AB Demo Project 12-Month Follow-Up Survey
Accelerated Benefits Demonstration Project
AB Demo Twelve-Month Follow-Up Survey
AB Demo Project 12-Month Follow-Up Survey
OMB: 0960-0747
Accelerated Benefits Demonstration
12 Month Followup Survey
Draft
Julita Milliner-Waddell
Lisa Schwartz
David Wittenburg
Charles Michalopoulos
David Butler
Prepared by:
Mathematica Policy Research, Inc. and MDRC
CONTENTS
Section Page
A. CASE MANAGEMENT/RESPONDENT SELECTION 1
B. PHYSICAL, FUNCTIONAL, AND MENTAL HEALTH STATUS 15
C. HEALTH INSURANCE STATUS 28
D. USE OF MEDICAL SERVICES 39
E. UNMET MEDICAL NEEDS 47
F. EMPLOYMENT AND EARNINGS 58
G. USE OF SSA AND OTHER EMPLOYMENT SERVICES 71
H. FAMILY STATUS AND INCOME 73
I. CLOSING AND CONTACT INFORMATION 76
section A: CASE MANAGEMENT/RESPONDENT SELECTION
[Hello (Q1)]
A1. Hello, my name is [fill IntvName]. I am calling on behalf of the Social Security Administration. May I please speak to (NAME)?
SPEAKING TO NAME 01 SampMemb (A26)
NAME COMES TO THE PHONE 02 SampMemb (A26)
PERSON ASKS WHAT CALL IS ABOUT 03 WhatAbout (A2)
NEED TO CALLBACK 04 Callback
NAME HAS A HEALTH PROBLEM/DECEASED 05 HealthProb (A3)
NAME IS IN AN INSTITUTION 06 Institution (A10)
NAME HAS MOVED 07 KnowWhere (A15)
NAME DOES NOT SPEAK ENGLISH 08 Lang (A20)
NEVER HEARD OF NAME/WRONG NUMBER 09 Thanks (A33) Status 530
HUNG UP DURING INTRODUCTION 10 Status 640
REFUSED r Status 220
[WhatAbout (Q2)]
A2. The Social Security Administration recently sent (NAME) a letter saying that someone from Mathematica would be calling to see how {she/he} has been doing since we last spoke in {FILL MONTH}. This is in reference to the Accelerated Benefits Demonstration in which (NAME) was selected to participate in {FILL RA MONTH AND YEAR}.
PROGRAMMER: ALLOW INTERVIEWER TO ACCESS FAQs FROM THIS SCREEN.
NAME COMES TO THE PHONE 01 SampMemb (A26)
NEED TO CALLBACK 02 Callback
NAME HAS A HEALTH PROBLEM/DECEASED 03 HealthProb (A3)
NAME IS IN AN INSTITUTION 04 Institution (A10)
NAME MOVED 05 KnowWhere (A15)
NAME DOES NOT SPEAK ENGLISH 06 Lang (A20)
NAME DIDN'T RECEIVE LETTER 07 NoLetter (A28)
HUNG UP DURING INTRODUCTION 08 Status 640
SUPERVISOR REVIEW 09 Status 380
NEVER HEARD OF NAME/WRONG NUMBER 10 Thanks (A33) Status 530
REFUSED r Status 220
PAPERWORK REDUCTION ACT INFO: Before we begin, I’d like to give you some information about this survey. We estimate it will take about 45 minutes to complete the survey. If after completing the survey you would like to comment on that time estimate, you can send comments to: SSA, 6401 Security Blvd, Baltimore, MD 21235. The OMB number for this collection, which you can reference, is 0960-0747, and the expiration date is INSERT.
[HealthProb (Q3)]
A3. ENTER TYPE OF HEALTH PROBLEM.
HEARING PROBLEM 01 AmpTTY (A4)
SPEECH PROBLEM 02 AmpTTY (A4)
PHYSICAL PROBLEM 03 Important (A12)
COGNITIVE PROBLEM 04 Important (A12)
FRAIL/SICK 05 Important (A12)
IN A COMA 06 Important (A12)
DECEASED 07 Deceased (A9)
REFUSED r Status 220
[AmpTTY (Q4)]
A4. I can get on a phone that will amplify my voice or {NAME}'s voice, or we could use a TTY service. Would either of these enable {him/her} to complete the interview?
YES - USE AMPLIFIER PHONE 01 RespAvail (A5)
YES - USE TTY CAPABILITY 02 RespAvail (A5)
NO 00 Important (A12)
DON’T KNOW d Callback
REFUSED r Status 220
RespAvail (Q5)
A5. Is (NAME) available now?
YES 01 if AmpTTY (A4) = 1 then AmpPhone (A6) else CallTTY (A7)
NO 00 Callback
AmpPhone (Q6)
A6. Please hold while I get the amplifier phone.
INTERVIEWER: SET UP AMPLIFIER/WEAK SPEECH EQUIPMENT AND ASK GATEKEEPER TO CALL NAME TO THE PHONE.
NAME COMES TO THE PHONE 01 SampMemb (A26)
CALLBACK 02 Callback
[CallTTY (Q7)]
A7. I will call back in a few minutes after I have the help of the TTY operator.
ARRANGE CALL WITH OPERATOR 01 SampMemb (A26)
IF UNSUCCESSFUL SET CALLBACK 02 Callback
CallLater (Q8)
A8. Will (NAME) be able to talk on the telephone if I call back next week?
YES/MAYBE – CALLBACK 01 Callback
NO 00 Important (A12)
DON’T KNOW d CALLBACK
REFUSED r Status 220
[Deceased (Q9)]
A9. I am sorry to hear that (NAME) has passed away. I was calling about the Accelerated Benefits Demonstration in which (NAME) was selected to participate. We are conducting the study for the Social Security Administration. You might have seen a letter we recently sent (NAME). When did (NAME) pass away?
DATE: | | | / | | | / | 2 | 0 | | |
MO DAY YEAR
(01-12) (01-31) (2008-2010)
DON’T KNOW d
REFUSED r
Status 440
Please accept my condolences. Thank you. Good-bye.
[Institution (Q10)]
A10. ENTER TYPE OF INSTITUTION.
HOSPITAL 01 HomeSoon (A11)
NURSING HOME 02 HomeSoon (A11)
ASSISTED LIVING FACILITY 03 HomeSoon (A11)
GROUP HOME 04 HomeSoon (A11)
JAIL OR PRISON 05 Thanks (A33) Status 421
[HomeSoon (Q11)]
A11. I’m sorry to hear that. Until what date will (NAME) be staying there?
PROBE: Your best estimate is fine.
| | | / | 2 | 0 | | |
MONTH YEAR
(2008-2010)
PERMANENTLY 01 CanYou (A14)
.
DON’T KNOW d CanYou (A14)
REFUSED r CanYou (A14)
PROGRAMMER: IF DATE IS AFTER 6/1/2010, GO TO CanYou (A14)
IF D OR R, Callback.
If date is before 6/1/2010 ARRANGE CALLBACK Callback
[Important]
A12. We’d like to work with you {and (NAME)} to help {you/him/her} participate so that we can find out how {you have/(he/she) has} been doing. To help {you/(NAME)} participate, we can make a few adjustments. Please tell me which one will work best or be the easiest for {you/him/her}. [READ CHOICES 01, 02, 03, and 06 BELOW]
PROBE: I would like to help {you/(NAME)} participate. Please tell me what we can do to make that possible.
CODE ONE
SPEAKING WITH NAME:
I can break the interview into a few short calls, 01 (A34)
IF SPEAKING WITH INFORMANT:
You could help (NAME) answer questions
for {himself/herself}, 02 Asst Name (A23)
You or someone else could answer
questions on {his/her} behalf:
INFORMANT WILL ACT AS PROXY 03 (A14)
SOMEONE ELSE WILL PROXY, COMES TO
THE PHONE 04 (A14)
SOMEONE ELSE WILL PROXY, NOT AVAILABLE/
LIVES ELSEWHERE 05 (A40)
Or, do you have another way? (SPECIFY) 06 (A13)
CANNOT DO INTERVIEW WITH HELP/
NO PROXY AVAILABLE 07 (Status 410)
NONE/DON’T KNOW d (CALLBACK)
REFUSED r (Status 220)
A13. What way is that?
PROBE: I would like to help {you/(NAME)} participate. Please tell me what we can do to make that possible.
<OPEN> (Supervisor Review)
DON’T KNOW d (CALLBACK)
REFUSED r Thanks (Status 220)
A14. (Hello, my name is _________________, calling on behalf of the Social Security Administration.) Are you someone who is 18 years of age or older and can answer questions about (NAME’s) health and daily activities over the last 12 months?
PROGRAMMER: MAKE FAQ AVAILABLE HERE
YES 01 AsstName (A23)
NO 00 (CALLBACK)
DON’T KNOW d (CALLBACK)
REFUSED r (CALLBACK)
[KnowWhere (Q17)]
A15. Do you or anyone there know how we can reach (NAME)?
YES 01 (A16)
NO 00 (A31)
DON’T KNOW d (A33)
REFUSED r
Thanks (A33) Status 530
[NewPhone (Q18)]
A16. May I please have {his/her} telephone number?
TELEPHONE: | | | |-| | || |-| | | | |
DON’T KNOW d
REFUSED r
NewAddr (A17)
[NewAddr (Q19)]
A17. May I please have {his/her} address?
ADDRESS:
DON’T KNOW d
REFUSED r
Thanks (A33) if NewPhone eq DK/RF then Status 530 else Status 899
A18. PROGRAMMER CHECK A17: IS STATE OUTSIDE THE UNITED STATES AND DC?
YES (OUTSIDE USA) 01 (go to A18a)
NO (INSIDE USA) 00 (CALLBACK)
A18a. When do you expect (NAME) to return to live in the U.S.?
| | | / | 2 | 0 | | |
MONTH YEAR
(01-12) (2009-2010)
NEVER 00 Thanks (A33) Status 450
DON’T KNOW d (A41)
REFUSED r (A41)
A19. INTERVIEWER: IS DATE DURING FIELD PERIOD?
YES 01 (CALLBACK)
NO, AFTER 6/1/2010 00 Thanks (A33) Status 450
[Lang (Q20)]
A20. CODE LANGUAGE NEEDED TO COMPLETE INTERVIEW IF KNOWN.
SPANISH 01 Thanks (A33) Status 401
FRENCH 02
MANDARIN 03
CANTONESE 04
RUSSIAN 05
GERMAN 06
OTHER LANGUAGE 07 OtherLang (A21)
DON’T KNOW d NeedAsst (A22)
[OtherLang (Q21)]
A21. SPECIFY OTHER LANGUAGE.
LANGUAGE:
NeedAsst (A22)
[NeedAsst (Q22)]
A22. Hello, my name is _____________, calling on behalf of the Social Security Administration. The Social Security Administration recently sent (NAME) a letter saying that someone from Mathematica would be calling to see how (NAME) is doing since {he/she} was selected to participate in the Accelerated Benefits Demonstration in {FILL RA MONTH AND YEAR}. Mathematica is a nationally recognized research company based in Princeton, New Jersey. We are conducting a survey for the Social Security Administration about this special project. We are not selling anything or asking for contributions. We are looking for someone who is 18 years or older to help (NAME) by interpreting the interview for us. Are you 18 years of age or older?
IF YES: Would you be able to help (NAME) by interpreting the interview?
IF NO: Is there someone else 18 years or older who could come to the phone and help with the interview?
SPEAKING TO FAMILY MEMBER/FRIEND WHO
WILL ACT AS INTERPRETER 01 AsstName (A23)
NO INTERPRETER AVAILABLE 04 CALLBACK
SUPERVISOR REVIEW 05 Status 380
DON’T KNOW d CALLBACK
REFUSED r STATUS 210
[AsstName (Q23)]
A23. Before we begin, can you please tell me your name?
ASSISTANT/INTERPRETER/PROXY NAME
DON’T KNOW d
REFUSED r
AsstRel (A24)
[AsstRel (Q24)]
A24. And how are you related to [FILL FirstName]?
SPOUSE 01
CHILD 02
SIBLING 03
PARENT 04
NIECE/NEPHEW 05
FRIEND/NEIGHBOR/OTHER RELATIVE 06
GROUP/FOSTER HOME/ASSISTED LIVING
FACILITY ADMINISTRATOR/CARER 07
OTHER RELATIVE 08
NOT RELATED 09
DON’T KNOW d
REFUSED r GO TO A25a
[ASSISTANT/INTERPRETER INSTRUCTION (Q25a)]
A25a. Thank you for agreeing to assist (NAME) with the interview/interpret the interview for (him/her). (IF INTERPRETER, SAY: Please repeat the questions to (NAME) exactly as I read them to you.)
Screener/Survey *** GO TO A34
[SampMemb (Q31)]
[if Hello (Q1) eq <2> or WhatAbout (Q2) eq <1> then] Hello, my name is [fill IntvName]. I am calling on behalf of ...[endif]
A26. {Hello, my name is ________________, calling on behalf of the Social Security Administration.} I’m calling to followup and see how {you are/(NAME) is} doing since {you were/(he/she) was} selected to participate in the Accelerated Benefits (AB) Demonstration in {FILL RA MONTH YEAR}. {You/He/She} should have received a check for $25 as our thank you in advance for completing the survey along with a letter telling {you/him/her} that someone from Mathematica would be calling. The questions I have will take about 45 minutes to complete. Let’s start now.
(IF NEEDED: There are no right or wrong answers. If you get tired or need a break at any time, please tell me and we can take a break or I will call back later to finish the interview.)
PROGRAMMER: ALLOW INTERVIEWER TO ACCESS FAQs FROM THIS SCREEN.
