CONTACT INFORMATION AND DEMOGRAPHICS (dm)
DM-1. Are you still at (the current address as indicated on RIS)?
YES 1 (DM-3)
NO 2
DM-2. What is your current address?
STREET ADDRESS
CITY
STATE
ZIP CODE
DM-3. Is there a telephone number other than (the one indicated on the RIS) where we can reach you?
YES 1
NO 2 (DM-5)
DM-4. What is that number?
|__|__|__| - |__|__|__| - |__|__|__|__|
TELEPHONE NUMBER
DM-5. Are you planning to move in the next 3 months?
YES 1
NO 2 (DM-9a)
DM-6. What will your new address be?
STREET ADDRESS
CITY
STATE
ZIP CODE
DM-7. When will you move to this new address?
|__|__| / |__|__| / |__|__|__|__|
MONTH DAY YEAR
DM-8. Will you keep the same telephone number?
YES 1 (DM-9a)
NO 2
DM-9. What will your new telephone number be?
|__|__|__| - |__|__|__| - |__|__|__|__|
TELEPHONE NUMBER
[PROGRAMMER: ADD IN ITEM CO-10 FROM BASELINE INTERVIEW].
DM-9a. We’d like the names, addresses and phone numbers of two people who will know where you are if we need to contact you in the future and have trouble locating you. We will not contact these people except to have them help us locate you to speak with you again, should that be necessary. If we do contact them, we will not discuss any of your personal information with them.
CONTACT 1 NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
|__|__|__| - |__|__|__| - |__|__|__|__|
TELEPHONE NUMBER
CONTACT 2 NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
|__|__|__| - |__|__|__| - |__|__|__|__|
TELEPHONE NUMBER
Next, I will re-ask you some questions about yourself.
DM-10. What is your marital status?
Never married, 1
Married, 2
Living as married, 3
Separated, 4
Divorced, or 5
Widowed? 6
DM-11. What is the highest grade in school that you completed?
NO FORMAL SCHOOLING 11
SOME ELEMENTARY SCHOOLING 12
COMPLETED 8TH GRADE 13
SOME HIGH SCHOOL 14
COMPLETED HIGH SCHOOL OR GED 15
SOME COLLEGE OR TECHNICAL SCHOOL 16
COMPLETED ASSOCIATE’S DEGREE 17
COMPLETED BACHELOR’S DEGREE 18
SOME GRADUATE SCHOOL 19
COMPLETED MASTER’S DEGREE 20
COMPLETED DOCTORAL DEGREE 21
OTHER (SPECIFY) 91
DM-12. Describe who you have been living with during the past 30 days.
[INTERVIEWER: CODE ALL THAT APPLY.]
LIVING ALONE 1
LIVING WITH SPOUSE/SIGNIFICANT OTHER ONLY 2
LIVING WITH CHILDREN ONLY 3
LIVING WITH SPOUSE/SIGNIFICANT OTHER
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-13. Which of following best describes where you have been living during the past 30 days? Would you say…
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-21)
Some other place? (SPECIFY) 4
IF RESPONDENT LIVES ALONE, WITH FRIENDS, WITH OTHER NON-RELATED ADULTS, OR OTHER (DM-12 = 1, 7, 8, OR 9), CONTINUE WITH DM-14.
IF RESPONDENT LIVES WITH SPOUSE ONLY (DM-12 = 2), GO TO DM-21.
ELSE, GO TO DM-18.
DM-14. In this place where you live, do you receive visits from a case manager or some other person from a city or state agency?
YES 1
NO 2
DM-15. Are there staff from a mental health agency or other city or state agency who are living at the residence?
YES 1
NO 2
DM-16. Are your meals prepared by residential staff employed by a mental health center or other city or state agency?
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-14 = 1 OR DM-15 = 1 OR DM-16 = 1), CONTINUE WITH DM-17. OTHERWISE, GO TO BOX DM-1.
DM-17. Are there other people living in the apartment or house who receive help from the same agency as you?
YES 1
NO 2
BOX DM-1
IF RESPONDENT LIVES ALONE (DM-12 = 1), THEN GO TO DM-21.
DM-18. How many adults age 18 or over lived with you for most of the past 30 days?
|__|__| ADULTS
IF NO ADULTS LIVE WITH RESPONDENT (DM-18 = 0), THEN GO TO DM-20.
DM-19. Of these adults, how many are dependent on you for support?
|__|__| DEPENDENT ADULTS
DM-20. How many children under the age of 18 lived with you for most of the past 30 days?
|__|__| CHILDREN
DM-21. In the past three months, how many days have you been…
Living in a shelter or on the street? |__|__|
In jail or a correctional facility? |__|__|
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…
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…
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…
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…
[INTERVIEWER: SHOW HS CARD.]
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…
[INTERVIEWER: SHOW HS CARD.]
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…
[INTERVIEWER: SHOW HS CARD.]
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…
[INTERVIEWER: SHOW HS CARD.]
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.
