DEMOGRAPHICS (dm)
First, I would like to begin by asking you some questions about yourself.
DM-1. What is your date of birth?
(UCDI)
|__|__| / |__|__| / |__|__|__|__|
DM-2. [INTERVIEWER: CODE GENDER.]
(UCDI)
MALE 1
FEMALE 2
DM-3. Are you of Hispanic, Latino, or Spanish origin?
(Census)
YES 1
NO 2
DM-4. I’m going to read a list of races. {In addition to being Hispanic, please/Please} tell me which best describes your race. Are you…
(Census)
[INTERVIEWER: SELECT ALL THAT APPLY.]
White, 1
Black or African-American, 2
Asian, 3
American Indian or Alaskan Native, or 4
Native Hawaiian or Pacific Islander? 5
MULTIRACIAL 6
HISPANIC/MEXICAN 7
OTHER (SPECIFY)____________ 8
DM-5. What languages do you usually speak?
(UCDI)
English only, 1
Spanish only, 2
Both English and Spanish, 3
Both English and some other language, or 4
Some other language only? (SPECIFY) 5
DM-6. What is your marital status?
(UCDI)
Never married, 1
Married, 2
Living as married, 3
Separated, 4
Divorced, or 5
Widowed? 6
DM-7. What is the highest grade in school that you completed?
(UCDI)
NO FORMAL SCHOOLING 1
SOME ELEMENTARY SCHOOLING 2
COMPLETED 8TH GRADE 3
SOME HIGH SCHOOL 4
COMPLETED HIGH SCHOOL OR GED 5
SOME COLLEGE OR TECHNICAL SCHOOL 6
COMPLETED ASSOCIATE’S DEGREE 7
COMPLETED BACHELOR’S DEGREE 8
SOME GRADUATE SCHOOL 9
COMPLETED MASTER’S DEGREE 10
COMPLETED DOCTORAL DEGREE 11
DM-8. Describe who you have been living with during the past 30 days.
(NEW)
[INTERVIEWER: CODE ALL THAT APPLY.]
LIVING ALONE 1
LIVING WITH SPOUSE ONLY 2
LIVING WITH CHILDREN ONLY 3
LIVING WITH SPOUSE AND CHILDREN 4
LIVING WITH PARENTS 5
LIVING WITH OTHER RELATIVES (OTHER THAN
SPOUSE, CHILDREN, OR PARENTS) 6
LIVING WITH FRIENDS 7
LIVING WITH OTHER NON-RELATED ADULTS
(NOT NECESSARILY FRIENDS) 8
OTHER (SPECIFY) 9
DM-9. Which of following best describes where you have been living during the past 30 days? Would you say…
(NEW)
At one address in an apartment or house, 1
At more than one address in apartments or houses, 2
In a homeless shelter or homeless with no
particular address, or 3 (DM-17)
Some other place? (SPECIFY) 4 (DM-17)
IF RESPONDENT LIVES ALONE, WITH FRIENDS, WITH OTHER NON-RELATED ADULTS, OR IN SOME OTHER PLACE (DM-8 = 1, 7, 8, OR 9), CONTINUE WITH DM-10.
IF RESPONDENT LIVES WITH SPOUSE ONLY (DM-9 = 2), GO TO DM-17.
ELSE, GO TO DM-14.
DM-10. In this place where you live, do you receive visits from a case manager or some other person from a city or state agency?
(NEW)
YES 1
NO 2
DM-11. Are there staff from a mental health agency or other city or state agency who are living at the residence?
(NEW)
YES 1
NO 2
DM-12. Are your meals prepared by residential staff employed by a mental health center or other city or state agency?
(NEW)
YES 1
NO 2
IF RESPONDENT RECEIVES VISITS FROM A CASE MANAGER, STAFF FROM A MENTAL HEALTH AGENCY LIVE AT THE RESIDENCE, OR MEALS ARE PREPARED BY STAFF (DM-10 = 1 OR DM-11 = 1 OR DM-12 = 1), CONTINUE WITH DM-13. OTHERWISE, GO TO BOX DM-1.
DM-13. Are there other people living in the apartment or house who receive help from the same agency as you?
(NEW)
YES 1
NO 2
BOX DM-1
IF RESPONDENT LIVES ALONE (DM-8 = 1), THEN GO TO DM-17.
DM-14. How many adults age 18 or over lived with you for most of the past 30 days?
(NEW)
|__|__| ADULTS
IF NO ADULTS LIVE WITH RESPONDENT (DM-14 = 0), THEN GO TO DM-16.
DM-15. Of these adults, how many are dependent on you for support?
(NEW)
|__|__| DEPENDENT ADULTS
DM-16. How many children under the age of 18 lived with you for most of the past 30 days?
