was getting referrals a big problem, a small problem, or not a problem?


(1) Big problem

(2) Small problem

(3) Not a problem

(7) DON’T KNOW

(9) REFUSED


Subdomain 5. Person-centered care


IF F3Q22 = 2 (NO DOCTOR VISITS IN PAST YEAR), SKIP TO NEXT SUBDOMAIN.


F3Q51 During the past 12 months, how often did your doctors and other health care providers spend enough time with you? Would you say never, sometimes, usually, or always?


(1) Never

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW

(9) REFUSED


F3Q52 During the past 12 months, how often did your doctors and other health care providers listen carefully to you? Would you say never, sometimes, usually, or always?


(1) Never

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW

(9) REFUSED


F3Q53 How often are your doctors and other health care providers sensitive to your values and customs? Would you say never, sometimes, usually, or always?


(1) Never

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW

(9) REFUSED


F3Q54 Information about your health or health care can include things such as the causes of any health problems, how to care for yourself now, and what changes to expect in the future. In the past 12 months, how often did you get the specific information you needed from your doctors and other health care providers? Would you say never, sometimes, usually, or always?


(1) Never

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW

(9) REFUSED


F3Q55 During the past 12 months, how often did your doctors or other health care providers help you feel like a partner in your care? Would you say never, sometimes, usually, or always?


(1) Never

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW

(9) REFUSED


F3Q56 During the past 12 months, how often did your doctors or other health care providers encourage you to take responsibility for your health care needs, such as taking medication, understanding your health, or following medical advice? Would you say never, sometimes, usually, or always?


(1) Never

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW

(9) REFUSED


F3Q57 During the past 12 months, how often did your doctors or other health care providers talk directly to you and encourage you to ask questions? Would you say never, sometimes, usually, or always?


(1) Never

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW

(9) REFUSED



SECTION 4: TRANSITION SERVICES RELATED TO HEALTH


F4Q01 Have your doctors or other health care providers talked with you about how your health care needs might change as you got older?


(1) YES

(2) NO [SKIP TO Q03]

(7) DON’T KNOW [SKIP TO Q03]

(9) REFUSED [SKIP TO Q03]


F4Q02 Was a plan for addressing these changing needs developed with your doctors or other health care providers?

(1) YES [SKIP TO Q04]

(2) NO [SKIP TO Q04]

(7) DON’T KNOW [SKIP TO Q04]

(9) REFUSED [SKIP TO Q04]


F4Q03 Would a discussion about your health care needs have been helpful to you?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F4Q04 Do any of your doctors or other health care providers treat only children, teenagers, or adults?


(1) YES

(2) NO [SKIP TO Q07]

(7) DON’T KNOW [SKIP TO Q07]

(9) REFUSED [SKIP TO Q07]


F4Q05 Have they talked with you about eventually seeing doctors or other health care providers who treat adults?


(1) YES [SKIP TO Q07]

(2) NO

(7) DON’T KNOW

(9) REFUSED


F4Q06 Would a discussion about doctors who treat adults have been helpful to you?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F4Q07 Eligibility for health insurance often changes as children reach adulthood. Has anyone discussed with you how to obtain or keep some type of health insurance coverage?


(1) YES [SKIP TO Q09]

(2) NO

(7) DON’T KNOW

(9) REFUSED


F4Q08 Would a discussion about health insurance have been helpful to you?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F4Q09 Have your doctors or other health care providers helped you connect with other youth or adult mentors who could provide you with social, emotional, or career support?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED




SECTION 5: COMMUNITY-BASED SERVICES


F5Q01 Most of the previous questions have been about medical services provided by your doctors. There are other types of services people may need or use because of their health. These services may be educational, vocational, or rehabilitation services, or community programs such as housing services, social services, or recreational services.


Thinking about your health needs and the health-related services that you need, have you had any difficulties trying to use any services during the past 12 months?


(1) YES

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F5Q02 There are many reasons why people may have difficulty trying to use these services. Did you have difficulty trying to use these services for any of the following reasons?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F5Q02_A You could not get the information you needed.