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…
[INTERVIEWER: SHOW HS CARD.]
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…
[INTERVIEWER: SHOW HS CARD.]
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…
[INTERVIEWER: SHOW HS CARD.]
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…
[INTERVIEWER: SHOW HS CARD.]
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 AND AS-3 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. In the past 30 days, how many days have you used {INSERT SUBSTANCE}…
a. Any alcohol at all? |__|__|
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? |__|__|
c. Marijuana? (This includes pot, reefer, hashish,
cannabis.) |__|__|
d. Heroin? (This includes smack, horse, tar.) |__|__|
e. Non-prescription methadone? (This includes
Dolophine and LAAM.) |__|__|
f. Other opiates or analgesics? (This includes morphine,
dreamer junk, Demerol, Darvon, Darvocet, Codeine,
school boy, Percodan, Dilaudid, Talwin, OxyContin.) |__|__|
g. Barbiturates? (This includes Seconal, reds, red
devis, Nembutal, Tuninal or rainbows, phenobarbital
yellow jackets, purple hearts.) |__|__|
h. Sedatives, benzodiazepines, tranquilizers, or
hypnotics? (This includes Valium, Librium, Xanax,
Halcion, Klonipin.) |__|__|
i. Cocaine, crack, or coca leaves? |__|__|
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.) |__|__|
Hallucinogens? (This includes LSD, acid, purple
haze, mescaline, mesc, cactus, PCP, angel dust,
mushrooms, peyote.) |__|__|
l. Inhalants? (This includes nitrous oxide, whippets, glue,
amyl nitrate, mush, lockerroom, poppers, snappers,
gasoline, paint, nail polish remover.) |__|__|
m. More than one substance per day, including
alcohol? |__|__|
IF RESPONDENT HAS NOT USED ANY SUBSTANCES IN PAST 30 DAYS (ALL AS-1 = 0),
THEN GO TO AS-23.
ONLY ASK AS-2 AND AS-3 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).
HOWEVER, IF NO SUBSTANCE USE IN PAST 30 DAYS (AS-1 = 0),
THEN GO TO NEXT ITEM IN AS-1 OR AS-4.
AS-2. Was this prescribed for you?
YES 1
NO 2 (NEXT ITEM IN AS-1 OR AS-4)
AS-3. How many days in the past 30 did you take at least one extra dose of {INSERT SUBSTANCE}?
|__|__| DAYS
AS-4. Out of all the drugs I just mentioned, which substance is the major problem for you?
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-4 = 0),
THEN GO TO AS-7.
AS-5. How long was your last period of voluntary abstinence from this major substance?
[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
IF NEVER BEEN ABSTINENT (AS-5 = 00), THEN GO TO AS-7.
AS-6. How many months ago did this abstinence end?
[INTERVIEWER: CODE ‘00’ IF RESPONDENT IS STILL ABSTINENT.]
|__|__| NUMBER
MONTHS 1
YEARS 2
AS-7. In the past 30 days have you injected drugs?
YES 1
NO 2
IF RESPONDENT HAS NOT USED ANY ALCOHOL AT ALL IN PAST 30 DAYS (AS-1a = 0),
THEN GO TO BOX AS-1.
AS-8. How many times have you had alcohol DT’s in the past 30 days?
[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
BOX AS-1
IF RESPONDENT HAS NOT USED ANY DRUGS AT ALL IN PAST 30 DAYS
(ALL AS-1c THROUGH AS-1m = 0), THEN GO TO BOX AS-2.
AS-9. How many times have you overdosed on drugs in the past 30 days?
|__|__| NUMBER OF TIMES
BOX AS-2
IF RESPONDENT HAS NOT USED ANY ALCOHOL AT ALL IN PAST 30 DAYS (AS-1a = 0),
THEN GO TO BOX AS-3.
AS-10. How many times have you been treated for alcohol abuse in the past 30 days?
|__|__| NUMBER OF TIMES
IF NEVER BEEN TREATED FOR ALCOHOL ABUSE (AS-10 = 0), THEN GO TO AS-12.
AS-11. How many of those treatments involved a detox with no follow-up?
|__|__| NUMBER OF DETOX TREATMENTS
BOX AS-3
IF RESPONDENT HAS NOT USED ANY DRUGS AT ALL IN PAST 30 DAYS
(ALL AS-1c THROUGH AS-1m = 0), THEN GO TO BOX AS-4.
AS-12. How many times have you been treated for drug abuse in the past 30 days?
|__|__| NUMBER OF TIMES
IF NEVER BEEN TREATED FOR DRUG ABUSE (AS-12 = 0), THEN GO TO AS-14.
AS-13. How many of those treatments involved a detox with no follow-up?
|__|__| NUMBER OF DETOX TREATMENTS
BOX AS-4
IF RESPONDENT HAS NOT USED ANY ALCOHOL AT ALL IN PAST 30 DAYS (AS-1a = 0),
THEN GO TO BOX AS-5.
AS-14. How much have you spent on alcohol in the past 30 days?
