Form No number No number Economic Impact Questionnaire for Adults

Form Approved

OMB NO.

Expiration Date:

Attachment 20

Clinic Appointment Packet Materials

<<Economic Impact Questionnaire - Adults>>

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or an other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

The following information will be used with your clinical evaluation to study the relationship between your health and the economic well-being of your family.

1. How many adults 65 years of age or older live in your household?

______________ Adults

2. How many adults aged 18 to 64 live in your household?

______________ Adults

3. How many children less than 18 years of age live in your household?

______________ Children

4. What was the last grade or year of school you completed?

	1	No formal schooling
	2	1st through 8th Grade
	3	Some High School
	4	High School Graduate
	5	Trade, Technical, or Vocation School after High School
	6	Some College
	7	2-Year College Graduate
	8	4-Year College Graduate
	9	Post Graduate
	10	Other (Specify below)
		_____________________________________

5. Are you currently married, member of an unmarried couple, separated, divorced, widowed, or have you never been married?

	1	Married
	2	Member of an unmarried couple
	3	Separated
	4	Divorced
	5	Widowed
	6	Never been married
	95	Other (Specify below)
		_____________________________________

6. Are you currently working for pay full-time, part-time, or not at all?

1	Full-Time: At least 30 hours per week (SKIP TO 11)
2	Part-Time: Less than 30 hours per week (SKIP TO 11)
3	Not currently working for pay

7. What is the main reason that you are not currently working for pay?

1	Retired
2	Laid Off
3	Disabled
4	A Homemaker
5	A Student
6	Other (Specify below)
	____________________________________________________

8. Are you currently receiving unemployment benefits?

1	Yes
2	No (SKIP TO 10)

9. How much do you receive in unemployment benefits per week?

$ _____________________ Per Week

10. Are you unemployed and looking for work, or are you not looking for paid employment at this time?

1	Unemployed and looking for work
2	Not looking for paid employment at this time

11. During the past twelve months, did you do any work for pay?

1	Yes
2	No (SKIP TO 33)

12. In the last 12 months, did you miss any days of work because you were ill or injured?

1	Yes
2	No (SKIP TO 16)

13. In the last 12 months, how many days did you miss work because you were ill or injured? Please count only days when you had a job, but were unable to go to work.

______________ Days

14. How many of those days were you paid for, either as sick leave or vacation?

______________ Days

15. How many of those days were unpaid?

______________ Days

16. During the past four weeks, did you do any work for pay?

1	Yes
2	No (SKIP TO 33)

17. In how many of the last four weeks did you do any work for pay? Please include any sick leave or vacation time for which you were paid.

1	One week
2	Two weeks
3	Three weeks
4	All four weeks

18. In the weeks that you worked, on average, how many hours per week did you work? Please include any sick leave or vacation time for which you were paid.

______________ Hours Per Week

19. In the weeks that you worked, on average, how much did you earn per week, before taxes and other deductions?

$ _____________________ Per Week

20. In the last four weeks, did you miss any days of work because you were ill or injured?

1	Yes
2	No (SKIP TO 24)

21. In the last four weeks, how many days did you miss work because you were ill or injured? Please count only days when you had a job but were unable to go to work.

______________ Days

22. How many of those days were you paid for, either as sick leave or vacation?

______________ Days

23. How many of those days were unpaid?

______________ Days

24. In the last 4 weeks, how many times have you been late to work?

______________ Times

25. In the last 4 weeks, how many times have you left work early?

______________ Times

26. In the last 4 weeks, how many times have you stepped out during the day, not on a normal break?

______________ Times

27. In the last 4 weeks, how many times have you showed up to work even though you were too sick or injured?

______________ Times

27. In the last 4 weeks, how many times have you showed up to work even though you were too tired?

______________ Times

29. In the last 4 weeks, how many times have you showed up to work even though you were too stressed to get your job done right?

______________ Times

30. In the last 4 weeks, how many times have you made a mistake on the job because you were too sick or injured?

______________ Times

31. In the last 4 weeks, how many times have you made a mistake on the job because you were too tired?

______________ Times

32. In the last 4 weeks, how many times have you made a mistake on the job because you were too stressed?

______________ Times

33. During a typical day, how many hours do you spend on housework or taking care of children?

______________ Hours Per Day

34. Are you currently doing any unpaid volunteer work?

1	Yes
2	No (SKIP TO 36)

35. Are you currently volunteering full-time or part-time?

1	Volunteering full-time (at least 30 hours per week) (SKIP TO 37)
2	Volunteering part-time (less than 30 hours per week) (SKIP TO 37)

36. In the last six months, have you done any unpaid volunteer work?

1	Yes
2	No (SKIP TO 39)

37. In the last six months, how many weeks did you do any unpaid volunteer work?

______________ Weeks

38. On average, how many hours per week did you do volunteer work in the last six months?

______________ Hours Per Week

39. What were your own total earnings in calendar year 2006, as reported on your W-2 forms for that year?

$ _____________________

40. Did you have any other income in 2006, such as welfare, SSI, Social Security, or other pensions?

1	Yes
2	No (SKIP TO 42)

41. How much was your other income in 2006?

$ _____________________

42. Do you have a spouse or partner who lives with you?

1	Yes
2	No (SKIP TO 50)

43. During the last four weeks, did your spouse or partner do any work for pay?

1	Yes
2	No (SKIP TO 47)

44. In how many of the last four weeks did your spouse or partner do any work for pay? Please include any sick leave or vacation time for which he or she was paid.