BEGIN INTERVIEW 01 Consent (A34)
DID NOT RECEIVE LETTER OR CHECK 02 NoLetter (A28a)
RECEIVED LETTER BUT NOT CHECK 03 (A28b)
RECEIVED CHECK BUT NOT LETTER 04 (A28)
NOT A GOOD TIME 05 Callback
HUNG UP DURING INTRODUCTION 06 Status 640
SUPERVISOR REVIEW 07 Status 380
NAME WILL CALL MPR BACK 08 (A27)
CANNOT CASH CHECK 09 (A28b)
WANTS MORE INFORMATION FAQ
REFUSED r Status 200
A27. Thanks for offering to call in. Please write down our toll-free number. It is 866-275-8659. We are available days, evenings, and weekends. Please ask for Terry Mann when you call. If you call after hours, please leave a message and we will get back to you the next day.
(STATUS 830)
[NoLetter (Q32)]
A28. The letter was from the Social Security Administration and said that someone from Mathematica would be calling to see how {you have/(NAME) has} been doing since {you were/(he/she) was} selected to participate in the Accelerated Benefits Demonstration in {FILL RA MONTH YEAR}. I work for Mathematica. We are conducting a survey for the Social Security Administration about the Accelerated Benefits Demonstration. The information {you/(NAME)} and other participants give us will be used to improve programs for disabled persons. We are not selling anything or asking for contributions. If you like, I can read the letter to you now and we can start the interview. (IF NEEDED: I can also mail {you/him/her} another copy. {You/He/She} should receive the letter in about a week.) Let’s get started. Should I read the letter?
BEGIN INTERVIEW 01 Consent (A34)
WANTS ANOTHER LETTER/WANTS LETTER
READ TO THEM 02 NoLetter (A29)
NOT A GOOD TIME 03 Callback
WANTS MORE INFORMATION FAQ
REFUSED r Status 200
[A26=02]
A28a. The letter was from the Social Security Administration and said that someone from Mathematica would be calling to see how {you have/(NAME) has} been doing since {you were/(he/she) was} selected to participate in the Accelerated Benefits Demonstration in {FILL RA MONTH YEAR}. I work for Mathematica. We are conducting a survey for the Social Security Administration about the Accelerated Benefits Demonstration. The information you and other participants give us will be used to improve programs for disabled persons. We are not selling anything or asking for contributions. If you like, I can read the letter to you now and we can start the interview. We will mail you a check for $25 upon completion of the interview. Let’s get started. Should I read the letter?
BEGIN INTERVIEW 01 (A34)
WANTS ANOTHER LETTER AND CHECK/WANTS
LETTER READ TO THEM 02 NoLetter (A29)
NOT A GOOD TIME 03 Callback
WANTS MORE INFORMATION FAQ
REFUSED r Status 200
A26=03, 09]
A28b. I am sorry that there was a problem with the check. We will mail you a check for $25 upon completion of the interview. Can we begin?
BEGIN INTERVIEW 01 Consent (A34)
WANTS NEW CHECK FIRST 02 (A30a)
NOT A GOOD TIME 03 Callback
REFUSED r Status 200
[ReadLetter (Q34)]
A29. May I read the letter to you and then we can begin?
LOAD TEXT OF LETTER HERE
YES, READ THE LETTER 01 Consent (A34)
NO, WANTS ANOTHER LETTER FIRST 02 SendLetter (A30)
REFUSED r Status 200
[SendLetter (Q35)]
A30. Okay, I'll mail another letter and will call back in a few days. To what address should we mail the letter?
ADDRESS:
DON’T KNOW d
REFUSED r
Thanks (A33) Status 831
A28b=02
A30a. Okay, I’ll mail another check and will call back in a few days. To whom should we make the $25 check payable?
INTERVIEWER: VERIFY SPELLING
NAME:
FIRST, MIDDLE, LAST
ADDRESS:
DON’T KNOW d
REFUSED r
Thanks (A33) Status 831
A31. Is there someone else who might know how to reach (NAME)?
YES 01
NO 00 (A33) (Status 530)
DON’T KNOW d (A33) (Status 530)
REFUSED r (A33) (Status 530)
A32. What’s that person’s name and phone number?
PROBE: If you don’t have all the information, please tell me what you can.
NAME
FIRST, MIDDLE, LAST
Please give me the telephone number, starting with the area code first.
TELEPHONE: | | | |-| | || |-| | | | | (A33) Status 530)
DON’T KNOW d (A33) (Status 530)
REFUSED r (A33) (Status 530)
PROGRAMMER: THIS INFORMATION NEEDS TO BE SENT TO LOCATING AS A LEAD |
[Thanks (Q36)]
A33. Thank you very much for your time.
ENTER 1 TO CONTINUE
Consent
A34. Before we begin, I would like to remind {you/(NAME)} of a few things about being part of this study. There is no cost to be in the study and {you/(NAME)} do not have to do anything. The study is being conducted by a team of researchers at MDRC, Mathematica Policy Research, and the Office of Policy Development and Research at SSA. All of {your/(NAME’s)} information will be kept confidential and only the study team will have access to it. The information {you give/(he/she) gives} us will be used for research purposes only, and {your/his/her} name will not appear in any reports. {Your/(NAME’s)} answers will not affect {your/his/her} Social Security benefits and will not determine whether {you/he/she} receive(s) Medicare.
Can we continue with the interview?
YES 01 Whom (A34a)
NO 02 (Callback)
SUPERVISOR REVIEW 03 (Status 380)
WANTS MORE INFORMATION FAQ
REFUSED r (A33) (Status 200)
[Whom]
A34a. INTERVIEWER: WHO ARE YOU SPEAKING WITH?
NAME 01
INTERPRETER 02
ASSISTANT 03
PROXY 04
[Confirm]
A35. First, I need to confirm that I’ve reached the right person. (IF INTERPRETER, SAY: Please repeat the questions exactly as I word them.) Is {your/his/her} full name {FILL FROM PRELOADS}?
YES 01 (A37)
NAME CHANGED 02
NO 00
DON’T KNOW d (A44)
REFUSED r (A44)
(A35=02 or 00)
[NewName]
A36. For the record, what is {your/his/her} (new) name?
NAME
IDENTITY CONFIRMED 01
IDENTITY NOT CONFIRMED 02 (A44)
DON’T KNOW d (A44)
REFUSED r (A44)
PROGRAMMER: STORE NAME CHANGE IN NAME UPDATE BLOCK |
[State_Ask]
A37. {Are you/Is (he/she)} now living in {STATE FROM PRELOAD}?
YES 01 (A38)
NO 00 (A37a)
[State]
A37a. In what state {are you/is (he/she)} now living?
STATE | | | TWO LETTER CODE
DON’T KNOW d
REFUSED r
PROGRAMMER: STORE STATE CHANGE FOR USE IN FUTURE QUESTIONS AT STATE UPDATE BLOCK |
A38. What is {your/his/her} date of birth?
| | | | | | | | | | | (A42)
MONTH DAY YEAR
(01–12) (01-31) (1953–1990)
DON’T KNOW d (A39)
REFUSED r (A39)
[Age]
A39. How old {are you/is (he/she)}?
RECORD AGE | | | YEARS (18-56)
DON’T KNOW d (A43)
REFUSED r (A43)
[Proxy Name2]
A40. May I please have {his/her} name?
PROXY NAME:
DON’T KNOW d
REFUSED r
[Proxy Phone]
A40a. May I please have {his/her} telephone number?
TELEPHONE: | | | |-| | | |-| | | | |
DON’T KNOW d
REFUSED r
[Proxy Addr]
A40b. And {his/her} address?
ADDRESS:
DON’T KNOW d
REFUSED r
[Proxy Rel12]
A40c. How is {he/she} related to [fill FIRST NAME]?
SPOUSE 01
CHILD 02
SIBLING 03
PARENT 04
NIECE/NEPHEW 05
FRIEND/NEIGHBOR/OTHER RELATIVE 06
GROUP/FOSTER HOME/ASSISTED LIVING
FACILITY ADMINISTRATOR/CAREGIVER 07
OTHER RELATIVE 08
NOT RELATED 09
DON’T KNOW d
REFUSED r
If A12 = 04 THEN CALLBACK
A41. Please write down my toll free number and give it to someone who might know about (NAME’s) health and daily activities so they can get more information about the study. The toll free number is 866-275-8659.
CODE FOR SUPERVISOR REVIEW
A42. PROGRAMMER CHECK BIRTHDATE: IS MONTH, DAY, YEAR OF BIRTH AT A38=MONTH, DAY, AND YEAR OF BIRTH ON RECORD?
NO MATCH 00
1 MATCHES 01
2 MATCH 02
3 MATCH 03
A43. PROGRAMMER CHECK: IS (NAME’s) IDENTITY VERIFIED AND IS BIRTHDATE VERIFIED?
YES (VERIFIED) 01 (B1)
NO (FAILED VERIFICATION) 00
A44. Thanks for your patience. There seems to be a problem with my information. I need to check with my supervisor about what to do next. Someone from Mathematica will get back to {you/(NAME)}. Good-bye. Thank you.
SUPERVISOR REVIEW |
GO TO SECTION B
REFUSAL MODULE: THIS WILL DISPLAY WHEN BREAKOFF IS INDICATED IN BLAISE
NOTE: A REFUSAL CAN OCCUR AT ANY POINT IN THE INTERVIEW.
[WHO REFUSED]
INTERVIEWER: INDICATE WHO REFUSED.
SAMPLE MEMBER 01
GATEKEEPER 02
UNKNOWN PERSON 03
[REFUSAL REASON]
INTERVIEWER: INDICATE REFUSAL REASON TO BEST OF KNOWLEDGE.
CODE BEST
AFRAID TO LOSE BENEFITS 01
NO TIME 02
TOO SICK 03
NO INTEREST 04
PROVIDING CONSENT 05
UNHAPPY WITH RANDOM ASSIGNMENT STATUS 06
DON’T TRUST GOVERNMENT/SSA 07
CONFIDENTIALITY 08
NONE GIVEN 09
OTHER (SPECIFY) 10
SECTION B: PHYSICAL, FUNCTIONAL, AND MENTAL HEALTH STATUS
SF-36:1
(All)
(Asked at Baseline)
B1. I’d like to begin with some questions about how {your/(NAME’s} health is now.
In general, would {you/(NAME)} say {your/his/her} health is excellent, very good, good, fair, or poor?
EXCELLENT 01
VERY GOOD 02
GOOD 03
FAIR 04
POOR 05
DON’T KNOW d
REFUSED r
SF-36:2 modified
(All)
B2. Compared to when we spoke to {you/(NAME)}, in [fill RA MONTH YEAR], how would {you/he/she} rate {your/his/her} health in general now? Would {you/he/she} say it is much better now, somewhat better now, about the same, somewhat worse now, or much worse now?
MUCH BETTER NOW 01
SOMEWHAT BETTER NOW 02
ABOUT THE SAME 03 (B3a)
SOMEWHAT WORSE NOW 04
MUCH WORSE NOW 05
DON’T KNOW d (B3a)
REFUSED r (B3a)
(B2=01, 02, 04 or 05)
B2a. What is the main reason {you think/(NAME) thinks} {your/his/her} health is [fill MUCH BETTER, SOMEWHAT BETTER, SOMEWHAT WORSE OR MUCH WORSE] now than it was in [fill RA MONTH YEAR]?
INTERVIEWER: RECORD VERBATIM, THEN CODE
CODE ALL THAT APPLY
PROGRESSION OF DISEASE 01
BETTER HEALTH CARE 02
MORE DOCTOR VISITS 03
MORE/BETTER PRESCRIPTIONS MEDICINES 04
PHYSICAL THERAPY HELPED 05
STOPPED PHYSICAL THERAPY 06
CAN’T AFFORD PRESCRIPTION MEDICINES 07
STOPPED GOING TO THE DOCTOR 08
HAD TO CHANGE DOCTORS 09
HAD SURGERY 10
OTHER 11
DON’T KNOW d
REFUSED r
SF6D/SF36:3a
(All)
(Asked at Baseline)
B3a. My next questions are about activities {you/(NAME)} might do during a typical day.
How much does {your/(NAME’s)} health now limit {your/his/her} participation in vigorous activities, such as running, lifting heavy objects, or participating in strenuous sports? Would {you/(NAME)} say that {you are/(he/she) is} 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/SF36:3b
(All)
(Asked at Baseline)
B3b. How much does {your/(NAME’s)} health now limit {your/his/her} participation in moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf?
PROBE AS NEEDED: Would {you/(NAME)} say that {you are/(he/she) is} 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/SF36:3c
(All)
B3c. How much does {your/(NAME’s)} health now limit {you/him/her} from lifting or carrying groceries?
PROBE AS NEEDED: Would {you/(NAME)} say that {you are/(he/she) is} 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/SF36:3d
(All)
B3d. (How much does {your/(NAME’s)} health now limit {you/him/her}) from climbing several flights of stairs?
PROBE AS NEEDED: Would {you/(NAME)} say that {you are/(he/she) is} 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/SF36:3e
(All)
B3e. (How much does {your/(NAME’s)} health now limit {you/him/her}) from climbing one flight of stairs?
PROBE AS NEEDED: Would {you/(NAME)} say that {you are/(he/she) is} 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/SF36:3f
(All)
B3f. (How much does {your/(NAME’s)} health now limit {you/him/her}) from bending, kneeling, or stooping?
PROBE AS NEEDED: Would {you/(NAME)} say that {you are/(he/she) is} 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/SF36:3g
(All)
B3g. How much does {your/(NAME’s)} health now limit {you/him/her} from walking more than one mile?
PROBE AS NEEDED: Would {you/(NAME)} say that {you are/(he/she) is} 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/SF36:3h
(All)
B3h. (How much does {your/(NAME’s)} health now limit {you/him/her}) from walking several blocks?
PROBE AS NEEDED: Would {you/(NAME)} say that {you are/(he/she) is} 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/SF36:3i
(All)
B3i. (How much does {your/(NAME’s)} health now limit {you/him/her}) from walking one block?