[PROGRAMMER: PLEASE ADD A SOFT EDIT IF AS-1a > 0 AND RESPONSE TO AS-14 BELOW IS 0 (ZERO).]
$|__|__|__|__| . |__|__|
BOX AS-5
IF RESPONDENT HAS NOT USED ANY DRUGS AT ALL IN PAST 30 DAYS
(ALL AS-1c THROUGH AS-1m = 0), THEN GO TO AS-16.
AS-15. How much have you spent on drugs in the past 30 days?
[PROGRAMMER: PLEASE ADD A SOFT EDIT IF (ANY AS-1c THROUGH AS-1m) = 1 (YES) AND RESPONSE TO AS-15 BELOW IS 0 (ZERO).]
$|__|__|__|__| . |__|__|
AS-16. 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?
|__|__| NUMBER OF DAYS
IF RESPONDENT HAS NOT USED ANY ALCOHOL AT ALL IN PAST 30 DAYS (AS-1a = 0),
THEN GO TO BOX AS-6.
AS-17. How many days in the past 30 days have you experienced alcohol problems?
|__|__| NUMBER OF DAYS
BOX AS-6
IF RESPONDENT HAS NOT USED ANY DRUGS AT ALL IN PAST 30 DAYS
(ALL AS-1c THROUGH AS-1m = 0), THEN GO TO BOX AS-7.
AS-18. How many days in the past 30 days have you experienced drug problems?
|__|__| NUMBER OF DAYS
BOX AS-7
IF RESPONDENT HAS NOT USED ANY ALCOHOL AT ALL IN PAST 30 DAYS (AS-1a = 0),
THEN GO TO BOX AS-8.
AS-19. How troubled or bothered have you been in the past 30 days by alcohol problems? Would you say…
Not at all, 1
Slightly, 2
Moderately, 3
Considerably, or 4
Extremely? 5
BOX AS-8
IF RESPONDENT HAS NOT USED ANY DRUGS AT ALL IN PAST 30 DAYS
(ALL AS-1c THROUGH AS-1m = 0), THEN GO TO BOX AS-9.
AS-20. How troubled or bothered have you been in the past 30 days by drug problems? Would you say…
Not at all, 1
Slightly, 2
Moderately, 3
Considerably, or 4
Extremely? 5
BOX AS-9
IF RESPONDENT HAS NOT USED ANY ALCOHOL AT ALL IN PAST 30 DAYS (AS-1a = 0),
THEN GO TO BOX AS-10.
AS-21. How important to you now is treatment for these alcohol problems? Would you say…
Not at all, 1
Slightly, 2
Moderately, 3
Considerably, or 4
Extremely? 5
BOX AS-10
IF RESPONDENT HAS NOT USED ANY DRUGS AT ALL IN PAST 30 DAYS
(ALL AS-1c THROUGH AS-1m = 0), THEN GO TO AS-23.
AS-22. How important to you now is treatment for these drug problems? Would you say…
Not at all, 1
Slightly, 2
Moderately, 3
Considerably, or 4
Extremely? 5
AS-23. [INTERVIEWER: IS THE INFORMATION COLLECTED ON ALCOHOL AND DRUG USE SIGNIFICANTLY DISTORTED BY THE RESPONDENT’S MISREPRESENTATION?]
YES 1
NO 2
AS-24. [INTERVIEWER: IS THE INFORMATION COLLECTED ON ALCOHOL AND DRUG USE SIGNIFICANTLY DISTORTED BY THE RESPONDENT’S INABILITY TO UNDERSTAND THE QUESTIONS?]
YES 1
NO 2
EMPLOYMENT OUTCOMES and current income (EO)
A. EMPLOYMENT OUTCOMES
Now I’d like to ask you some questions about your work experience since the last time we talked}. That would be the time period from {INSERT DATE FROM LAST INTERVIEW} to today.
EO-1. Have you had a job since {INSERT DATE FROM LAST INTERVIEW}?
YES 1 (EO-3)
NO 2
EO-2. Have you filled out a job application or spoken with a prospective employer since {INSERT DATE FROM LAST INTERVIEW}?
YES 1
NO 2
GO TO EO-30.
EO-3. How many jobs have you had since {INSERT DATE FROM LAST INTERVIEW}? Please count all jobs you have held for pay. Remember that all of your responses are strictly confidential.
[PROGRAMMER: PLEASE ADD A HARD EDIT IF EO-1 = 1 (YES) AND RESPONSE TO EO-3 BELOW IS 0 (ZERO).]
|__|__|
NUMBER OF JOBS
EO-4. Are you currently working at a job or business for pay?
YES 1
NO 2
Now, I am going to ask some questions about any and all jobs you’ve held for pay 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 since {INSERT DATE FROM LAST INTERVIEW}, and I cannot share this information with SSA under any circumstances.
ASK EO-5 TO EO-16 FOR EACH JOB HELD IN PAST THREE MONTHS/SINCE LAST INTERVIEW.
