Quarterly -- Control Group

CONTROL GROUP QUARTERLY INTERVIEW QUESTIONNAIRE (CQ)

A. BENEFICIARY CONTACT INFORMATION

CQ-1. Are you still at {INSERT CURRENT ADDRESS ON FILE}?

(NEW)

YES 1 (CQ-3)

NO 2

CQ-2. What is your current address?

(NEW)

STREET ADDRESS

CITY

STATE

ZIP CODE

CQ-3. Is there another telephone number where we can reach you?

(NEW)

YES 1

NO 2 (CQ-5)

CQ-4. What is that number?

(NEW)

|__|__|__| - |__|__|__| - |__|__|__|__|

TELEPHONE NUMBER

CQ-5. Are you planning to move in the next 3 months?

(NEW)

YES 1

NO 2 (CQ-10)

CQ-6. What will your new address be?

(NEW)

STREET ADDRESS

CITY

STATE

ZIP CODE

CQ-7. When will you move to this new address?

(EIR)

|__|__| / |__|__| / |__|__|__|__|

MONTH DAY YEAR

CQ-8. Will you keep the same telephone number?

(NEW)

YES 1 (CQ-10)

NO 2

CQ-9. What will your new telephone number be?

(NEW)

|__|__|__| - |__|__|__| - |__|__|__|__|

TELEPHONE NUMBER

B. EMPLOYMENT OUTCOMES

Now I’d like to ask you some questions about your work experience {in the past 3 months/since the last time we talked}. That would be the time period from {INSERT MONTH AND YEAR FROM THREE MONTHS AGO/INSERT DATE FROM LAST INTERVIEW} to today.

CQ-10. Have you had a job {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}?

(NEW)

YES 1 (CQ-12)

NO 2

CQ-11. Have you filled out a job application or spoken with a prospective employer {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}?

(IPS)

YES 1

NO 2

GO TO CQ-35.

CQ-12. How many jobs have you had {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}? Please count all jobs you have held for pay. Remember that all of your responses are strictly confidential.

(NEW)

|__|__| NUMBER OF JOBS

CQ-13. 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 any and all jobs you’ve held for pay {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} 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. Again, remember that I am interested in all of the jobs you’ve had {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}, and I cannot share this information with SSA under any circumstances.

ASK CQ-14 TO CQ-25 FOR EACH JOB HELD IN PAST THREE MONTHS.

CQ-14. What {is/was} your job title?/ What job did you do before that?

(NSHA)

[INTERVIEWER: USE THE SOC CODES LISTED BELOW TO CODE RESPONDENT’S MAIN JOB.]

NAME OF JOB/JOB TITLE

CQ-15. What {do/did} you do on the job?

(NSHA)

[INTERVIEWER: PROBE IF NECESSARY: “What {is/was} your job description? What {are/were} your job responsibilities?]

[INTERVIEWER: USE THE SOC CODES LISTED BELOW TO CODE RESPONDENT’S MAIN JOB.]

JOB DUTIES

CQ-16. What month and year did you begin that job?

(EIR)

|__|__| / |__|__|__|__|

MONTH YEAR

CQ-17. What month and year did that job end?

(EIR)

|__|__| / |__|__|__|__|

MONTH YEAR

CURRENT JOB 99

CQ-18. 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 times that you {produce/produced}?

(NEW)

YES 1 (CQ-20)

NO 2

CQ-19. What {is/was} your hourly wage?

(NEW)

$|___|___|___|.|__|__| HOURLY WAGE

CQ-20. 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

CQ-21. {Is/Was} any person who {supervises/supervised} your work an employee of a mental health or rehabilitation agency?

(NEW)

YES 1

NO 2

CQ-22. {Is/Was} this job reserved only for people who get services from a mental health or rehabilitation agency?

(NEW)

YES 1 (CQ-24)

NO 2

CQ-23. 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

CQ-24. {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 CQ-26)

CQ-25. 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

CQ-26. What was your main job {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}? Your main job is the job at which you worked the longest or worked the most hours.

(NEW)

[INTERVIEWER: SELECT THE MAIN JOB FROM LIST OF ALL JOBS IN PAST 3 MONTHS.]

NAME OF MAIN JOB/JOB TITLE

Now, I am going to ask you some additional questions about your main job, that is your job as (a/an) {INSERT JOB TITLE FROM CQ-26}.

CQ-27. How many hours per day {do/did} you usually work as (a/an) {INSERT JOB TITLE FROM CQ-26}?

(NSHA-Mod)

|__|__| HOURS

CQ-28. How many days per week {do/did} you usually work as (a/an) {INSERT JOB TITLE FROM CQ-26}?

(NSHA-Mod)

|__| DAYS

CQ-29. How many weeks per month {do/did} you usually work as (a/an) {INSERT JOB TITLE FROM CQ-26}?

(NSHA)

|__| WEEKS

CQ-30. About how much {do/did} you earn at this job before taxes and other deductions?

(NSHA)

$|___|___|___|___|___|___|___|   |__|__| UNIT¹

CQ-31. Is that before taxes and other deductions {are/were} taken out or after taxes and other deductions {are/were} taken out?

(NEW)

YES 1

NO 2

CQ-32. {Are/Were} the following benefits available to you at your job as (a/an) {INSERT JOB TITLE FROM CQ-26}?

(IPS)

YES NO

a. Medical insurance? 1 2

b. Vacation leave? 1 2

c. Sick leave? 1 2

d. Any other benefits? (SPECIFY) 1 2

CQ-33. Are you still working at this job?