(NEW)
|__|__| CHILDREN
DM-17. In the past three months, how many days have you been…
(OCAM)
Living in a shelter or on the street? |__|__|
In jail or a correctional facility? |__|__|
WORK history AND INCOME (WI)
A. WORK HISTORY
Now I’d like to ask you some questions about your work history.
WI-1. Have you ever worked at a job or business for pay?
(NSHA)
YES 1
NO 2 (WI-22)
WI-2. Have you worked at a job or business for pay in the past 2 years?
(NSHA)
YES 1
NO 2 (WI-22)
WI-3. Are you currently working at a job or business for pay?
(NSHA)
YES 1
NO 2
Now, I am going to ask some questions about your work history in the past 2 years starting with your {current/ most recent} job. If you {have/had} more than one job, tell me about the main job first. Also, if you have held more than one position within the same company, you should tell me about those positions as separate jobs. You should include part-time and full-time jobs, but only include jobs or positions you have held for pay.
ASK WI-4 TO WI-14 FOR EACH JOB HELD IN PAST TWO YEARS.
WI-4. What {is/was} your job title?/ What job did you do before that?
(NSHA)
NAME OF JOB/JOB TITLE
WI-5. What month and year did you begin that job?
(EIR)
|__|__| / |__|__|__|__|
MONTH YEAR
WI-6. What month and year did that job end?
(EIR)
|__|__| / |__|__|__|__|
MONTH YEAR
CURRENT JOB 99
WI-7. Is it possible that you {are/were} paid a piece rate? That is, your pay {is/was} not based on an hourly rate but on the number of items that you {produce/produced}?
(NEW)
YES 1 (WI-9)
NO 2
WI-8. What {is/was} your hourly wage?
(NEW)
$|___|___|___|.|__|__| HOURLY WAGE
WI-9. Now I want to know who {writes/wrote} your paycheck or {pays/paid} your wages. Which of the following best describes who {writes/wrote} your paycheck or {pays/paid} your wages for this job? Would you say…
(NEW)
The employer, 1
A mental health or rehabilitation agency, or 2
Someone else? (SPECIFY) 3
WI-10. Is any person who {supervises/supervised} your work an employee of a mental health or rehabilitation agency?
(NEW)
YES 1
NO 2
WI-11. Is this job reserved only for people who get services from a mental health or rehabilitation agency?
(NEW)
YES 1 (WI-13)
NO 2
WI-12. So this job could have been taken by anybody who applied for it and was qualified, including someone who does not have a disability?
(NEW)
YES 1
NO 2
WI-13. {Does/Did} this job have a time limit to it? That is, {is/was} it only temporary?
(NEW)
YES 1
NO 2 (NEXT JOB OR BOX WI-1)
WI-14. Describe what is meant by it being “time limited.” {Is/Was} this a seasonal job or a transitional job of some kind?
(NEW)
SEASONAL JOB 1
TRANSITIONAL JOB 2
OTHER JOB (SPECIFY) 3
BOX WI-1
ASK INTRO TO WI-15 TO WI-21 ABOUT THE MOST RECENT OR CURRENT JOB HELD AND THE LONGEST JOB HELD. ASK ABOUT MOST RECENT OR CURRENT JOB FIRST AND THEN ASK ABOUT THE LONGEST JOB.
Now, I am going to ask you some additional questions about your job(s). You said you {work/worked} {as (a/an) (JOB TITLE IN WI-4)} from {MONTH AND YEAR STARTED IN WI-5} to {MONTH AND YEAR STOPPED IN WI-6/the present}.
WI-15. {Are/Were} you self-employed?
(NSHA)
YES 1
NO 2
WI-16. How many hours per day {do/did} you usually work at this job?
(NSHA)
|__|__| HOURS
WI-17. How many days per week {do/did} you usually work at this job?
(NSHA)
|__| DAYS
WI-18. How many weeks per month {do/did} you usually work at this job?
(NSHA)
|__| WEEKS
WI-19. How many months per year {do/did} you usually work at this job?
(NSHA)
|__|__| MONTHS
WI-20. About how much {do/did} you earn at this job?
(NSHA)
$|___|___|___|___|___|___|___| |__|__| UNIT1
WI-21. Is that before taxes and other deductions {are/were} taken out or after taxes and other deductions {are/were} taken out?
(NEW)
BEFORE TAXES 1
AFTER TAXES 2
WI-22. Have you worked at a volunteer job in the past month?
(EIR)
YES 1
NO 2
IF RESPONDENT IS CURRENTLY WORKING (WI-3 = 1) THEN GO TO WI-24.