EO-5. What {is/was} your job title?/ What job did you do before that?
[INTERVIEWER: PLEASE MAKE SURE EACH JOB TITLE IS UNIQUE.]
NAME OF JOB/JOB TITLE
EO-6. What month and year did you begin that job?
|__|__| / |__|__|__|__|
MONTH YEAR
EO-7. What month and year did that job end?
|__|__| / |__|__|__|__|
MONTH YEAR
CURRENTLY WORKING 95
[PROGRAMMER; PLEASE ADD THE THREE NEW ITEMS BELOW. WE BASICALLY MOVED ITEMS EO-2O THROUGH EO-22 HERE TO BE INCLUDED IN THE SUBROUTINE THAT IS REPEATED FOR EACH JOB THAT IS ENUMERATED. WE ALSO REMOVED THE FILL FROM THE ITEMS.]
EO-7a. How many hours per day {do/did} you usually work at that job?
|__|__|
HOURS
EO-7b. How many days per week {do/did} you usually work at that job?
|__|
DAYS
EO-7c. How many weeks per month {do/did} you usually work at that job?
|__|
WEEKS
EO-8. What {are/were} your main activities or duties on this job?
JOB DUTIES
EO-8a. What {is/was} the name of the organization or company you {work/worked} for?
NAME OF ORGANIZATION/COMPANY
CASUAL LABOR/SELF-EMPLOYED 95
EO-8b. What type of business {is/was} it, that is what type of product {is/was} made or what type of service {is/was} provided?
TYPE OF BUSINESS
EO-9. What {is/was} your hourly wage?
$|___|___|___|.|__|__| HOURLY WAGE
EO-10. 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}?
YES 1 (EO-11)
NO 2
CASUAL LABOR/SELF-EMPLOYED 3
EO-11. 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…
The employer, 1
A mental health or rehabilitation agency, or 2
CASUAL LABOR/SELF-EMPLOYED 3
Someone else? (SPECIFY) 91
EO-12. {Is/Was} any person who {supervises/supervised} your work an employee of a mental health or rehabilitation agency?
YES 1
NO 2
CASUAL LABOR/SELF-EMPLOYED 3
EO-13. {Is/Was} this job reserved only for people who get services from a mental health or rehabilitation agency?
YES 1 (EO-15)
NO 2
CASUAL LABOR/SELF-EMPLOYED 3
EO-14. So this job could have been taken by anybody who applied for it and was qualified, including someone who does not have a disability?
YES 1
NO 2
CASUAL LABOR/SELF-EMPLOYED 3
EO-15. {Does/Did} this job have a time limit to it? That is, {is/was} it only temporary?
YES 1
NO 2 (NEXT JOB OR EO-17)
CASUAL LABOR/SELF-EMPLOYED 3 (NEXT JOB OR EO-17)
EO-16. Describe what is meant by it being “time limited.” {Is/Was} this a seasonal job or a transitional job of some kind?
SEASONAL JOB 1
TRANSITIONAL JOB 2
OTHER JOB (SPECIFY) 3
EO-17. What was your main job since {INSERT DATE FROM LAST INTERVIEW}? Your main job is the job at which you worked the longest or worked the most hours.
[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 EO-17}.
EO-18. Did anyone help you get this job?
YES 1
NO 2 (EO-19a)
EO-19. Who helped you? Was it…
Someone from {INSERT NAME OF MHTS SITE}, 1
Someone from another vocational program
(SPECIFY), or 2
Someone else? (SPECIFY) 3
[PROGRAMMER: ADD IN NEW ITEM].
EO-19a. {Are you working/Did you work} full-time or part-time as (a/an) {INSERT JOB TITLE FROM EO-17}?
FULL-TIME 1
PART-TIME 2
ITEMS EO-20 THROUGH EO-22 WERE DELETED.
EO-23. About how much {do/did} you earn at this job?
$|___|___|___|___|___|___|___| |__|__| UNIT1
EO-24. Is that before taxes and other deductions {are/were} taken out or after taxes and other deductions {are/were} taken out?
BEFORE TAXES 1
AFTER TAXES 2
EO-25. {Are/Were} the following benefits available to you at your job as (a/an) {INSERT JOB TITLE FROM EO-17}?
YES NO
a. Medical insurance? 1 2
b. Vacation leave? 1 2
c. Sick leave? 1 2
d. Any other benefits? (SPECIFY) 1 2
EO-26. We would like to know how you {feel/felt} about your job as (a/an) {INSERT JOB TITLE FROM EO-17}. I am going to read you a series of statements about that job. Please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree.
[INTERVIEWER: SHOW EO CARD.]