PROBE AS NEEDED: Would {you/(NAME)} say that {you are/(he/she) is} 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/SF36:3j
(All)
(Asked at Baseline)
B3j. (How much does {your/(NAME’s)} health now limit {you/him/her}) from bathing or dressing {yourself/himself/herself}?
PROBE AS NEEDED: Would {you/(NAME)} say that {you are/(he/she) is} 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
(All)
SF6D/SF36:4a
B4a. Now, please think about the past 4 weeks. During the past 4 weeks, {have you/has (NAME)} had any of the following problems with {your/his/her} work or other regular daily activities as a result of {your/his/her} physical health? During the past 4 weeks, did {you/(NAME)} cut down the amount of time {you/he/she} spent on work or other activities?
PROBE AS NEEDED: Because of {your/his/her} physical health.
YES 01
NO 00
DON’T KNOW d
REFUSED r
SF6D/SF36:4b
B4b. During the past 4 weeks, did {you/(NAME)} accomplish less than {you/he/she} would like?
PROBE AS NEEDED: Because of {your/his/her} physical health.
YES 01
NO 00
DON’T KNOW d
REFUSED r
SF6D/SF36:4c
(Asked at Baseline)
B4c. During the past 4 weeks, {were you/was (NAME)} limited in the kind of work or other activities {you/he/she} could do?
PROBE AS NEEDED: Because of {your/his/her} physical health.
YES 01
NO 00
DON’T KNOW d
REFUSED r
SF6D/SF36:4d
B4d. During the past 4 weeks, did {you/(NAME)} have difficulty performing the work or other activities{you/he/she} could do, for example, it took extra time?
PROBE AS NEEDED: Because of {your/his/her} physical health.
YES 01
NO 00
DON’T KNOW d
REFUSED r
SF6D/SF36:5a
B5a. During the past 4 weeks, {have you/has (NAME)} had any of the following problems with {your/his/her} work or other regular daily activities as a result of any emotional problems such as feeling depressed or anxious? During the past 4 weeks, did {you/(NAME)} cut down the amount of time {you/he/she} spent on work or other activities?
PROBE AS NEEDED: Because of emotional problems such as feeling depressed or anxious.
YES 01
NO 00
DON’T KNOW d
REFUSED r
SF6D/SF36:5b
B5b. Did {you/(NAME)} accomplish less than {you/he/she} would like?
PROBE AS NEEDED: Because of emotional problems such as feeling depressed or anxious.
YES 01
NO 00
DON’T KNOW d
REFUSED r
SF6D/SF36:5c
B5c. Did {you/(NAME)} not do work or other activities as carefully as usual?
PROBE AS NEEDED: Because of emotional problems such as feeling depressed or anxious.
YES 01
NO 00
DON’T KNOW d
REFUSED r
SF6D/SF36:6
(All)
B6. During the past 4 weeks, to what extent has {your/(NAME’s)} physical health or emotional problems interfered with {your/his/her} normal social activities with family, friends, neighbors, or groups? Would {you/he/she} say not at all, slightly, moderately, quite a bit, or extremely?
NOT AT ALL 01
SLIGHTLY 02
MODERATELY 03
QUITE A BIT 04
EXTREMELY 05
DON’T KNOW d
REFUSED r
SF6D/SF36:7
(All)
(Asked at Baseline)
B7. How much bodily pain {have you/has (NAME)} had during the past 4 weeks? Would {you/he/she} say none at all, slight pain, moderate pain, quite a bit of pain, or an extreme amount of pain?
NONE AT ALL 01
SLIGHT 02
MODERATE 03
QUITE A BIT 04
EXTREME 05
DON’T KNOW d
REFUSED r
SF6D/SF36:8
(All)
(Asked at Baseline)
B8. During the past 4 weeks, how much did pain interfere with {your/(NAME’s)} normal work, including both work outside the home and housework? Would {you/he/she} say not at all, slightly, moderately, quite a bit, or extremely?
NOT AT ALL 01
SLIGHTLY 02
MODERATELY 03
QUITE A BIT 04
EXTREMELY 05
DON’T KNOW d
REFUSED r
SF6D/SF36:9a
(All)
B9a. These next questions are about how {you feel /(NAME) feels} and how things have been with {you/him/her} during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
During the past 4 weeks, how much of the time did {you/(NAME)} feel full of pep? Would {you/he/she} 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 01
MOST OF THE TIME 02
A GOOD BIT OF THE TIME 03
SOME OF THE TIME 04
A LITTLE OF THE TIME 05
NONE OF THE TIME 06
DON’T KNOW d
REFUSED r
SF36:9b – MHI-5
(All)
B9b. During the past 4 weeks, how much of the time {have you/has (NAME)} been a nervous person? Would {you/he/she} 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 01
MOST OF THE TIME 02
A GOOD BIT OF THE TIME 03
SOME OF THE TIME 04
A LITTLE OF THE TIME 05
NONE OF THE TIME 06
DON’T KNOW d
REFUSED r
SF36:9c – MHI-5
(All)
B9c. During the past 4 weeks, how much of the time {have you/has (NAME)} felt so down in the dumps nothing could cheer {you/him/her} up?
PROBE AS NEEDED: Would {you/he/she} 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 01
MOST OF THE TIME 02
A GOOD BIT OF THE TIME 03
SOME OF THE TIME 04
A LITTLE OF THE TIME 05
NONE OF THE TIME 06
DON’T KNOW d
REFUSED r
SF36:9d – MHI-5
(All)
B9d. During the past 4 weeks, how much of the time have {you/has (NAME)} felt calm and peaceful?
PROBE AS NEEDED: Would {you/he/she} 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 01
MOST OF THE TIME 02
A GOOD BIT OF THE TIME 03
SOME OF THE TIME 04
A LITTLE OF THE TIME 05
NONE OF THE TIME 06
DON’T KNOW d
REFUSED r
SF6D/SF36:9e
(All)
(Asked at Baseline)
B9e. During the past 4 weeks, how much of the time did {you/(NAME)} have a lot of energy?
PROBE AS NEEDED: Would {you/he/she} 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 01
MOST OF THE TIME 02
A GOOD BIT OF THE TIME 03
SOME OF THE TIME 04
A LITTLE OF THE TIME 05
NONE OF THE TIME 06
DON’T KNOW d
REFUSED r
SF6D/SF36:9f – MHI-5
(All)
(Asked at Baseline)
B9f. During the past 4 weeks, how much of the time {have you/has (NAME)} felt downhearted and blue? Would {you/he/she} 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 01
MOST OF THE TIME 02
A GOOD BIT OF THE TIME 03
SOME OF THE TIME 04
A LITTLE OF THE TIME 05
NONE OF THE TIME 06
DON’T KNOW d
REFUSED r
SF36:9g
(All)
B9g. During the past 4 weeks, how much of the time did {you/(NAME)} feel worn out?
PROBE AS NEEDED: Would {you/he/she} 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 01
MOST OF THE TIME 02
A GOOD BIT OF THE TIME 03
SOME OF THE TIME 04
A LITTLE OF THE TIME 05
NONE OF THE TIME 06
DON’T KNOW d
REFUSED r
SF36:9h – MHI-5
(All)
B9h. During the past 4 weeks, how much of the time {have you/has (NAME)} been a happy person?
PROBE AS NEEDED: Would {you/he/she} 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 01
MOST OF THE TIME 02
A GOOD BIT OF THE TIME 03
SOME OF THE TIME 04
A LITTLE OF THE TIME 05
NONE OF THE TIME 06
DON’T KNOW d
REFUSED r
SF36:9i
(All)
B9i. During the past 4 weeks, how much of the time did {you/(NAME)} feel tired?
PROBE AS NEEDED: Would {you/he/she} 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 01
MOST OF THE TIME 02
A GOOD BIT OF THE TIME 03
SOME OF THE TIME 04
A LITTLE OF THE TIME 05
NONE OF THE TIME 06
DON’T KNOW d
REFUSED r
SF6D/SF36:10
(All)
(Asked at Baseline)
B10. During the past 4 weeks, how much of the time has {your/(NAME’s)} physical health or emotional problems interfered with {your/his/her} social activities like visiting friends or relatives? Would {you/he/she} 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 01
MOST OF THE TIME 02
A GOOD BIT OF THE TIME 03
SOME OF THE TIME 04
A LITTLE OF THE TIME 05
NONE OF THE TIME 06
DON’T KNOW d
REFUSED r
SF6D/SF36:11
(All)
B11a. Now, please tell me how true or false each of the following statements are for {you/(NAME)}.
I seem to get sick a little easier than other people. Would {you/(NAME)} say this is definitely true, mostly true, mostly false, or definitely false for {you/him/her}?
DEFINITELY TRUE 01
MOSTLY TRUE 02
MOSTLY FALSE 03
DEFINITELY FALSE 04
DON’T KNOW d
REFUSED r
B11b. I am as healthy as anybody I know. Would {you/(NAME)} say this is definitely true, mostly true, mostly false, or definitely false for {you/him/her}?
DEFINITELY TRUE 01
MOSTLY TRUE 02
MOSTLY FALSE 03
DEFINITELY FALSE 04
DON’T KNOW d
REFUSED r
B11c. I expect my health to get worse. Would {you/(NAME)} say this is definitely true, mostly true, mostly false, or definitely false for {you/him/her}?
DEFINITELY TRUE 01
MOSTLY TRUE 02
MOSTLY FALSE 03
DEFINITELY FALSE 04
DON’T KNOW d
REFUSED r
B11d. My health is excellent. Would {you/(NAME)} say this is definitely true, mostly true, mostly false, or definitely false for {you/him/her}?
DEFINITELY TRUE 01
MOSTLY TRUE 02
MOSTLY FALSE 03
DEFINITELY FALSE 04
DON’T KNOW d
REFUSED r
(30-DAY Functioning & Disability (F&D)-modified)
B12. During the past 4 weeks, how often did {you/(NAME)} stay in bed more than half the day because of problems with either {your/his/her} physical health or {your/his/her} mental health? Would {you/he/she} 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 01
MOST OF THE TIME 02
A GOOD BIT OF THE TIME 03
SOME OF THE TIME 04
A LITTLE OF THE TIME 05
NONE OF THE TIME 06
DON’T KNOW d
REFUSED r
SECTION C: HEALTH INSURANCE STATUS
(All)
(Asked at Baseline)
C1. Now I have some questions about health insurance. The last time we spoke to {you/(NAME)} in [fill MONTH, YEAR of LAST CONTACT], we asked {you/him/her} some questions about health insurance. I need to ask those questions again so that we can update our information. {Your/(NAME’s)} answers will not affect [your/his/her} participation in the study.
{Are you/Is (NAME)} currently covered by Medicaid?
Medicaid is a program that pays for the health care of persons in need. [IF NAME IS DIFFERENT THAN MEDICAID, SAY: In {your/(NAME’s)} state, {you/he/she} may also hear it called {STATEMED FROM (NAME’s) CURRENT STATE}.]
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
C2. {Are you/Is (NAME)} currently covered by Medicare? 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 (C4)
NO 00
DON’T KNOW d
REFUSED r
(C2=00, d or r)
(Asked at Baseline)
C3. {Are you/Is (NAME)} currently covered by a Medi‑Gap plan? A Medi-Gap plan pays for costs not covered by Medicare.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
C4. {Are you/Is (NAME)} currently covered by military health care, through Armed Forces retirement benefits, the VA, TRICARE, CHAMPUS, or CHAMPVA?
PROBE: TRICARE is a managed health care program for active duty service members, National Guard and Reserve members, retirees, their families and survivors worldwide. CHAMPUS-the Civilian Health and Medical Program of the Uniformed Services, was a health care program for military personnel. It is now known as TRICARE. CHAMPVA—the Civilian Health and Medical Program of the Department of Veterans Affairs is a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
C5. {Are you/Is (NAME)} currently covered by a plan from the Indian Health Service?
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
C6. {Are you/Is (NAME)} 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)
(Asked at Baseline)
C7. {Are you/Is (NAME)} 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
(All)
(Asked at Baseline)
C8. {Are you/Is (NAME)} currently covered by a state government program other than Medicaid?
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
C9. Not counting (IF AB OR AB PLUS, SAY: AB), COBRA, dental, optical, or prescription plans, {are you/is (NAME)} currently covered by (IF AB or AB PLUS, SAY ”other”) private health insurance, for example, private insurance that {you get/(he/she) gets} through a current or former employer, a family member, or that {you purchase/(he/she) purchases} on {your/his/her} own?
YES 01
NO 00 (C12)
DON’T KNOW d (C12)
REFUSED r (C12)
(C9=01)
(Asked at Baseline)
C10. Is {your/(NAME’s)} private health insurance provided through {your/his/her} current or former employer or through {your/his/her} spouse or partner’s current or former employer? Please include coverage provided through unions.
CODE ONE ONLY
(NAME’s) EMPLOYER/UNION 01 (C12)
SPOUSE/PARTNER’S EMPLOYER 02 (C12)
NO, NOT PROVIDED BY CURRENT OR
FORMER EMPLOYER 00
DON’T KNOW d
REFUSED r
(C9=01)
(Asked at Baseline)
C11. Is {your/(NAME’s)} private health insurance paid for by {you/(NAME)}, a family member, by both {you/(NAME)} and a family member, or by someone else?
CODE ONE ONLY
PAID BY (NAME) 01 (C12)
PAID BY FAMILY MEMBER(S) 02 (C12)
PAID BY BOTH (NAME) AND FAMILY MEMBER 03 (C12)
SOMEONE ELSE 04
DON’T KNOW d (C12)
REFUSED r (C12)
(C11=04)
(Asked at Baseline)
C11_Other. Who or what is the other source that pays for {your/(NAME’s)} private health insurance?