WI-23. Which of the following best describes your current work status? Would you say…
(EIR)
Have a job but currently not at work (for instance on
a leave of absence or suspended), 1
Looking for work, 2
Keeping house or caregiving, 3
Going to school, 4
Doing volunteer work, 5
In vocational training, 6
Unable to work, or 7
Something else? (SPECIFY) 8
B. CURRENT INCOME SOURCES
WI-24. Please tell me how much money you received from the following sources during the past month. Remember, everything you tell me is strictly confidential.
(EIR-Mod)
a. Any earned income or money from all paid employment,
including tips or commissions. Please tell me the take
home amount $|__|__|,|__|__|__|.|__|__|
b. Social Security Disability Income $|__|__|,|__|__|__|.|__|__|
c. Social Security Retirement or Survivors Benefits $|__|__|,|__|__|__|.|__|__|
d. Supplemental Security Income (SSI) $|__|__|,|__|__|__|.|__|__|
f. VA or other armed services disability benefits $|__|__|,|__|__|__|.|__|__|
g. Other state or county social welfare benefits such as
general assistance or public aid $|__|__|,|__|__|__|.|__|__|
h. Food stamps or assistance from the Temporary
Assistance for Needy Families (TANF) program $|__|__|,|__|__|__|.|__|__|
i. Vocational program such as Vocational Rehabilitation,
the Job Training Partnership Act, or Easter Seal $|__|__|,|__|__|__|.|__|__|
j. Unemployment compensation $|__|__|,|__|__|__|.|__|__|
k. Retirement, pension (including military), investing, or
savings income that you receive regular payments
from $|__|__|,|__|__|__|.|__|__|
l. Alimony and child support $|__|__|,|__|__|__|.|__|__|
m. Money from family members including gifts, loans,
or bill payments $|__|__|,|__|__|__|.|__|__|
WI-25. Sometimes people’s income is increased through other sources that are not reported to the government. The kinds of things I’m referring to include money received by doing odd jobs such as babysitting or yard work, helping in a business, or doing work “under the table.” Did you receive any income this way last month that you have not already told me about? Remember, what you tell me is strictly confidential. I cannot share this information with anyone, no matter what the reason.
(EIR-Mod)
YES 1
NO 2 (BOX WI-2)
WI-26. How much did you receive that you have not already told me about?
(EIR-Mod)
$|__|__|,|__|__|__|.|__|__|
BOX WI-2
IF RESPONDENT LIVES WITH OTHER ADULTS IN A NON-SUPERVISED SETTING
{(DM-8 = 2, 3, 4, 5, OR 6) OR [(DM-8 = 7 OR 8) AND DM-11 = 2 AND DM-12 = 2 AND DM-13 = 2]},
THEN ASK WI-27. OTHERWISE, GO TO NEXT SECTION.
WI-27. About how much was your total household income last month? Household income means the total amount of money that everyone in your household, except yourself, received during the past month.
(EIR-Mod)
$|__|__|,|__|__|__|.|__|__|
HEALTH STATUS (HS)
The next few questions ask about your health and how well you are able to do your usual activities. First I will ask about your health now. Please try to answer the question as accurately as you can.
HS-1. In general, would you say your health is…
(SF-12)
Excellent, 1
Very good, 2
Good, 3
Fair, or 4
Poor? 5
Now, I’m going to ask about activities that you might do during a typical day. As I read each item, please tell me if your health now limits you a lot, limits you a little, or does not limit you at all in these activities.
HS-2. Does your health now limit you in moderate activities such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? Does it limit you…
(SF-12)
A lot, 1
A little, or 2
Not at all? 3
HS-3. Does your health now limit you in climbing several flights of stairs? Does it limit you…
(SF-12)
A lot, 1
A little, or 2
Not at all? 3
The next two questions ask about your physical health and your daily activities.
HS-4. During the past 4 weeks, how much of the time have you accomplished less than you would have liked to as a result of your physical health? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
HS-5. During the past 4 weeks, how much of the time were you limited in the kind of work or other regular daily activities you do as a result of your physical health? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
Now I will ask about any emotional problems and your daily activities.
HS-6. During the past 4 weeks, how much of the time have you accomplished less than you would have liked to as a result of any emotional problems, such as feeling depressed or anxious? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
HS-7. During the past 4 weeks, how much of the time did you not do work or other activities as carefully as usual as a result of any emotional problems, such as feeling depressed or anxious? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
HS-8. During the past 4 weeks, how much did pain interfere with your normal work, including both work outside the home and housework? Did it interfere.
(SF-12)
Not at all, 1
A little bit, 2
Moderately, 3
Quite a bit, or 4
Extremely? 5
These next questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give me the one answer that comes closest to the way you have been feeling.