F5Q02_B There was too much paperwork required.


F5Q02_C You didn't have enough money to pay for the services.


F5Q02_D Transportation was a problem.


F5Q02_E There were long waiting lists.


F5Q02_F There were problems in communication between service providers.


F5Q02_G You had language, communication, or cultural problems with the service providers.


F5Q02_H You could not find service providers who had the skills you needed.


F5Q02_I The types of services you needed were not available in your area.


F5Q02_J The types of services you needed were available but you were not eligible.


F5Q02_K The types of services you needed were available but you had used up all eligible benefits.


F5Q02_L You didn't have the time to figure it all out.



SECTION 6: HEALTH INSURANCE COVERAGE


Subdomain 1. Current coverage and past year coverage


F6Q01_INT The next questions are about health insurance.


F6Q01 Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicaid?


(1) YES [SKIP TO Q02]

(2) NO [SKIP TO Q04]

(7) DON’T KNOW [SKIP TO Q02]

(9) REFUSED [SKIP TO Q02]


F6Q02 Are you insured by Medicaid, the State Children’s Health Insurance Program (S-CHIP), or any other insurance program for people with low income or disabilities?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


IF Q01 IN (7, 9) AND Q02 IN (2, 7, 9), [SKIP TO Q04]

ELSE, [SKIP TO Q03]


F6Q03 During the past 12 months, was there any time when you were not covered by ANY health insurance?


(1) YES [SKIP TO NEXT SUBDOMAIN]

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F6Q04 During the past 12 months, have you had health care coverage?


(1) YES [SKIP TO NEXT SUBDOMAIN]

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


Subdomain 2. Adequacy of health insurance


F6Q20 The next questions are about your health insurance or health care plans. Does your health insurance offer benefits or cover services that meet your needs? Would you say:


(1) Never

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW

(9) REFUSED


F6Q22 Does your health insurance allow you to see the health care providers you need? Would you say:


(1) Never

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW

(9) REFUSED


F6Q21A Not including health insurance premiums or costs that are covered by insurance, do you pay any money for your health care? Include out-of-pocket payments for all types of health-related needs such as co-payments, dental or vision care, medications, and any kind of therapy.


(1) YES [SKIP TO Q21B]

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F6Q21B How often are these costs reasonable? Would you say:


(1) Never

(2) Sometimes

(3) Usually

(4) Always

(7) DON’T KNOW

(9) REFUSED


SECTION 7. TRANSITION SERVICES RELATED TO SCHOOL


F7_INTRO Next, I would like to ask you some questions about your education.


F7Q01 During the past 6 years, did you receive any vocational or career training to help you prepare for a job?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F7Q02 What is the highest grade or year of school you have completed?


(01) 8th GRADE OR LESS

(02) 9th-12th GRADE NO DIPLOMA

(03) HIGH SCHOOL GRADUATE OR GED COMPLETED

(04) COMPLETED A VOCATIONAL, TRADE, OR BUSINESS SCHOOL PROGRAM

(05) SOME COLLEGE CREDIT BUT NO DEGREE

(06) ASSOCIATE DEGREE (AA, AS)

(07) BACHELOR’S DEGREE (BA, BS, AB)

(08) MASTER’S DEGREE (MA, MS, MSW, MBA)

(09) DOCTORATE (PhD, EdD) or PROFESSIONAL DEGREE (MD, DDS, DVM, JD)

(77) DON’T KNOW

(99) REFUSED


F7Q03 Did you ever meet with adults at school or somewhere else to set goals for what you would do after high school and make a plan for how to achieve them? Sometimes this is called a transition plan.


(1) YES

(2) NO [SKIP TO NEXT SUBDOMAIN]

(7) DON’T KNOW [SKIP TO NEXT SUBDOMAIN]

(9) REFUSED [SKIP TO NEXT SUBDOMAIN]


F7Q04 Did you participate in the development of that plan?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED







SECTION 8. SELF-DETERMINATION


Note: These items are adapted from the The Arc’s Self-Determination Scale.