STRONGLY SOMEWHAT SOMEWHAT STRONGLY
AGREE AGREE DISAGREE DISAGREE
a. I feel good about this job. 1 2 3 4
b. This job is worthwhile. 1 2 3 4
c. The working conditions are good. 1 2 3 4
d. I have a fairly good chance for promotion in this job. 1 2 3 4
e. This is a dead-end job. 1 2 3 4
f. My co-workers help me to like this job more. 1 2 3 4
g. I am happy with the amount this job pays. 1 2 3 4
h. The vacation time and other benefits on this job are okay. 1 2 3 4
i. I need more money than this job pays. 1 2 3 4
j. This job does not provide the medical coverage I need. 1 2 3 4
k. My supervisor is fair. 1 2 3 4
l. My supervisor is hard to please. 1 2 3 4
m. My supervisor praises me when I do my job well. 1 2 3 4
n. My supervisor is difficult to get along with. 1 2 3 4
o. My supervisor recognizes my efforts. 1 2 3 4
p. My co-workers are easy to get along with. 1 2 3 4
q. My co-workers are lazy. 1 2 3 4
r. My co-workers are unpleasant. 1 2 3 4
s. My co-workers don’t like me. 1 2 3 4
t. I want to quit this job. 1 2 3 4
u. I often feel tense on the job. 1 2 3 4
v. I don’t know what’s expected of me on this job. 1 2 3 4
w. I feel physically worn out at the end of the day. 1 2 3 4
ITEM EO-27 WAS DELETED.
EO-28. What was the main reason this job ended?
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
EO-29. What could have made this a better job experience for you? Would you say…
YES NO
a. A more flexible schedule? 1 2
b. Additional supports from mental health or
vocational staff? 1 2
c. Changes in your work space or work setting? 1 2
d. More time off? 1 2
e. Anything else? (SPECIFY) 1 2
EO-30. Would you like to have a {different} paying job now in the community?
YES 1
NO 2
[PROGRAMMER: ADD IN NEW ITEM].
ONLY ASK EO-30a IF WORKING PART-TIME AT MAIN JOB (EO-19a = 2).
EO-30a. People have many reasons for not working full-time. Why {are you not working/did you not work} full-time?
COULDN’T FIND FULL-TIME JOB 1
TOO SICK TO WORK FULL-TIME 2
DON’T WANT TO WORK MORE 3
OTHER DEMANDS ON TIME (i.e., PETS, CHILD) 4
MAKE ENOUGH MONEY WORKING PART-TIME 5
OTHER (SPECIFY) 91
B. CURRENT INCOME SOURCES
EO-31. Please tell me how much money you received from the following sources during the past month. Remember, everything you tell me is strictly confidential.
a. Any earned income or money from all paid employment,
including tips or commissions. Please tell me the take
home amount $|__|__|,|__|__|__|.|__|__|
[PROGRAMMER: PLEASE HAD A HARD EDIT IF EO-4 = 1 (YES) AND RESPONSE TO EO-31a ABOVE IS 0 (ZERO). PLEASE ADD A SOFT EDIT IF EO-1 = 1 (YES) AND RESPONSE TO EO-31a ABOVE IS 0 (ZERO).]
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 $|__|__|,|__|__|__|.|__|__|
EO-32. 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.
YES 1
NO 2 (BOX EO-1)
EO-33. How much did you receive that you have not already told me about?
$|__|__|,|__|__|__|.|__|__|
BOX EO-1
IF RESPONDENT LIVES WITH OTHER ADULTS IN A NON-SUPERVISED SETTING
{(DM-12 = 2, 3, 4, 5, OR 6) OR [(DM-12 = 7 OR 8) AND DM-14 = 2 AND DM-15 = 2 AND DM-16 = 2]},
THEN ASK EO-34. OTHERWISE, GO TO INTRO TO EO-35.
EO-34. About how much was your total household income last month? Household income means the total amount of money that everyone in your household, including yourself, received during the past month.
$|__|__|,|__|__|__|.|__|__|
[PROGRAMMER: ADD IN ITEM AT-6 FROM BASELINE INTERVIEW. PLEASE NOTE ITEM (i) HAS BEEN ADDED AS A NEW ITEM.]
I’d like to ask you a few questions about your basic understanding of Social Security benefits.
EO-35. Fear of losing benefits is common among most beneficiaries. Please tell me whether you agree or disagree with these statements about Social Security benefits.
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
i. If I go to work, the Social Security Administration might think I’m really
not sick and that I can work. 1 2 3
ONLY ASK CQ-38 AND CQ-39 FOR BENEFICIARIES IN THE CONTROL GROUP.
CQ-38. Did you receive any employment, vocational, job skills, or job finding services since {INSERT DATE FROM LAST INTERVIEW}?
YES 1
NO 2 (NEXT SECTION)
CQ-39. Tell me about those services.
[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
HEALTH CARE SERVICE UTILIZATION (HC)
[PROGRAMMER: ADD IN ITEMS HC-1 THROUGH HC-18 ON HEALTH INSURANCE COVERAGE FROM BASELINE INTERVIEW].
ONLY ASK HC-1 THROUGH HC-18 FOR BENEFICIARIES IN THE CONTROL GROUP.
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?
[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?
[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?
[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?
YES 1
NO 2
HC-5. Are you enrolled in Part D of Medicare which provides coverage for prescription medications?
