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Specification:
Section: CHILD SUPPORT AGREEMENTS
Enter Text
CS03
Earlier we recorded that **READ ABOVE FOR NAMES OF ALL CHILDREN**
did not have [FILL TEMP] other parent staying in the household.
ENTER (P) TO PROCEED
@
Mark One Only
CS04
Does [fill CHILDNAMET] have a parent living elsewhere?
(1)
(2)
Yes
No
@
Multiple Entry
CS05
[fill TEMP1]
[fill TEMP2]
Why doesn't [fill CHILDNAMET] have a biological or adoptive parent
living outside the household?
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Other parent has died
Both parents live in the household
Parents are separated/divorced
Don't want contact with child's other parent
Don't know where child's other parent is
Other parent lives elsewhere
Other parent legally terminated their parental rights
Other parent is no longer recognized as a parent by
this household
(9) Child was adopted by a single parent
(10) Other
@
Mark One Only
CS08
[fill TEMP1]
Child support payments can be specified in
written or verbal child support agreements.
Have child support payments ever been
agreed to or awarded for **READ NAME(S)**?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 1 of 82
Survey:
Section: CHILD SUPPORT AGREEMENTS
Items Booklet
Multiple Entry
CS10
Which children are covered by a written or verbal child support
agreement?
ENTER LINE NUMBER OF EACH CHILD
ENTER (N) FOR NO MORE
@1
@2
@3
@4
@5
@6
@7
@8
@9
@10
@11
@12
@13
@14
@15
@16
@17
@18
@19
@20
@21
@22
@23
@24
@25
@26
@27
@28
@29
@30
CS13
Mark One Only
Were any of these children covered by different child support
agreements? By that we mean separate agreements involving different
absent parents.
(1)
(2)
Yes
No
@
CS14
Enter Number
How many different child support agreements cover these children?
@
(number of agreements)
CS15
Multiple Entry
Which of these children were covered by the MOST RECENT child
support agreement?
ENTER LINE NUMBERS OF EACH CHILD COVERED BY THE MOST RECENT
AGREEMENT
ENTER (N) FOR NO MORE
@1
@2
@3
@4
@5
@6
@7
@8
@9
@10
@11
@12
@13
@14
@15
@16
@17
@18
@19
@20
@21
@22
@23
@24
@25
@26
@27
@28
@29
@30
Mark One Only
CS17
The following questions refer to the MOST
RECENT CHILD SUPPORT AGREEMENT. This is
the agreement covering **READ NAME(S) OF
CHILD(REN)**.
Was this a voluntary written agreement
ratified by the court, a court-ordered
agreement, some other type of written
agreement, or a non-written verbal
agreement?
(1)
(2)
(3)
(4)
Voluntary written agreement
ratified by the court
Court-ordered agreement
Other type of written agreement
A non-written verbal agreement
@
Page 2 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: CHILD SUPPORT AGREEMENTS
Enter Number
CS18
In what year was this agreement FIRST reached?
@
Multiple Entry
CS19
What was the dollar amount of that agreement? You may report this
as a weekly, biweekly, monthly, or an annual amount.
$@AMT per
(1)
(2)
(3)
(4)
Per week
Biweekly
Per month
Per year
@1
Mark One Only
CS21
THE AMOUNT YOU HAVE ENTERED [fill CS19@AMT] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
Proceed
@
Mark One Only
CS22
Has the dollar amount ever changed?
(1)
(2)
Yes
No
@
Enter Number
CS23
In what year was the amount LAST changed?
@
Multiple Entry
CS24
What was the dollar amount for the agreement after the last change?
$@AMT per
(1)
(2)
(3)
(4)
Per week
Biweekly
Per month
Per year
@1
Tuesday, November 24, 2009
Page 3 of 82
Survey:
Section: CHILD SUPPORT AGREEMENTS
Mark One Only
Items Booklet
CS26
THE AMOUNT YOU HAVE ENTERED [fill CS24@AMT] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
Proceed
@
Mark One Only
CS27
Was that change made or agreed to by a government agency such as a
court or child support agency?
(1)
(2)
Yes
No
@
Mark One Only
CS28
These next few questions are asking information about the past
12 months.
Were any payments due from [fill MONTH4] [fill TINTYR] to
[fill MONTH4] [fill INTYR]?
(1)
(2)
Yes
No
@
Mark One Only
CS29
Why weren't any payments due during that period?
(1)
(2)
(3)
(4)
(5)
Child(ren) over the age limit
Other parent not working
Other parent in jail or institution
Payment suspended by court or child support agency
Other reason
@
Multiple Entry
CS30
What is the total amount of child support payments [fill TEMPNAME]
[fill WASWERE] supposed to receive during that period from the
most recent agreement?
$ @AMT
Mark One Only
CS32
THE AMOUNT YOU HAVE ENTERED [fill CS30@AMT] [fill LGSMFIL].
(1)
(P)
BACK UP AND CORRECT
Proceed
@
Page 4 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: CHILD SUPPORT AGREEMENTS
Mark One Only
CS33
How are these payments supposed to be received?
Are they received...
READ RESPONSES
(1)
(2)
(3)
(4)
Directly from the other parent
Through the court
Through the welfare or child support agency
Some other method
@
Multiple Entry
CS34
What is the total amount that [fill HESHE] ACTUALLY RECEIVED in
child support payments under that agreement during that period?
[if INDEX eq <1>]
Please include any child support passed through the welfare agency,
Excluding your regular A.F.D.C[if TEMP2 eq <> and TEMP3 eq <>] or[else],[endif]
[fill TEMP1] [fill TEMP2] [fill TEMP3][endif]
ENTER (N) FOR NONE
$ @AMT
Mark One Only
CS36
THE AMOUNT YOU HAVE ENTERED [fill CS34@AMT] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
Proceed
@
Mark One Only
CS37A
From [fill MONTH4] [fill TINTYR] to [fill MONTH4] [fill INTYR], did
[fill TEMPNAME] receive EVERY SINGLE ONE of the child support payments
[fill HESHE] [fill WASWERE] supposed to receive?
(1)
(2)
Yes
No
@
Mark One Only
CS37B
Of the child support payments [fill TEMPNAME] received from
[fill MONTH4] [fill TINTYR] to [fill MONTH4] [fill INTYR], how many
were received ON TIME? Would you say all of them were on time,
most of them, some of them, or none of them?
(1)
(2)
(3)
(4)
All
Most
Some
None
@
Tuesday, November 24, 2009
Page 5 of 82
Survey:
Section: CHILD SUPPORT AGREEMENTS
Mark One Only
Items Booklet
CS37C
For the child support payments [fill TEMPNAME] received, how many of
them were for the FULL amount [fill HESHE] [fill WASWERE] supposed to
receive? Would you say all of them, most of them, some of them, or
none of them?
(1)
(2)
(3)
(4)
All
Most
Some
None
@
Mark One Only
CS38
Sometimes child support that was not paid in previous years is added
to the amount of support owed today. This is sometimes called back
support, back payments, or arrearages.
Did [fill PTEMPNAME] most recent agreement for the past 12 months
include payment for back support?
(1)
(2)
Yes
No
@
Enter Number
CS39
How much of the child support owed the last 12 months was considered
back payment?
$@
Mark One Only
CS39B
THE AMOUNT YOU HAVE ENTERED AS BACK SUPPORT OWED IN THE AGREEMENT
[fill CS39@] IS GREATER THAN THE TOTAL AMOUNT THE RESPONDENT STATED
WAS OWED IN THE AGREEMENT, [fill CS30@AMT].
(1)
(P)
BACK UP AND CORRECT
Proceed
@
Mark One Only
CS39C
[fill C_AREIS] [fill TEMPNAME] owed any back payments?
(1)
(2)
Yes
No
@
Enter Number
CS39D
To date, what is the amount of back payments OWED to [fill TEMPNAME]?
$@
Page 6 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: CHILD SUPPORT AGREEMENTS
CS39F
Mark One Only
THE AMOUNT YOU HAVE ENTERED [fill CS39D@] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
Proceed
@
CS39G
Enter Number
How much back payment did [FILL TEMPNAME] actually RECEIVE the
last 12 months?
ENTER (N) FOR NONE
$@
CS39I
Mark One Only
THE AMOUNT YOU HAVE ENTERED AS BACK SUPPORT RECEIVED [fill CS39G]
IS GREATER THAN THE TOTAL AMOUNT OF CHILD SUPPORT
RECEIVED, [fill CS34@AMT].
(1)
(P)
BACK UP AND CORRECT
PROCEED
@
CS40
Multiple Entry
What kinds of provisions for health care costs are included in
the child support agreement?
READ ALL RESPONSES
ENTER ALL YES RESPONSES
ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
@1
Non-custodial parent to provide health insurance
Custodial parent to provide health insurance
Non-custodial parent to pay actual medical costs directly
Child support payments to include cash medical support
No provisions for health insurance were included in agreement
Other provisions
@2
@3
@4
@5
@6
Mark One Only
CS41
What child custody arrangements does the
child support agreement for **READ NAME(S)
OF CHILD(REN)** specify?
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Joint legal and physical custody
Joint legal with mother physical
custody
Joint legal with father physical
custody
Mother legal and physical custody
Father legal and physical custody
Split custody
Other custody arrangement
@
Tuesday, November 24, 2009
Page 7 of 82
Survey:
Section: CHILD SUPPORT AGREEMENTS
Mark One Only
Items Booklet
CS42
Does the child support agreement specify the amount of time that
the [fill TEMP1] will spend with the other parent?
(1)
(2)
Yes
No
@
Mark One Only
CS44
Did all the children spend about the same number of days with the
other parent in the last 12 months?
(1)
(2)
Yes
No
@
Multiple Entry
CS45
[roster begin CHGRD]
[if CHSFLAG eq <1> and CSKEEP eq <1> and CS44 eq <1>]
CHILD'S NAME: [fill CHILDNAMET]
LN: [fill GRDX2]
[endif]
[roster end CHGRD]
[if CS44 eq <2>]
CHILD'S NAME: [fill OLDNAME] LN: [fill TMP1] [endif]
What is the total amount of time **READ NAMES OF CHILDREN ABOVE** spent
with the other parent from [fill MONTH4] [fill TINTYR] to
[fill MONTH4] [fill INTYR]?
ENTER ONE RESPONSE
ENTER (N) FOR NO TIME
Number of days
@DAYS
Number of weeks @WEEKS
Number of Months @MONTHS
Mark One Only
CS46
Where does the other parent of **READ
NAME(S) OF CHILDREN** now live?
