Revised Materials

0960-0747 revised documents.pdf

Accelerated Benefits Demonstration Project

Revised Materials

OMB: 0960-0747

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MEMORANDUM

TO:

Christopher Silanskis and Robert Weathers

FROM:

AB Project Team

P.O. Box 2393
Princeton, NJ 08543-2393
Telephone (609) 799-3535
Fax (609) 799-0005
www.mathematica-mpr.com

DATE: 2/25/2008

ABD - 016
SUBJECT:

Accelerated Benefits Baseline Questionnaire Changes

The current version of the Accelerated Benefits baseline questionnaire, highlighting changes
made between the version that was submitted with the OMB package and the current version, is
attached for your information (see Attachment 1). In addition to showing the changes discussed
during our briefing with OMB on January 10, 2008, changes that were made as a result of
pretesting, CATI testing, and interviewer feedback are also highlighted. The vast majority of
changes made to the questionnaire reflect the following:
• All wording appropriate for proxy respondents was removed.
• Valid values and edit checks were added.
• Skip logic was added.
• Programmer checks were added.
• Minor wording changes were made.
• Probes were incorporated into some questions.
• Coding of some items was moved to after the interview was completed to facilitate
interviewing and reduce burden.
These changes, along with our rationale for implementing each of them, are summarized in
Attachment 2, “Summary of Changes to the AB Baseline Questionnaire”.
Current versions of the advance letter, notification materials, frequently asked questions
(FAQs), and Understanding of Benefits forms which will be sent to sample members are also
included as attachments to this memo.
The revised burden estimate for the baseline interview is presented in Table 1. The burden
estimate has been revised to eliminate the focus groups and pilot survey, which were dropped
from the design, and to show the two phases of baseline data collection. The revised table shows
the expected number of participants to both phases of the baseline survey, the number of
screening and full interviews expected, hours per response, and the total response burden
associated with each data collection effort.

An Affirmative Action/Equal Opportunity Employer

MEMO TO:
FROM:
DATE:
PAGE:

Christopher Silanskis and Robert Weathers
AB Project Team
2/25/2008
2
TABLE 1
REVISED RESPONSE BURDEN

Data Collection Point

Number of
Respondents

Responses per
Respondent

Hours per
Response

Total Response
Burden (Hours)

Phase 1 Baseline Screener

284

0.17

Phase 1 Baseline Interview

0.66

Phase 2 Baseline Screener

16,673

0.17

2,834

Phase 2 Baseline Interview

1,934

0.66

1,276

480

0.5

240

19,437

4,442

Early Use Survey/
Six-Month Followup Survey
Total

We are seeking 2,000 total responses to the baseline survey and 480 responses to the sixmonth follow-up survey. We will screen 16,957 respondents to achieve our baseline enrollment
goals. We estimate 0.17 hours per completed screener and 0.66 hours per completed baseline
interview. Respondents will incur no monetary costs for completing the interview.
Please let us know if you have any questions about any of these materials or information.
ATTACHMENTS:
1. Baseline Questionnaire Comparison Documents
2. Summary of Changes to the AB Baseline Questionnaire
3. Advance Mailing
4. Notification Materials – AB Health Plan
5. Notification Materials – AB Health Plan Plus
6. Notification Materials – Control Group
7. POMCO Welcome Letters

ATTACHMENT 1
BASELINE QUESTIONNAIRE COMPARISON DOCUMENTS

SECTION B: HEALTH INSURANCE COVERAGE AND CONSENT
(All)

B1.

First, I’d like to ask about different types of health insurance coverage you might have. Are you
currently covered by
PROBE: MedicaidMedicaid? Medicaid is a program that pays for the health care of persons in
need. In your state, you may also hear it called {STATEMED FROM (NAME’s) CURRENT
STATE}. Your Medicaid looks like {DESCRIBE STATE CARD}.
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r

(All)

B2.

Are you currently covered byMedicare?
PROBE: MedicareMedicare?

Medicare is the health insurance plan for people 65 years old and
older or for people with certain disabilities. The Medicare card is red, white and blue and says
“Medicare Health Insurance” in the white section across the top.

YES ................................................................................... 01 (B4)
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r

(B2=00, d or r)

B3.

Are you currently covered by a Medi-Gap plan? A Medi-Gap plan pays for costs not covered by
Medicare.
PROBE: A Medi-Gap plan pays for costs not covered by Medicare.

YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r

DRAFT

Prepared by Mathematica Policy Research, Inc.

(All)

B4.

Are you currently covered by military health care, through Armed Forces retirement benefits, the
VA, TRICARE, CHAMPUS, or CHAMP-VA?
PROBE:

TRICARE is a managed health care program for active duty and retired members of
the uniformed services, their families and survivors. CHAMPUS is a health care
program for dependents of active or retired military personnel. CHAMP-VA is health
insurance for dependents or survivors of disabled veterans.
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r

(All)

B5.

Are you currently covered by a plan from the Indian Health Service?
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r

(All)

B6.

Are you currently covered by Workers Compensation?
PROBE: Workers Compensation provides wage replacement benefits, medical treatment,
vocational rehabilitation, and other benefits to workers or their dependents who are
injured at work or acquire an occupational disease.
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r

(All)

B7.

Are you currently covered by a COBRA plan?
PROBE: COBRA (The Consolidated Omnibus Budget Reconciliation Act) gives workers and
their families who lose health benefits the right to continue health benefits provided by
their former employer’s group plan for a limited period of time.
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r

DRAFT

Prepared by Mathematica Policy Research, Inc.

(All)

B8.

Are you currently covered by a state government program other than Medicaid?
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r

(All)

B9.

Not counting COBRA, dental, optical, or prescription plans, are you currently covered by private
health insurance, for example, private insurance that you get through a former employer, a family
member, or that you purchase on your own?
YES ................................................................................... 01
NO ..................................................................................... 00 (B12)
DON’T KNOW ................................................................... d (B12)
REFUSED ......................................................................... r (B12)

(B9=01)

B10.