YES 1
NO 2
HC-6. Are you covered by Medicare supplemental insurance or Medigap?
[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?
YES,EMPLOYER 1
YES, COBRA OR BOUGHT PERSONALLY 2
YES, THROUGH A FAMILY MEMBER 3
NO 4 (HC-9)
YES, SOME OTHER PRIVATE
SOURCE (SPECIFY) 91
HC-8. Does this plan pay for some part of your prescription medications?
YES 1
NO 2
HC-9. Are you covered by Medicaid?
[INTERVIEWER: PROBE IF NECESSARY: “Medicaid is the government assistance program that helps pay for health care.”]
YES 1
NO 2
HC-10. {INSERT STATE SCHIP PROGRAM } is a government assistance program that helps pay for health care for children in this state. Sometimes this program helps pay for health care for parents too. Are you covered by {INSERT STATE SCHIP PROGRAM}?
YES 1
NO 2
HC-11. Are you covered by a military health insurance plan such as CHAMPUS, CHAMP-VA, or TRICARE?
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?
YES (SPECIFY) 1
NO 2 (HC-14)
HC-13. Does this plan pay for some part of your prescription medications?
YES 1
NO 2
HC-14. Do you receive medications or get help in paying for medications from any other programs?
[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?
[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?
YES 1
NO 2
BOX HC-1
IF RESPONDENT IS UNINSURED (HC-2 = 1), THEN CONTINUE WITH HC-17.
OTHERWISE, GO TO SECTION B.
HC-17. In the past, have you ever had health insurance?
YES 1
NO 2 (HC-19)
HC-18. When did you become uninsured? Would you say…
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-1. Since {INSERT DATE FROM LAST INTERVIEW}, did you receive any care in an emergency room?
YES 1
NO 2 (HC-9)
ITEM HC-2 WAS DELETED.
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 since {INSERT DATE FROM LAST INTERVIEW}.
ASK HC-3 TO HC-8 ABOUT EACH EMERGENCY ROOM VISIT SINCE DATE OF LAST INTERVIEW.
HC-3. When did you go on your most recent visit?/When did you go before that?
[INTERVIEWER: ASK RESPONDENT ABOUT PREVIOUS EMERGENCY ROOM VISITS BY READING THE DATE AND NAME OF THE LAST EMERGENCY ROOM VISIT ENTERED. VISITS MUST BE WITHIN THE LAST SIX MONTHS.]
|__|__| - |__|__|__|__|
MONTH YEAR
HC-4. Where did you go?
[INTERVIEWER: ENTER NAME OF EMERGENCY ROOM. IF RESPONDENT DOES NOT KNOW THE NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION. ENTER THE WORD “DELETE” TO INDICATE THIS ENTRY IS AN ERROR.]
NAME OF EMERGENCY ROOM
HC-5. There may be more than one reason for this visit. Please tell us all the reasons for this visit. Was it for…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-3) AND NAME OF PLACE (RESPONSE TO HC-4) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
A physical problem, 1
A mental health problem, 2
An alcohol problem, 3
A drug problem, or 4
Some other problem? (SPECIFY) 91
HC-6. Were you admitted to the hospital following this emergency room visit?
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-3) AND NAME OF PLACE (RESPONSE TO HC-4) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
YES 1
NO 2 (NEXT VISIT OR HC-9)
HC-7. 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…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-3) AND NAME OF PLACE (RESPONSE TO HC-4) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
A physical problem, 1
A mental health problem, 2
An alcohol problem, 3
A drug problem, or 4
Some other problem? (SPECIFY) 91
HC-8. How many nights did you stay in the hospital?
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-3) AND NAME OF PLACE (RESPONSE TO HC-4) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
|__|__| NIGHTS
HC-9. Since {INSERT DATE FROM LAST INTERVIEW}, have you stayed overnight in a hospital (other than the ones you mentioned in the previous questions)?
YES 1
NO 2 (HC-15)
ITEM HC-10 WAS DELETED.
I would like to get more information about your hospital stays since {INSERT DATE FROM LAST INTERVIEW}. Let’s begin with the most recent time you were in the hospital and work backwards since {INSERT DATE FROM LAST INTERVIEW}.
ASK HC-11 TO HC-14 ABOUT EACH HOSPITAL VISIT SINCE DATE OF LAST INTERVIEW.
HC-11. When did you stay in the hospital?/When did you stay before that?
|__|__| - |__|__|__|__|
MONTH YEAR
HC-12. Where did you stay?
[INTERVIEWER: ENTER NAME OF HOSPITAL. IF RESPONDENT DOES NOT KNOW THE NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION. ENTER THE WORD “DELETE” TO INDICATE THIS ENTRY IS AN ERROR.]
NAME OF HOSPITAL
HC-13. There may be more than one reason for this hospital stay. Please tell us all the reasons for your admission. Was it for…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-11) AND NAME OF PLACE (RESPONSE TO HC-12) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
A physical problem, 1
A mental health problem, 2
An alcohol problem, 3
A drug problem, or 4
Some other problem? (SPECIFY) 91
HC-14. How many nights did you stay in the hospital?