(1)
(2)
(3)
(4)
(5)
(6)
Same county or city
Same state (different county or
city)
Different state
Other parent now deceased
Other
Unknown
@
Mark One Only
CS47
Do you and the other parent still live in the same state or states
where the initial child support agreement was reached?
(1)
(2)
Yes
No
@
Page 8 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: CHILD SUPPORT AGREEMENTS
Mark One Only
CS48
Who moved?
(1)
(2)
(3)
Subject person
Other parent
Both subject person and other parent
@
Multiple Entry
CS49
Now I would like to ask a few questions specifically about the
MOST RECENT NON-WRITTEN CHILD SUPPORT AGREEMENT OR UNDERSTANDING.
In what year was this agreement first reached?
@YEAR
Multiple Entry
CS50
What was the dollar amount of that agreement? You may report this
as a weekly, biweekly, monthly, or an annual amount.
$ @AMT per
(1)
(2)
(3)
(4)
Per week
Biweekly
Per month
Per year
@1
Mark One Only
CS52
THE AMOUNT YOU HAVE ENTERED [fill CS50@AMT] IS UNUSUALLY LARGE.
(1) BACK UP AND CORRECT
(P) Proceed
@
Mark One Only
CS53
Has the dollar amount ever changed?
(1)
(2)
Yes
No
@
Multiple Entry
CS54
In what year was the amount LAST changed?
@YEAR
Tuesday, November 24, 2009
Page 9 of 82
Survey:
Section: CHILD SUPPORT AGREEMENTS
Items Booklet
Multiple Entry
CS55
What was the dollar amount for the agreement after the last change?
$ @AMT per
(1)
(2)
(3)
(4)
Per week
Biweekly
Per month
Per year
@1
Mark One Only
CS57
THE AMOUNT YOU HAVE ENTERED [fill CS55@AMT] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
Proceed
@
Mark One Only
CS58
These next few questions are asking information about the past
12 months.
Were any payments to be received from [fill MONTH4] [fill TINTYR] to
[fill MONTH4] [fill INTYR]?
(1)
(2)
Yes
No
@
Mark One Only
CS59
Why weren't any payments due during that period?
(1)
(2)
(3)
(4)
Child(ren) over the age limit
Other parent not working
Other parent in jail or institution
Other reason
@
Multiple Entry
CS60
What is the total amount of child support payments [fill TEMPNAME]
[fill WASWERE] supposed to receive during that period from the most
recent agreement?
$ @AMT
Mark One Only
CS62
THE AMOUNT YOU HAVE ENTERED [fill CS60@AMT] IS UNUSUALLY LARGE
(1)
(P)
BACK UP AND CORRECT
Proceed
@
Page 10 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: CHILD SUPPORT AGREEMENTS
Multiple Entry
CS63
What is the total amount that [fill HESHE] ACTUALLY RECEIVED in child
support payments under that agreement during that period?
[if INDEX eq <1>]
Please include any child support passed through the welfare agency,
Excluding your regular A.F.D.C[if TEMP2 ne <> and TEMP3 ne <>] or[else],[endif]
[fill TEMP1] [fill TEMP2] [fill TEMP3][endif]
ENTER (N) FOR NONE
$ @AMT
Mark One Only
CS65
THE AMOUNT YOU HAVE ENTERED [fill CS63@AMT] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
Proceed
@
Mark One Only
CS66A
From [fill MONTH4] [fill TINTYR] to [fill MONTH4] [fill INTYR], did
[fill TEMPNAME] receive EVERY SINGLE ONE of the child support payments
[fill HESHE] [fill WASWERE] supposed to receive?
(1)
(2)
Yes
No
@
Mark One Only
CS66B
Of the child support payments [fill TEMPNAME] received from
[fill MONTH4] [fill TINTYR] to [fill MONTH4] [fill INTYR], how many
were received ON TIME?
Would you say all of them were on time, most of them, some of them,
or none of them?
(1)
(2)
(3)
(4)
All
Most
Some
None
@
Mark One Only
CS66C
For the child support payments [fill TEMPNAME] received, how many of
them were for the FULL amount [fill HESHE] [fill WASWERE] supposed
to receive? Would you say all of them, most of them, some of them,
or none of them?
(1)
(2)
(3)
(4)
All
Most
Some
None
@
Tuesday, November 24, 2009
Page 11 of 82
Survey:
Section: CHILD SUPPORT AGREEMENTS
Mark One Only
Items Booklet
CS67
Sometimes child support that was not paid in previous years is added
to the amount of support owed today. This is sometimes called back
support, back payments, or arrearages.
Did [fill PTEMPNAME] most recent agreement for the past 12 months
include payment for back support?
(1)
(2)
Yes
No
@
Multiple Entry
CS68
How much of the child support owed the last 12 months was considered
back payment?
$ @AMT
Mark One Only
CS68B
THE AMOUNT YOU HAVE ENTERED AS BACK SUPPORT OWED IN THE AGREEMENT
[fill CS68@AMT] IS GREATER THAN THE TOTAL AMOUNT THE RESPONDENT
STATED WAS OWED IN THE AGREEMENT, [fill CS60@AMT].
(1)
(P)
BACK UP AND CORRECT
PROCEED
@
Mark One Only
CS68C
[fill C_AREIS] [fill TEMPNAME] owed any back payments?
(1)
(2)
Yes
No
@
Enter Number
CS68D
To date, what is the amount of back payments OWED to [fill TEMPNAME]?
$@
Mark One Only
CS68F
THE AMOUNT YOU HAVE ENTERED [fill CS68D] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
Proceed
@
Enter Number
CS68G
How much back payment did [fill TEMPNAME] actually RECEIVE the last
12 months?
ENTER (N) FOR NONE
$@
Page 12 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: CHILD SUPPORT AGREEMENTS
CS68I
Mark One Only
THE AMOUNT YOU HAVE ENTERED AS BACK SUPPORT RECEIVED [fill CS68G]
IS GREATER THAN THE TOTAL AMOUNT OF CHILD SUPPORT
OWED. [fill CS63@AMT].
(1)
(P)
BACK UP AND CORRECT
PROCEED
@
CS69
Multiple Entry
What kinds of provisions for health care costs are included in the
child support agreement?
READ ALL RESPONSES
ENTER ALL YES RESPONSES
ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
@1
Non-custodial parent to provide health insurance
Custodial parent to provide health insurance
Non-custodial parent to pay actual medical costs directly
Child support payments include cash medical support
No provisions for health insurance were included in agreement
Other provisions
@2
@3
@4
@5
@6
Mark One Only
CS70
What child custody arrangements does the
child support agreement for **READ NAME(S)
OF CHILDREN** specify?
(1)
(2)
(3)
(4)
(5)
Child(ren) live with mother
Child(ren) live with father
Child(ren) live with mother and
with father
None
Other
@
Mark One Only
CS71
Does the child support agreement specify the amount of time that
the [fill TEMP1] will spend with the other parent?
(1)
(2)
Yes
No
@
Mark One Only
CS73
Did all the children spend about the same number of days with the
other parent in the last 12 months?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 13 of 82
Survey:
Section: CHILD SUPPORT AGREEMENTS
Items Booklet
Multiple Entry
CS74
-CS74[roster begin CHGRD]
[if CHSFLAG eq <1> and CSKEEP eq <1> and (CS73 eq <1> or CS73 eq <>)]
CHILD'S NAME: [fill CHILDNAMET]
LN: [fill GRDX2]
[endif]
[roster end CHGRD]
[if CS73 eq <2>]
CHILD'S NAME: [fill OLDNAME] LN: [fill TMP1] [endif]
What is the total amount of time **READ NAMES OF CHILDREN ABOVE** spent
with the other parent from [fill MONTH4] [fill TINTYR] to
[fill MONTH4] [fill INTYR]?
ENTER ONE RESPONSE
ENTER (N) FOR NO TIME
Number of days
@DAYS
Number of weeks @WEEKS
Number of months @MONTHS
Mark One Only
CS77
[if TMP1 gt <1>]
[else]
One reason a parent might not have a written agreement about child
support payments is because the child's father was never
LEGALLY IDENTIFIED.
[endif]
Was [fill CHILDNAMET]'s father ever legally identified by a
court ruling?
(1)
(2)
Yes
No
@
Mark One Only
CS78
Was [fill CHILDNAMET]'s father ever legally identified by a
blood test or other genetic test?
(1)
(2)
Yes
No
@
Mark One Only
CS79
Did [fill CHILDNAMET]'s father ever write his OWN signature on
the application for [fill CHILDNAMET]'s birth certificate?
(1)
(2)
Yes
No
@
Page 14 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: CHILD SUPPORT AGREEMENTS
Mark One Only
CS80
Other than the application for a birth certificate, did
[fill CHILDNAMET]'s father ever sign a statement or affidavit
that legally specifies that he is [fill CHILDNAMET]'s father?
(1)
(2)
Yes
No
@
Mark One Only
CS81
Did [fill CHILDNAMET]'s father ever sign any other papers,
such as insurance forms, a personal letter, or a card, that could
identify him as [fill CHILDNAMET]'s father?
(1)
(2)
Yes
No
@
Multiple Entry
CS83
One reason a parent might not have a written agreement about
child support payments is because the child's father was never
LEGALLY IDENTIFIED. One way to legally identify the child's
father is through marriage.
[fill C_WASWERE] [fill HESHE] ever married to [fill CHILDNAMET]'s
father?
(1)
(2)
Yes
No
@
Mark One Only
CS84
Was [fill CHILDNAMET]'s father ever legally identified by a
court ruling?
(1)
(2)
Yes
No
@
Mark One Only
CS85
Was [fill CHILDNAMET]'s father ever legally identified by a
blood test or other genetic test?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 15 of 82
Survey:
Section: CHILD SUPPORT AGREEMENTS
Items Booklet
CS86
Mark One Only
Did [fill CHILDNAMET]'s father ever write his OWN signature
on the application for [fill CHILDNAMET]'s birth certificate?
(1)
(2)
Yes
No
@
CS87
Mark One Only
Other than the application for a birth certificate, did
[fill CHILDNAMET]'s father ever sign a statement or affidavit
that legally specifies that he is [fill CHILDNAMET]'s father?
(1)
(2)
Yes
No
@
CS88
Mark One Only
Did [fill CHILDNAMET]'s father ever sign any other papers, such
as insurance forms, a personal, letter or a card, that could identify
him as [fill CHILDNAMET]'s father?
(1)
(2)
Yes
No
@
CS89
Multiple Entry
Why was this agreement for **READ NAME(S)
OF CHILDREN** never put in writing?