Is your private health insurance provided through your current or former employer or through your
spouse or partner’s current or former employer?
YOUR EMPLOYER ........................................................... 01 (B13)
SPOUSE/PARTNER’S EMPLOYER................................. 02 (B13)
NO, NOT PROVIDED BY CURRENT OR
FORMER EMPLOYER................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r

(B9=01)

B11.

Is your private health insurance paid for by you, a family member, by both you and a family
member, or by someone else?
PAID BY YOU ...................................................................
PAID BY FAMILY MEMBER(S) ........................................
PAID BY YOU AND FAMILY MEMBER............................
SOMEONE ELSE..............................................................
DON’T KNOW ...................................................................
REFUSED .........................................................................

DRAFT

01
02
03
04
d
r

(B13)
(B13)
(B13)
(B13)
(B13)

Prepared by Mathematica Policy Research, Inc.

(B11=04)

B11_Other. Who or what is the other source?
__________________________________________________
DON’T KNOW ...................................................................
REFUSED .........................................................................

d
r

GO TO B13

(B1, B2, B3, B4, B5, B6, B7, B8, AND B9 =00, d, or r)

B12.

Let me confirm. Do you have any health insurance coverage to help pay for services from
hospitals or doctors? This kind of health insurance covers doctor visits, trips to the emergency
room, and hospital stays.
YES ................................................................................... 01
NO ..................................................................................... 00 (B15) ELIGIBLE
DON’T KNOW ................................................................... d (B15) INELIGIBLE
REFUSED ......................................................................... r (B15) INELIGIBLE

(B12=01)

B12a. What kind of health insurance coverage do you have? Do you have . .
PROBE: Anything else?
INTERVIEWER: DO NOT ACCEPT LIMITED COVERAGE PLANS LIKE DENTAL ONLY,
PRESCRIPTION ONLY, ETC.
CODE ALL THAT APPLY
Medicaid, ........................................................................... 01
Medicare,........................................................................... 02
Medi-Gap,.......................................................................... 03
VA/TRICARE/CHAMPUS/CHAMP-VA,............................. 04
Indian Health Service, ....................................................... 05
Worker’s Compensation,................................................... 06
COBRA,............................................................................. 07
State Government Program, ............................................. 08
Private health insurance purchased on own, .................... 09
Private health insurance purchased through employer,.... 10
Private health insurance through your spouse/partner’s
plan, or ........................................................................... 11
Some other kind of health insurance ................................ 12
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r

DRAFT

Prepared by Mathematica Policy Research, Inc.

(B1, B2, B3, B4, B5, B6, B7, B8, B9 OR B12=01) OR (B12a=ANSWER)

B13.

Does someone from your health plan such as a nurse or caseworker call or visit you on a regular
basis to check on your condition?
YES ................................................................................... 01
NO ..................................................................................... 00 (B16)
DON’T KNOW ................................................................... d (B16)
REFUSED ......................................................................... r (B16)

(B13=01)

B14.

How often does someone from your health plan call or visit you? Would you say . . .
once per week, ..................................................................
twice per month, ................................................................
once per month, ................................................................
once every 3 months, or....................................................
some other schedule? .......................................................
DON’T KNOW ...................................................................
REFUSED .........................................................................

01
02
03
04
05
d
r

(B16)
(B16)
(B16)
(B16)
(B16)
(B16)

(B14=05)

B14_Other. What is the other schedule?
PROBE: Your best estimate is fine.
| | | TIMES PER
(01-12)
CODE ONE
WEEK ...............................................................................
MONTH ............................................................................
QUARTER........................................................................
YEAR................................................................................
OTHER (SPECIFY) ..........................................................

01
02
03
04
05

DON’T KNOW ..................................................................
REFUSED ........................................................................

d
r

GO TO B16

DRAFT

Prepared by Mathematica Policy Research, Inc.

(B12=d, r, OR 00)

B15.

In what month and year did you last have health insurance coverage?
PROGRAMMER: ALLOW ANY YEAR TO BE ENTERED.
PROGRAMMER: ADD PROMPT: IF YEAR IS BEFORE, 1990, SAY, I want to be sure I
recorded your answer correctly. Did you say [fill YEAR]?
| | | | | | | |
MONTH
YEAR
(01-12)
(1990-2009)
NEVER HAD INSURANCE .............................................. 00 (B16)
DON’T KNOW .................................................................. d
REFUSED ........................................................................ r

(B15=DATE, d OR r)

B15a. When you had insurance {in FILL MONTH/YEAR/the last time} what kind of insurance did you
have? Did you have . . .
PROBE: Anything else?
INTERVIEWER: DO NOT ACCEPT LIMITED COVERAGE PLANS LIKE DENTAL ONLY,
PRESCRIPTION ONLY, ETC.
READ LIST IF NECESSARY
CODE ALL THAT APPLY
Medicaid, ........................................................................... 01
Medicare,........................................................................... 02
Medi-Gap,.......................................................................... 03
VA/TRICARE/CHAMPUS/CHAMP-VA,............................. 04
Indian Health Service, ....................................................... 05
Worker’s Compensation,................................................... 06
COBRA,............................................................................. 07
State Government Program, ............................................. 08
Private health insurance purchased on own, .................... 09
Private health insurance purchased through employer,.... 10
Private health insurance through your spouse/partner’s
plan, or ........................................................................... 11
Some other kind of health insurance?............................... 12
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r

DRAFT

Prepared by Mathematica Policy Research, Inc.

(All)

B16.

Sometimes people have (IF INSURED “additional”) health plans that cover specific health needs
like prescription drugs or dental care. These next questions are about these kinds of limited
coverage plans.
Do you have Medicare Part D coverage for prescription drugs?
IF NEEDED:

Medicare Part D is prescription drug insurance coverage that is provided by
private companies and available to everyone with Medicare.
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(All)

B16a. IF ANY OF B1 TO B9=01, OR B12=01, OR B16=01 SAY:
Not counting the health plan(s) that you already told me about, do you have a separate insurance
plan that helps pay for prescription medications?
IF B12=00, SAY:
(Although you don’t currently have coverage that helps pay for services from hospitals or doctors)
do you have insurance that helps pay for prescription medications?
PROBE: Do not include Medi-Gap or Medicare Part D plans here.
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(All)

B17.