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-11) AND NAME OF PLACE (RESPONSE TO HC-12) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
|__|__| NIGHTS
HC-15. {Other than a hospital or emergency room, did/Did} you receive help for a psychiatric emergency or crisis from some other source 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 (HC-21)
ASK HC-16 TO HC-20 ABOUT EACH PSYCHIATRIC EMERGENCY CENTER VISIT
IN PAST THREE MONTHS.
HC-16. Where did you go on your most recent visit?/Where did you go before that?
[INTERVIEWER: ENTER NAME OF PSYCHIATRIC EMERGENCY CENTER. IF RESPONDENT DOES NOT KNOW THE NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION THAT WILL UNIQUELY IDENTIFY THIS VISIT FROM ANY OTHER VISIT. ENTER THE WORD “DELETE” TO INDICATE THIS ENTRY IS AN ERROR.]
NAME OF PSYCHIATRIC EMERGENCY CENTER
HC-17. How many times since {INSERT DATE FROM LAST INTERVIEW} did you receive services at {INSERT NAME OF PSYCHIATRIC EMERGENCY CENTER}?
|__|__| TIMES
HC-18. When you went to {INSERT NAME OF PSYCHIATRIC EMERGENCY CENTER} who did you see? Anyone else?
[INTERVIEWER: IF RESPONDENT DOES NOT KNOW THE NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION THAT WILL UNIQUELY IDENTIFY THIS PROVIDER FROM ANY OTHER PROVIDER.]
PROVIDER 1
PROVIDER 2
PROVIDER 3
ASK HC-19 AND HC-20 ABOUT EACH PROVIDER NAMED IN HC-18.
HC-19. How many times since {INSERT DATE FROM LAST INTERVIEW} did you see {INSERT NAME OF PROVIDER IN HC-18}?
[PROGRAMMER: DISPLAY NAME OF CENTER (RESPONSE TO HC-16) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
|__|__| TIMES
HC-20. Did {INSERT NAME OF PROVIDER IN HC-18}…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY NAME OF CENTER (RESPONSE TO HC-16) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
Write a prescription for you or consult with you on
medication, 1
Provide you with some kind of mental health
counseling, 2
Provide you with some kind of vocational
counseling, 3
Provide you with some kind of spiritual or religious
counseling, 4
Provide you with some kind of peer support? 91
HC-21. {Other than your hospital stays, emergency room visits, and visits for psychiatric crises that you have already mentioned, did/Did} you go to another clinic or mental health provider since {INSERT DATE FROM LAST INTERVIEW}?
YES 1
NO 2 (HC-29)
HC-22. How many times since {INSERT DATE FROM LAST INTERVIEW} did you go to another clinic or mental health provider?
|__|__| TIMES
ASK HC-23 TO HC-27 ABOUT EACH CLINIC OR
MENTAL HEALTH PROVIDER VISIT IN PAST THREE MONTHS.
HC-23. Where did you go on your most recent visit?/Where did you go before that?
[INTERVIEWER: ENTER NAME OF CLINIC OR MENTAL HEALTH PROVIDER. IF RESPONDENT DOES NOT KNOW THE NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION THAT WILL UNIQUELY IDENTIFY THIS CLINIC FROM ANY OTHER CLINIC. ENTER THE WORD “DELETE” TO INDICATE THIS ENTRY IS AN ERROR.]
NAME OF CLINIC OR MENTAL HEALTH PROVIDER
HC-24. Please tell us all the reasons for your visit. Was it for a…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY NAME OF CLINIC (RESPONSE TO HC-23) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
A physical problem, 1
A mental health problem, 2
An alcohol problem, 3
A drug problem, or 4
Some other problem? (SPECIFY) 91
HC-25. How many times since {INSERT DATE FROM LAST INTERVIEW} did you receive services at this particular place?
[PROGRAMMER: DISPLAY NAME OF CLINIC (RESPONSE TO HC-23) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
|__|__| TIMES
HC-26. When you went to {INSERT NAME OF CLINIC OR MENTAL HEALTH PROVIDER} who did you see? Anyone else?
[INTERVIEWER: IF RESPONDENT DOES NOT KNOW THE NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION THAT WILL UNIQUELY IDENTIFY THIS PROVIDER FROM ANY OTHER PROVIDER.]
PROVIDER 1
PROVIDER 2
PROVIDER 3
ASK HC-27 AND HC-28 ABOUT EACH PROVIDER NAMED IN HC-26.
HC-27. How many times since {INSERT DATE FROM LAST INTERVIEW} did you see {INSERT NAME OF PROVIDER IN HC-26}?