ENTER ALL YES RESPONSES
ENTER (N) AFTER LAST REPLY
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
@1
Legal paternity was not
established
Unable to locate parent
Other parent unable to pay
Final agreement pending
Accepted property settlement in
lieu of child support
Do not want a legal child
support award
Did not try to get child support
Other reason
@2
@3
@4
@5
@6
@7
@8
Mark One Only
CS90
Where does the other parent for this agreement now live?
(1)
(2)
(3)
(4)
(5)
(6)
Same county or city
Same state (different county or city)
Different state
Other parent now deceased
Other
Unknown
@
Page 16 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: CHILD SUPPORT AGREEMENTS
Mark One Only
CS91
[fill C_DODOES] [fill HESHE] and the other parent still live in the
same states(s) where the initial child support agreement was reached?
(1)
(2)
Yes
No
@
Mark One Only
CS92
Who moved?
(1)
(2)
(3)
Subject person
Other parent
Both subject person and other parent
@
Multiple Entry
CS94
Now I would like to ask a few questions
about the OTHER CHILD SUPPORT AGREEMENTS
[fill HESHE] had for **READ NAME(S) OF
CHILDREN**. What was the dollar amount
of [fill TEMP1] You may report this as a
weekly, biweekly, monthly, or an annual
amount.
$ @AMT per
(1)
(2)
(3)
(4)
Per week
Biweekly
Per month
Per year
@1
Mark One Only
CS96
THE AMOUNT YOU HAVE ENTERED [fill CS94@AMT] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
Proceed
@
Multiple Entry
CS97
What is the total amount that [fill HESHE] actually received in
child support payments under [fill TEMP1] during that period?
ENTER (N) IF NOTHING RECEIVED
$ @AMT
Mark One Only
CS99
THE AMOUNT YOU HAVE ENTERED [fill CS97@AMT] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
Proceed
@
Tuesday, November 24, 2009
Page 17 of 82
Survey:
Section: CHILD SUPPORT AGREEMENTS
Items Booklet
CS100
Mark One Only
ROSTER CS02
[roster begin CHGRD]
[if CSKEEP eq <1>]
CHILD'S NAME: [fill CHILDNAMET]
[endif]
[roster end CHGRD]
LN: [fill GRDX2]
For [fill TEMP1], (READ NAMES ABOVE), [fill HAVHAS] [fill HESHE]
ever asked a public agency, such as the child support enforcement
office or welfare agency, for help in obtaining child support?
(1)
(2)
Yes
No
@
CS101
Multiple Entry
In what year did [fill HESHE] LAST ASK for help?
@YEAR
CS102
Multiple Entry
What type of help did [fill HESHE] ask for in [fill HISHER]
last contact?
ENTER ALL YES RESPONSES
ENTER (N) AFTER LAST REPLY
(1)
(2)
(3)
(4)
(5)
(6)
(7)
@1
Locate the other parent
Establish paternity
Establish support obligation
Establish medical support
Enforce support order
Modify an order
Other
@2
@3
@4
@5
@6
@7
Mark One Only
CS103
Did [fill HESHE] receive any help from the agency as a result of
[fill HISHER] last contact?
(1)
(2)
Yes
No
@
Page 18 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: CHILD SUPPORT AGREEMENTS
CS104
Multiple Entry
What kind of help did [fill HESHE] receive as a result of
[fill HISHER] last contact or referral from the welfare office?
ENTER ALL YES RESPONSES
ENTER (N) AFTER LAST REPLY
(1)
(2)
(3)
(4)
(5)
(6)
(7)
@1
Locate the other parent
Establish paternity
Establish support obligation
Establish medical support
Enforce support order
Modify an order
Other
@2
@3
@4
@5
@6
@7
Mark One Only
CS107
[if CSTMP gt <1>]
[else]
One reason a parent might not have a written agreement about child
support payments is because the child's father was never LEGALLY
IDENTIFIED.
[endif]
Was [fill CHILDNAMET]'s father ever legally identified by a court
ruling?
(1)
(2)
Yes
No
@
Mark One Only
CS108
Was [fill CHILDNAMET]'s father ever legally identified by a
blood test or other genetic test?
(1)
(2)
Yes
No
@
Mark One Only
CS109
Did [fill CHILDNAMET]'s father ever write his OWN signature
on the application for [fill CHILDNAMET]'s birth certificate?
(1)
(2)
Yes
No
@
Mark One Only
CS110
Other than the application for a birth certificate, did
[fill CHILDNAMET]'s father ever sign a statement that legally
or affidavit specifies that he is [fill CHILDNAMET]'s father?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 19 of 82
Survey:
Section: CHILD SUPPORT AGREEMENTS
Mark One Only
Items Booklet
CS111
Did [fill CHILDNAMET]'s father ever sign any other papers,
such as insurance forms, a personal letter, or a card, that could
identify him as [fill CHILDNAMET]'s father?
(1)
(2)
Yes
No
@
Mark One Only
CS113
[if TMP1 gt <1>]
[else]
One reason a parent might not have a written agreement about child
support payments is because the child's father was never LEGALLY
IDENTIFIED. One way to legally identify the child's father is
through marriage.
[endif]
[fill C_WASWERE] [fill HESHE] ever married to [fill CHILDNAMET]'s
father?
(1)
(2)
Yes
No
@
Mark One Only
CS115
Do **READ NAME(S)** all have the same
father?
(1)
(2)
Yes
No
@
Mark One Only
CS116
Was [fill CHILDNAMET]'s father ever legally identified by a
court ruling?
(1)
(2)
Yes
No
@
Mark One Only
CS117
Was [fill CHILDNAMET]'s father ever legally identified by a
blood test or other genetic test?
(1)
(2)
Yes
No
@
Page 20 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: CHILD SUPPORT AGREEMENTS
CS118
Mark One Only
Did [fill CHILDNAMET]'s father ever write his OWN signature
on the application for [fill CHILDNAMET]'s birth certificate?
(1)
(2)
Yes
No
@
CS119
Mark One Only
Other than the application for a birth certificate, did
[fill CHILDNAMET]'s father ever sign a statement that legally
or affidavit specifies that he is [fill CHILDNAMET]'s father?
(1)
(2)
Yes
No
@
CS120
Mark One Only
Did [fill CHILDNAMET]'s father ever sign any other papers,
such as insurance forms, a personal letter, or a card, that could
identify him as [fill CHILDNAMET]'s father?
(1)
(2)
Yes
No
@
CS123
Mark One Only
[roster begin CHGRD]
[if CHSFLAG eq <3> and CSKEEP eq <1>]
CHILD'S NAME: [fill CHILDNAMET]
LN: [fill GRDX2]
[endif]
[roster end CHGRD]
Do **READ NAMES ABOVE** all have the same [fill TEMP1]?
(1)
(2)
Yes
No
@
CS124
Multiple Entry
Why were child support payments not agreed to or awarded for
[fill OLDNAME]?
ENTER ALL YES RESPONSES
ENTER (N) AFTER LAST REPLY
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
@1
Legal paternity was not established
Unable to locate parent
Other parent unable to pay
Final agreement pending
Accepted property or cash settlement in lieu of child support
Do not want a legal child support award
Did not try to get child support
Other reason
@2
Tuesday, November 24, 2009
@3
@4
@5
@6
@7
@8
Page 21 of 82
Survey:
Section: CHILD SUPPORT AGREEMENTS
Items Booklet
CS125
Mark One Only
Where does the other parent for [fill OLDNAME]
now live?
(1)
(2)
(3)
(4)
(5)
(6)
Same county or city
Same state (different county or city)
Different state
Other parent now deceased
Other
Unknown
@
CS125A
Mark One Only
Was there ever an agreement by a court order or other government
agency about the amount of time the [if NUMKIDZ1 gt <1>]children[else]child[endif]
would spend with the other parent?
(1)
(2)
Yes
No
@
CS126
Multiple Entry
What is the total amount of time [fill OLDNAME] spent with the
other parent from [fill MONTH4] [fill TINTYR] to [fill MONTH4]
[fill INTYR]?
ENTER ONE RESPONSE
ENTER (N) FOR NO TIME
Number of :
days
@DAYS
or
weeks @WEEKS
or
months @MONTHS
CS128
Multiple Entry
Why were child support agreements not agreed to or awarded for
[fill OLDNAME]?
ENTER ALL YES RESPONSES
ENTER (N) AFTER LAST REPLY
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
@1
Page 22 of 82
Legal paternity was not established
Unable to locate parent
Other parent unable to pay
Final agreement pending
Accepted property or cash settlement in lieu of child support
Do not want a legal child support award
Did not try to get child support
Other reason
@2
@3
@4
@5
@6
@7
@8
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: CHILD SUPPORT AGREEMENTS
Mark One Only
CS129
Where does the other parent for [fill OLDNAME]
now live?
(1)
(2)
(3)
(4)
(5)
(6)
Same county or city
Same state (different county or city)
Different state
Other parent now deceased
Other
Unknown
@
Mark One Only
CS129A
Was there ever an agreement by a court order or other government
agency about the amount of time the [if NUMKIDZ1 gt <1>]children[else]child[endif]
would spend with the other parent?
(1)
(2)
Yes
No
@
Multiple Entry
CS130
What is the total amount of time [fill OLDNAME] spent with the other
parent from [fill MONTH4] [fill TINTYR] to [fill MONTH4] [fill INTYR]?
ENTER ONE RESPONSE
ENTER (N) FOR NO TIME
Number of:
days
@DAYS
or
weeks @WEEKS
or
months @MONTHS
Mark One Only
CS131
Were any payments received from the other
[fill TEMP1] in the last 12 months for
**READ NAME(S)**?
(1)
(2)
Yes
No
@
Multiple Entry
CS132
What is the total amount that [fill HESHE] received from the
other [fill TEMP1] in the past 12 months?
$ @AMT
Mark One Only
CS134
THE AMOUNT YOU HAVE ENTERED [fill CS132@AMT] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
Proceed
@
Tuesday, November 24, 2009
Page 23 of 82
Survey:
Section: CHILD SUPPORT AGREEMENTS
Mark One Only
Items Booklet
CS135
For ANY of the children we have discussed, did the child's other
parent or parents provide any non-cash items during the last 12
months? Such items would include things like diapers, clothing,
or services such as child care.
(1)
(2)
Yes
No
@
Mark One Only
CS135A
[if CS28 eq <1> or CS58 eq <1>]
Earlier you said you were supposed to receive child support payments
during the last 12 months from your most recent agreement.