F8_INTRO The next questions are statements about activities that you may do. For each statement, please indicate how often you do each activity: never, rarely, sometimes, usually, or always.


(1) Never

(2) Rarely

(3) Sometimes

(4) Usually

(5) Always

(7) DON’T KNOW

(9) REFUSED


F8Q01_A I keep my appointments and meetings.


F8Q01_B I choose how to spend my personal money.


F8Q01_C I plan weekend activities that I like to do.


F8Q02 How often is the following statement true for you? “I am able to make choices that are important to me.” Would you say that is never true, rarely true, sometimes true, usually true, or always true?


(1) Never

(2) Rarely

(3) Sometimes

(4) Usually

(5) Always

(7) DON’T KNOW

(9) REFUSED


F8Q03 How often is the following statement true for you? “I am able to make friends in new situations.” Would you say that is never true, rarely true, sometimes true, usually true, or always true?


(1) Never

(2) Rarely

(3) Sometimes

(4) Usually

(5) Always

(7) DON’T KNOW

(9) REFUSED


SECTION 9. SATISFACTION AND SUPPORT


F9Q01 In general, how satisfied are you with your life? Would you say very satisfied, satisfied, dissatisfied, or very dissatisfied?


(1) Very satisfied

(2) Satisfied

(3) Dissatisfied

(4) Very dissatisfied

(7) DON’T KNOW

(9) REFUSED


F9Q02 How often do you get the social and emotional support you need from your family or friends? Would you say never, rarely, sometimes, usually, or always?


(1) Never

(2) Rarely

(3) Sometimes

(4) Usually

(5) Always

(7) DON’T KNOW

(9) REFUSED


F9Q03 If the option was available, would you like to connect with other youth or adult mentors who could provide you with social, emotional, or career support?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F9Q04 Now, thinking about your health needs and all the medical and health-related services you receive, how satisfied or dissatisfied are you with those services? Would you say very satisfied, somewhat satisfied, somewhat dissatisfied or very dissatisfied?


(1) Very satisfied

(2) Somewhat satisfied

(3) Somewhat dissatisfied

(4) Very dissatisfied

(7) DON’T KNOW

(9) REFUSED




SECTION 10. DEMOGRAPHICS


F10_INTRO Now I have a few more general questions about you and your household.


Subdomain 1. Marital status and living arrangements


F10Q11 Are you currently married, separated, divorced, widowed, or never married?


(1) Married

(2) Separated

(3) Divorced

(4) Widowed

(5) Never married

(7) DON’T KNOW

(9) REFUSED


F10Q12 Are you currently living with a spouse or partner?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F10Q13 Are you currently living with your parent(s)?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


IF F10Q12 = 1 OR F10Q13 = 1, SKIP TO F10Q15.


F10Q14 Do you live alone?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F10Q15 Are you happy with your current living arrangement, or would you like to change where you live or who you live with?


(1) HAPPY WITH CURRENT ARRANGEMENT

(2) WOULD LIKE TO CHANGE

(7) DON’T KNOW

(9) REFUSED



Subdomain 2. Personal earnings and program participation


F10Q21 The next question is about your total income in the past 12 months, including income from all sources such as wages, salaries, Social Security, help from relatives and so forth. Can you tell me that amount before taxes?


___ ___ ___ ___ ___ ___ Dollars

(777777) DON’T KNOW

(999999) REFUSED


F10Q22 Compared to other people your age, do you think you have more ability, about the same ability, or less ability to pay for the things you need?

(1) More ability

(2) About the same ability

(3) Less ability

(7) DON’T KNOW

(9) REFUSED


F10Q23 At any time during the past 12 months, even for one month, did you receive any cash assistance from a state or county welfare program, such as [state TANF name] or General Assistance?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED


F10Q24 During the past 12 months, did you receive Food Stamps?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

F10Q25 During the past 12 months, did you receive Supplemental Security Income (also called SSI)?


(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED




File Typeapplication/msword
File TitleAttachment 3:
Authorziy6
Last Modified Byziy6
File Modified2007-06-04
File Created2007-06-04
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