HS-9. During the past 4 weeks, how much of the time have you felt calm and peaceful? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
HS-10. During the past 4 weeks, how much of the time did you have a lot of energy? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
HS-11. During the past 4 weeks, how much of the time have you felt downhearted and depressed? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
HS-12. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities, like visiting with friends or relatives? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
ALCOHOL AND SUBSTANCE USE (AS)
The next set of questions are about how frequently you drink alcoholic beverages or use drugs. Remember that your answers are strictly confidential.
ASK AS-2 THROUGH AS-5 IMMEDIATELY AFTER A ‘YES’ RESPONSE FOR EACH SUB-ITEM IN
AS-1. (EXAMPLE: ASK AS-1A. IF ‘YES’ THEN ASK AS-2A, AS-3A, ETC. GO BACK TO AS-1B AND IF ‘YES’ THEN ASK AS-2B, AS-3B, ETC.)
AS-1. Have you ever used {INSERT SUBSTANCE}?
(ASI)
YES NO
a. Any alcohol at all? 1 2
b. Alcohol to the point where you felt the effects of it,
for example you felt like you got “a buzz,” were
“high,” or drunk? 1 2
c. Marijuana? (This includes pot, reefer, hashish,
cannabis.) 1 2
d. Heroin? (This includes smack, horse, tar.) 1 2
e. Non-prescription methadone? (This includes
Dolophine and LAAM.) 1 2
f. Other opiates or analgesics? (This includes morphine,
dreamer junk, Demerol, Darvon, Darvocet, Codeine,
school boy, Percodan, Dilaudid, Talwin, OxyContin.) 1 2
g. Barbiturates? (This includes Seconal, reds, red
devis, Nembutal, Tuninal or rainbows, phenobarbital
yellow jackets, purple hearts.) 1 2
h. Sedatives, benzodiazepines, tranquilizers, or
hypnotics? (This includes Valium, Librium, Xanax,
Halcion, Klonipin.) 1 2
i. Cocaine, crack, or coca leaves? 1 2
j. Methamphetamines, amphetamines, or stimulants?
(This includes Ecstasy, uppers, bennies, meth, speed,
speedball, dexies, pep pill, crank, crystal, monster
pep pill, black beauties, ice, batu.) 1 2
Hallucinogens? (This includes LSD, acid, purple
haze, mescaline, mesc, cactus, PCP, angel dust,
mushrooms, peyote.) 1 2
l. Inhalants? (This includes nitrous oxide, whippets, glue,
amyl nitrate, mush, lockerroom, poppers, snappers,
gasoline, paint, nail polish remover.) 1 2
m. More than one substance per day, including
alcohol? 1 2
IF RESPONDENT HAS NEVER USED ANY SUBSTANCE (ALL AS-1 = 2), THEN GO TO AS-25.
AS-2. How many years of your life have you regularly used {INSERT SUBSTANCE}?
(ASI)
[INTERVIEWER: PROBE IF NECESSARY: “By regularly, I mean three or more times per week.”]
|__|__| YEARS
AS-3. In the past 30 days, how many days have you used {INSERT SUBSTANCE}?
(ASI)
|__|__| DAYS
ONLY ASK AS-4 AND AS-5 FOR MARIJUANA (AS-1C = 1); OTHER OPIATES OR ANALGESICS
(AS-1F = 1); BARBITURATES (AS-1G = 1); SEDATIVES, TRANQUILIZERS, OR HYPNOTICS
(AS-1H = 1); AND METHAMPHETAMINES, AMPHETAMINES, OR STIMULANTS (AS-1J = 1).
AS-4. Was this prescribed for you?
(ASI)
YES 1
NO 2 (NEXT ITEM IN AS-1 OR AS-6)
AS-5. How many days in the past 30 did you take at least one extra dose of {INSERT SUBSTANCE}?
(ASI)
|__|__| DAYS
AS-6. Out of all the drugs I just mentioned, which substance is the major problem for you?
(ASI)
NO MAJOR PROBLEM 0
ALCOHOL 1
MARIJUANA 2
HEROIN 3
METHADONE 4
OTHER OPIATES/ANALGESICS 5
BARBITUATES 6
SEDATIVES/BENZODIAZEPINES/HYPNOTICS/
TRANQUILIZERS 7
COCAINE/CRACK 8
METHAMPHETAMINES/AMPHETAMINES/
STIMULANTS 9
HALLUCINOGENS 10
INHALANTS 11
MAJOR PROBLEM WITH ALCOHOL AND ONE
OR MORE DRUGS (SPECIFY ) 12
MAJOR PROBLEM WITH MORE THAN ONE
DRUG (SPECIFY) 13
IF NO MAJOR ALCOHOL OR SUBSTANCE ABUSE PROBLEM (AS-6 = 0),
THEN GO TO AS-9.