[endif]
Did any government or public agency collect any child support from
[if CS28 gt <0> or CS58 gt <0>][fill TEMP2]'s [endif]other parent on [fill PTEMPNAME] behalf
from [fill MONTH4] [fill TINTYR] to [fill MONTH4] [fill INTYR]?
(1)
(2)
Yes
No
@
Mark One Only
CS135B
Did the agency collect ALL or SOME of the child support due the last
12 months from [fill TEMP2]'s other parent?
(1)
(2)
All
Some
@
Enter Number
CS135C
How much child support income did the public or government agency
collect on [fill PTEMPNAME] behalf?
$@
Page 24 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: SUPPORT FOR NON-HOUSEHOLD MEMBERS
Mark One Only
SUP01
During the past 12 months, did [fill TEMPNAME] make payments
for the support of [fill PTEMPNAME] child or children under 21
years of age who live outside the household?
DO NOT INCLUDE PAYMENTS FOR A CHILD WHO IS AWAY AT SCHOOL BUT
WHO IS CONSIDERED PART OF THE HOUSEHOLD.
DO NOT INCLUDE PAYMENTS ALREADY REPORTED BY ANOTHER HOUSEHOLD MEMBER.
(1)
(2)
Yes
No
@
Multiple Entry
SUP02
Did [fill TEMPNAME] make regular payments, lump-sum payments,
or some other kind of payment?
MARK ALL THAT APPLY
ENTER (N) FOR NO MORE
(1)
(2)
(3)
@1
Regular payments
Lump sum payments
Other
@2
@3
Enter Number
SUP03
For how many children did [fill HESHE] make support
payments?
Number of Children: @
Mark One Only
SUP04
[fill TEMP1] under 18 years of age?
IF RESPONSE IS YES ENTER (1)
IF RESPONSE IS NO ENTER (0)
Number of Child(ren): @
Mark One Only
SUP05
Were any of these payments the result of a court order or
some other kind of agreement?
(1)
(2)
Yes
No
@
Enter Number
SUP06
The next few questions concern the most recent child support
agreement for [fill PTEMPNAME] children.
How many children were covered by that agreement?
Number of Children: @
Tuesday, November 24, 2009
Page 25 of 82
Survey:
Section: SUPPORT FOR NON-HOUSEHOLD MEMBERS
Mark One Only
Items Booklet
SUP07
Was this agreement a:
READ ALL CATEGORIES
(1)
(2)
(3)
(4)
Voluntary written agreement ratified by the court
Court-ordered agreement
Other type of written agreement
Non-written agreement
@
Enter Number
SUP08
In what year was this agreement FIRST reached?
Year:
@
Mark One Only
SUP09
Has the dollar amount agreed to originally ever been changed?
(1)
(2)
Yes
No
@
Enter Number
SUP10
In what year was the amount last changed?
Year:
@
Mark One Only
SUP11
Was this change made or agreed to by a court or child support
agency?
(1)
(2)
Yes
No
@
Mark One Only
SUP12
[fill C_AREIS] [fill TEMPNAME] still supposed to pay child
support?
(1)
(2)
Yes
No
@
Enter Number
SUP13
How much did [fill TEMPNAME] pay in child support under this
agreement during the past 12 months?
ENTER (N) FOR NONE
Amount: $@
Page 26 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: SUPPORT FOR NON-HOUSEHOLD MEMBERS
SUP14
Mark One Only
Were these payments made:
READ ALL CATEGORIES
(1)
(2)
(3)
(4)
(5)
Through employment related wage withholding?
Directly to the other parent?
Directly to the court?
Directly to a child support agency?
By some other method?
@
SUP15
Multiple Entry
What kinds of provisions for health care costs were included
in the child support agreement?
MARK ALL THAT APPLY
ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
@1
Non-custodial parent to provide health insurance
Custodial parent to provide health insurance
Non-custodial parent to pay medical costs directly
Child support payments to include cash medical support
Other provision
No provisions for health insurance or expenses
@2
@3
@4
@5
@6
Mark One Only
SUP16
What child support custody arrangement does the child support
agreement specify?
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Joint legal and physical custody
Joint legal with mother physical custody
Joint legal with father physical custody
Mother legal and physical custody
Father legal and physical custody
Split custody
Other-Specify
@
Mark One Only
SUP17
Does the child support agreement specify the amount of time
[fill TEMPNAME] may spend with [fill hisher] [fill TEMP1]?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 27 of 82
Survey:
Section: SUPPORT FOR NON-HOUSEHOLD MEMBERS
Multiple Entry
Items Booklet
SUP18
What is the total amount of time [fill TEMPNAME] spent with
[fill TEMP] under age 21 during the last 12
months?
ALLOW ONE RESPONSE IN ONE CATEGORY ONLY
ENTER (N) FOR NONE
Days:
@1
Weeks: @2
Months: @3
Mark One Only
SUP19
We talked about the most recent support agreement. Was there
any other agreement that covered [fill PTEMPNAME] other
[fill TEMP] under age 21 living outside of this household?
(1)
(2)
Yes
No
@
Enter Number
SUP20
How much did [fill TEMPNAME][fill
TEMP] during the past 12 months?
ENTER (N) FOR NONE
Amount:$@
Mark One Only
SUP21
Did [fill TEMPNAME] make any payments for any other of
[fill PTEMPNAME] children under age 21 living outside the
household without any kind of child support agreement in place?
(1)
(2)
Yes
No
@
Enter Number
SUP22
What is the total amount of the payments [fill TEMPNAME] made
on behalf of [fill PTEMPNAME] children under age 21 in the last
12 months?
Amount: $@
Multiple Entry
SUP23
What is the total amount of time [fill TEMPNAME] spent with
[fill TEMP] under age 21 during the past 12 months?
ALLOW ONE RESPONSE IN ONE CATEGORY ONLY
ENTER (N) FOR NONE
Days:
@1
Weeks: @2
Months: @3
Page 28 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: SUPPORT FOR NON-HOUSEHOLD MEMBERS
Mark One Only
SUP24
During the past 12 months, did [fill TEMPNAME] make regular
or lump sum payments for the support of any other person not
living in [fill PTEMPNAME] household?
(1)
(2)
Yes
No
@
Enter Number
SUP25
For how may other people did/do [fill TEMPNAME] make support
payments?
People: @
Mark One Only
SUP26
How is [fill TEMP1] [fill TEMPNAME] make support payments
for related to [fill TEMPNAME]?
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Parent
Spouse
Ex-spouse
Child under 21
Child over 21
Other relative
Not related
@
Mark One Only
SUP27
Where was this person most often living during the past 12 months?
READ ALL CATEGORIES
(1)
(2)
(3)
Private home or apartment
Nursing home
Someplace else
@
Enter Number
SUP28
How much did [fill TEMPNAME] pay for the support of this
person during the past 12 months?
Amount: $@
Tuesday, November 24, 2009
Page 29 of 82
Survey:
Section: SUPPORT FOR NON-HOUSEHOLD MEMBERS
Mark One Only
Items Booklet
SUP30
How is [fill TEMP1] [fill TEMPNAME] make/makes support
payments for related to [fill TEMPNAME]?
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Parent
Spouse
Ex-spouse
Child under 21
Child over 21
Other relative
Not related
@
Mark One Only
SUP31
Where was this person most often living during the past 12
months?
READ ALL CATEGORIES
(1)
(2)
(3)
Private home or apartment
Nursing home
Someplace else
@
Enter Number
SUP32
How much did [fill TEMPNAME] pay for the support of this
person during the past 12 months?
Amount: $@
Enter Number
SUP34
How much did [fill TEMPNAME] pay for the support of other
people that we have not talked about during the past 12 months?
Amount: $@
Page 30 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
ADQ1
Mark One Only
These next few questions are about
[fill PTEMPNAME] health. Would you say
[fill PTEMPNAME] health in general is
excellent, very good, good, fair, or poor?
(1)
(2)
(3)
(4)
(5)
Excellent
Very Good
Good
Fair
Poor
@
ADQ2
Multiple Entry
MARK BY OBSERVATION IF APPARENT
[fill C_DODOES] [fill TEMPNAME] use any of the
following aids?
a. A cane, crutches, or a
walker?
(1) Yes (2) No
@1
b. A wheelchair,electric scooter,
or similar aid for getting
around?
(1) Yes (2) No
@2
c. A hearing aid?
(1) Yes (2) No
@3
Mark One Only
ADQ3
[fill C_HAVHAS] [fill TEMPNAME] used a cane, crutches, or
a walker for six months or longer?
(1)
(2)
Yes
No
@
Mark One Only
ADQ4
[fill C_DODOES] [fill TEMPNAME] have difficulty seeing the
words and letters in ordinary newspaper print even when wearing
glasses or contact lenses if [fill HESHE] usually wear(s) them?
(1)
(2)
(3)
Yes
No
Person is blind
@
Mark One Only
ADQ5
[fill C_AREIS] [fill TEMPNAME] able to see the words
and letters in ordinary newspaper print at all?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 31 of 82
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Mark One Only
Items Booklet
ADQ6
[if ADQ2@3 eq <1>]
[fill C_DODOES] [fill TEMPNAME] have difficulty hearing
what is said in a normal conversation with another person
even when wearing [fill hisher] hearing aid?
[else]
[if ADQ2@3 ne <1>]
[fill C_DODOES] [fill TEMPNAME] have difficulty hearing
what is said in a normal conversation with another person?
[endif][endif]
(1)
(2)
(3)
Yes
No
Person is deaf
@
Mark One Only
ADQ7
[fill C_AREIS] [fill TEMPNAME] able to hear what is said
in a normal conversation at all?
(1)
(2)
Yes
No
@
Mark One Only
ADQ8
[fill C_DODOES] [fill TEMPNAME] have difficulty having
[fill HISHER] speech understood?
DO NOT ENTER (1) FOR YES IF THE PERSON HAS TROUBLE SIMPLY
BECAUSE THEY SPEAK A LANGUAGE OTHER THAN ENGLISH
(1)
(2)
Yes
No
@
Mark One Only
ADQ9
In general, are people able to understand
[fill PTEMPNAME] speech at all?
(1)
(2)
Yes
No
@
Mark One Only
ADQ10
[fill C_DODOES] [fill TEMPNAME] have any difficulty lifting
and carrying something as heavy as 10 pounds such as a bag of groceries?
(1)
(2)
Yes
No
@
Page 32 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Mark One Only
ADQ11
[fill C_AREIS] [fill TEMPNAME] able to lift and carry
a 10 pound bag of groceries at all?
(1)
(2)
Yes
No
@
Mark One Only
ADQ12
Would [fill TEMPNAME] have any difficulty lifting and carrying a
25 pound bag of pet food?