IF ANY OF B1 TO B9=01, OR B12=01:
Not counting the health plan(s) that you already told me about, do you have coverage for dental
care?
IF B12=00, SAY:
(Although you don’t currently have coverage that helps pay for services from hospitals or doctors)
do you have coverage for dental care?

YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

DRAFT

Prepared by Mathematica Policy Research, Inc.

(All)

B18.

IF ANY OF B1 TO B9=01, OR B12=01 SAY:
Not counting the health plan(s) that you already told me about, do you have optical coverage for
eyeglasses or contact lenses?
IF B12=00, SAY:
(Although you don’t currently have coverage that helps pay for services from hospitals or doctors)
do you have optical coverage for eyeglasses or contact lenses?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(All)

ELIG_ck. PROGRAMMER: DO ANY OF QUESTIONS B1, B2, B3, B4, B5, B6, B7, B8, B9=01, OR
DOES B12=01, d or r?
TURN OFF RECORDER IF INELIGIBLE
YES ................................................................................. 01 (END1)
NO ................................................................................... 00 (B19)
CONSENT
B19.

Thank you for taking the time to answer my questions, [Mr./Ms.] {LAST NAME}. Based on your
answers, you can take part in the Accelerated Benefits research study or AB for short. I would
like to tell you a little more about this. Please stop me at any time if you have a question.
The purpose of the study is to learn if receiving a generous health care benefit and other services
improves the health and ability of people with disabilities to return to work, if they choose to do so.
The Social Security Administration is paying for the study.
If you agree to participate in the AB study, you will be placed into one of three groups. One group
will be given health benefits. A second group will be given the same health benefits and will also
be offered services to help them meet their health needs and make it easier for them to return to
work, if they choose to do so. The third group will not get any extra benefits. Picking which group
you are in will be done randomly, like flipping a coin. You will have the same chance of being
assigned to any of the three groups as everyone else in the study.
Do you have any questions about what I’ve read so far?
YES ................................................................................. 01 (B19a)
NO ................................................................................... 00 (B20)

DRAFT

Prepared by Mathematica Policy Research, Inc.

(B19=01)

B19a. INTERVIEWER: ASK IF NECESSARY: What is your question?
INTERVIEWER: ENTER VERBATIM QUESTION

(All)

B20.

Being in the study will not change any of the rules that determine whether you receive Disability
Insurance cash benefits. If you agree to be in this study, we will conduct a 30 minute interview
with you now for which you will receive $25. We may also contact you in about six months and
then again in about a year and a half to find out about your health and the care you are receiving.
You will receive $25 for each of the interviews you complete. You can refuse to answer any
question. This will not affect your ability to take part in AB.
If you are selected to receive the AB health benefits, they could be very valuable to you. You will
be able to use up to $100,000 in health care services. The AB health benefits will cover
treatments that could help improve your health so that you can enjoy more independence and an
increased level of activity.
If you are assigned to one of the groups that receives the AB health benefits, we will send you a
description of the study and the benefits in writing. We will give your information to the
organizations that will be managing the health benefits and services. Someone from POMCO,
the organization managing your health benefits, will be available to answer any questions you
might have about the benefits package. You will be able to use these health benefits until you
become eligible for Medicare.
Do you have any questions at this time?
YES ................................................................................. 01 (B20a)
NO ................................................................................... 00 (B21)

(B20=01)

B20a. INTERVIEWER: ASK IF NECESSARY: What is your question?
INTERVIEWER: ENTER VERBATIM QUESTION

DRAFT

Prepared by Mathematica Policy Research, Inc.

(All)

B21.

In addition to your answers during our interviews, if you agree to be in the study, we will get
information from administrative records about your benefits and your earnings from work. We will
also get information about your use of health care and other services from the organizations
providing AB services. We will get the information for up to ten years.
Only members of the study team will have access to your information. The study team includes
researchers at MDRC and Mathematica, and at the Social Security Administration’s Office of
Program Development and Research.
The information collected as part of this study will be used for research purposes only and will be
kept private and confidential to the extent provided by law. The Social Security Administration will
never use your information to determine your eligibility for Social Security benefits, the amount of
benefits you receive, or your eligibility for Medicare. Your name will never appear in any public
document.
Taking part in the study is up to you, and it does not require you to do anything. If you agree to be
in the study, you do not have to use the health benefits or any other services that are offered.
Being in the study will not change any Social Security program rules that determine whether you
receive Social Security benefits.
You may leave the study at any time, but if you leave the study, you will no longer receive the AB
health care benefits. We will use any information we collect while you are in the study.
If you have any questions about the program or your rights as a participant, you may contact
program staff at 1-866-907-1936.
Do you have any questions now?
YES ................................................................................. 01 (B21a)
NO ................................................................................... 00 (B22)

(B21=01)

B21a. INTERVIEWER: ASK IF NECESSARY: What is your question?
INTERVIEWER: ENTER VERBATIM QUESTION

(All)

B22.

Do you understand everything I have read to you?
YES ................................................................................. 01 (B23)
NO ................................................................................... 00 (B22a)

(B22=01)

B22a. INTERVIEWER: ASK IF NECESSARY: What questions can I answer for you?
INTERVIEWER: ENTER VERBATIM QUESTION

DRAFT

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B23.

Do you agree to be in the study?
YES ................................................................................. 01 (C1)
NO ................................................................................... 00

(B23=00)

B24.

Please remember that by agreeing to be in the study today you are only agreeing to be randomly
assigned to one of the three study groups. If you are assigned to one of the groups that receives
health benefits, you do not have to use those benefits. Being in the study will not change any of
the rules that determine whether you receive Disability Insurance cash benefits. Your information
will be kept confidential. Your participation in this study is very important because it will allow SSA
to learn how to better serve individuals with a disability. You will receive $25 for completing the
interview. Will you reconsider your decision?
YES, I WILL PARTICIPATE ............................................ 01 (C1)
NO, I WILL NOT PARTICIPATE ..................................... 00

(B24=00)

B25.