[PROGRAMMER: DISPLAY NAME OF CLINIC (RESPONSE TO HC-23) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
|__|__| TIMES
HC-28. Did {INSERT NAME OF PROVIDER IN HC-26}…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY NAME OF CLINIC (RESPONSE TO HC-23) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
Write a prescription for you or consult with you on
medication, 1
Provide you with some kind of mental health
counseling, 2
Provide you with some kind of vocational
counseling, 3
Provide you with some kind of spiritual or religious
counseling, 4
Provide you with some kind of peer support? 91
HC-29. Are you currently taking any prescription medications for an emotional or mental problem, or a problem with your nerves?
YES 1
NO 2 (NEXT SECTION)
HC-30. How often do you use your psychiatric medications as prescribed by the doctor or as directed on the label? Would you say…
Most of the time, and by that I mean at least 80% of the time, 1
Some of the time, and by that I mean 50% to 80% of the time, or 2
Less than half the time, which means less than 50% of the time? 3
HC-31. Do you have all of the information you need about your psychiatric medications? Would you say…
Yes, I have all of the information I need, or 1
No, I do not have enough information? 2
HC-32. In general, how do you feel about taking psychiatric medications? Would you say…
Positive, 1
Negative, or 2
Neither one? 3
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?
[INTERVIEWER: SHOW QL CARD.]
TERRIBLE 1
UNHAPPY 2
MOSTLY DISSATISFIED 3
MIXED 4
MOSTLY SATISFIED 5
PLEASED 6
DELIGHTED 7
ONLY ASK QL-2 THROUGH QL-6 FOR BENEFICIARIES IN THE TREATMENT GROUP.
Now I want to ask about the vocational services you were getting.
QL-2. How do you feel about the vocational services you received at {INSERT NAME OF MHTS SITE}?
[INTERVIEWER: SHOW QL CARD.]
TERRIBLE 1
UNHAPPY 2
MOSTLY DISSATISFIED 3
MIXED 4
MOSTLY SATISFIED 5
PLEASED 6
DELIGHTED 7
QL-3. How do you feel about the assistance you received from the Nurse Care Coordinator at {INSERT NAME OF MHTS SITE}?
[INTERVIEWER: PROBE IF NECESSARY: “By Nurse Care Coordinator, I mean (INSERT NAME OF NURSE CARE COORDINATOR AT YOUR SITE).
[INTERVIEWER: SHOW QL CARD.]
TERRIBLE 1
UNHAPPY 2
MOSTLY DISSATISFIED 3
MIXED 4
MOSTLY SATISFIED 5
PLEASED 6
DELIGHTED 7
QL-4. How do you feel about the systematic medication management services you received at {INSERT NAME OF MHTS SITE}?
[INTERVIEWER: PROBE IF NECESSARY: “By systematic medication management, I mean the help you received from your prescriber and the Nurse Care Coordinator to help you manage your medications.
[INTERVIEWER: SHOW QL CARD.]
TERRIBLE 1
UNHAPPY 2
MOSTLY DISSATISFIED 3
MIXED 4
MOSTLY SATISFIED 5
PLEASED 6
DELIGHTED 7
QL-5. How do you feel about any other behavioral health services that you received at {INSERT NAME OF MHTS SITE}?
[INTERVIEWER: PROBE IF NECESSARY: “By other behavioral health services, I mean any help you may have received with case management, substance use, housing, family or social intervention, or help with financial or legal problems.
[INTERVIEWER: SHOW QL CARD.]
TERRIBLE 1
UNHAPPY 2
MOSTLY DISSATISFIED 3
MIXED 4
MOSTLY SATISFIED 5
PLEASED 6
DELIGHTED 7
QL-6. Now I’d like to ask you a few additional questions about the services you received at {INSERT NAME OF MHTS SITE}. I am going to read you a series of statements about your experience with {INSERT NAME OF MHTS SITE}. Please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree.
[INTERVIEWER: SHOW EO CARD.]
STRONGLY SOMEWHAT SOMEWHAT STRONGLY
AGREE AGREE DISAGREE DISAGREE
a. No child care services were offered. 1 2 3 4
b. {INSERT NAME OF MHTS SITE} did not help me with
transportation. 1 2 3 4
c. {INSERT NAME OF MHTS SITE} had limited job opportunities 1 2 3 4
d. The enrollment process at {INSERT NAME OF MHTS SITE}
was complicated. 1 2 3 4
e. It felt like there wasn’t anybody else like me at
{INSERT NAME OF MHTS SITE}. 1 2 3 4
f. The options offered by {INSERT NAME OF MHTS SITE} to
help me with my mental illness were limited. 1 2 3 4
g. I need more help to get ready to go back to work. 1 2 3 4
h. I did not want to tell any employers about my mental illness
so I did not have a job coach with me at my job. 1 2 3 4
i. I did not want any help from {INSERT NAME OF MHTS SITE}
with my mental illness. I just wanted help finding a job. 1 2 3 4
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) 91
| File Type | application/msword |
| File Title | HE1 |
| Author | Beckey Downes |
| Last Modified By | 177717 |
| File Modified | 2009-04-23 |
| File Created | 2009-04-23 |