RECORD VERBATIM
<OPEN>
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
C12. Sometimes people have (IF INSURED, INCLUDING AB AND AB PLUS, SAY: “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/Does (NAME)} 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)
(Asked at Baseline)
C13a. IF ANY OF C1 TO C9=01, SAY:
PROGRAMMER: IF AB OR AB PLUS, FILL “AB.” IF CONTROL, FILL “OTHER.”
Not counting (AB (or) other health plans that {you/(NAME)} already told me about), {do you/does (NAME)} have a separate insurance plan that helps pay for prescription medications? Do not include Medi-Gap or Medicare Part D plans here.
IF C1 TO C9=00, D OR R, SAY:
(Although {you do/(NAME) does} not currently have coverage that helps pay for services from hospitals or doctors) {do you/does (he/she)} have insurance that helps pay for prescription medications? Do not include Medi-Gap or Medicare Part D plans here.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
C13b. IF ANY OF C1 TO C9=01, SAY:
PROGRAMMER: IF AB OR AB PLUS, FILL “AB.” IF CONTROL, FILL “OTHER.”
Not counting (AB (or) other health plan(s) that {you/(NAME)} already told me about), {do you/does (he/she)} have coverage for dental care?
IF C1 TO C9=00, D OR R, SAY:
(Although {you do/(NAME) does}not currently have coverage that helps pay for services from hospitals or doctors) {do you/does (he/she)} have coverage for dental care?
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
C13c. IF ANY OF C1 TO C9=01, SAY:
PROGRAMMER: IF AB OR AB PLUS, FILL “AB.” IF CONTROL, FILL “OTHER.”
Not counting (AB (or) other health plan(s) that {you/(NAME)} already told me about) {do you/does (he/she)} have optical coverage for eyeglasses or contact lenses?
IF C1 TO C9=00, D OR R, SAY:
(Although {you do/(NAME) does} not currently have coverage that helps pay for services from hospitals or doctors) {do you/does (he/she)} have optical coverage for eyeglasses or contact lenses?
YES 01
NO 00
DON’T KNOW d
REFUSED r
AB
AND AB PLUS, GO TO C15
(Control)
C14ck. PROGRAMMER: DID SAMPLE MEMBER HAVE INSURANCE AT SIX-MONTH SURVEY?
YES 01 (C14)
NO 00 (C14a)
NOT IN 6-MONTH SAMPLE n (C14a)
(Control)
(C1 to C9=00, d or r)
C14. When we spoke to {you/(NAME)} in [fill SIX-MONTH SURVEY MONTH, YEAR] {you/he/she} told us that {you/he/she} had picked up [fill INSURANCE TYPE from 6-MONTH B1 to B7, B9 or B10)] insurance coverage. {Do you/Does (he/she)} still have that insurance coverage?
YES 01 (C14c)
NO 00 (C14c)
DON’T KNOW d (C15)
REFUSED r (C15)
(Control)
C14a. (IF NO INSURANCE OR NOT INTERVIEWED AT 6-MONTH, SAY: When we spoke to {you/(NAME)} in [fill RA MONTH YEAR] you/he/she} told us that {you/he/she} [(last had insurance in [fill (BL_B15 MONTH, YEAR)/never had insurance)]. {Have you/Has (NAME)} had health insurance at any time since then?
YES 01
NO 00 (C15)
DON’T KNOW d (C15)
REFUSED r (C15)
(Control)
(C14=01)
C14b. What kind of insurance {have you/has (NAME)} had since [fill RA MONTH YEAR]?
PROBE: If {you/he/she} had more than one type of insurance since that time, please answer about {your/his/her} most recent coverage.
INTERVIEWER: DO NOT ACCEPT LIMITED COVERAGE PLANS LIKE DENTAL ONLY, PRESCRIPTION ONLY, ETC.
READ LIST IF NECESSARY
CODE ONE ONLY
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 NAME’S
SPOUSE/PARTNER’S PLAN 11
SOME OTHER KIND OF HEALTH INSURANCE 12
DON’T KNOW d
REFUSED r
(Control)
(C14=01 or C14a=01)
C14c. In what month and year did that insurance coverage begin?
| | | | | | | |
MONTH YEAR
(01-12) (2007-2010)
DON’T KNOW d
REFUSED r
IF
C14=01 “STILL HAS 6-MONTH INSURANCE,” GO TO C14e.
(Control)
(C14=00 or C14a=01)
C14d. In what month and year did that insurance coverage end?
| | | | | | | |
MONTH YEAR
(01-12) (2007-2010)
DON’T KNOW d
REFUSED r
(Control)
(C14a=01)
C14e. In addition to the [fill INSURANCE FROM C14b], {have you/has (NAME)} had any other insurance coverage since [fill RA MONTH YEAR]?
YES 01
NO 00 (C15)
DON’T KNOW d (C15)
REFUSED r (C15)
(Control)
(C14e=01)
C14f. What kind of other insurance {have you/has (NAME)} had since [fill RA MONTH YEAR]?
INTERVIEWER: DO NOT ACCEPT LIMITED COVERAGE PLANS LIKE DENTAL ONLY, PRESCRIPTION ONLY, ETC.
READ LIST IF NECESSARY
CODE ONE ONLY
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 NAME’S
SPOUSE/PARTNER’S PLAN 11
SOME OTHER KIND OF HEALTH INSURANCE 12
DON’T KNOW d
REFUSED r
(Control)
(C14e=01)
C14g. In what month and year did that insurance coverage begin?
| | | | | | | |
MONTH YEAR
(01-12) (2007-2010)
DON’T KNOW d
REFUSED r
(Control)
(C14e=0)
C14h. In what month and year did that insurance coverage end?
| | | | | | | |
MONTH YEAR
(01-12) (2007-2010)
DON’T KNOW d
REFUSED r
(All)
Center for Studying Health System Change Household Survey
C15. Now, please think about {your/(NAME’s)} medical expenses, since [fill RA MONTH YEAR], about how much did {you/he/she} or anyone else spend out-of-pocket for {your/his/her} medical care? Include out-of-pocket expenses for prescription drugs, copayments, health insurance premiums, and deductibles, but do not include, dental costs, or any other costs paid by {your/his/her} health insurance.
Would {you/(NAME)} say {you/he/she} paid less than $10,000, more than $10,000 but less than $50,000, more than $50,000 but less than $100,000 or more than $100,000?
PROBE: Your best estimate is fine.
LESS THAN $10,000 01
MORE THAN $10,000 BUT LESS THAN $50,000 02 (C15b)
MORE THAN $50,000 BUT LESS THAN $100,000 03 (C15c)
MORE THAN $100,000 04 (C15d)
DON’T KNOW d (D1)
REFUSED r (D1)
(C15=01)
C15a. Would {you/(NAME)} say it was . . .
Less than $1,000, 01
Between $1,000 and $2,500, 02
Between $2,500 and $5,000, 03
Between $5,000 and $7,500, or 04
Between $7,500 and $10,000? 05
DON’T KNOW d
REFUSED r
GO
TO D1
(C15=02)
C15b. Would {you/(NAME)} say it was . . .
Between $10,000 and $15,000, 01
Between $15,000 and $20,000……………………………..02
Between $20,000 and $25,000, 03
Between $25,000 and $30,000, 04
Between $30,000 and $35,000, 05
Between $35,000 and $40,000, 06
Between $40,000 and $45,000, or 07
Between $45,000 and $50,000 08
DON’T KNOW d
REFUSED r
GO
TO D1
(C15=03)
C15c. Would {you/(NAME)} say it was . . .
Between $50,000 and $55,000 01
Between $55,000 and $60,000, 02
Between $60,000 and $65,000, 03
Between $65,000 and $70,000, 04
Between $75,000 and $80,000, 05
Between $85,000 and $90,000, 06
Between $90,000 and $95,000, or 07
Between $95,000 and $100,000 08
DON’T KNOW d
REFUSED r
GO
TO D1
(C15=04)
C15d. Would {you/(NAME)} say it was . . .
Between $100,000 and $110,000, 01
Between $110,000 and $120,000, 02
Between $120,000 and $130,000, 03
Between $130,000 and $140,000, 04
Between $140,000 and $150,000, or 05
More than $150,000 06
DON’T KNOW d
REFUSED r
SECTION d: USE OF MEDICAL SERVICES
(All)
(Asked at Baseline)
D1. These next questions are about {your/(NAME’s)} usual sources of medical care.
Since [fill RA MONTH YEAR], did {you/he/she} have a doctor whom {you/he/she} saw or a place {you/he/she} went to regularly to receive medical care?
YES 01
NO 00 (D2)
DON’T KNOW d (D2)
REFUSED r (D2)
(D1=01)
(Asked at Baseline-modified)
D1a. Which one of the following kinds of doctors or places did {you/(NAME)} see or go to most often since [fill RA MONTH YEAR]? Did {you/he/she} see . . .
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/(he/she) goes} to most often.
CODE ONE
an internist, general practitioner, or family doctor, 01 (D1b)
a specialist, 02 (D1b)
a psychiatrist, psychologist, or social worker, 03 (D1b)
did {you/he/she} go to a clinic, or 04 (D1b)
some other kind of place or doctor? 05
DON’T KNOW d (D1b)
REFUSED r (D1b)
(C3a=05)
D1a_Other. What other type of doctor or place did {you/(NAME)} see or go to most often for medical care since [fill RA MONTH YEAR]?
<OPEN>
DON’T KNOW d
REFUSED r
(D1=01)
(Asked at Baseline)
D1b. How many times {have you/has (NAME)} seen this doctor or gone to this place for medical care since [fill RA MONTH YEAR]?
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/his/her} answer correctly. Did {you/he/she} say that {you have/(he/she) has} (seen a doctor/visited this place) [fill NUMBER] since [fill RA MONTH YEAR]?
| | | NUMBER OF VISITS (D2)
(01-98)
NEVER/ZERO 00 (D2)
DON’T KNOW d
REFUSED r
(D1b=d or r)
D1c. Since [fill RA MONTH YEAR], would {you/(NAME)} say {you/he/she} saw this doctor or went to this place for medical care . . .
CODE ONE
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
(All)
(AB 6-Month Survey-modified)
D2. (IF D1=01, say “In addition to the doctor or place {you/(NAME)} just mentioned), did {you/he/she} see or go to any (IF D1a=01, SAY: other) internists, general practitioners, or family doctors for medical care since [fill RA MONTH YEAR]?
CODE ONE
YES 01
NO 00 (D2c)
DON’T KNOW d (D2c)
REFUSED r (D2c)
(D2=01)
D2a. How often did {you/(NAME)} see (an/another) internist, general practitioner, or family doctor since [fill RA MONTH YEAR]?
PROBE: Your best estimate is fine.
| | | NUMBER OF VISITS (D2c)
(1-50)
NEVER/ZERO 00 (D3)
DON’T KNOW d
REFUSED r
(D2a=d or r)
D2b. Since [fill RA MONTH YEAR], would {you/(NAME)} say {you/he/she} saw (an/another) internist, general practitioner, or family doctor . . .
CODE ONE
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
(D1a=01 or D2=01)
(CTS)
D2c. (Were any of these visits/Was this visit) to an internist, general practitioner, or family doctor for routine preventive care such as a physical examination or check up?
YES 01
NO 00
DON’T KNOW d
REFUSED r
(D1a=01 or D2=01)
(CTS)
D2d. (Were any of these visits/Was this visit) to an internist, general practitioner, or family doctor a routine check up for an ongoing health problem?
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
(AB 6-Month Survey-modified)
D3. (IF D1=01, say “In addition to the doctor(s) or place(s) you already told me about,) did {you/(NAME)} see or go to any (IF D1a=02, SAY: other) specialists for medical care since [fill RA MONTH YEAR]? Please do not include visits to psychologists, psychiatrists, or social workers here.
PROBE AS NEEDED: Specialists include doctors such as surgeons, allergists, (IF FEMALE: obstetricians, gynecologists) orthopedists, cardiologists, oncologists, and dermatologists. Specialists mainly treat one type of problem.
CODE ONE
YES 01
NO 00 (D4)
DON’T KNOW d (D4)
REFUSED r (D4)
(D3=01)
D3a. How often did {you/(NAME)} see (a/another) specialist since [fill RA MONTH YEAR]?
PROBE: Your best estimate is fine.
| | | NUMBER OF VISITS (D4)
(1-50)
NEVER/ZERO 00 (D4)
DON’T KNOW d
REFUSED r
(D3a=d or r)
D3b. Since [fill RA MONTH YEAR], would {you/(NAME)} say {you/he/she} saw (a/another) specialist . . .
CODE ONE
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
(All)
(AB 6-Month Survey-modified)
D4. (IF D1=01, say “In addition to the doctor(s) or place(s) you already told me about,”) did {you/(NAME)} see or go to any (IF D1a=03, SAY: other) psychologists, psychiatrists, or social workers for medical care since [fill RA MONTH YEAR]?
CODE ONE
YES 01
NO 00 (D5)
DON’T KNOW d (D5)
REFUSED r (D5)
(D4=01)
D4a. How often have {you/(NAME)} seen (a/another) psychologist, psychiatrist, or social worker since [fill RA MONTH YEAR]?
PROBE: Your best estimate is fine.
| | | NUMBER OF VISITS (D5)
(1-50)
NEVER/ZERO 00 (D5)
DON’T KNOW d
REFUSED r
(D4a=d or r)
D4b. Since [fill RA MONTH YEAR], would {you/(NAME)} say {you/he/she} saw (a/another) psychologist, psychiatrist, or social worker . . .
CODE ONE
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
(All)
D5. (IF D1=01, say “In addition to the doctor(s) or place(s) you already told me about,”) did {you/(NAME)} see or go to any (IF D1a=05, SAY: other) health care providers such as a nurse, nurse practitioner, physician’s assistant, physiatrist, rehabilitation specialist, or physical therapist since [fill RA MONTH YEAR]?