(1)
(2)
Yes
No
@
Mark One Only
ADQ13
[if ADQ11 eq <1>]
We have recorded that [fill TEMPNAME] would have diffculty lifting
10 pounds but would be able to do it.
[endif]
Would [fill TEMPNAME] be able to lift and
carry a 25 pound bag of pet food[if ADQ12 eq <1>] at all?[else]?[endif]
(1)
(2)
Yes
No
@
Mark One Only
ADQ14
[fill C_DODOES] [fill TEMPNAME] have any difficulty
pushing or pulling large objects such as
a living room chair?
(1)
(2)
Yes
No
@
Mark One Only
ADQ15
[fill C_AREIS] [fill TEMPNAME] able to push or
pull such large objects at all?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 33 of 82
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Items Booklet
ADQ16
Multiple Entry
[fill C_DODOES] [fill TEMPNAME] have any difficulty (1) Yes
(2) No
a. Standing or being on
[fill HISHER] feet for one
hour?
@1
b. Sitting for one hour?
@2
c. Stooping, crouching, or
kneeling?
@3
d. Reaching over [fill HISHER]
head?
@4
Mark One Only
ADQ17
[fill C_DODOES] [fill TEMPNAME] have difficulty using
[fill HISHER] hands and fingers to do things
such as picking up a glass or grasping a pencil?
(1)
(2)
Yes
No
@
Mark One Only
ADQ18
[fill C_AREIS] [fill TEMPNAME] able to use [fill HISHER]
hands and fingers to grasp and handle at all?
(1)
(2)
Yes
No
@
Mark One Only
ADQ19
[fill C_DODOES] [fill TEMPNAME] have any difficulty
walking up a flight of 10 stairs?
(1)
(2)
Yes
No
@
Mark One Only
ADQ20
[fill C_AREIS] [fill TEMPNAME] able to walk up a flight of
10 stairs at all?
(1)
(2)
Yes
No
@
Page 34 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Mark One Only
ADQ21
[fill C_DODOES] [fill TEMPNAME] have any difficulty walking a
quarter of a mile - about 3 city blocks?
(1)
(2)
Yes
No
@
Mark One Only
ADQ22
[fill C_AREIS] [fill TEMPNAME] able to walk a quarter
of a mile at all?
(1)
(2)
Yes
No
@
Mark One Only
ADQ23
[fill C_DODOES] [fill TEMPNAME] have any difficulty
using an ordinary telephone?
(1)
(2)
Yes
No
@
Mark One Only
ADQ24
[fill C_AREIS] [fill TEMPNAME] able to use an ordinary
telephone at all?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 35 of 82
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Items Booklet
ADQ25
Multiple Entry
Because of a physical or mental health condition,
[fill DODOES] [fill TEMPNAME] have difficulty doing any of
the following by [fill SELF]?
EXCLUDE THE EFFECTS OF TEMPORARY CONDITIONS IF AN AID IS USED, ASK WHETHER THE PERSON HAS DIFFICULTY
WHEN USING THE AID.
(1)
Yes
(2)
No
a. Getting around INSIDE
the home?
@1
b. Going OUTSIDE the home,
for example, to shop or
visit a doctor's office?
@2
c. Getting in and out of bed
or a chair?
@3
d. Taking a bath or shower
@4
e. Dressing?
@5
f. Walking?
@6
g. Eating?
@7
h. Using or getting to the
toilet?
@8
i. Keeping track of money
or bills?
@9
j. Preparing meals?
@10
k. Doing light housework such
as washing dishes or sweeping
a floor?
@11
l. Taking the right amount of
prescribed medicine at the
right time?
@12
Page 36 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
ADQ26
Multiple Entry
[fill C_DODOES] [fill TEMPNAME] need the help of
another person with :
READ ACTIVITY LISTED
(1) Yes
(2) No
[if ADQ25@1 eq <1>]
a. Getting around INSIDE
the home?
[endif]
@1
[if ADQ25@2 eq <1>]
b. Going OUTSIDE the home,
for example, to shop or
visit a doctor's office?
[endif]
[if ADQ25@3 eq <1>]
@2
c. Getting in and out of bed
or a chair?
[endif]
@3
[if ADQ25@4 eq <1>]
d. Taking a bath or shower?
[endif]
[if ADQ25@5 eq <1>]
@4
e. Dressing?
[endif]
@5
[if ADQ25@6 eq <1>]
f. Walking?
[endif]
[if ADQ25@7 eq <1>]
@6
g. Eating?
[endif]
@7
[if ADQ25@8 eq <1>]
h. Using or getting to the
toilet?
[endif]
[if ADQ25@9 eq <1>]
@8
i. Keeping track of money and bills?@9
[endif]
[if ADQ25@10 eq <1>]
j. Preparing meals?
[endif]
@10
[if ADQ25@11 eq <1>]
k. Doing light housework
such as washing dishes
or sweeping a floor?
[endif]
[if ADQ25@12 eq <1>]
l. Taking the right amount
of prescribed medicine
at the right time?
[endif]
Tuesday, November 24, 2009
@11
@12
Page 37 of 82
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Items Booklet
AD27A
Mark One Only
You have said [fill TEMPNAME] need(s) the help of
another person with one or more activities. Who
generally helps [fill TEMPNAME] with these activities?
MARK ONLY ONE
First Helper
-----------RELATIVE
(1)
(2)
(3)
(4)
(5)
NONRELATIVE
Son
Daughter
Spouse
Parent
Other relative
(6) Friend or Neighbor
(7) Paid help
(8) Other nonrelative
Did not receive help
(9) Did not receive help
@
AD27B
Enter Number
ASK OR VERIFY : THIS PERSON MUST BE 15 YEARS OF AGE OR OLDER
Is the person who generally helps [fill TEMPNAME] with
these activities a member of this household?
ENTER LINE NUMBER OF PERSON OR (N) IF NOT A HOUSEHOLD MEMBER
@
AD27C
Mark One Only
Does anyone else help [fill TEMPNAME] with these
activities?
MARK ONLY ONE
NO ONE ELSE HELPED
(1) No one else helped
RELATIVE
(2)
(3)
(4)
(5)
(6)
NONRELATIVE
Son
Daughter
Spouse
Parent
Other relative
(7) Friend or Neighbor
(8) Paid help
(9) Other nonrelative
@
Enter Number
AD27D
ASK OR VERIFY : THIS PERSON MUST BE 15 YEARS OF AGE OR OLDER
Is this person a member of this household?
ENTER LINE NUMBER OF PERSON OR (N) IF NOT A HOUSEHOLD MEMBER
@
Page 38 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Mark One Only
ADQ29
For how long [fill HAVHAS] [fill TEMPNAME] needed help of
another person?
(1)
(2)
(3)
(4)
(5)
Less
6 to
1 to
3 to
More
than 6 months
11 month
2 years
5 years
than 5 years
@
Mark One Only
ADQ30
During the past month, did [fill TEMPNAME] or
([fill PTEMPNAME] family) pay for any of the help
that [fill TEMPNAME] received?
(1)
(2)
Yes
No
@
Enter Number
ADQ31
How much was paid for such help in [fill TEMP5]?
ENTER ($1-$999999)
$@
Multiple Entry
ADQ32
SHOW FLASHCARD CC FOR PERSONAL VISIT INTERVIEWS.
I have recorded that [fill TEMPNAME] [fill HAVHAS] difficulty
with certain activities. Which condition or conditions
cause these difficulties?
Any Others?
ENTER (N) FOR NONE OR NO MORE
ENTER (H) FOR LIST OF HEALTH CONDITIONS
IF THE PERSON REPORTS MORE THAN THREE CONDITIONS ENTER THE
APPROPRIATE CODE FOR THE FIRST THREE CONDITIONS THE RESPONDENT
IDENTIFIED.
@1
@2
@3
Enter Text
ADQ32A
Specify the exact "Other" condition that causes this difficulty.
@
Tuesday, November 24, 2009
Page 39 of 82
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Multiple Entry
Items Booklet
ADQ33
SHOW FLASHCARD CC FOR PERSONAL VISIT INTERVIEWS
I have recorded that [fill PTEMPNAME] health
is [fill TEMPQ33]. Which condition or conditions
cause [fill PTEMPNAME] health problems?
Any Others?
IF THE PERSON REPORTS MORE THAN THREE CONDITIONS ENTER THE
APPROPRIATE CODE FOR THE FIRST THREE CONDITIONS THE RESPONDENT
IDENTIFIED
MARK ALL THAT APPLY
ENTER (H) FOR LIST OF HEALTH CONDITIONS
ENTER (N) FOR NONE OR NO MORE
@1
@2
@3
Enter Text
ADQ33A
Specify the exact "Other" condition that causes your health problem.
@
Mark One Only
ADQ34
[if ADQ32@2 eq or ADQ33@2 eq ]
Is this condition the result of a motor vehicle accident?
[else]
Are any of these conditions the result of a motor vehicle
accident?
[endif]
(1)
(2)
Yes
No
@
Enter Number
ADQ35
Which of the conditions that you mentioned do you
consider to be the main reason for [fill PTEMPNAME]
difficulties?
[fill BIGTEMP]
[fill BIGTEMP2]
[fill BIGTEMP3]
@ Main condition
Multiple Entry
ADQ36
When did [fill BIGTEMP4]
first begin to bother [fill TEMPNAME]?
ENTER (S) FOR SINCE BIRTH
ENTER 4 DIGIT YEAR
@yr
Page 40 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
ADQ36B
Multiple Entry
Do you know what month?
@mn
ADQ37
Mark One Only
[fill C_HAVHAS] [fill TEMPNAME] had this condition for at
least 5 months?
(1)
(2)
Yes
No
@
ADQ38
Mark One Only
Is this condition expected to last for at least
12 more months?
(1)
(2)
Yes
No
@
ADQ39
Multiple Entry
[fill C_DODOES] [fill TEMPNAME] have (1) Yes
(2) No
a. A learning disability
such as dyslexia?
@1
b. Mental retardation?
@2
c. A developmental disability
such as autism or
cerebral palsy?
@3
d. Alzheimer's disease or
any other serious
problem with confusion
or forgetfulness?
@4
e. Any other mental or
emotional condition?
@5
Mark One Only
ADQ40
[fill C_AREIS] [fill TEMPNAME] frequently depressed
or anxious?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 41 of 82
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Items Booklet
ADQ41
Multiple Entry
[fill C_DODOES] [fill TEMPNAME] have (1)
Yes
(2)
No
a. A lot of trouble
getting along with
other people and
making and keeping
friendships
@1
b. A lot of trouble
concentrating long
enough to finish
everyday tasks
@2
c. A lot of trouble
coping with day-to-day
stresses?