I’d like to mail you some information about the study so that you can take some more time to
review it and reconsider whether you would like to participate. I will check back with you in about
a week to see if you have any questions. The materials I send will also include a toll free number
you can call to get answers to any questions you may have before I call you again. Please let me
confirm your mailing address. RECORD ADDRESS INFORMATION. Thank you very much for
your time.
GO TO THANKS
STATUS AS 831

(B1, B2, B3, B4, B5, B6, B7, B8, B9, OR B12=01, d, OR r)

>END1< Thank you very much for your time. Those are all the questions I have. Based on the
information that you provided, you are not eligible for the AB Program. Best wishes to you.
IF ASKED WHY: At this time, the AB program is only for persons who do not currently have
health insurance.

DRAFT

Prepared by Mathematica Policy Research, Inc.

STATE MEDICAID PROGRAM NAMES
STATE

PROGRAM NAME

STATE

PROGRAM NAME

Alabama

Alabama Medicaid

Nebraska

Nebraska Medical Assistance Program

Alaska

Alaska Medicaid

Nevada

HIWA (Health Insurance for Work
Enhancement)

Arizona

Arizona Health Care Cost Containment System
(AHCCCS)

New Hampshire

Medicaid

Arkansas

Arkansas Medical Assistance/ /Connect Care

New Jersey

New Jersey FamilyCare

California

Medi-Cal

New Mexico

SALUD/Molina/Lovelace/Presbyterian

Colorado

Medicaid

New York

New York Medicaid CHOICE/Family Health
Plus

Connecticut

CT Medicaid

North Carolina

Carolina ACCESS

Delaware

Diamond State Health Plan

North Dakota

Medicaid

District of
Columbia

Medical Assistance (MA)

Ohio

Aged, Blind, or Disabled (ABD)
Program/Covered Families and Children
(CFC) Program

Florida

MediPass

Oklahoma

SoonerCare

Georgia

Georgia Better Health Care

Oregon

Oregon Health Plan

Hawaii

Hawaii Medicaid:FFS (fee for Service) and MedQUEST

Pennsylvania

HealthChoices/Lancaster Community Health
Plan'

Idaho

Idaho Medicaid Access Card

Rhode Island

RIte Care

Illinois

Family Care/Medical Assistance/MediPlan

South Carolina

Partners for Health

Indiana

Hoosier Healthwise

South Dakota

Medicaid/Medical Assistance

Iowa

Medical Assistance

Tennessee

TennCare

Kansas

MediKan, HealthWave

Texas

Texas Health Steps (THSteps) (STEPs)

Kentucky

KYHealthChoices/Kentucky Patient Access and
Care System(KenPAC)

Utah

Utah Medical Assistance Program (UMAP)

Louisiana

CommunityCARE Program/LaMedicaid

Vermont

Vermont Health Access Plan (VHAP)

Maine

MaineCare

Maryland

HealthChoice Program

Massachusetts

MassHealth

Virginia

Medicaid/Medallion/Medallion II

Michigan

PROGRAMMER: HIDE SENTENCE “In your
state” FOR MICHIGAN RESPONDENTS

Washington

Healthy Options/medical coupons

Community Choice Michigan, Great Lakes Health
Plan, Health Plan of Michigan, HealthPlus
Partners, M-CAID, McLaren Health Plan, Midwest
Health Plan, Molina Health Care, OmniCare
Health Plan, PHP-MM Family Care, Priority Health
Government Programs, Total Health Care, UP
Health Plan
Minnesota

Medical Assistance (MA)

West Virginia

West Virginia Physician Assured Access
System (PAAS)/Mountain Health Trust-(MHT)

Mississippi

Mississippi Medicaid

Wisconsin

Badger Care/Medical Assistance

Missouri

Missouri Medicaid

Wyoming

Medicaid

Montana

Montana Medicaid/PASSPORT to Health

DRAFT

Prepared by Mathematica Policy Research, Inc.

SECTION C: HEALTH AND FUNCTIONAL STATUS
(All)

C1.

Now I willLet’s

continue with the survey.interview. The next questions are about your health.

In general, would you say your health is…
excellent, .........................................................................
very good,........................................................................
good, ...............................................................................
fair, or ..............................................................................
poor? ...............................................................................
DON’T KNOW .................................................................
REFUSED .......................................................................

01
02
03
04
05
d
r

(All)

C2ft.

How tall are you?
INTERVIEWER: ENTER FEET ON THIS SCREEN AND INCHES ON THE NEXT.
| | FEET
(3-8)
DON’T KNOW .................................................................
REFUSED .......................................................................

d (C3)
r (C3)

(C2ft>3)

C2in.

PROBE: ROUND TO NEAREST WHOLE NUMBER (E.G., ENTER 6 FOR 5 ½ INCHES).
INTERVIEWER: ENTER INCHES ON THIS SCREEN.
|

| INCHES
(0-12)

(00-11)
DON’T KNOW .................................................................
REFUSED .......................................................................

d
r

(All)

C3.

How much do you weigh?
|

(50-999)POUNDS

(050-997)
DON’T KNOW .................................................................
REFUSED .......................................................................

DRAFT

d
r

Prepared by Mathematica Policy Research, Inc.

(All)
C4.

What physical, mental, or sensory disability is the main reason {you/(NAME)} applied for disability benefits?
PROBE 1: What do doctors call {your/(NAME’s)} health condition?
PROBE 2: What causes this condition?
RECORD VERBATIM RESPONSE.

(All)
C5.

{Do you/Does (NAME)} have any other physical, mental or sensory conditions that make {you/him/her} eligible for
disability benefits?
YES......................................................................... 01
NO........................................................................... 00 (C7)
DON’T KNOW.........................................................

d (C7)

REFUSED...............................................................

r (C7)

(C5=01)
C6.