AS-7. How long was your last period of voluntary abstinence from this major substance?
(ASI)
[INTERVIEWER: PROBE IF NECESSARY: “Have you ever stopped using this substance for over a month? When was the last time you stopped using this substance for over a month? Did you stay clean on your own, or were you in some sort of a controlled environment at the time? How long did that period of abstinence last?”
[INTERVIEWER: CODE ‘00’ IF RESPONDENT HAS NEVER BEEN ABSTINENT.]
|__|__| NUMBER
MONTHS 1
YEARS 2
AS-8. How many months ago did this abstinence end?
(ASI)
[INTERVIEWER: CODE ‘00’ IF RESPONDENT IS STILL ABSTINENT.]
|__|__| NUMBER
MONTHS 1
YEARS 2
AS-9. In the past 30 days have you injected drugs?
(ASI)
YES 1
NO 2
AS-10. How many times have you had alcohol DT’s?
(ASI)
[INTERVIEWER: STATE IF NECESSARY: “DT’s occur 24 to 48 hours after a person’s last drink. They consist of tremors or shaking and delirium or severe disorientation. They are often accompanied by fever. There are sometimes, but not always, hallucinations. True DT’s are usually so severe that they require some type of medical care or outside intervention.”]
|__|__| NUMBER OF TIMES
AS-11. How many times have you overdosed on drugs?
(ASI)
|__|__| NUMBER OF TIMES
AS-12. How many times in your life have you been treated for alcohol abuse?
(ASI)
|__|__| NUMBER OF TIMES
AS-13. How many of those treatments involved a detox with no follow-up?
(ASI)
|__|__| NUMBER OF DETOX TREATMENTS
AS-14. How many times in your life have you been treated for drug abuse?
(ASI)
|__|__| NUMBER OF TIMES
AS-15. How many of those treatments involved a detox with no follow-up?
(ASI)
|__|__| NUMBER OF DETOX TREATMENTS
AS-16. How much have you spent on alcohol in the past 30 days?
(ASI)
$|__|__|__|__| . |__|__|
AS-17. How much have you spent on drugs in the past 30 days?
(ASI)
$|__|__|__|__| . |__|__|
AS-18. How many days in the past 30 days have you been treated in an outpatient setting or attended self-help groups like AA or NA?
(ASI)
|__|__| NUMBER OF DAYS
AS-19. How many days in the past 30 days have you experienced alcohol problems?
(ASI)
|__|__| NUMBER OF DAYS
AS-20. How many days in the past 30 days have you experienced drug problems?
(ASI)
|__|__| NUMBER OF DAYS
AS-21. How troubled or bothered have you been in the past 30 days by alcohol problems? Would you say…
(ASI)
Not at all, 1
Slightly, 2
Moderately, 3
Considerably, or 4
Extremely? 5
AS-22. How troubled or bothered have you been in the past 30 days by drug problems? Would you say…
(ASI)
Not at all, 1
Slightly, 2
Moderately, 3
Considerably, or 4
Extremely? 5
AS-23. How important to you now is treatment for these alcohol problems? Would you say…
(ASI)
Not at all, 1
Slightly, 2
Moderately, 3
Considerably, or 4
Extremely? 5
AS-24. How important to you now is treatment for these drug problems? Would you say…
(ASI)
Not at all, 1
Slightly, 2
Moderately, 3
Considerably, or 4
Extremely? 5
AS-25. [INTERVIEWER: IS THE INFORMATION COLLECTED ON ALCOHOL AND DRUG USE SIGNIFICANTLY DISTORTED BY THE RESPONDENT’S MISREPRESENTATION?]
(ASI)
YES 1
NO 2
AS-26. [INTERVIEWER: IS THE INFORMATION COLLECTED ON ALCOHOL AND DRUG USE SIGNIFICANTLY DISTORTED BY THE RESPONDENT’S INABILITY TO UNDERSTAND THE QUESTIONS?]
(ASI)
YES 1
NO 2
ATTITUDES TOWARD WORK (AT)
AT-1. Would you like to have a {different} paying job now in the community?
(IPS)
YES 1
NO 2
AT-2. What job would you like to have? Any others?
(IPS)
[INTERVIEWER: Probe for type of job to get a good understanding of what it is the respondent actually wants to do. Setting and job description would be important information. For example, street musician may be very different from a concert pianist.]
[INTERVIEWER: Record up to three job preferences.]
FIRST JOB PREFERENCE
SECOND JOB PREFERENCE
THIRD JOB PREFERENCE
AT-3. How many hours a week would you like to work?