1	One week
2	Two weeks
3	Three weeks
4	All four weeks

45. In the weeks that your spouse or partner worked, on average, how many hours per week did he or she work? Please include any sick leave or vacation time for which he or she was paid.

______________ Hours Per Week

46. In the weeks that your spouse or partner worked, on average, how much did he or she earn per week, before taxes and other deductions?

$ _____________________ Per Week

47. What were your spouse or partner’s total earnings in calendar year 2006, as reported on his or her W-2 forms for that year?

$ _____________________

48. Did your spouse or partner have any other income in 2006, such as welfare, SSI, Social Security, or other pensions?

1	Yes
2	No (SKIP TO 50)

49. How much was your spouse or partner’s other income in 2006?

$ _____________________

50. Not including you or your spouse or partner, what was the total combined income of all other members of your family living with you during the year 2006? Please include money from jobs, work on the side, welfare, SSI, Social Security or other pensions, and any other money income received by other family members living with you.

$ _____________________

51. Are you covered by any of the following types of health insurance? Please mark all categories that apply.

1	Health insurance provided by an employer - either yours or someone else’s, such as your spouse’s
2	Medicare
3	Medicaid
4	Other (Specify below)
	____________________________________________________
5	Not covered by any health insurance

52. During the past four weeks, did you or anyone else purchase any prescription drugs for your use?

1	Yes
2	No (SKIP TO 54)

53. In the grid below, please list each prescription drug you or anyone else purchased for your use during the past four weeks and the amount paid “out-of-pocket” (not covered by insurance)?

Prescription Drug Name	Amount Paid Out-of-Pocket
1.	$ ___________ . _____
2.	$ ___________ . _____
3.	$ ___________ . _____
4.	$ ___________ . _____
5.	$ ___________ . _____
6.	$ ___________ . _____
7.	$ ___________ . _____
8.	$ ___________ . _____
9.	$ ___________ . _____
10.	$ ___________ . _____
11.	$ ___________ . _____
12.	$ ___________ . _____

54. During the past four weeks, did you or anyone else purchase any nonprescription (“over-the-counter”) drugs for your use?

1	Yes
2	No (SKIP TO 56)

55. How much in total did you or anyone else spend on nonprescription (“over-the-counter”) drugs for your use during the past four weeks?

$ ___________ . _____

56. Did you have any other health-related expenses during the past four weeks? Do not include any visits to healthcare professionals, emergency rooms, or hospitalizations.

1	Yes
2	No (SKIP TO 58)

57. In the grid below, please record the description of any other health-related expenses you had during the past four weeks and the amount you paid. Do not include expenses related to visits to healthcare professionals, emergency rooms, or hospitalizations, or maintaining your health, such as a health club membership.

Description of Other Health-Related Expense	Amount Paid
1. ______________________________________________________	$ ___________ . _____
2. ______________________________________________________	$ ___________ . _____
3. ______________________________________________________	$ ___________ . _____
4. ______________________________________________________	$ ___________ . _____
5. ______________________________________________________	$ ___________ . _____
6. ______________________________________________________	$ ___________ . _____
7. ______________________________________________________	$ ___________ . _____
8. ______________________________________________________	$ ___________ . _____
9. ______________________________________________________	$ ___________ . _____
10. _____________________________________________________	$ ___________ . _____
11. _____________________________________________________	$ ___________ . _____
12. _____________________________________________________	$ ___________ . _____
13. _____________________________________________________	$ ___________ . _____
14. _____________________________________________________	$ ___________ . _____

58. The next two questions ask about paid household help who may have worked in your home for any reason.

During the past four weeks, have you paid any household help to perform services for you, such as house cleaning, personal care, or providing transportation?

1	Yes
2	No (SKIP TO 60)

59. How much in total did you spend on household help during the past four weeks?

$ ___________ . _____

60. The next questions ask about your employment status when you were younger. For each age below that applies to you, please answer the following three questions.

a Did you do any work for pay?

b. (If “Yes” to A.) Did you work the full year?

c. (If “Yes” to A.) When working, did you usually work at least 30 hours per week?

			If “Yes” to Question A, Answer Questions B and C
	A. Did you do any work for pay?		B. Did you work the full year?		C. When working, did you usually work at least 30 hours per week?
	YES	NO	YES	NO	YES	NO
Age 16	1	2	1	2	1	2
Age 20	1	2	1	2	1	2
Age 25	1	2	1	2	1	2
Age 30	1	2	1	2	1	2
Age 35	1	2	1	2	1	2
Age 40	1	2	1	2	1	2
Age 45	1	2	1	2	1	2
Age 50	1	2	1	2	1	2
Age 55	1	2	1	2	1	2

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