What are those conditions?
PROBE 1: What do doctors call {your/(NAME’s)} health condition?
PROBE 2: What causes this condition?
INTERVIEWER: RECORD VERBATIM RESPONSE.
CONDITION 1
CONDITION 2
CONDITION 3

NO C4, C4a, C4b, C5 OR C6 THIS VERSION.
(All)

C7.

Do you use a wheelchair, scooter, walker, crutches or cane to move around?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(IF NOT CONDUCTING INTERVIEW OVER TTY OR TTD)

C8.

Some people use things to help hear or speak, such as a hearing aid, American sign language or
ASL, TTY or TTD, or speech recognition software. Do you use anything like this?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

DRAFT

Prepared by Mathematica Policy Research, Inc.

(All)

C8a.

Some people use things to help them read, hear or speak, such as large print or Braille,a screen reader,
or a screen reader. Do
you use anything like this?
hearing aid, American sign language or ASL, TTY or TTD, or speech recognition software.

YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(C8 OR C8a =01)

C9.

What do you use?
CODE ALL THAT APPLY
LARGE PRINT OR BRAILLE .......................................... 01
SCREEN READER ......................................................... 02
ADAPTED COMPUTER KEYBOARD ............................ 03
HEARING AID OR HEARING DEVICE .......................... 04
AMERICAN SIGN LANGUAGE (ASL) ............................ 05
TTD/TTY.......................................................................... 06
SPEECH RECOGNITION SOFTWARE ......................... 07
OTHER (SPECIFY)......................................................... 08
___________________________________________
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

SF6D:3A
(All)
C10a.C9a.

These next questions are about activities and whether {you need/he/she needs} help from others with
might do during a typical day.

these activities.you

{Do you/Does (NAME)} need help or supervision from others with bathing or showering?
YES......................................................................... 01
NO........................................................................... 00
DON’T KNOW.........................................................

REFUSED...............................................................

(All)
C10b.

{Do you/Does (NAME)} need help or supervision from others with dressing?
YES......................................................................... 01
NO........................................................................... 00

DRAFT

DON’T KNOW.........................................................

REFUSED...............................................................

Prepared by Mathematica Policy Research, Inc.

(All)
C10c.

{Do you/Does (NAME)} need help or supervision from others with preparing meals?
YES......................................................................... 01
NO........................................................................... 00
DON’T KNOW.........................................................

REFUSED...............................................................

(All)
C10d.

{Do you/Does (NAME)} need help or supervision from others with eating?

YES ................................................................................. 01
NO......................................................................................................... 00

How much does your health now limit your participation in vigorous activities, such as running,
lifting heavy objects, or participating in strenuous sports? Would you say that you are limited a
lot, limited a little, or not limited at all?
LIMITED A LOT............................................................... 01
LIMITED A LITTLE.......................................................... 02
NOT LIMITED AT ALL .................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

SF6D:3B

(All)
C9b.

How much does your health now limit your participation in moderate activities, such as moving a
table, pushing a vacuum cleaner, bowling or playing golf?
PROBE AS NEEDED: Would you say that you are limited a lot, limited a little, or not limited at
all?
LIMITED A LOT............................................................... 01
LIMITED A LITTLE.......................................................... 02
NOT LIMITED AT ALL .................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(SF6D:3J
(All)

C9c.

How much does your health now limit you from bathing or dressing yourself?
PROBE AS NEEDED: Would you say that you are limited a lot, limited a little, or not limited at
all?
LIMITED A LOT............................................................... 01
LIMITED A LITTLE.......................................................... 02
NOT LIMITED AT ALL .................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

DRAFT

Prepared by Mathematica Policy Research, Inc.

(All)

C10b. Now, please tell me whether you need help from others with these other activities that you might
do during a typical day.
C10e.

Do you need help or supervision from others with using the toilet?preparing meals?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(All)
C10f.

{Do you/Does (NAME)}C10c.

Do you need help or supervision from others with using the

telephone?eating?

{Do you/Does (NAME)} need help or supervision from others with using public transportation or riding in an automobile?
YES......................................................................... 01
NO........................................................................... 00
DON’T KNOW.........................................................

REFUSED...............................................................

(All)
C10h.

{Do you/Does (NAME)} need help or supervision from others to get in and out of bed or chairs?
YES......................................................................... 01
NO........................................................................... 00
DON’T KNOW.........................................................

REFUSED...............................................................

(All)
C10i............................................................................... {Do you/Does (NAME)} have difficulty walking?
(All)

C10d. (Do you need help or supervision from others) with using the toilet?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

DRAFT

Prepared by Mathematica Policy Research, Inc.

(All)

C10e. (Do you need help or supervision from others) with using the telephone?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
C10j.

{Do you/Does (NAME)} need help or supervision from others to get around inside the home?
YES......................................................................... 01
NO........................................................................... 00
DON’T KNOW.........................................................

REFUSED...............................................................

(All)
C10k.

{Do you/Does (NAME)} need help or supervision from others with taking medication?
YES......................................................................... 01
NO........................................................................... 00
DON’T KNOW.........................................................

REFUSED...............................................................

(All)
C10l............................... {Do you/Does (NAME)} have difficulty lifting or carrying a 10 pound package?
(C7 NE 02)

C10f.

Do you need help or supervision from others with using public transportation?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(C7 NE 02)

C10g. (Do you need help or supervision from others) with riding as a passenger in a car?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

DRAFT

Prepared by Mathematica Policy Research, Inc.

(All)
C10m.

{Do you/Does (NAME)} have difficulty climbing stairs?

(All)

C10h. (Do you need help or supervision from others) to get in and out of bed or a chair?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(C7 NE 02)

C10i.

Do you need help or supervision from others to get around inside the home?
DON’T KNOW.........................................................

REFUSED...............................................................

YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
C10n.

{Do you/Does (NAME)} have difficulty standing for long periods of time?
YES......................................................................... 01
NO........................................................................... 00
DON’T KNOW.........................................................