(IPS)
|__|__| HOURS
AT-4. How many days a week would you like to work?
(IPS)
|__| DAYS
AT-5. How much would you like to be paid an hour?
(IPS)
$|__|__|__| . |__|__| HOURLY WAGE
I’d like to ask you a few questions about your basic understanding of Social Security benefits.
AT-6. Fear of losing benefits is common among most beneficiaries. Please tell me whether you agree or disagree with these statements about Social Security benefits.
(EIDP)
DISAGREE NOT SURE AGREE
a. As soon as people start working they stop getting their benefit checks. 1 2 3
b. I can make more money just collecting my benefit checks than I can if
I go to work while on benefits. 1 2 3
c. I can make money at a job and still collect my benefit checks. 1 2 3
d. As soon as people start working they lose their medical coverage. 1 2 3
e. Unless a job offers coverage of mental health and prescriptions, I can’t
afford to take it. 1 2 3
f. If I go to work, get off of benefits and get sick right away, I’ll have a hard
time getting back on benefits. 1 2 3
g. I can’t afford to get training to help me get a better job. 1 2 3
h. If I knew that I wouldn’t lose all of my benefits, I would try to get a job
or get a better job. 1 2 3
HEALTH CARE COVERAGE AND SERVICE UTILIZATION (HC)
A. HEALTH CARE COVERAGE
Now I’d like to ask you some questions about health insurance.
HC-1. Do you have health insurance coverage now?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “For instance, are you covered by a plan that someone else in your family has, or through a health plan your employer provides, or Medicare, Medicaid, or a plan you bought on your own?”]
YES 1 (HC-3)
NO 2
HC-2. So, you are uninsured, is that correct?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “This means no Medicaid coverage or any other government sponsored health insurance coverage.”]
YES 1 (HC-15)
NO 2
HC-3. Are you covered by Medicare?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “Medicare is the health insurance plan for people 65 and older or for people with certain disabilities.”]
YES 1
NO 2 (HC-7)
HC-4. Are you enrolled in Part B of Medicare which provides coverage for doctor and clinic visits, laboratories, and other nonhospital services?
(HCC)
YES 1
NO 2
HC-5. Are you enrolled in Part D of Medicare which provides coverage for prescription medications?
(HCC)
YES 1
NO 2
HC-6. Are you covered by Medicare supplemental insurance or Medigap?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “These policies are designed to cover the costs of health care that are not covered by Medicare.”]
YES 1
NO 2
HC-7. Are you covered by any private health insurance plan (excluding Medigap plans), such as health insurance that you obtain through an employer, through COBRA, through a family member, or buy personally?
(NSHA-Mod)
YES,EMPLOYER 1
YES, COBRA OR BOUGHT PERSONALLY 2
YES, THROUGH A FAMILY MEMBER 3
YES, SOME OTHER PRIVATE
SOURCE (SPECIFY) 4
NO 5 (HC-9)
HC-8. Does this plan pay for some part of your prescription medications?
(NSHA)
YES 1
NO 2
HC-9. Are you covered by {Medicaid/INSERT STATE NAME}?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “{Medicaid/INSERT STATE NAME} is the government assistance program that helps pay for health care.”]
YES 1
NO 2
HC-10. Are you covered by {SCHIP/INSERT STATE SCHIP PROGRAM}?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “{SCHIP/INSERT STATE SCHIP PROGRAM } is the government assistance program for children and sometimes for their parents that helps pay for health care.”]
YES 1
NO 2
HC-11. Are you covered by a military health insurance plan such as CHAMPUS, CHAMP-VA, or TRICARE?
(HCC)
YES 1
NO 2
HC-12. Do you have state, county or any other government health insurance coverage through some other source that I have not mentioned?
(HCC)
YES (SPECIFY) 1
NO 2 (HC-14)
HC-13. Does this plan pay for some part of your prescription medications?
(HCC)
YES 1
NO 2
HC-14. Do you receive medications or get help in paying for medications from any other programs?
(NEW)
[INTERVIEWER: PROBE IF NECESSARY: “Programs such as State Pharmacy Assistance Program, Pharmaceutical Companies.”]
YES (SPECIFY) 1
NO 2
HC-15. Do you get free or subsidized health care services directly from any other program?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “Programs such as State and local government programs, VA, Indian Health Service (IHS), or another program I have not mentioned.”]
YES (SPECIFY) 1
NO 2 (BOX HC-1)
HC-16. Does this program also provide prescription medications?
(HCC)
YES 1
NO 2
BOX HC-1
IF RESPONDENT IS UNINSURED (HC-2 = 1), THEN CONTINUE WITH HC-17.