IF NEEDED: A physiatrist is a physician specializing in physical medicine and rehabilitation. Physiatrists specialize in restoring optimal function to people with injuries to the muscles, bones, tissues, and nervous system such as stroke victims.
CODE ONE
YES 01
NO 00 (D6)
DON’T KNOW d (D6)
REFUSED r (D6)
(D5=01)
D5a. How often did {you/(NAME)} see this type of health care provider since [fill RA MONTH YEAR]?
PROBE: Your best estimate is fine.
| | | NUMBER OF VISITS (D6)
( 1-50)
NEVER/ZERO 00 (D6)
DON’T KNOW d
REFUSED r
(D5a=d or r)
D5b. Since [fill RA MONTH YEAR], would {you/(NAME)} say {you/he/she} saw this type of health care provider. . .
CODE ONE
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
(All)
(Asked at Baseline)
D6. Now, I have some questions about other sources of medical care.
Since [fill RA MONTH YEAR] how many times {were you/was (NAME)} admitted for an overnight or longer stay in a hospital? Would {you/he/she} say . . .
Never, 00 (D8)
1 to 2 times, 01
3 to 5 times, 02
6 to 10 times, or 03
More than 10 times? 04
DON’T KNOW d
REFUSED r
(D9 NE 00, d or r)
(Asked at Baseline)
D7. All together, how many nights {have you/has (NAME)} spent in the hospital since [fill RA MONTH YEAR]?
| | | NUMBER OF HOSPITAL NIGHT STAYS
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
D8. Since [fill RA MONTH YEAR] how many times {were you/was (NAME)} a patient in a nursing home, convalescent home, or other long-term health care facility? Please include skilled nursing facilities and rehabilitation facilities. Would {you/he/she} say . . .
Never, 00
1 to 2 times, 01
3 to 5 times, 02
6 to 10 times, or 03
More than 10 times? 04
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
D9. Since [fill RA MONTH YEAR] how many times did {you/(NAME)} visit an emergency room? Would {you/he/she} say . . .
Never, 00 (E0)
1 to 2 times, 01
3 to 5 times, 02
6 to 10 times, or 03
More than 10 times? 04
DON’T KNOW d (E0)
REFUSED r (E0)
D9a. When {you/(NAME)} visited the emergency room . . .
. . . did {your/his/her} symptoms come on after {your/his/her} doctor’s regular office hours?
YES 01
NO 00
DON’T KNOW d
REFUSED r
D9b. . . . did {you/he/she} go to the emergency room because this is where {you/he/she} always {go/goes} for medical care?
YES 01
NO 00
DON’T KNOW d
REFUSED r
SECTION E: UNMET MEDICAL NEEDS
(All)
E0. INTERVIEWER CHECKPOINT: DOES THE RESPONDENT SEEM FATIGUED, CONFUSED, OR IN NEED OF ENCOURAGEMENT?
SEEMS FATIGUED/CONFUSED 01 (E0a)
NEEDS ENCOURAGEMENT 02 (E0c)
NOT SURE 03 (E0c)
NO 00 (E1)
(E0=01)
E0a. Are you feeling tired, or can we continue?
TIRED 01
CONTINUE 02 (E0d)
(E0a=01)
E0b. 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 (E0d)
YES, BREAK AND CALL BACK 02 (E0d)
NO, CONTINUE NOW 03 (E0d)
(E0=02 or 03)
E0c. You’re doing fine. (Your answers are very helpful to this study./There are no right or wrong answers to these questions.)
(E0=01, 02 or 03)
E0d. INTERVIEWER ACTION: WHAT DID YOU DO?
NOT FATIGUED; NO ENCOURAGEMENT
PROVIDED 01
FATIGUED; HELD ON 02
FATIGUED; SCHEDULED CALL BACK 03 (GO TO CALL BACK SCREEN)
FATIGUED, BUT WANTED TO CONTINUE 04
PROVIDED ENCOURAGEMENT AND CONTINUED 05
(All)
(Asked at Baseline)
E1. These next questions are about medical needs that may or may not have been taken care of. Since [fill RA MONTH YEAR], was there any time when {you/(NAME)} didn’t see a doctor or get the medical care {you/he/she} needed?
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
E2. Since [fill RA MONTH YEAR] was there any time when {you/(NAME)} put off or postponed seeing a doctor or getting medical care {you/he/she} needed?
YES 01
NO 00 (E4)
DON’T KNOW d (E4)
REFUSED r (E4)
(E1 or E2=01)
E3a. Since [fill RA MONTH YEAR], what was the main reason {you/(NAME)} put off or postponed seeing a doctor?
PROBE (IF R GIVES MORE THAN ONE RESPONSE): We are just asking for the main reason here. We will ask about other reasons shortly.
PROGRAMMER: DISPLAY ANSWER CHOICE “01” FOR CONTROL ONLY
CODE ONE
DID NOT HAVE HEALTH INSURANCE 01
DOCTOR DID NOT ACCEPT INSURANCE 02
COULD NOT AFFORD IT 03
A DOCTOR WAS NOT AVAILABLE IN AREA 04
HAD NO TRANSPORTATION 05
TOO SICK TO GO TO THE DOCTOR 06
COULD NOT GET THE PRE-APPROVAL FROM
INSURANCE COMPANY 07
SOME OTHER REASON (SPECIFY) 08
DON’T KNOW d
REFUSED r
E3b. Were there any other reasons?
YES 01
NO 00 (E4)
DON’T KNOW d (E4)
REFUSED r (E4)
(E3b=01)
E3c. What were the other reasons {you/(NAME)} put off or postponed seeing a doctor?
PROGRAMMER: DISPLAY ANSWER CHOICE “01” FOR CONTROL ONLY
CODE ALL THAT APPLY
DID NOT HAVE HEALTH INSURANCE 01
DOCTOR DID NOT ACCEPT INSURANCE 02
COULD NOT AFFORD IT 03
A DOCTOR WAS NOT AVAILABLE IN AREA 04
HAD NO TRANSPORTATION 05
TOO SICK TO GO TO THE DOCTOR 06
COULD NOT GET THE PRE-APPROVAL FROM
INSURANCE COMPANY 07
SOME OTHER REASON (SPECIFY) 08
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
E4. Since [fill RA MONTH YEAR] {were you/was (NAME)} referred to another doctor, specialist, therapist, psychologist, or other medical professional?
YES 01
NO 00 (E6)
DON’T KNOW d (E6)
REFUSED r (E6)
(E4=01)
(Asked at Baseline)
E4a. Did {you/(NAME)} go for all of the visits for which {you were/(he/she) was} referred?
YES 01 (E6)
NO 00
DON’T KNOW d (E6)
REFUSED r (E6)
(E4a=00)
E5a. What was the main reason {you/(NAME)} did not go for all of {your/his/her} recommended visits?
PROGRAMMER: DISPLAY ANSWER CHOICE “01” FOR CONTROL ONLY
CODE ONE
DID NOT HAVE HEALTH INSURANCE 01
DOCTOR DID NOT ACCEPT INSURANCE 02
COULD NOT AFFORD IT 03
A DOCTOR WAS NOT AVAILABLE IN AREA 04
HAD NO TRANSPORTATION 05
TOO SICK TO GO TO THE DOCTOR 06
COULD NOT GET THE PRE-APPROVAL FROM
INSURANCE COMPANY 07
SOME OTHER REASON (SPECIFY) 08
DON’T KNOW d
REFUSED r
E5b. Were there any other reasons?
YES 01
NO 00 (E6)
DON’T KNOW d (E6)
REFUSED r (E6)
(E5b=01)
E5c. What were the other reasons {you/(NAME)} did not go for all of {your/his/her} recommended visits?
PROGRAMMER: DISPLAY ANSWER CHOICE “01” FOR CONTROL ONLY
CODE ALL THAT APPLY
DID NOT HAVE HEALTH INSURANCE 01
DOCTOR DID NOT ACCEPT INSURANCE 02
COULD NOT AFFORD IT 03
A DOCTOR WAS NOT AVAILABLE IN AREA 04
HAD NO TRANSPORTATION 05
TOO SICK TO GO TO THE DOCTOR 06
COULD NOT GET THE PRE-APPROVAL FROM
INSURANCE COMPANY 07
SOME OTHER REASON (SPECIFY) 08
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
E6. Since [fill RA MONTH YEAR] did a doctor or clinic send {you/(NAME)} for tests or x-rays?
YES 01
NO 00 (E8)
DON’T KNOW d (E8)
REFUSED r (E8)
(E6=01)
(Asked at Baseline)
E6a. Did {you/(NAME)} go for all of the tests or x-rays for which {you were/(he/she) was} sent?
YES 01 (E8)
NO 00
DON’T KNOW d (E8)
REFUSED r (E8)
(E6a=00)
E7a. What was the main reason {you/(NAME)} did not go for all of {your/his/her} recommended tests or x-rays?
PROGRAMMER: DISPLAY ANSWER CHOICE “01” FOR CONTROL ONLY
CODE ONE
DID NOT HAVE HEALTH INSURANCE 01
THE PLACE DID NOT ACCEPT INSURANCE 02
COULD NOT AFFORD IT 03
TEST WAS NOT AVAILABLE IN AREA 04
HAD NO TRANSPORTATION 05
TOO SICK TO TAKE THE TEST OR X-RAY 06
COULD NOT GET THE PRE-APPROVAL FROM
INSURANCE COMPANY 07
SOME OTHER REASON (SPECIFY) 08
DON’T KNOW d
REFUSED r
E7b. Were there any other reasons?
YES 01
NO 00 (E8)
DON’T KNOW d (E8)
REFUSED r (E8)
(E7b=01)
E7c. What were the other reasons {you/(NAME)} did not go for all of {your/his/her} recommended tests or x-rays?
PROGRAMMER: DISPLAY ANSWER CHOICE “01” FOR CONTROL ONLY
CODE ALL THAT APPLY
DID NOT HAVE HEALTH INSURANCE 01
PLACE DID NOT ACCEPT INSURANCE 02
COULD NOT AFFORD IT 03
TEST WAS NOT AVAILABLE IN AREA 04
HAD NO TRANSPORTATION 05
TOO SICK TO TAKE THE TEST OR X-RAY 06
COULD NOT GET THE PRE-APPROVAL FROM
INSURANCE COMPANY 07
SOME OTHER REASON (SPECIFY) 08
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
E8. Since [fill RA MONTH YEAR] did a doctor order or recommend any medical procedures or surgery for {you/(NAME)}?
YES 01
NO 00 (E10)
DON’T KNOW d (E10)
REFUSED r (E10)
(E8=01)
(Asked at Baseline)
E8a. Did {you/(NAME)} have all the procedures or surgeries {your/his/her} doctor recommended?
YES 01 (E10)
NO 00
DON’T KNOW d (E10)
REFUSED r (E10)
(E8a=00)
E9a. What was the main reason {you/(NAME)} did not have the recommended procedures or surgeries?
PROGRAMMER: DISPLAY ANSWER CHOICE “01” FOR CONTROL ONLY
CODE ONE
DID NOT HAVE HEALTH INSURANCE 01
SURGEON/PLACE DID NOT ACCEPT INSURANCE 02
COULD NOT AFFORD IT 03
SURGERY WAS NOT AVAILABLE IN AREA 04
HAD NO TRANSPORTATION 05
TOO SICK TO HAVE PROCEDURE/SURGERY 06
COULD NOT GET THE PRE-APPROVAL FROM
INSURANCE COMPANY 07
SOME OTHER REASON (SPECIFY) 08
DON’T KNOW d
REFUSED r
E9b. Were there any other reasons?
YES 01
NO 00 (E10)
DON’T KNOW d (E10)
REFUSED r (E10)
(E9b=01)
E9c. What were the other reasons {you/(NAME)} did not have the recommended procedures or surgeries?
PROGRAMMER: DISPLAY ANSWER CHOICE “01” FOR CONTROL ONLY
CODE ALL THAT APPLY
DID NOT HAVE HEALTH INSURANCE 01
SURGEON/PLACE DID NOT ACCEPT INSURANCE 02
COULD NOT AFFORD IT 03
SURGERY WAS NOT AVAILABLE IN AREA 04
HAD NO TRANSPORTATION 05
TOO SICK TO HAVE PROCEDURE/SURGERY 06
COULD NOT GET THE PRE-APPROVAL FROM
INSURANCE COMPANY 07
SOME OTHER REASON (SPECIFY) 08
DON’T KNOW d
REFUSED r
(All)
E10. The next questions are about prescriptions. {Do you/Does (NAME)} regularly take prescription medicines?
YES 01
NO 00 (F1)
DON’T KNOW d (F1)
REFUSED r (F1)
(E10=01)
E10a. How many different prescription medicines {do you/does (NAME)} regularly take?
| | | PRESCRIBED MEDICATIONS (E10ck)
(1-20)
DON’T KNOW d
REFUSED r
(E10a=d or r)
E10b. Would {you/(NAME)} say that {you/he/she} regularly take one to two, three to four, five to six, or more than six prescription medicines?
1 TO 2 01
3 TO 4 02
5 TO 6 03
MORE THAN 6 04
DON’T KNOW d
REFUSED r
PROGRAMMER:
IF E10a >6 OR E10b=04, GO TO E10ck, OTHERWISE, GO TO E11.
(E10a>6 OR E10b=4)
E10ck Is that the number of pills, or the number of different medications?
PILLS 01
DIFFERENT MEDICATIONS 02
DON’T KNOW d
REFUSED r
IF E10ck=02, d, OR r, GO TO NEXT QUESTION. IF E10ck=01, GO TO PREVIOUS QUESTION, E10a OR E10b. |
(All)
(Asked at Baseline)
E11. Since [fill RA MONTH YEAR], were there any prescription medicines that {you were/(he/she) was} supposed to use, but did not get when first prescribed because of the cost?