REFUSED...............................................................

(All)

C11a.

Now, please think about the past 4 weeks. During the past 4 weeks, how much difficulty did {you/(NAME)} have doing
{your/his/her} daily work, both at home and away from home, because of {your/his/her} physical health? Would you
say . . .
None, ..................................................................... 01
A little, .................................................................... 02
Some, ..................................................................... 03
A lot, or.................................................................... 04
Could {you/he/she} not do daily work? ................... 05

DRAFT

DON’T KNOW.........................................................

REFUSED...............................................................

Prepared by Mathematica Policy Research, Inc.

(All)
C11b.

How much bodily pain {have you/has NAME} had in the past 4 weeks? Would you say . . .
None, ..................................................................... 01
A little, .................................................................... 02
Some, or ................................................................ 03
A lot? ...................................................................... 04
DON’T KNOW.........................................................

REFUSED...............................................................

(All)
C11c.

During the past 4 weeks, how much energy did {you/(NAME)} have? Would you say . . .
None, ..................................................................... 01
A little, .................................................................... 02
Some, or ................................................................ 03
A lot? ...................................................................... 04
DON’T KNOW.........................................................

REFUSED...............................................................

(All)
C11d.

During the past 4 weeks, how much did {your/(NAME’s)} physical health or emotional problems limit {your/his/her} usual
social activities with family or friends? Would you say . . .
None, ..................................................................... 01
A little, .................................................................... 02
Some, ..................................................................... 03
A lot, or.................................................................... 04
Could {you/he/she} not do social activities? ........... 05
DON’T KNOW.........................................................

REFUSED...............................................................

(All)
C12.

During the past 4 weeks, how often have {you/(NAME)} been bothered by emotional problems, such as feeling unhappy,
anxious, depressed, or irritable? Would you say…
All of the time, ......................................................... 01
Most of the time, ..................................................... 02
Some of the time,.................................................... 03
A little of the time, or ............................................... 04
None of the time?.................................................... 00

DRAFT

DON’T KNOW.........................................................

REFUSED...............................................................

Prepared by Mathematica Policy Research, Inc.

(All)
C13.

During the past 4 weeks, how much of the time have {you/(NAME)} felt downhearted and blue? Would you say . . .
All of the time, ......................................................... 01
Most of the time, ..................................................... 02
Some of the time,.................................................... 03
A little of the time, or ............................................... 04
None of the time?.................................................... 00
DON’T KNOW.........................................................

REFUSED...............................................................

(All)

C14.

During the past 4 weeks, how much did personal or emotional problems keep {you/(NAME)} from doing {your/his/her}
usual work, school or other daily activities? Would you say . . .
Not at all, ................................................................ 01
A little, .................................................................... 02
Some, ..................................................................... 03
A lot, or.................................................................... 04
Could {you/he/she} not do daily activities? ............ 05
DON’T KNOW.........................................................

REFUSED...............................................................

(C12 AND C13 NE 00, d OR r)
C15.

During the past 4 weeks, how often have physical health problems been the main cause of these feelings? Would you
say…
All of the time, ......................................................... 01
Most of the time, ..................................................... 02
Some of the time,.................................................... 03
A little of the time, or ............................................... 04
None of the time?.................................................... 00
DON’T KNOW.........................................................

REFUSED...............................................................

(All)

C10j.

Do you need reminders, help or supervision from others to take your medication?
YES ................................................................................. 01
NO ................................................................................... 00
DO NOT TAKE MEDICATION ........................................ 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

DRAFT

Prepared by Mathematica Policy Research, Inc.

(C7 NE 01 OR 02)

C10k. Do you have difficulty walking?
YES ................................................................................. 01
NO ................................................................................... 00
NOT APPLICABLE/UNABLE TO DO.............................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)

C10l.

Do you have difficulty lifting or carrying a 10 pound package?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(C7 NE 01 OR 02)

C10m. Do you have difficulty climbing a flight of stairs?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(C7 NE 01 OR 02)

C10n. Do you have difficulty standing for long periods of time?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

SF6D:4C
(All)

C10o. Now, please think about the past 4 weeks. During the past 4 weeks, were you limited in the kind
of work or other activities you could do as a result of your physical health?
YES ................................................................................ 01
NO .................................................................................. 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

DRAFT

Prepared by Mathematica Policy Research, Inc.

SF6D: 7
(All)

C10p. How much bodily pain have you had during the past 4 weeks? Would you say none at all, slight
pain, moderate pain, quite a bit of pain, or an extreme amount of pain?
NONE AT ALL .................................................................
SLIGHT ...........................................................................
MODERATE ....................................................................
QUITE A BIT ...................................................................
EXTREME .......................................................................
DON’T KNOW .................................................................
REFUSED .......................................................................

01
02
03
04
05
d
r

SF6D:8
(All)

C10q. During the past 4 weeks, how much did pain interfere with your normal work, including both work
outside the home and housework? Would you say not at all, slightly, moderately, quite a bit, or
extremely?
NOT AT ALL....................................................................
SLIGHTLY .......................................................................
MODERATELY................................................................
QUITE A BIT ...................................................................
EXTREMELY...................................................................
DON’T KNOW .................................................................
REFUSED .......................................................................

01
02
03
04
05
d
r

SF6D:9e
(All)

C10r.

During the past 4 weeks, how often did you have a lot of energy? 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 ..........................................................
MOST OF THE TIME ......................................................
A GOOD BIT OF THE TIME ...........................................
SOME OF THE TIME......................................................
A LITTLE OF THE TIME .................................................
NONE OF THE TIME ......................................................
DON’T KNOW .................................................................
REFUSED .......................................................................

DRAFT

01
02
03
04
05
06
d
r

Prepared by Mathematica Policy Research, Inc.

SF6D:9f
(All)

C10s. During the past 4 weeks, how often have you 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 ..........................................................
MOST OF THE TIME ......................................................
A GOOD BIT OF THE TIME ...........................................
SOME OF THE TIME......................................................
A LITTLE OF THE TIME .................................................
NONE OF THE TIME ......................................................
DON’T KNOW .................................................................
REFUSED .......................................................................