@3
Mark One Only
ADQ42
During the past 12 months, did the problems just
mentioned seriously interfere with [fill PTEMPNAME]
ability to manage everyday activities?
(1)
(2)
Yes
No
@
Mark One Only
ADQ43
[fill C_DODOES] [fill TEMPNAME] have a long-lasting physical or
mental condition that has made it difficult to remain
employed or to find a job?
(1)
(2)
Yes
No
@
Mark One Only
ADQ44
Does [fill PTEMPNAME] health or condition prevent
[fill TEMPNAME] from working at a job or business?
(1)
(2)
Yes
No
@
Mark One Only
ADQ45
[fill C_DODOES] [fill TEMPNAME] have a physical, mental, or
other health condition that limits the kind or
amount of work [fill TEMPNAME] can do around the house?
(1)
(2)
Yes
No
@
Page 42 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Mark One Only
ADQ46
Does [fill PTEMPNAME] health or condition completely
prevent [fill TEMPNAME] from doing work around the
house?
(1)
(2)
Yes
No
@
Multiple Entry
ADQ47
SHOW FLASHCARD CC FOR PERSONAL VISIT INTERVIEWS.
I have recorded that [fill TEMPNAME] [fill HAVHAS] a limitation
in working [fill TEMPQ47]. Which condition or conditions
cause this limitation?
ENTER (H) FOR LIST OF HEALTH CONDITIONS
ENTER (N) FOR NONE OR NO MORE
IF THE PERSON REPORTS MORE THAN THREE CONDITIONS ENTER THE
APPROPRIATE CODE FOR THE FIRST THREE CONDITIONS THE RESPONDENT
IDENTIFIED.
Any Others?
@1
@2
@3
Enter Text
ADQ47A
Specify the exact "Other" condition that causes your work limitation.
@
Multiple Entry
ADQ48
Which of the conditions that you mentioned do you
consider to be the main reason for [fill PTEMPNAME]
limitation?
[fill BIGTEMP]
[fill BIGTEMP2]
[fill BIGTEMP3]
@1
Enter Text
ADQ48A
Specify the exact "Other" condition you consider to be the main reason
for your limitation.
@
Tuesday, November 24, 2009
Page 43 of 82
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Items Booklet
ADQ49
Mark One Only
In the last 12 months, [fill HAVHAS] [fill TEMPNAME] applied
for social security disability benefits for
[fill self]?
(1)
(2)
Yes
No
@
ADQ50
Mark One Only
These next few questions are about computer usage.
computer or laptop in this household?
(1)
(2)
Is there a
Yes
No
@
ADQ51
Mark One Only
[fill C_DODOES] [fill TEMPNAME] use a computer at home?
(1)
(2)
Yes
No
@
ADQ52
Mark One Only
[fill C_DODOES] [fill TEMPNAME]
[fill HISHER] main job?
(1)
(2)
use a computer as part of
Yes
No
@
Mark One Only
ADQ53
[fill C_DODOES] [fill TEMPNAME] use a computer at school?
(1)
(2)
Yes
No
@
Mark One Only
ADQ54
[fill C_DODOES] [fill TEMPNAME] use the Internet from any location?
(1)
(2)
Yes
No
@
Page 44 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
ADQ55
Mark One Only
[fill C_DODOES] [fill TEMPNAME] connect to the Internet at home?
(1)
(2)
Yes
No
@
ADQ56
Mark One Only
[fill C_DODOES] [fill TEMPNAME] connect to the Internet at work?
(1)
(2)
Yes
No
@
ADQ57
Mark One Only
[fill C_DoDoes] [fill TEMPNAME] use the Internet at school?
(1)
(2)
Yes
No
@
ADQ58
Multiple Entry
[fill C_DoDoes] [fill TEMPNAME] use the Internet at
a. a public library
b. a community center
c. someone else's house
d. Other, specify
(1)
@1
(1)
@2
(1)
@3
(1)
@4
Yes
(2) No
Yes
(2) No
Yes
(2) No
Yes
(2) No
Enter Text
ADQ58OTH
Please specify the other place that you use the Internet:
@
Mark One Only
ADQ59
Now we're going to talk about how [fill TEMPNAME] may have used the
Internet this year.
This year, [fill HAVHAS] [fill TEMPNAME] used the Internet to take
a course online?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 45 of 82
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Mark One Only
Items Booklet
ADQ60
This year, [fill HAVHAS] [fill TEMPNAME] used the Internet to search for
information about health services or practices?
(1)
(2)
Yes
No
@
Mark One Only
ADQ61
This year, [fill HAVHAS] [fill TEMPNAME] used the Internet to search
for information about government services or agencies?
(1)
(2)
Yes
No
@
Mark One Only
ADQ62
This year, [fill HAVHAS] [fill TEMPNAME] used the Internet to search
for a job?
(1)
(2)
Yes
No
@
Mark One Only
ONLINE
Would [fill HESHE] be willing to respond to future SIPP interviews
over the Internet?
(1)
(2)
Yes
No
@
Mark One Only
INTSTILL
If the SIPP questionnaire was available through the Internet, we
expect it would work like this:
-
you could answer the questionnaire at your convenience;
an interviewer would not directly administer the
questionnaire;
it might take longer to complete the questionnaire than
the current practice;
everyone in the household would be asked to fill in parts
of the questionnaire for themselves.
-
Under these conditions, would your household be willing to respond
to future SIPP interviews over the Internet?
(1)
(2)
Yes
No
@
Page 46 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
CDQ1A
Mark One Only
Does [fill CDNAME] have a serious physical or mental condition
or a developmental delay that limits ordinary activities?
[r]H[n]
(1)
(2)
Yes
No
@
CDQ1B
Mark One Only
Does [fill CDNAME] have a long-lasting condition that limits
[fill HISHERG] ability to move [fill HISHERG] arms or legs?
(1)
(2)
Yes
No
@
CDQ1C
Mark One Only
Does [fill CDNAME] have a long-lasting condition that limits
[fill HISHERG] ability to walk, run, or play?
[r]H[n]
(1)
(2)
Yes
No
@
CDQ3
Mark One Only
Because of a physical, learning, or mental condition, does
[fill CDNAME] have any limitations in [fill HISHERG] ability
to do regular school work?
[r]H[n]
(1)
(2)
Yes
No
@
CDQ4
Mark One Only
Has [fill CDNAME] ever received special education services?
[r]H[n]
(1)
(2)
Yes
No
@
Mark One Only
CDQ5
Is [fill CDNAME] currently receiving special education
services?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 47 of 82
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Items Booklet
CDQ6
Multiple Entry
Does [fill CDNAME] have:
[r]H[n]
(1)
Yes
(2)
No
a. A learning disability
such as dyslexia?
@1
b. Mental retardation?
@2
c. A developmental
disability such as
autism or cerebral palsy?
@3
d. Attention Deficit Hyperactivity
Disorder (ADHD)
@4
e. Any other developmental condition
for which [fill HESHEG] has received
therapy or diagnostic services? @5
CDQ6A
Mark One Only
Does [fill CDNAME] take medication or receive treatment for
ADHD?
(1) Yes
(2) No
@
CDQ7
Multiple Entry
MARK BY OBSERVATION IF APPARENT:
Does [fill CDNAME] use any of the following aids?
(1)
Yes
(2)
No
a. A cane, crutches, or a walker?
@1
b. A wheelchair or an electric
scooter?
@2
c. A hearing aid?
@3
Mark One Only
CDQ8
Has [fill CDNAME] used a cane, crutches, or a walker
for six months or longer?
(1)
(2)
Yes
No
@
Page 48 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
CDQ9
Mark One Only
Does [fill CDNAME] have difficulty seeing the words and
letters in ordinary newspaper print, even when wearing
glasses or contact lenses if [fill HESHEG] usually wears them?
(1)
(2)
(3)
Yes
No
Person is blind
@
CDQ10
Mark One Only
Is [fill CDNAME] able to see the words and letters in
ordinary newspaper print at all?
(1)
(2)
Yes
No
@
CDQ11
Mark One Only
[if CDQ7@3 eq <1>]
Does [fill CDNAME] have difficulty hearing
what is said in a normal conversation with another person
even when wearing [fill hisherg] hearing aid?
[else]
[if CDQ7@3 ne <1>]
Does [fill CDNAME] have difficulty hearing
what is said in a normal conversation with another person?
[endif][endif]
(1)
(2)
(3)
Yes
No
Person is deaf
@
CDQ12
Mark One Only
Is [fill CDNAME] able to hear what is said in a normal
conversation at all?
(1)
(2)
Yes
No
@
CDQ13
Mark One Only
Does [fill CDNAME] have any difficulty having
[fill HISHERG] speech understood?
[r]H[n]
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 49 of 82
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Mark One Only
Items Booklet
CDQ14
In general, are people able to understand [fill CDNAME]'s
speech at all?
(1)
(2)
Yes
No
@
Mark One Only
CDQ15
Does [fill CDNAME] have a long-lasting condition that limits
[fill HISHERG] ability to walk, run, or take part in sports
and games?
(1)
(2)
Yes
No
@
Mark One Only
CDQ16
Because of a long-lasting physical or mental condition does
[fill CDNAME] have any difficulty getting around INSIDE the
home by [fill SELFG]?
(1)
(2)
Yes
No
@
Mark One Only
CDQ17
Does [fill CDNAME] need the help of another person with
getting around inside the home?
(1)
(2)
Yes
No
@
Mark One Only
CDQ18
Does [fill CDNAME] have any difficulty getting in and out
of bed or a chair by [fill SELFG]?
(1)
(2)
Yes
No
@
Mark One Only
CDQ19
Does [fill CDNAME] need the help of another person with
getting in and out of bed or a chair?
(1)
(2)
Yes
No
@
Page 50 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Mark One Only
CDQ20
Does [fill CDNAME] have any difficulty taking a bath
or shower by [fill SELFG]?
(1)
(2)
Yes
No
@
Mark One Only
CDQ21
Does [fill CDNAME] need the help of another person with
taking a bath or shower?
(1)
(2)
Yes
No
@
Mark One Only
CDQ22
Because of a long-lasting condition does [fill CDNAME] have
any difficulty putting on [fill HISHERG] clothing by [fill SELFG]?
(1)
(2)
Yes
No
@
Mark One Only
CDQ23
Does [fill CDNAME] need the help of another person with putting
on [fill HISHERG] clothing?