PROBE: That is, {you/he/she} did not fill the prescription at all when {you/he/she} got it.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
E12. Since [fill RA MONTH YEAR] were there any prescription medicines that {you were/(he/she) was} supposed to use, but did not get the entire prescription filled because of the cost?
PROBE: That is, {you/he/she} filled the prescription but got less than the prescribed amount, for example, if the prescription was written for 30 pills {you/he/she} got a lesser amount.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
E13. Since [fill RA MONTH YEAR] were there any prescription medicines that {you were/(he/she) was} supposed to use, but did not refill when {you/he/she} ran out because of the cost?
PROBE: That is, {you/he/she} went some time without being able to take the needed medication because it was finished.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
E14. Since [fill RA MONTH YEAR] were there any prescription medicines that {you/he/she} used less often than prescribed in order to stretch them out because of the cost?
PROBE: That is, {you/he/she} used less of the medication or skipped days of taking the medication.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
E15. These next few questions ask about other reasons {you/(NAME)} may not have taken {your/his/her} medications as prescribed. Since [fill RA MONTH YEAR] were there any prescription medicines that {you/he/she} did not take as prescribed because {you/he/she} forgot to take them?
READ IF NECESSARY: As prescribed means taking the right dosage at the right time.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
E16. Since [fill RA MONTH YEAR] were there any prescription medicines that {you/he/she} did not take as prescribed because {you/he/she} did not understand the directions?
READ IF NECESSARY: As prescribed means taking the right dosage at the right time.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
E17. Since [fill RA MONTH YEAR] were there any prescription medicines that {you/he/she} did not take as prescribed because {you/he/she} did not feel that {you/he/she} needed them?
READ IF NECESSARY: As prescribed means taking the right dosage at the right time.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
E18. Since [fill RA MONTH YEAR] were there any prescription medicines that {you/he/she} did not take as prescribed because {you/he/she} did not like the side effects?
READ IF NECESSARY: As prescribed means taking the right dosage at the right time.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(All)
E19. Since [fill RA MONTH YEAR] were there any prescription medicines that {you/he/she} did not take as prescribed because the drug did not work well?
READ IF NECESSARY: As prescribed means taking the right dosage at the right time.
YES 01
NO 00
DON’T KNOW d
REFUSED r
SECTION F: EMPLOYMENT AND EARNINGS
(All)
(Asked at Baseline)
F1. These next questions are about employment.
{Are you/Is (NAME)} currently working at a job for pay? Include both part-time and full-time jobs, as well as any self-employment jobs you held for pay or profit.
YES 01 (F3)
NO 00
DON’T KNOW d
REFUSED r
(F1=00, d or r)
F2. Since [fill RA MONTH YEAR], {have you/has (NAME)} worked at a job for pay? Include both part-time and full-time jobs, as well as any self-employment jobs you held for pay or profit.
YES 01 (F4)
NO 00 (F13)
DON’T KNOW d (F13)
REFUSED r (F13)
(F1=01)
(Asked at Baseline)
F3. How many jobs {do you/does (NAME)} currently have? Include both part-time and full-time jobs, as well as any self-employment jobs you held for pay or profit.
INTERVIEWER: TREAT JOBS WITH TEMPORARY AGENCIES AS ONE JOB, REGARDLESS OF THE NUMBER OF ASSIGNMENTS.
| | NUMBER OF JOBS
(1-5)
DON’T KNOW d
REFUSED r
(F1=01 or F2=01)
F4. PROGRAMMER: IF F1=01, USE FILL: (Including {your/(NAME’s)} {current job/(FILL NUMBER FROM F3) current jobs}, How many different jobs have {you/he/she} had since [fill RA MONTH YEAR]? Include both part-time and full-time jobs, as well as any self-employment jobs you held for pay or profit.
INTERVIEWER: IF A JOB THAT WAS INTERRUPTED BY TWO OR MORE UNPAID WEEKS, COUNT AS SEPARATE JOBS, EVEN IF IT IS WITH THE SAME EMPLOYER. IF THE SEPARATION WAS LESS THAN TWO WEEKS, COUNT IT AS ONE JOB.
INTERVIEWER: TREAT JOBS WITH TEMPORARY AGENCIES AS ONE JOB, REGARDLESS OF THE NUMBER OF ASSIGNMENTS.
| | NUMBER OF JOBS
(1-5)
DON’T KNOW d
REFUSED r
(F1=01 or F2=01)
(Asked at Baseline)
F4a. {Were you/Was (NAME)} self-employed at any time since [fill RA MONTH YEAR]?
YES 01
NO 00
DON’T KNOW d
REFUSED r
|
JOB 1 |
JOB 2 |
(F1 or F2=01) F5. Starting with {your/his/her} (current job/main job/the most recent job} that {you/he/she} had), please tell me the name of the companies, organizations, and people {you have/(NAME) has} worked for since [fill RA MONTH YEAR].
PROBE: Your main job is the one with the most hours.
PROBE: IF F3 OR F4 >1 SAY: What was the job before that? |
(SPECIFY) [specify] 01
DON’T KNOW d
REFUSED r
|
(SPECIFY) [specify] 01
DON’T KNOW d
REFUSED r
|
(F1 or F2=01) F5a. Let me verify. Since [fill RA MONTH YEAR] {you/(NAME)} worked at [fill F5 NAMES]. Is this correct, or are there any other jobs {you/he/she} may have had?
IF CORRECT, ENTER “1” AND CONTINUE. IF NOT CORRECT, GO BACK TO F3, F4, AND F5 TO ENTER CORRECT NUMBER AND NAMES OF JOBS HELD. |
CORRECT 01
NOT CORRECT 00
DON’T KNOW d
REFUSED r
|
CORRECT 01
NOT CORRECT 00
DON’T KNOW d
REFUSED r
|
(F4a=01) (Asked at Baseline) F5b. {(Are/Were) you/(Is/Was) (NAME)} self-employed at this job? |
YES 01 NO 00 DON’T KNOW d REFUSED r |
YES 01 NO 00 DON’T KNOW d REFUSED r |
(Asked at Baseline) F6. (There are a number of special work programs available to people with disabilities.) {(Is/Was) your/ (NAME)’s} job at [fill JOB NAME] part of a sheltered workshop program, transitional employment program, the Business Enterprise Program for the blind, or a supported employment program?
PROBE: A sheltered workshop is a program that provides employment with subsidized wages (or special wages that would not be available in a regular job) for people with disabilities.
PROBE: A transitional employment program allows workers with disabilities to work at reduced levels while they ease back into the workplace.
PROBE: The Business Enterprise Program for the blind offers legally blind persons the opportunity to own their own businesses.
PROBE: Supported employment programs provide job coaches or other on-the-job supports to help individuals with disabilities get and keep jobs. |
YES 01 NO 00 DON’T KNOW d REFUSED r
|
YES 01 NO 00 DON’T KNOW d REFUSED r
|
JOB 3 |
JOB 4 |
JOB 5 |
(SPECIFY) [specify] 01
DON’T KNOW d
REFUSED r
|
(SPECIFY) [specify] 01
DON’T KNOW d
REFUSED r
|
(SPECIFY) [specify] 01
DON’T KNOW d
REFUSED r
|
CORRECT 01
NOT CORRECT 00
DON’T KNOW d
REFUSED r
|
CORRECT 01
NOT CORRECT 00
DON’T KNOW d
REFUSED r
|
CORRECT 01
NOT CORRECT 00
DON’T KNOW d
REFUSED r
|
YES 01 NO 00 DON’T KNOW d REFUSED r |
YES 01 NO 00 DON’T KNOW d REFUSED r |
YES 01 NO 00 DON’T KNOW d REFUSED r |
YES 01 NO 00 DON’T KNOW d REFUSED r
|
YES 01 NO 00 DON’T KNOW d REFUSED r
|
YES 01 NO 00 DON’T KNOW d REFUSED r
|
|
JOB 3 |
JOB 4 |
(F1 or F2=01) (Asked at Baseline) F7. In what month and year did {you/(NAME)} start working for [fill JOB NAME]?
PROBE: Since [fill RA DATE].
RECORD MONTH AND YEAR. |
| | | / | | | | | (F9) MONTH YEAR (1-12) (2007-2010)
DON’T KNOW d
REFUSED r
|
| | | / | | | | | (F9) MONTH YEAR (1-12) (2007-2010)
DON’T KNOW d
REFUSED r
|
(F7=d or r) (Asked at Baseline-reference period modified) F8. Would {you/(NAME)} say {you/he/she} began working at [fill JOB NAME] within the past six months, between six months and one year ago, between a year and a year and a half ago, between a year and a half and two years ago, or more than two years ago?
PROBE: Your best estimate is fine. |
WITHIN THE PAST 6 MONTHS, 01
BETWEEN SIX MONTHS AND A YEAR AGO, 02
BETWEEN A YEAR AND A YEAR AND A HALF AGO, 03
BETWEEN A YEAR AND A HALF AND TWO YEARS AGO, OR 04
MORE THAN 2 YEARS AGO 05
DON’T KNOW d
REFUSED r |
WITHIN THE PAST 6 MONTHS, 01
BETWEEN SIX MONTHS AND A YEAR AGO, 02
BETWEEN A YEAR AND A YEAR AND A HALF AGO, 03
BETWEEN A YEAR AND A HALF AND TWO YEARS AGO, OR 04
MORE THAN 2 YEARS AGO 05
DON’T KNOW d
REFUSED r |
(F1 or F2=01) F9. In what month and year did that job at [fill JOB NAME] end, or are you still working there?
PROBE: Since [fill RA DATE].
RECORD MONTH AND YEAR. |
| | | / | | | | | (F10) MONTH YEAR (1-12) (2007-2010)
STILL AT JOB (F10) n
DON’T KNOW d
REFUSED r |
| | | / | | | | | (F10) MONTH YEAR (1-12) (2007-2010)
STILL AT JOB (F10) n
DON’T KNOW d
REFUSED r |
JOB 3 |
JOB 4 |
JOB 5 |
| | | / | | | | | (F9) MONTH YEAR (1-12) (2007-2010)
DON’T KNOW d
REFUSED r
|
| | | / | | | | | (F9) MONTH YEAR (1-12) (2007-2010)
DON’T KNOW d
REFUSED r
|
| | | / | | | | | (F9) MONTH YEAR (1-12) (2007-2010)
DON’T KNOW d
REFUSED r
|
WITHIN THE PAST 6 MONTHS, 01
BETWEEN SIX MONTHS AND A YEAR AGO, 02
BETWEEN A YEAR AND A YEAR AND A HALF AGO, 03
BETWEEN A YEAR AND A HALF AND TWO YEARS AGO, OR 04
MORE THAN 2 YEARS AGO 05
DON’T KNOW d
REFUSED r |
WITHIN THE PAST 6 MONTHS, 01
BETWEEN SIX MONTHS AND A YEAR AGO, 02
BETWEEN A YEAR AND A YEAR AND A HALF AGO, 03
BETWEEN A YEAR AND A HALF AND TWO YEARS AGO, OR 04
MORE THAN 2 YEARS AGO 05
DON’T KNOW d
REFUSED r |
WITHIN THE PAST 6 MONTHS, 01
BETWEEN SIX MONTHS AND A YEAR AGO, 02
BETWEEN A YEAR AND A YEAR AND A HALF AGO, 03
BETWEEN A YEAR AND A HALF AND TWO YEARS AGO, OR 04
MORE THAN 2 YEARS AGO 05
DON’T KNOW d
REFUSED r |
| | | / | | | | | (F10) MONTH YEAR (1-12) (2007-2010)
STILL AT JOB (F10) n
DON’T KNOW d
REFUSED r |
| | | / | | | | | (F10) MONTH YEAR (1-12) (2007-2010)
STILL AT JOB (F10) n
DON’T KNOW d
REFUSED r |
| | | / | | | | | (F10) MONTH YEAR (1-12) (2007-2010)
STILL AT JOB (F10) n
DON’T KNOW d
REFUSED r |
|
JOB 1 |
JOB 2 |
(F9=d or r) F9a. Would {you/(NAME)} say {your/his/her} job at [fill JOB NAME] ended within the past month, between one and 3 months ago, between 3 and 6 months ago, between 6 and 12 months ago, or more than 12 months ago?
PROBE: Your best estimate is fine. |
WITHIN THE PAST MONTH 01 BETWEEN 1 AND 3 MONTHS AGO 02 BETWEEN 3 AND 6 MONTHS AGO 03 BETWEEN 6 AND 12 MONTHS AGO, OR 04 MORE THAN 12 MONTHS AGO 05 DON’T KNOW d REFUSED r |
WITHIN THE PAST MONTH 01 BETWEEN 1 AND 3 MONTHS AGO 02 BETWEEN 3 AND 6 MONTHS AGO 03 BETWEEN 6 AND 12 MONTHS AGO, OR 04 MORE THAN 12 MONTHS AGO 05 DON’T KNOW d REFUSED r |
(F9 NE n, d, or r) F9b. What was the main reason your job at [fill JOB NAME] ended? Was it because . . .
CODE ONE RESPONSE. |
{you were /(NAME was )} laid off 01 (your /(NAME’s)} health worsened 02 {you/(NAME)} needed to take care of a family member 03 {you/(NAME)} retired 04 {you/(NAME)} returned to school 05 {you/(NAME)} moved 06 {you/(NAME)} got a better job 07 {you/(NAME)} were discharged or fired; or 08 some other reason 09 |
{you were /(NAME was )} laid off 01 (your /(NAME’s)} health worsened 02 {you/(NAME)} needed to take care of a family member 03 {you/(NAME)} retired 04 {you/(NAME)} returned to school 05 {you/(NAME)} moved 06 {you/(NAME)} got a better job 07 {you/(NAME)} were discharged or fired; or 08 some other reason 09 |
(F1 or F2=01) (Asked at Baseline) F10. How many hours per week, {(do/did) you/(did/does) (NAME)} usually work at [fill JOB NAME]?