(IPS)

YES 1 (CQ-35)

NO 2

CQ-34. What was the main reason this job ended?

(IPS)

QUIT 1

FIRED 2

LAID OFF 3

TIME LIMITED JOB SUCH AS SEASONAL OR

TEMPORARY JOB 4

REASSIGNED TO ANOTHER JOB 5

OTHER (SPECIFY) 6

CQ-35. 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 (CQ-37)

CQ-36. How much did you receive that you have not already told me about?

(EIR-Mod)

$|__|__|,|__|__|__|.|__|__|

CQ-37. Would you like to have a {different} paying job now in the community?

(IPS)

YES 1

NO 2

CQ-38. Did you receive any employment, vocational, job skills, or job finding services {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}?

(IPS)

YES 1

NO 2 (CQ-40)

CQ-39. Tell me about those services.

(IPS)

[INTERVIEWER: CODE ALL THAT APPLY.]

SUPPORTED EMPLOYMENT 1

JOB FINDING SERVICES 2

JOB SKILLS TRAINING 3

VOCATIONAL REHABILITATION 4

PREVOCATIONAL WORK CREW 5

OTHER EMPLOYMENT OR VOCATIONAL

SERVICES 6

C. HEALTH CARE SERVICES

CQ-40. {In the past 3 months/Since INSERT DATE FROM LAST INTERVIEW}, did you receive any care in an emergency room?

(HCC)

YES 1

NO 2 (CQ-48)

CQ-41. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} 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 3 months/since INSERT DATE FROM LAST INTERVIEW}.

ASK CQ-42 TO CQ-47 ABOUT EACH EMERGENCY ROOM VISIT.

CQ-42. When did you go?/When did you go before that?

(HCC)

|__|__| - |__|__|__|__|

MONTH YEAR

CQ-43. Where did you go?

(HCC)

NAME OF EMERGENCY ROOM

CQ-44. 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

CQ-45. Were you admitted to the hospital following this emergency room visit?

(HCC)

YES 1

NO 2 (NEXT VISIT OR CQ-48)

CQ-46. 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

CQ-47. How many nights did you stay in the hospital?

(HCC)

|__|__| NIGHTS

CQ-48. {In the past 3 months/Since INSERT DATE FROM LAST INTERVIEW}, have you stayed overnight in a hospital other than the ones you mentioned in the previous questions?

(HCC)

YES 1

NO 2 (CQ-54)

CQ-49. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} did you stay overnight in a hospital?

(HCC)

|__|__| TIMES

ASK CQ-50 TO CQ-53 ABOUT EACH OVERNIGHT HOSPITAL STAY.

CQ-50. When did you stay in the hospital?/When did you stay before that?

(HCC)

|__|__| - |__|__|__|__|

MONTH YEAR

CQ-51. Where did you stay?

(HCC)

NAME OF HOSPITAL

CQ-52. 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

CQ-53. How many nights did you stay in the hospital?

(HCC)

|__|__| NIGHTS

CQ-54. Other than a hospital or emergency room, did you receive help for a psychiatric emergency or crisis from some other source {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}? 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.

YES 1

NO 2 (CQ-60)

ASK CQ-55 TO CQ-59 ABOUT EACH PSYCHIATRIC EMERGENCY CENTER VISIT.

CQ-55. Where did you go?/Where did you go before that?

(HCC)

NAME OF PSYCHIATRIC EMERGENCY CENTER

CQ-56. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} did you receive services at this particular place?

(HCC)

|__|__| TIMES

CQ-57. When you went to {INSERT NAME OF PSYCHIATRIC EMERGENCY CENTER} who did you see? Anyone else?

(NEW)

PROVIDER 1

PROVIDER 2

PROVIDER 3

ASK CQ-58 AND CQ-59 ABOUT EACH PROVIDER NAMED IN CQ-57.

CQ-58. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} did you see {INSERT NAME OF PROVIDER IN CQ-57}?

(HCC)

|__|__| TIMES

CQ-59. Did {INSERT NAME OF PROVIDER IN CQ-57}…

(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

CQ-60. Other than your hospital stays, emergency room visits, and visits for psychiatric crises that you have already mentioned, did you go to another clinic or mental health provider {during the past 3 months/since INSERT DATE FROM LAST INTERVIEW}?

(HCC)

YES 1

NO 2 (CQ-68)

CQ-61. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} did you go to another clinic or mental health provider?

(HCC)

|__|__| TIMES

ASK CQ-62 TO CQ-67 ABOUT EACH CLINIC OR MENTAL HEALTH PROVIDER VISIT.

CQ-62. Where did you go?/Where did you go before that?

(HCC)

NAME OF CLINIC OR MENTAL HEALTH PROVIDER

CQ-63. 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

CQ-64. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} did you receive services at this particular place?

(HCC)

|__|__| TIMES

CQ-65. 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 CQ-66 AND CQ-67 ABOUT EACH PROVIDER NAMED IN CQ-65.

CQ-66. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} did you see {INSERT NAME OF PROVIDER IN CQ-65}?

(HCC)

|__|__| TIMES

CQ-67. Did {INSERT NAME OF PROVIDER IN CQ-65}…

(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

CQ-68. 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 (INTERVIEW END)

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) 88CWSSpecifyUnitPayEarnedOther

“CWSSpecified Other Unit of Pay Earned”

MHTS QUARTERLY QUESTIONNAIRE FOR CONTROL GROUP Page 11