(1)
(2)
Yes
No
@
Mark One Only
CDQ24
Does [fill CDNAME] have any difficulty eating food
by [fill SELFG]?
(1)
(2)
Yes
No
@
Mark One Only
CDQ25
Does [fill CDNAME] need the help of another person
with eating food?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 51 of 82
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Mark One Only
Items Booklet
CDQ26
Does [fill CDNAME] have any difficulty using or getting
to the toilet by [fill SELFG]?
(1)
(2)
Yes
No
@
Mark One Only
CDQ27
Does [fill CDNAME] need the help of another person with
using or getting to the toilet?
(1)
(2)
Yes
No
@
Mark One Only
CDQ28
Does [fill CDNAME] have an emotional or mental condition that
makes it difficult to play with or get along with other
children of the same age?
(1)
(2)
Yes
No
@
Multiple Entry
CDQ29
SHOW FLASHCARD DD FOR PERSONAL VISIT INTERVIEWS.
I have recorded that [fill CDNAME] has difficulty with certain
activities. Which condition or conditions cause this difficulty?
Any others?
Enter (N) for None or No More.
Enter (H) for list of health conditions.
IF THE PERSON REPORTS MORE THAN THREE CONDITIONS
ENTER THE APPROPRIATE CODE FOR THE FIRST THREE
CONDITIONS THE RESPONDENT IDENTIFIED.
@1
@2
@3
Enter Text
CDQ29A
Specify the exact "Other" condition that causes this difficulty.
@
Page 52 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: FUNCTIONAL LIMITATIONS & DISABILITY (ADLT & CHLD)
Mark One Only
CDQ30
[if CDQ29@2 eq ]
Is this condition the result of a motor vehicle accident?
[else]
Are any of these conditions the result of a motor
vehicle accident?
[endif]
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 53 of 82
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Items Booklet
HB04
Mark One Only
Does [fill PTEMPNAME] employer offer a health insurance plan to
ANY of its employees?
(1)
(2)
Yes
No
@
HB05
Mark One Only
Why [fill AREIS] [fill TEMPNAME] NOT covered by this plan?
READ EACH CATEGORY
(1)
(2)
(3)
(4)
Ineligible
Denied coverage
Chose not to be covered
Other
@
HB06
Multiple Entry
Specify the exact "OTHER" reason [fill TEMPNAME] [fill WASWERE] not
covered by this plan.
@1
HB07
Multiple Entry
Why [fill WASWERE] [fill TEMPNAME] ineligible?
MARK ALL THAT APPLY
ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
@1
Probationary period not completed
Contract or temporary employee
Part-time employee
Other
@2
@3
@4
Multiple Entry
HB08
Specify the exact "OTHER" reason [fill TEMPNAME] [fill WASWERE]
ineligible for health insurance.
@1
Mark One Only
HB09
Why [fill WASWERE] [fill TEMPNAME] denied coverage?
(1)
(2)
(3)
Turned down based on pre-existing condition
Turned down based on age
Other
@
Page 54 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
HB10
Multiple Entry
Specify the exact "OTHER" reason [fill TEMPNAME] [fill WASWERE]
denied coverage.
@1
HB11
Multiple Entry
SHOW FLASHCARD EE
Why did [fill TEMPNAME] choose not to be covered?
READ EACH CATEGORY
MARK ALL THAT APPLY
ENTER (N) FOR NO MORE
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
@1
Covered by other health insurance
[fill C_HAVHAS] medical savings account
Plan had no family coverage
Plan too costly
Plan did not cover pre-existing conditions
Plan had too many limitations on coverage
[fill DOESDID] not need or want coverage
[fill DOESDID] not believe in health insurance
Had insurance but canceled it because of
dissatisfaction
Other
@2
@3
@4
@5
@6
@7
@8
@9
@10
HB12
Multiple Entry
Specify the reason [fill TEMPNAME] chose not to be covered.
@1
HB13
Multiple Entry
SHOW FLASHCARD FF
In offering health insurance, did [fill PTEMPNAME] employer offer
[fill HIMHER] the opportunity to choose:
READ EACH CATEGORY
MARK ALL THAT APPLY
ENTER (N) FOR NONE OR NO MORE
(1)
(2)
(3)
(4)
(5)
@1
Cash deposited in a 401(k) plan instead of health benefits?
Cash or a salary bonus instead of health benefits?
A high deductible health insurance plan combined with a
Medical Savings Account (MSA)
Tax-free employee contributions to a Flexible Spending
Account (FSA)
Other benefits (e.g. life insurance, day care, vacation) in
place of health benefits
@2
Tuesday, November 24, 2009
@3
@4
@5
Page 55 of 82
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Items Booklet
HB17
Mark One Only
Was [fill PTEMPNAME] health insurance coverage obtained through:
READ EACH CATEGORY
(1)
(2)
(3)
(4)
Spouse's group/employer plan
Other private group plan
An individually purchased policy
Other health insurance
@
HB18
Multiple Entry
Specify the "OTHER" health insurance policy.
@1
HB20
Mark One Only
Can [fill TEMPNAME] obtain coverage under this plan for [fill HISHER]
spouse and other family or non-family members?
(1)
(2)
Yes
No
@
HB22
Multiple Entry
Who may obtain coverage under this plan?
MARK ALL THAT APPLY
ENTER (N) FOR NONE OR NO MORE
(1)
(2)
(3)
(4)
(5)
@1
Spouse
Children
Grandchildren
Other family members
Non-family members
@2
@3
@4
@5
Mark One Only
HB24
Why did [fill TEMPNAME] choose NOT to obtain coverage for
[fill CHNAME1]?
MARK THE MAIN REASON
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Child is covered by Medicaid
Child is covered by Medicare
Child is covered by other private policy
Child is covered by the group policy of someone not
living in this household
Too costly to obtain coverage for child
Plan did not cover pre-existing conditions of child
Child is in good health
Child is covered by the group policy of someone else
living in this household
Other reason
@
Page 56 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Enter Text
HB25
Specify the exact "OTHER" reason [fill TEMPNAME] chose not to obtain
coverage for [fill HISHER] children who are eligible under this plan.
@
Multiple Entry
HB27
How much [fill DODOES] [fill TEMPNAME] pay for [fill HISHER] health
plan?
$ @AMT
Mark One Only
HB28
THE AMOUNT ENTERED [FILL HB27@AMT] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
PROCEED
@
Mark One Only
HB29
How often [fill DODOES] [fill TEMPNAME] pay this amount?
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Weekly
Every two weeks
Twice monthly
Monthly
Semi-annually
Annually
Other
@
Enter Text
HB30
Specify the exact "OTHER" amount of time that [fill TEMPNAME] pay.
@
Mark One Only
HB32
[fill C_DODOES] [fill PTEMPNAME] contributions for [fill HISHER]
health plan receive special tax treatment? For example, are
[fill HISHER] contributions made through a premium reimbursement
account, often called a premium conversion plan?
(1)
(2)
Yes
No
@
Mark One Only
HB34
When [fill TEMPNAME] left that employer did [fill HISHER] share of
the premium increase?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 57 of 82
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Items Booklet
HB36
Mark One Only
How long after [fill TEMPNAME] left that employer can this health
plan continue to be in effect?
(1)
(2)
(3)
(4)
(5)
(6)
Until age 65 or Medicare eligibility
Less than 1 month
1 to 18 months
19 to 36 months
More than 36 months
For life
@
HB38
Mark One Only
Does [fill PTEMPNAME] health plan cover Medicare coinsurance and
deductibles?
(1)
(2)
Yes
No
@
HB39
Multiple Entry
In offering health insurance, did [fill PTEMPNAME] employer offer
[fill HIMHER] the opportunity to choose:
READ EACH CATEGORY
MARK ALL THAT APPLY
ENTER (N) FOR NONE OR NO MORE
(1)
(2)
(3)
(4)
(5)
@1
Cash deposited in a 401(k) plan instead of health benefits?
Cash or a salary bonus instead of health benefits?
A high deductible health insurance plan combined with a
Medical Savings Account (MSA)
Tax-free employee contributions to a Flexible Spending
Account (FSA)
Other benefits (e.g. life insurance, day care, vacation) in
place of health benefits
@2
@3
@4
@5
HB40
Enter Text
The next few questions are about the characteristics of
[fill PTEMPNAME] health insurance. We are interested in
knowing if [fill PTEMPNAME] current plan is an HMO, that is,
a Health Maintenance Organization.
[r]H[n]
(P)
Proceed
@
Mark One Only
HB42
Is [fill PTEMPNAME] plan an HMO?
(1)
(2)
Yes
No
@
Page 58 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Mark One Only
HB43
Does [fill PTEMPNAME] insurance plan require [fill HIMHER] to sign
up with a certain primary care doctor, group of doctors, or with a
certain clinic to which [fill HESHE] must go for all of
[fill HISHER] routine care?
(1)
(2)
Yes
No
@
Multiple Entry
HB44
Is there a book or list of doctors associated with the plan?
(1)
(2)
Yes
No
@
Multiple Entry
HB45
If [fill TEMPNAME] [fill DODOES] NOT have a referral, will
[fill PTEMPNAME] plan pay for any of the costs of visits to
doctors who are NOT associated with [fill PTEMPNAME] plan?
(1)
(2)
Yes
No
@
Mark One Only
HB47
Did [fill PTEMPNAME] [fill TEMP1] employer offer more than one health
insurance plan from which to choose, or was [fill HISHER] plan the
only choice?
(1)
(2)
Employer offers more than one plan to choose from
Respondent's plan is the only one
@
Mark One Only
HB49
In addition to the kind of plan [fill TEMPNAME] chose, did
[fill HISHER] [fill TEMP1] employer offer any traditional health
insurance plans that let [fill HIMHER] choose [fill HISHER] own
doctor and that reimburse [fill HIMHER] or pay the doctor directly
following submission of medical bills?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 59 of 82
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Items Booklet
HB50
Mark One Only
In addition to the kind of plan [fill TEMPNAME] chose, did
[fill HISHER] [fill TEMP1] employer offer any health insurance
plans through Health Maintenance Organizations, HMOs?
[r]H[n]
(1)
(2)
Yes
No
@
Mark One Only
HB51
Does [fill PTEMPNAME] employer provide any educational
materials to help [fill HIMHER] make [fill HISHER] choice?
(1)
(2)
Yes
No
@
Mark One Only
HB52
Did the educational materials provide an easy way to compare the
costs, benefits, quality or any differences between the plans?
(1)
(2)
Yes
No
@
Mark One Only
HB53
[fill C_DODOES] [fill TEMPNAME] or a family member have a pre-existing
medical condition that is not covered by this plan?