01
02
03
04
05
06
d
r

Was C14
(C10r=06, d, or r OR C10s NE 06, d or r)

C10s_a. During the past 4 weeks, how often have physical health problems been the main cause of
these feelings? 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, .........................................................
MOST OF THE TIME, .....................................................
A GOOD BIT OF THE TIME ...........................................
SOME OF THE TIME......................................................
A LITTLE OF THE TIME .................................................
NONE OF THE TIME ......................................................
DON’T KNOW .................................................................
REFUSED .......................................................................

01
02
03
04
05
06
d
r

SF6D:10
(All)

C10t.

During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities like visiting friends or relatives? 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 ..........................................................
MOST OF THE TIME ......................................................
A GOOD BIT OF THE TIME ...........................................
SOME OF THE TIME......................................................
A LITTLE OF THE TIME .................................................
NONE OF THE TIME ......................................................
DON’T KNOW .................................................................
REFUSED .......................................................................

DRAFT

01
02
03
04
05
06
d
r

Prepared by Mathematica Policy Research, Inc.

NO C12a – C12h, C13 THIS VERSION
SF6D:5
(All)

C14a. During the past 4 weeks, did personal or emotional problems cause you to accomplish less than
you would like in your work or other regular daily activities?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

Was C13
(All)

C15.

During the past 4 weeks, how much did personal or emotional problems keep you from doing
your usual work, school or other daily activities? Would you say not at all a little, some, a lot or
could you not do daily activities?
NOT AT ALL....................................................................
A LITTLE .........................................................................
SOME..............................................................................
A LOT ..............................................................................
COULD NOT DO DAILY ACTIVITIES ............................
DON’T KNOW .................................................................
REFUSED .......................................................................

DRAFT

01
02
03
04
05
d
r

Prepared by Mathematica Policy Research, Inc.

SECTION D: USE OF MEDICAL SERVICES
(All)

D1.

INTERVIEWER CHECKPOINT: DOES THE RESPONDENT SEEM FATIGUED, CONFUSED, OR
IN NEED OF ENCOURAGEMENT?
SEEMS FATIGUED/CONFUSED ................................... 01 (D1a)
NEEDS ENCOURAGEMENT ......................................... 02 (D1c)
NO/NEITHER/NOT SURE ...................................... 00 (D1a)
(D1=01 OR 00)NOT

SURE .................................................. 03 (D1c)
NO ................................................................................... 00 (D2)

(D1=01)

D1a. Are you feeling tired, or can we continue?
TIRED.............................................................................. 01
CONTINUE...................................................................... 02 (D1d)

(D1a=01)

D1b. Would you like to take a break? I can either hold on or call you back and continue the interview at
another time?
YES, BREAK, HOLD ON ................................................ 01 (D1d)
YES, BREAK AND CALL BACK ..................................... 02 (D1d)
NO, CONTINUE NOW .................................................... 03 (D1d)
(D1=02)
(D1=02 OR 03)

D1c. You’re doing fine. (Your answers are very helpful to this study./There are no right or wrong
answers to these questions.)
(All)
(D1=01, 02 OR 03)

D1d. INTERVIEWER ACTION: WHAT DID YOU DO?
NOT FATIGUED; NO ENCOURAGEMENT
PROVIDED...................................................................
FATIGUED; HELD ON ....................................................
FATIGUED; SCHEDULED CALL BACK.........................
FATIGUED, BUT WANTED TO CONTINUE ..................
PROVIDED ENCOURAGEMENT AND CONTINUED...

DRAFT

01
02
03
04
05

(GO TO CALL BACK SCREEN)

Prepared by Mathematica Policy Research, Inc.

(All)
(D1d NE 03)

D2.

These next questions are about your usual sources of medical care.
Do you have a doctor whom you see or a place you go to regularly to receive medical care?
YES ................................................................................. 01
NO ................................................................................... 00 (D3)
DON’T KNOW ................................................................. d (D3)
REFUSED ....................................................................... r (D3)

(D2=01)

D2a.

Which one of the following kinds of doctors or places do you see or go to most often? Do you
see . . .
IF NEEDED:PROBE:

Specialists include doctors such as surgeons, allergists, (IF FEMALE:
obstetricians, gynecologists), orthopedists, cardiologists, and dermatologists.
Specialists mainly treat just one type of problem.

IF RESPONDS WITH MORE THAN ONE: Please tell me which one of these you go to most
frequently?
CODE ONE
aA

general practitioner, an internist, or
family doctor, ..................................................................
aA specialist,....................................................................
aA psychiatrist or psychologist, or ...................................
doDo you go to a clinic, or ...............................................
someSome other kind of place or doctor? ........................
DON’T KNOW .................................................................
REFUSED .......................................................................

01
02
03
04
05
d
r

(D3)
(D3)
(D3)
(D3)
(D3)
(D3)

(D2a=05)

D2_Other. What is this other place or type of doctor you go to most often?
_________________________________________________________________

DON’T KNOW .................................................................
REFUSED .......................................................................

DRAFT

d
r

Prepared by Mathematica Policy Research, Inc.

(All)

D3.

How many times have you seen ({this/a} doctor/visited this place) in the past six months, that is
since {FILL DATE}?
PROBE: Your best estimate is fine.
PROGRAMMER: ALLOW THE INTERVIEWER TO ENTER ANY NUMBER UP TO 98, BUT
SHOW PROMPT IF MORE THAN 30.
INTERVIEWER: IF NUMBER OF VISITS IS MORE THAN 30, SAY: I want to be sure I recorded
your answer correctly. Did you say that you have (seen a doctor/visited this place) [fill NUMBER]
times in the past 6 months?
| | | NUMBER OF VISITS PAST 6 MONTHS
(01-98)

(D3b)

ZERO .............................................................................. 00 (D3c)
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(D3=d OR r)

D3a.