OTHERWISE, GO TO HC-19.
HC-17. In the past, have you ever had health insurance?
(HCC)
YES 1
NO 2 (HC-19)
HC-18. When did your health insurance under this plan end? Would you say…
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “When did you become uninsured?”]
Within the past six months, 1
Within the past year, 2
Within the past 2 years, 3
With in the past 5 years, or 4
More than 5 years ago? 5
B. HEALTH CARE SERVICE UTILIZATION
HC-19. During the past 6 months, did you receive any care in an emergency room?
(HCC)
YES 1
NO 2 (HC-27)
HC-20. How many times in the past 6 months did you go to an emergency room?
(HCC)
|__|__| TIMES
I would like to get more information about your emergency room visits. Let’s begin with the most recent time you visited an emergency room and work backwards over the past 6 months.
ASK HC-21 TO HC-26 ABOUT EACH EMERGENCY ROOM VISIT IN PAST SIX MONTHS.
HC-21. When did you go?/When did you go before that?
(HCC)
|__|__| - |__|__|__|__|
MONTH YEAR
HC-22. Where did you go?
(HCC)
NAME OF EMERGENCY ROOM
HC-23. There may be more than one reason for this visit. Please tell us all the reasons for this visit. Was it for a…
(HCC)
YES NO
a. Physical problem? 1 2
b. Mental health problem? 1 2
c. Alcohol problem? 1 2
d. Drug problem? 1 2
e. Some other problem? (SPECIFY) 1 2
HC-24. Were you admitted to the hospital following this emergency room visit?
(HCC)
YES 1
NO 2 (NEXT VISIT OR HC-27)
HC-25. There may be more than one reason why you were admitted to the hospital following this emergency room visit. Please tell us all the reasons for this admission into the hospital. Was it for a…
(HCC-Mod)
YES NO
a. Physical problem? 1 2
b. Mental health problem? 1 2
c. Alcohol problem? 1 2
d. Drug problem? 1 2
e. Some other problem? (SPECIFY) 1 2
HC-26. How many nights did you stay in the hospital?
(HCC)
|__|__| NIGHTS
HC-27. During the past 12 months, have you stayed overnight in a hospital other than the ones you mentioned in the previous questions?
(HCC)
YES 1
NO 2 (HC-33)
HC-28. How many times in the past 12 months, that is since {INSERT MONTH AND YEAR FROM 12 MONTHS AGO}, were you admitted to a hospital other than the times you mentioned earlier?
(HCC)
|__|__| TIMES
I’d like to get more information about your hospital stays over the past 12 months other than the ones you mentioned earlier. Let’s begin with the most recent time you were in the hospital and work backwards over the past year.
ASK HC-29 TO HC-32 ABOUT EACH HOSPITAL VISIT IN PAST 12 MONTHS.
HC-29. When did you stay in the hospital?/When did you stay before that?
(HCC)
|__|__| - |__|__|__|__|
MONTH YEAR
HC-30. Where did you stay?
(HCC)
NAME OF HOSPITAL
HC-31. There may be more than one reason for this hospital stay. Please tell us all the reasons for your admission. Was it for a…
(HCC)
YES NO
a. Physical problem? 1 2
b. Mental health problem? 1 2
c. Alcohol problem? 1 2
d. Drug problem? 1 2
e. Some other problem? (SPECIFY) 1 2
HC-32. How many nights did you stay in the hospital?
(HCC)
|__|__| NIGHTS
HC-33. Other than a hospital or emergency room, did you receive help for a psychiatric emergency or crisis from some other source in the past 6 months? This includes help from a mobile treatment or outreach team, crisis center, psychiatric stabilization program, peer crisis support, or other program providing psychiatric crisis care.
(HCC-Mod)
YES 1
NO 2 (HC-39)
ASK HC-34 TO HC-38 ABOUT EACH PSYCHIATRIC EMERGENCY CENTER VISIT
IN PAST 6 MONTHS.
HC-34. Where did you go?/Where did you go before that?
(HCC)
NAME OF PSYCHIATRIC EMERGENCY CENTER
HC-35. How many times in the past 6 months did you receive services at this particular place?
(HCC)
|__|__| TIMES
HC-36. When you went to {INSERT NAME OF PSYCHIATRIC EMERGENCY CENTER} who did you see? Anyone else?
(NEW)
PROVIDER 1
PROVIDER 2
PROVIDER 3
ASK HC-37 AND HC-38 ABOUT EACH PROVIDER NAMED IN HC-36.
HC-37. How many times in the past 6 months did you see {INSERT NAME OF PROVIDER IN HC-36}?