PROBE: Include overtime if {you/he/she} usually work(ed) overtime. |
| | | (F11) (1-80)
VARIES v
DON’T KNOW d
REFUSED r
|
| | | (F11) (1-80)
VARIES v
DON’T KNOW d
REFUSED r
|
(F8=v, d or r) F10a. Would {you/(NAME)} say {you/he/she} (work/works/worked) less than 10 hours per week, between 10 and 14 hours per week, between 15 and 19 hours per week, between 20 and 24 hours per week, between 25 and 29 hours per week, between 30 and 34 hours per week, between 35 and 39 hours per week, or 40 or more hours per week? |
LESS THAN 10 HOURS PER WEEK 01 BETWEEN 10 AND 14 HOURS PER WEEK 02 BETWEEN 15 AND 19 HOURS PER WEEK 03 BETWEEN 20 AND 24 HOURS PER WEEK 04 BETWEEN 25 AND 29 HOURS PER WEEK 05 BETWEEN 30 AND 34 HOURS PER WEEK 06 BETWEEN 35 AND 39 HOURS PER WEEK 07 40 OR MORE HOURS PER WEEK 08 DON’T KNOW d REFUSED r |
LESS THAN 10 HOURS PER WEEK 01 BETWEEN 10 AND 14 HOURS PER WEEK 02 BETWEEN 15 AND 19 HOURS PER WEEK 03 BETWEEN 20 AND 24 HOURS PER WEEK 04 BETWEEN 25 AND 29 HOURS PER WEEK 05 BETWEEN 30 AND 34 HOURS PER WEEK 06 BETWEEN 35 AND 39 HOURS PER WEEK 07 40 OR MORE HOURS PER WEEK 08 DON’T KNOW d REFUSED r |
(F1 or F2=01) (Asked at Baseline) F11. What kind of work {do/did} {you/(NAME)} do at [fill JOB NAME]?
PROBE: That is, what (is/was) {your/his/her} occupation? |
RECORD VERBATIM
DON’T KNOW d
REFUSED r |
RECORD VERBATIM
DON’T KNOW d
REFUSED r |
JOB 3 |
JOB 4 |
JOB 5 |
WITHIN THE PAST MONTH 01 BETWEEN 1 AND 3 MONTHS AGO 02 BETWEEN 3 AND 6 MONTHS AGO 03 BETWEEN 6 AND 12 MONTHS AGO, OR 04 MORE THAN 12 MONTHS AGO 05 DON’T KNOW d REFUSED r |
WITHIN THE PAST MONTH 01 BETWEEN 1 AND 3 MONTHS AGO 02 BETWEEN 3 AND 6 MONTHS AGO 03 BETWEEN 6 AND 12 MONTHS AGO, OR 04 MORE THAN 12 MONTHS AGO 05 DON’T KNOW d REFUSED r |
WITHIN THE PAST MONTH 01 BETWEEN 1 AND 3 MONTHS AGO 02 BETWEEN 3 AND 6 MONTHS AGO 03 BETWEEN 6 AND 12 MONTHS AGO, OR 04 MORE THAN 12 MONTHS AGO 05 DON’T KNOW d REFUSED r |
{you were /(NAME was )} laid off 01 (your /(NAME’s)} health worsened 02 {you/(NAME)} needed to take care of a family member 03 {you/(NAME)} retired 04 {you/(NAME)} returned to school 05 {you/(NAME)} moved 06 {you/(NAME)} got a better job 07 {you/(NAME)} were discharged or fired; or 08 some other reason 09 |
{you were /(NAME was )} laid off 01 (your /(NAME’s)} health worsened 02 {you/(NAME)} needed to take care of a family member 03 {you/(NAME)} retired 04 {you/(NAME)} returned to school 05 {you/(NAME)} moved 06 {you/(NAME)} got a better job 07 {you/(NAME)} were discharged or fired; or 08 some other reason 09 |
{you were /(NAME was )} laid off 01 (your /(NAME’s)} health worsened 02 {you/(NAME)} needed to take care of a family member 03 {you/(NAME)} retired 04 {you/(NAME)} returned to school 05 {you/(NAME)} moved 06 {you/(NAME)} got a better job 07 {you/(NAME)} were discharged or fired; or 08 some other reason 09 |
| | | (F11) (1-80)
VARIES v
DON’T KNOW d
REFUSED r
|
| | | (F11) (1-80)
VARIES v
DON’T KNOW d
REFUSED r
|
| | | (F11) (1-80)
VARIES v
DON’T KNOW d
REFUSED r
|
LESS THAN 10 HOURS PER WEEK 01 BETWEEN 10 AND 14 HOURS PER WEEK 02 BETWEEN 15 AND 19 HOURS PER WEEK 03 BETWEEN 20 AND 24 HOURS PER WEEK 04 BETWEEN 25 AND 29 HOURS PER WEEK 05 BETWEEN 30 AND 34 HOURS PER WEEK 06 BETWEEN 35 AND 39 HOURS PER WEEK 07 40 OR MORE HOURS PER WEEK 08 DON’T KNOW d REFUSED r |
LESS THAN 10 HOURS PER WEEK 01 BETWEEN 10 AND 14 HOURS PER WEEK 02 BETWEEN 15 AND 19 HOURS PER WEEK 03 BETWEEN 20 AND 24 HOURS PER WEEK 04 BETWEEN 25 AND 29 HOURS PER WEEK 05 BETWEEN 30 AND 34 HOURS PER WEEK 06 BETWEEN 35 AND 39 HOURS PER WEEK 07 40 OR MORE HOURS PER WEEK 08 DON’T KNOW d REFUSED r |
LESS THAN 10 HOURS PER WEEK 01 BETWEEN 10 AND 14 HOURS PER WEEK 02 BETWEEN 15 AND 19 HOURS PER WEEK 03 BETWEEN 20 AND 24 HOURS PER WEEK 04 BETWEEN 25 AND 29 HOURS PER WEEK 05 BETWEEN 30 AND 34 HOURS PER WEEK 06 BETWEEN 35 AND 39 HOURS PER WEEK 07 40 OR MORE HOURS PER WEEK 08 DON’T KNOW d REFUSED r |
RECORD VERBATIM
DON’T KNOW d
REFUSED r |
RECORD VERBATIM
DON’T KNOW d
REFUSED r |
RECORD VERBATIM
DON’T KNOW d
REFUSED r |
|
JOB 1 |
JOB 2 |
(F1 or F2=01) (Asked at Baseline) F12. What kind of business is this?
PROBE 1: For what type of organization or industry {do/did} {you/(NAME)} work? For example, accounting firm, daycare center, educational facility, food services.
PROBE 2: What {does/did} the company {you work(ed)/he/she works(ed)} for make, sell, or do? |
RECORD VERBATIM
DON’T KNOW d
REFUSED r
|
RECORD VERBATIM
DON’T KNOW d
REFUSED r
|
(F1 or F2=01) F12a. (My next questions are about earnings.)
What (is/was) {your/(NAME’s)} usual pay, including tips and commissions at [fill JOB NAME] before taxes or other deductions (are/were) taken?
PROBE: Your best estimate is fine.
INTERVIEWER: ACCEPT MOST CONVENIENT PAY PERIOD. IF NECESSARY, CONFIRM PAY PERIOD. |
$ | | | |,| | | |.| | | (F12c) (5.00 – 300,000.00)
PER HOUR 1 PER WEEK 2 ONCE EVERY TWO WEEKS 3 TWICE A MONTH 4 PER MONTH 5 PER YEAR 6 OTHER (SPECIFY) [specify] 7
NOT YET PAID n
DON’T KNOW d
REFUSED r |
$ | | | |,| | | |.| | | (F12c) (5.00 – 300,000.00)
PER HOUR 1 PER WEEK 2 ONCE EVERY TWO WEEKS 3 TWICE A MONTH 4 PER MONTH 5 PER YEAR 6 OTHER (SPECIFY) [specify] 7
NOT YET PAID n
DON’T KNOW d
REFUSED r |
(F12a=n, d, or r) F12b. I’ll read some ranges. Please try to estimate {your/(NAME’s)} annual pay at [fill JOB NAME]. Would {you/he/she} say {your/his/her} annual earnings (are/were) . . .
PROBE: Does this include tips and commissions? |
Less than $10,000, 01 $10,000 or more, but less than $20,000, 02 $20,000 or more but less than $30,000, 03 $30,000 or more but less than $40,000, 04 $40,000 or more but less than $50,000, 05 $50,000 or more but less than $75,000, 06 $75,000 or more but less than $100,000, or 07 more than $100,000? 08 DON’T KNOW (F21) d REFUSED (F21) r
|
Less than $10,000, 01 $10,000 or more, but less than $20,000, 02 $20,000 or more but less than $30,000, 03 $30,000 or more but less than $40,000, 04 $40,000 or more but less than $50,000, 05 $50,000 or more but less than $75,000, 06 $75,000 or more but less than $100,000, or 07 more than $100,000? 08 DON’T KNOW (F21) d REFUSED (F21) r
|
(F12 NE n, d, or r OR F12a NE d or r) F12c. Is that before or after taxes? |
BEFORE TAXES 01
AFTER TAXES 02
DON’T KNOW d
REFUSED r
|
BEFORE TAXES 01
AFTER TAXES 02
DON’T KNOW d
REFUSED r
|
JOB 3 |
JOB 4 |
JOB 5 |
RECORD VERBATIM
DON’T KNOW d
REFUSED r
|
RECORD VERBATIM
DON’T KNOW d
REFUSED r
|
RECORD VERBATIM
DON’T KNOW d
REFUSED r
|
$ | | | |,| | | |.| | | (F12c) (5.00 – 300,000.00)
PER HOUR 1 PER WEEK 2 ONCE EVERY TWO WEEKS 3 TWICE A MONTH 4 PER MONTH 5 PER YEAR 6 OTHER (SPECIFY) [specify] 7
NOT YET PAID n
DON’T KNOW d
REFUSED r |
$ | | | |,| | | |.| | | (F12c) (5.00 – 300,000.00)
PER HOUR 1 PER WEEK 2 ONCE EVERY TWO WEEKS 3 TWICE A MONTH 4 PER MONTH 5 PER YEAR 6 OTHER (SPECIFY) [specify] 7
NOT YET PAID n
DON’T KNOW d
REFUSED r |
$ | | | |,| | | |.| | | (F12c) (5.00 – 300,000.00)
PER HOUR 1 PER WEEK 2 ONCE EVERY TWO WEEKS 3 TWICE A MONTH 4 PER MONTH 5 PER YEAR 6 OTHER (SPECIFY) [specify] 7
NOT YET PAID n
DON’T KNOW d
REFUSED r |
Less than $10,000, 01 $10,000 or more, but less than $20,000, 02 $20,000 or more but less than $30,000, 03 $30,000 or more but less than $40,000, 04 $40,000 or more but less than $50,000, 05 $50,000 or more but less than $75,000, 06 $75,000 or more but less than $100,000, or 07 more than $100,000? 08 DON’T KNOW (F21) d REFUSED (F21) r
|
Less than $10,000, 01 $10,000 or more, but less than $20,000, 02 $20,000 or more but less than $30,000, 03 $30,000 or more but less than $40,000, 04 $40,000 or more but less than $50,000, 05 $50,000 or more but less than $75,000, 06 $75,000 or more but less than $100,000, or 07 more than $100,000? 08 DON’T KNOW (F21) d REFUSED (F21) r
|
Less than $10,000, 01 $10,000 or more, but less than $20,000, 02 $20,000 or more but less than $30,000, 03 $30,000 or more but less than $40,000, 04 $40,000 or more but less than $50,000, 05 $50,000 or more but less than $75,000, 06 $75,000 or more but less than $100,000, or 07 more than $100,000? 08 DON’T KNOW (F21) d REFUSED (F21) r
|
BEFORE TAXES 01
AFTER TAXES 02
DON’T KNOW d
REFUSED r
|
BEFORE TAXES 01
AFTER TAXES 02
DON’T KNOW d
REFUSED r
|
BEFORE TAXES 01
AFTER TAXES 02
DON’T KNOW d
REFUSED r
|
GO TO F21 |
(F2=00, d or r)
F13. Since [fill RA MONTH YEAR] {have you/has (NAME)} looked for work?
YES 01
NO 00 (F21)
UNABLE TO WORK n (F21)
DON’T KNOW d (F21)
REFUSED r (F21)
(NBS)
(301)
F14. {Have you/Has (NAME)} been looking for work during the past 4 weeks?
YES 01
NO 00 (F21)
UNABLE TO WORK n (F21)
DON’T KNOW d (F21)
REFUSED r (F21)
(F14=01)
F15. {Are you/Is (NAME)} looking for part-time or full-time work?
PART-TIME 01
FULL-TIME 02
EITHER PART- OR FULL-TIME 03
DON’T KNOW d
REFUSED r
(F14=01)
F16. About how many hours per week would {you/(NAME)} like to work?
PROBE: Your best estimate is fine.
| | | HOURS
(1-60)
DON’T KNOW d
REFUSED r
(F14=01)
F17. {Have/Has} {you/(NAME)} received any job offers since [fill RA MONTH YEAR]?
YES 01
NO 00 (F21)
DON’T KNOW d (F21)
REFUSED r (F21)
(F17=01)
F18. Did {you/(NAME)} turn any of these job offers down?
YES 01
NO 00 (F21)
DON’T KNOW d (F21)
REFUSED r (F21)
(F18=01)
F19a. There are many reasons why people sometimes do not accept a job offer. Please tell me if any of these are reasons why {you/(NAME)} did not accept a job that {you were/(he/she) was} offered.