In the past 6 months, would you say you saw {this/a} {doctor/visited {this/a} clinic}…clinic} . . .
1 to 2 times, ............................................................ 01
3 to 4 times, ............................................................ 02
5 to 6 times, or ........................................................ 03
more than 6 times? ................................................. 04

CODE ONE
zero times,....................................................................... 00 (D3c)
1 to 5 times,..................................................................... 01
6 to 10 times,................................................................... 02
11 to 15 times, ................................................................ 03
16 to 20 times, or ……………………………………………04
more than 20 times? ....................................................... 05
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

DRAFT

Prepared by Mathematica Policy Research, Inc.

(D3>01) (D3a NE 00)

D3b.

How would you rate the medical care you received in the past 6 months in terms of overall quality
of care and services? Would you say it was excellent, very good, good, fair, or poor?
EXCELLENT ...................................................................
VERY GOOD...................................................................
GOOD .............................................................................
FAIR ................................................................................
POOR..............................................................................
DID NOT RECEIVE MEDICAL CARE ............................
DON’T KNOW .................................................................
REFUSED .......................................................................

01
02
03
04
05
n
d
r

(All)
D3b.D3c.

In the past 6 months, that is since [FILLDATE], was there any time when you didn’t see a
doctor or get the medical care you needed?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r

(All)
D3c.D3d.

In the past 6 months, was there any time when you put off or postponed seeing a doctor
or getting medical care you needed?
YES ................................................................................. 01
NO ................................................................................... 00 (D4)
DON’T KNOW ................................................................. d (D4)
REFUSED ....................................................................... r (D4)

(D3b OR D3c=01)
(D3c OR D3d=01)
D3d.D3e.
In the

past 6 months, why is it that you did not see a doctor at all or postponed seeing a
doctor?

INTERVIEWER: RECORD VERBATIM RESPONSE NOW AND CODE LATER

DRAFT

Prepared by Mathematica Policy Research, Inc.

________________________________________________________________

PROBE: WereD3e_a.

Were there any other reasons?
CODE ALL THAT APPLY
COST/INSURANCE
COULD NOT AFFORD IT/TOO EXPENSIVE...................................

NO INSURANCE ..............................................................................

INSURANCE DID NOT COVER .......................................................

DOCTOR OR HOSPITAL DID NOT ACCEPT INSURANCE............

DENIED APPROVAL OR REFERRAL TO SEE SPECIALIST BY
INSURANCE COMPANY...............................................................

AWAITING APPROVAL OR REFERRAL FROM INSURANCE
COMPANY TO SEE SPECIALIST.................................................

ACCESS
COULD NOT GET CONVENIENT APPOINTMENT .......................

TRANSPORTATION PROBLEM ......................................................

WAITING FOR UPCOMING APPOINTMENT ..................................

COULD NOT FIND SPECIALISTS KNOWLEDGEABLE
ABOUT CONDITION ....................................................................

PHYSICAL ACCESS PROBLEM (E.G., WHEELCHAIR RAMP,
ACCESSIBLE MEDICAL EQUIPMENT)........................................

DOCTORS DON’T WANT TO TREAT PEOPLE WITH
{MY/(NAME’S) DISABILITY ...........................................................

QUALITY
DID NOT LIKE DOCTOR OR DOCTOR’S ADVICE .........................

WENT TO ANOTHER DOCTOR INSTEAD......................................

PROBLEMS AT PLACE—LONG WAIT, NO BATHROOM,
NOT ACCESSIBLE........................................................................

CLINIC/OFFICE IN UNSAFE NEIGHBORHOOD.............................

DOCTORS DON’T SPEND ENOUGH TIME ....................................

INSENSITIVE/DISRESPECTFUL DOCTORS/MEDICAL STAFF
(NEGATIVE ATTITUDES, MISPERCEPTION ABOUT DISABILITY) 18
POOR COORDINATION OF CARE WITH OTHER MEDICAL
PROVIDERS..................................................................................

AVOIDANCE/ALTERNATIVES
THOUGHT PROBLEM WOULD GO AWAY, OR PROBLEM
WENT AWAY.................................................................................

USED HOME REMEDY....................................................................

HEALTH GOT WORSE ....................................................................

HEALTH OF OTHER FAMILY MEMBER INTERFERED .................

OTHER REASONS
DENIED APPROVAL FOR DURABLE MEDICAL EQUIPMENT
(DME) OR REPAIR OF DME.........................................................

AWAITING APPROVAL FOR DURABLE MEDICAL EQUIPMENT

DRAFT

(DME) OR REPAIR OF DME..........................................................

OTHER .............................................................................................

DON’T KNOW...................................................................................

REFUSED.........................................................................................

Prepared by Mathematica Policy Research, Inc.

(All)PROBE:

Anything else?
YES ................................................................................. 01
DON’T KNOW ................................................................. d (D3)
REFUSED ....................................................................... r (D3)

INTERVIEWER: RECORD VERBATIM RESPONSE NOW AND CODE LATER
________________________________________________________________

NO MORE REASONS .................................................... 00

D4.

In the past 6 months, were you referred to another doctor, specialist, therapist, psychologist, or
medical professional, or sent for tests or x-rays by a doctor or clinic {you/he/she} visited?
YES ................................................................................. 01
NO ................................................................................... 00 (D6a)
DON’T KNOW.........................................................

d (D6a)

REFUSED...............................................................

r (D6a)

(D4=01)
D5.

Did {you/(NAME)} or will {you/he/she} go for all, some, or none of the visits or tests for which {you were/he/she was}
referred?
ALL.......................................................................... 01 (D6a)
SOME ..................................................................... 02
NONE...................................................................... 03
DON’T KNOW.........................................................

d (D6a)

REFUSED...............................................................

r (D6a)

(D5=02 OR 03)
D6.

Why did or will {you/(NAME)} not go for all of {your/his/her} recommended visits or tests?
PROBE: Were there any other reasons?

CODE ALL THAT APPLY
COST/INSURANCE
COULD NOT AFFORD IT/TOO EXPENSIVE...................................