(HCC)
|__|__| TIMES
HC-38. Did {INSERT NAME OF PROVIDER IN HC-36}…
(HCC)
YES NO
a. Write a prescription for you or consult with you on
medication? 1 2
b. Provide you with some kind of mental health
counseling? 1 2
c. Provide you with some kind of vocational
counseling? 1 2
d. Provide you with some kind of spiritual or religious
guidance? 1 2
e. Provide you with some kind of peer support? 1 2
HC-39. Other than your hospital stays or emergency room visits, did you go to another clinic or mental health provider during the past 3 months?
(HCC)
YES 1
NO 2 (HC-46)
I’d like to know more about these visits. Let’s begin with the most recent time you went to another clinic or mental health provider and work backwards over the past 3 months.
ASK HC-40 TO HC-45 ABOUT EACH CLINIC OR
MENTAL HEALTH PROVIDER VISIT IN PAST 3 MONTHS.
HC-40. Where did you go?/Where did you go before that?
(HCC)
NAME OF CLINIC OR MENTAL HEALTH PROVIDER
HC-41. Please tell us all the reasons for your visit. Was it for a…
(HCC)
YES NO
a. Physical problem? 1 2
b. Mental health problem? 1 2
c. Alcohol problem? 1 2
d. Drug problem? 1 2
e. Some other problem? (SPECIFY) 1 2
HC-42. How many times in the past 3 months did you receive services at this particular place?
(HCC)
|__|__| TIMES
HC-43. When you went to {INSERT NAME OF CLINIC OR MENTAL HEALTH PROVIDER} who did you see? Anyone else?
(NEW)
PROVIDER 1
PROVIDER 2
PROVIDER 3
ASK HC-44 AND HC-45 ABOUT EACH PROVIDER NAMED IN HC-43.
HC-44. How many times in the past 3 months did you see {INSERT NAME OF PROVIDER IN HC-43}?
(HCC)
|__|__| TIMES
HC-45. Did {INSERT NAME OF PROVIDER IN HC-43}…
(HCC)
YES NO
a. Write a prescription for you or consult with you on
medication? 1 2
b. Provide you with some kind of mental health
counseling? 1 2
c. Provide you with some kind of vocational
counseling? 1 2
d. Provide you with some kind of spiritual or religious
guidance? 1 2
e. Provide you with some kind of peer support? 1 2
HC-46. Are you currently taking any prescription medications for an emotional or mental problem, or a problem with your nerves?
(PORT/NSHA-Mod)
YES 1
NO 2 (NEXT SECTION)
HC-47. What are the names of each of the prescription medicines that you are taking for an emotional or mental problem or a problem with your nerves? Any others?
(PORT/NSHA-Mod)
MEDICATION 1
MEDICATION 2
MEDICATION 3
MEDICATION 4
QUALITY OF LIFE (QL)
This is called the Delighted-Terrible Scale. The scale goes from terrible, which has the lowest ranking of 1, to delighted, which has the highest ranking of 7. There are also points 2 through 6 with descriptions below them.
[INTERVIEWER: Read points on the scale.]
We’ll use this scale to help you tell me how you feel about different things in your life. All you have to do is point to the label on the scale that best describes how you feel. For example, if I ask “how do you feel about chocolate ice cream” and you are someone who loves chocolate ice cream, you might point to ‘delighted.’ On the other hand, if you hate chocolate ice cream, you might point to ‘terrible.’ If you feel equally satisfied and dissatisfied with chocolate ice cream, then you would point to the middle of the scale.
Let’s begin. The first question is a very general one.
QL-1. How do you feel about your life in general?
(QOLI-M)
TERRIBLE 1
UNHAPPY 2
MOSTLY DISSATISFIED 3
MIXED 4
MOSTLY SATISFIED 5
PLEASED 6
DELIGHTED 7
Now I want to ask about the vocational services you are getting.
QL-2. How do you feel about the vocational services you were getting before enrolling in this study?
(QOLI-M)
TERRIBLE 1
UNHAPPY 2
MOSTLY DISSATISFIED 3
MIXED 4
MOSTLY SATISFIED 5
PLEASED 6
DELIGHTED 7
1 UNIT
EVERY HOUR 10
EVERY DAY 11
EVERY WEEK 12
EVERY TWO WEEKS 13
TWICE A MONTH 14
EVERY MONTH 15
EVERY QUARTER 16
EVERY YEAR 17
OTHER (SPECIFY) 88
MHTS BASELINE QUESTIONNAIRE Page
| File Type | application/msword |
| File Title | HE1 |
| Author | Beckey Downes |
| Last Modified By | 177717 |
| File Modified | 2009-03-18 |
| File Created | 2009-03-18 |