{You were/(NAME was)} worried {you/he/she} would lose health insurance benefits.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(F18=01)
F19b. {You were/(NAME was)} worried {you/(he/she} would lose benefits {you need/(he/she) needs} like Social Security, disability insurance, or workers’ compensation if {you/he/she} accepted the job.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(F18=01)
F20. Are there any other reasons that I did not mention that made {you/(NAME)} turn down a recent job offer?
YES 01
NO 00 (F21)
DON’T KNOW d (F21)
REFUSED r (F21)
(F20=01)
F20_Other. What were the other reasons {you/(NAME)} did not accept the job offer?
RECORD VERBATIM
<OPEN>
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
F21. There are many ways people find out about how working will affect their benefits. For example, some people call the Social Security office, some search the internet, and others contact disability service organizations. Did {you/(NAME)} contact anyone or do any of these things in order to find out how {your/his/her} benefits would be affected if {you/he/she} went to work?
YES 01
NO 00 (G1)
DON’T KNOW d (G1)
REFUSED r (G1)
(F21=01)
F22. Who did {you/(NAME)} contact or what did {you/he/she} do to find out how {your/his/her} benefits would be affected if {you/he/she} went to work?
CODE ALL THAT APPLY
SOCIAL SECURITY OFFICE 01 (G1)
INTERNET 02 (G1)
EMPLOYMENT BENEFITS COUNSELOR/
AB PLUS COACH 03 (G1)
DISABILITY SERVICE ORGANIZATION 04 (G1)
OTHER 05
DON’T KNOW d (G1)
REFUSED r (G1)
(F22=05)
F22_Other Which organization did {you/(NAME)} contact to find out how {your/his/her} benefits would be affected if {you/he/she} went to work?
RECORD VERBATIM
<OPEN>
DON’T KNOW d
REFUSED r
SECTION G: USE OF SSA AND OTHER EMPLOYMENT SERVICES
(NBS-E20 modified)
(All)
G1. My next questions are about incentives and supports that Social Security offers to people getting disability benefits, to encourage them to work.
Since [fill RA MONTH YEAR], did a person or organization help {you/him/her} understand how working would affect {your/his/her} Social Security benefits?
YES 01
NO 00 (G3)
DON’T KNOW d (G3)
REFUSED r (G3)
(G1=01)
G2. Where did {you/he/she} get help? Was it from . . .
IF NEEDED: A WIPA is a local organization that has arranged with Social Security to provide work incentive and planning services for Social Security SSDI and SSI beneficiaries. This program replaced the former Benefits Planning Assistance and Outreach (BPAO) Program.
CODE ALL THAT APPLY
A Work Incentives Planning and Assistance (WIPA)
project or SSA, 01
An AB Plus coach or employment benefits counselor, or 02
Some other type of place? 03
DON’T KNOW d
REFUSED r
(All)
G3. Since [fill RA MONTH YEAR], {have you/has (NAME)} received rehabilitation and/or employment services?
YES 01
NO 00 (G6)
DON’T KNOW d (G6)
REFUSED r (G6)
(G2=01)
G4. Did {you/he/she} receive rehabilitation or employment services from . . .
a. A Ticket to Work Employment Network? YES..01 NO..00
b. A State Vocational Rehabilitation agency? YES..01 NO..00
c. A State unemployment office? YES..01 NO..00
d. A Center for Independent Living? YES..01 NO..00
e. A Private rehabilitation provider? YES..01 NO..00
f. Or some other type of place? YES..01 NO..00
DON’T KNOW d
REFUSED r
(G3=01)
G5. Which of the following employment services {have you/has (NAME)} received since [fill RA MONTH YEAR]? Did {you/he/she} receive . .
-
code one per row
YES
NO
DON’T KNOW
REFUSED
a. A work or job assessment?
01
00
d
r
b. Help to find a job?
01
00
d
r
c. Training to learn a new job or skill?
01
00
d
r
d. Advice about making modifications or accommodations to {your/(NAME)’s} job or workplace?
01
00
d
r
e. On-the-job training, job coaching, or support services?
01
00
d
r
f. Career counseling?
01
00
d
r
g. Some other employment service?
01
00
d
r
(All)
G8. Since [fill RA MONTH YEAR] {have you/has (NAME)} enrolled in school or taken any classes to help {you/him/her} get a new job or change careers? (IF ANY G5.a-G5.g=01, SAY: “Please do not include any training {you have/(he/she) has} already told me about.”)
PROBE: This could include vocational training in high school, college classes, or other instructional programs.
YES 01
NO 00 (H1)
DON’T KNOW d (H1)
REFUSED r (H1)
(G8=01)
G9. {Are you/Is (NAME)} currently enrolled in school or taking any classes?
YES 01
NO 00
DON’T KNOW d
REFUSED r
SECTION H: FAMILY STATUS AND INCOME
(Asked at Baseline)
H1. We’re almost finished. I just have a few final questions about {your/(NAME’s)} household. How many adults 18 years of age or older live in {your/his/her} household, including {yourself/himself/herself}?
PROBE: This includes all adults who usually live there, even if they are temporarily away on business, on vacation, in a hospital, away at school, or on military duty.
| | | ADULTS
(01-10)
LIVES IN A GROUP HOME 99 (H4)
DON’T KNOW d
REFUSED r
(H1 NE 99)
(Asked at Baseline)
H2. How many children under 18 years of age live in {your/his/her} household?
PROBE: This includes all children who usually live there, even if they are temporarily away on vacation, in a hospital, or away at school.
ZERO/NONE 00 (H2ck)
| | | CHILDREN
(01-10)
DON’T KNOW d (H4)
REFUSED r (H4)
(All)
H2ck. PROGRAMMER: DOES SAMPLE MEMBER LIVE ALONE; THAT IS, H1=01 AND H2=00?
YES 01 (H4)
NO 00
(H2ck=00)
(Asked at Baseline)
H3. Now please think back to last year. How many people in {your/(NAME’s)} household worked at a job for pay last year?
PROBE: That is, (2008/2009).
| | |
(01-10)
ZERO/NONE 00
DON’T KNOW d
REFUSED r
(All)
(Asked at Baseline)
H4. ([IF H3>1, SAY: Counting everyone in {your/(NAME’s)} household who worked for pay last year], what was {your/his/her} total (IF H1 NE 99, SAY: household) income in (2008/2009)? Please include benefits, earnings, and all other sources of income.
Was it . . .
Less than $10,000, 01
$10,000 or more, but less than $20,000, 02
$20,000 or more but less than $30,000, 03
$30,000 or more but less than $40,000, 04
$40,000 or more but less than $50,000, 05
$50,000 or more but less than $75,000, 06
$75,000 or more but less than $100,000, or 07
more than $100,000? 08
DON’T KNOW d
REFUSED r
(All)
H5. Did {you//(NAME)} receive any food stamp benefits during (2008/2009)?
YES 01
NO 00
DON’T KNOW d
REFUSED r
(NSAF)
(All)
H6. Since [fill RA MONTH YEAR] did {you/(NAME) (IF H1>1, SAY: “or other adults in {your/his/her} family”) ever cut the size of {your/his/her} meals or skip meals because there wasn’t enough money for food?
PROBE: Since [fill RA MONTH] of last year.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(NSAF)
(All)
H7. Since [fill RA MONTH YEAR], was there a time when {you/(NAME} (IF H2ck=00, SAY: “and (your/his/her) family”)} were not able to pay {your/his/her} mortgage, rent, or utility bills?
PROBE: Since [fill RA MONTH] of last year.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(NSAF)
(All)
H8. Since [fill RA MONTH YEAR], did {you/(NAME)} (IF H2>0, SAY: “or {your/his/her} children”) move in with other people even for a little while because {you/he/she} could not afford to pay {your/his/her} mortgage, rent, or utility bills?
PROBE: Since [fill RA MONTH] of last year.
YES 01
NO 00
DON’T KNOW d
REFUSED r
(NSAF)
(All)
H9. Since [fill RA MONTH YEAR], has {your/(NAME’s)} household ever been without telephone service for more than 24 hours?
PROBE: Since [fill RA MONTH] of last year.
IF NEEDED: Do not include temporary loss of service due to storms, damaged wires, or phone company maintenance.
YES 01
NO 00
DON’T KNOW d
REFUSED r
SECTION I: CLOSING AND CONTACT INFORMATION
(All)
I1. PROGRAMMER: IF WE HAVE NAME, ADDRESS, AND PHONE NUMBER FROM EITHER THE SCREENER OR FROM THE OTHER PRELOADED INFORMATION DISPLAY THAT NAME, ADDRESS, AND PHONE NUMBER.
That concludes this interview. Please verify {your/(NAME’s)} current contact information. Is {your/his/her} current address and phone number . . . READ FROM PRELOADS?
SAME AS PROVIDED 00 (I2a)
INCORRECT INFORMATION ABOVE, NEED TO
ENTER NEW INFORMATION 01
DON’T KNOW d
REFUSED r
(I1=01, d, or r)
I2. UPDATE INFORMATION BELOW
What is the correct spelling of {your/(NAME’s)} name and {your/his/her} current mailing address and phone number?
PROBE: Is there an apartment number?
NAME (VERIFY SPELLING)
ADDRESS LINE 1
ADDRESS LINE 2
CITY/TOWN
STATE
ZIP CODE
TELEPHONE
DON’T KNOW d
REFUSED r
(All)
I2a. {Do you/Does (NAME)} have a cell phone number?
YES 01
NO 00 (I3)
DON’T KNOW d (I3)
REFUSED r (I3)
(I2a=01)
I2b. What is {your/his/her} cell phone number?
<OPEN>
DON’T KNOW d
REFUSED r
(All)
I3. {Do you have/Does (NAME) have} an email address?
YES 01
NO 00 (I5)
DON’T KNOW d (I5)
REFUSED r (I5)
(I3=01)
I4. What is {your/(NAME’s)} email address?
<OPEN>
DON’T KNOW d
REFUSED r
(All)
I5. INTERVIEWER: ARE YOU SPEAKING WITH (NAME), AN INTERPRETER, OR A PROXY?
NAME 01 (I10)
INTERPRETER 02
PROXY 03
(I5=02 OR 03)
I6. What is the correct spelling of your full name?
INTERVIEWER: PRESS 1 TO CONTINUE
NAME: DISPLAY PROXY’S/INTERPRETER’S FULL NAME FROM SCREENER OR PRELOADED INFORMATION WITH FIRST NAME BOLD
FIRST NAME: <OPEN>
VERIFY SPELLING
DON’T KNOW d
REFUSED r
(I5=02 OR 03)
I7. What is your current mailing address and phone number?
PROGRAMMER: DISPLAY INTERPRETER/PROXY’S FULL ADDRESS IF AVAILABLE
PROGRAMMER: ADD OPTION TO FILL “SAME AS R”
PROBE: Is there an apartment number?
ADDRESS LINE 1
ADDRESS LINE 2
CITY/TOWN
STATE
ZIP CODE
TELEPHONE
DON’T KNOW d
REFUSED r
(I5=02 OR 03)
I7a. Do you have a cell phone number?
YES 01
NO 00 (I8)
DON’T KNOW d (I8)
REFUSED r (I8)
(I7a=01)
I7b. What is your cell phone number?
<OPEN>
DON’T KNOW d
REFUSED r
(I5=02)
I8. Do you have an email address?
YES 01
NO 00 (I10)
DON’T KNOW d (I10)
REFUSED r (I10)
(I8=01)
I9. What is your email address?
<OPEN>
DON’T KNOW d
REFUSED r
I10. We may contact {you/(NAME)} again in the future to see how {you are/(he/she) is} doing and update our information. In case we have trouble reaching {you/him/her}, what is the name, address, and phone number of a close relative or friend who is not living with {you/(NAME)} and is likely to know {your/his/her} location in the future? For example, {your/his/her} mother, father, brother, sister, aunt, uncle, or close friend.
{Do you/Does (NAME)} have a contact person?
-
CONTACT PERSON 1
YES 01
NO 00 (THNX)
DON’T KNOW d (THNX)
REFUSED r (THNX)
(I10=01)
I11. What is that person’s name and address?
PROBE: Is there an apartment number?
NAME
ADDRESS LINE 1
ADDRESS LINE 2
CITY/TOWN
STATE
ZIP CODE
DON’T KNOW d
REFUSED r
(I10=01)
I11a. Please give me the telephone number, area code first.
<OPEN>
DON’T KNOW d
REFUSED r
(I10=01)
I11b. {Do you/Does (NAME)} have a cell phone, pager number or email address for [FILL NAME FROM I11]?
YES 01
NO 00 (I12)
DON’T KNOW d (I12)
REFUSED r (I12)
(I11b=01)
I11c. What is [FILL NAME FROM I11’s] cell phone number? Please give me the number, area code first.
<OPEN>
What is [FILL NAME FROM I11’s] pager number? Please give me the number, area code first.
<OPEN>
What is [FILL NAME FROM I11’s] email address?
<OPEN>
DON’T KNOW d
REFUSED r
(I10=01)
I12. How is [FILL NAME FROM I11] related to {you/(NAME)}, if at all?
(NAME’s) SPOUSE/PARTNER 01
(NAME’s) MOTHER 02
(NAME’s) FATHER 03
(NAME’s) SON OR DAUGHTER 04
GRANDPARENT OF (NAME) 05
BROTHER/SISTER OF (NAME) 06
AUNT/UNCLE OF (NAME) 07
OTHER RELATIVE OF (NAME) 08
NOT RELATED 09
STAFF AT RESIDENCE 10
DON’T KNOW d
REFUSED r
(All)
THNX. That was my last question. Thanks very much for your time. Best wishes to {you/(NAME)}.
| File Type | application/msword |
| File Title | MPR Reference No |
| File Modified | 2008-12-30 |
| File Created | 2008-12-08 |
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