(1)
(2)
Yes
No
@
Mark One Only
HB56
Does [fill PTEMPNAME] employer offer a plan to any of its employees
that provides nursing home or home care coverage for long-term care
needs to employees or family members?
(1)
(2)
Yes
No
@
Mark One Only
HB57
[fill C_AREIS] [fill TEMPNAME] covered under this long term care plan?
(1)
(2)
Yes
No
@
Page 60 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Mark One Only
HB58
Does [fill PTEMPNAME] employer pay for all, part, or none of the costs
of the plan?
(1)
(2)
(3)
All
Part
None
@
Multiple Entry
HB59
How much [fill DODOES] [fill TEMPNAME] pay for [fill HISHER] long
term care plan?
$ @AMT
Mark One Only
HB60
THE AMOUNT ENTERED [FILL HB59@AMT] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
PROCEED
@
Mark One Only
HB61
How often [fill DODOES] [fill TEMPNAME] pay this amount?
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Weekly
Every two weeks
Twice monthly
Monthly
Semi-annually
Annually
Other
@
Multiple Entry
HB62
Specify the exact "OTHER" amount of time that [fill TEMPNAME] pay.
@1
Mark One Only
HB65
If [fill TEMPNAME] [fill WASWERE] to retire from this job, would
[fill HESHE] be able to obtain health insurance from
[fill HISHER] current employer at [fill HISHER] employer's group
rate throughout [fill HISHER] retirement years?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 61 of 82
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Items Booklet
HB66
Mark One Only
If [fill TEMPNAME] were to retire, could [fill HESHE] continue
the health insurance plan at [fill HISHER] employer's group rate
until age 65?
(1)
(2)
Yes
No
@
HB67
Mark One Only
[fill C_DODOES] [fill TEMPNAME] expect that [fill HISHER] employer
would pay for all, part, or none of the cost of this health plan
after [fill HISHER] retirement?
(1)
(2)
(3)
All
Part
None
@
HB68
Mark One Only
Can retirees obtain coverage under this plan for spouses and other
family or non-family members?
(1)
(2)
Yes
No
@
HB69
Multiple Entry
Who may obtain coverage under this plan?
MARK ALL THAT APPLY
ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
@1
Spouse
Children
Grandchildren
Other family members
Non-family members
@2
@3
@4
@5
Mark One Only
HB73
[fill C_HAVHAS] [fill TEMPNAME] ever worked at a paid job for one
year or more?
(1)
(2)
Yes
No
@
Page 62 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Mark One Only
HB77
These next few questions are about the availability of health
insurance from [fill PTEMPNAME] former employer.
Did [fill PTEMPNAME] former employer offer health insurance coverage
to its employees?
(1)
(2)
Yes
No
@
Mark One Only
HB78
[fill C_WASWERE] [fill TEMPNAME] covered by the employer health plan
on the last day [fill HESHE] worked for that employer?
(1)
(2)
Yes
No
@
Mark One Only
HB79
Did [fill TEMPNAME] continue this coverage after [fill HESHE]
left that employer?
(1)
(2)
Yes
No
@
Mark One Only
HB80
Did [fill TEMPNAME] continue [fill HISHER] coverage through COBRA
or as a retiree health benefit?
[r]H[n]
(1) COBRA
(2) Retiree health benefit
@
Tuesday, November 24, 2009
Page 63 of 82
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Items Booklet
HB81
Multiple Entry
SHOW FLASHCARD GG
What [fill AREIS] the main reason(s) [fill TEMPNAME] [fill AREIS]
no longer covered by this plan?
IF RESPONDENT APPEARS TO HAVE DIFFICULTY READING THE FLASHCARD,
THEN READ CATEGORIES TO THE RESPONDENT
MARK ALL THAT APPLY
ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
@1
Eligibility period expired
Too expensive
Covered by another plan
Did not want or need coverage
Medicare coverage
Had to be eligible for a pension
Retirement requirement not met
Retirees not covered
Age or service eligibility requirement not met
Became ineligible after employer amended plan
Employer dropped plan
Employer canceled plan for retirees
Other
@2
@3
@4
@5
@6
@7
@8
@9
@10
@11
@12
@13
Multiple Entry
HB84
In what year did [fill TEMPNAME] leave that job?
@AMT
Multiple Entry
HB85
For how many years did [fill TEMPNAME] work for that employer?
ENTER ONE RESPONSE
ENTER (N) FOR NO TIME
Number of Years
Number of Months
@YEARS
@MONTHS
Mark One Only
HB87
When [fill TEMPNAME] worked for that employer, [fill WASWERE]
[fill HESHE] covered under a union or employee association contract?
(1)
(2)
Yes
No
@
Enter Text
HB87a
What is the name of that employer?
@
Page 64 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Enter Text
HB87b
EMPLOYER = [fill HB87a]
What kind of business or industry was that?
READ IF NECESSARY: What did they make or do where [fill HESHE] worked?
@
Mark One Only
HB88
ASK OR VERIFY
Was [fill HB87a]:
(1)
(2)
(3)
(4)
A Government organization (includes Armed Forces)
A Private, For Profit, Company
A Non-Profit Organization, including tax exempt
and charitable organizations
A family business or farm
@
Mark One Only
HB89
Was that Federal Government, State Government, or Local Government
or active-duty Armed Forces?
(1)
(2)
(3)
(4)
Federal (civilian only)
State
Local (County, City, Township)
Armed Forces (active duty only)
@
Mark One Only
HB90
EMPLOYER = [fill HB87a]
ASK OR VERIFY
Was it mainly -(1)
(2)
(3)
(4)
(5)
Manufacturing
Wholesale Trade
Retail Trade
Service
Or Something Else
@
Multiple Entry
HB91
EMPLOYER = [fill HB87a]
What kind of work [fill WASWERE] [fill HESHE]
[fill TEMP4], that is, what was [fill HISHER]
occupation?
READ IF NECESSARY: for example: bookkeeper, plumber, press operator
@1
Tuesday, November 24, 2009
Page 65 of 82
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Multiple Entry
Items Booklet
HB92
EMPLOYER = [fill HB87a]
What were [fill HISHER] usual activities or duties on this job?
READ IF NECESSARY: For example: Keeping account books,
repairing pipes, operating printing press
@1
Multiple Entry
HB93
When [fill TEMPNAME] left that job, how much did [fill HESHE]
usually earn per week before deductions? Include any overtime
pay, commissions, or tips usually received.
$ @AMT
Mark One Only
HB94
THE AMOUNT ENTERED [FILL HB93@AMT] IS UNUSUALLY LARGE.
(1)
(P)
BACK UP AND CORRECT
PROCEED
@
Mark One Only
HB95
SHOW FLASHCARD HH
About how many people were employed at all locations?
IF RESPONDENT APPEARS TO HAVE DIFFICULTY READING THE FLASHCARD,
THEN READ THE CATEGORIES TO THE RESPONDENT.
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Less than 10
10 - 24
25 - 49
50 - 99
100 - 249
250 - 499
500 - 999
1000+
@
Mark One Only
HB96
Would it be fewer than 20 people?
(1)
(2)
Yes
No
@
Mark One Only
HB99
[fill C_DODOES] [fill TEMPNAME] expect to be covered by Medicare
when [fill HESHE] [fill TEMP2] age 65?
(1)
(2)
Yes
No
@
Page 66 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: EMPLOYER PROVIDED HEALTH BENEFITS
Mark One Only
HB100
[fill C_AREIS] [fill TEMPNAME] postponing any medical care because
of costs until [fill HESHE] [fill TEMP3] eligible for Medicare?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 67 of 82
Survey:
Section: ADULT WELL BEING
Items Booklet
AW2_APT
Mark One Only
ASK ONLY IF NECESSARY
Is there more than one housing unit in this building?
(1)
(2)
Yes
No
@
AW5_CNDUR
Multiple Entry
SHOW FLASHCARD II
READ ANSWER CATEGORIES IF NECESSARY
Do you currently have the following items in your home, in
working condition?
(1)
@1
@2
@3
@4
@5
@6
@7
@8
@9
@10
@11
@12
@13
Yes
(2) No
(01)Washing machine
(02)Clothes dryer
(03)Dishwasher
(04)Refrigerator
(05)Stand-alone food freezer (separate from refrigerator)
(06)Color television
(07)Gas or electric stove (with or without oven)
(08)Microwave oven
(09)VCR or DVD (or other video recorder-player such as TiVo)
(10)Air conditioner (central or room)
(11)Personal computer
(12)Cellular phone or mobile phone
(13)Regular telephone
AW6_CBLD1
Mark One Only
You didn't list a washing machine in your home. Is there a
washing machine in your BUILDING provided for your use?
(1)
(2)
Yes
No
@
AW7_CBLD2
Mark One Only
You didn't list a dryer in your home.
BUILDING provided for your use?
(1)
(2)
Is there a dryer in your
Yes
No
@
AW8_CBLD13
Mark One Only
You didn't list a telephone in your home.
people to reach you by telephone?
(1)
(2)
(3)
(4)
Is there a way for
Yes, neighbor's phone, common phone, pay phone
Yes, cell phone
Yes, other device
No, cannot be reached by telephone
@
Page 68 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: ADULT WELL BEING
AW9_ROOMS
Enter Number
The next set of questions are about the quality of your
neighborhood, crime in your neighborhood, and the type of services
available to you. First, I will ask about your home.
How many rooms are there in your home?
not count the bathrooms.
Count the kitchen but do
ACCEPTABLE RANGE IS 1-20
ENTER (20) TO INDICATE 20 OR MORE ROOMS
@ (Number of rooms)
Multiple Entry
AW10_HOUSE1
SHOW FLASHCARD JJ
READ ANSWER CATEGORIES IF NECESSARY
Are any of the following conditions present in your home?
ENTER ALL THAT APPLY/ENTER (N) FOR NO MORE
[fill AW10_1:b](1) Problem with pests such as rats, mice, roaches,
or other insects
[fill AW10_2:b](2) A leaking roof or ceiling
[fill AW10_3:b](3) Broken window glass or windows that can't shut
[fill AW10_4:b](4) Exposed electrical wires in the finished areas
of your home
[fill AW10_5:b](5) A toilet, hot water heater, or other plumbing
that doesn't work
[fill AW10_6:b](6) Holes in the walls or ceiling, or cracks wider
than the edge of a dime
[fill AW10_7:b](7) Holes in the floor big enough for someone to
catch their foot on
@1
Enter Text
AW10_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Multiple Entry
AW11_HOUSE2
SHOW FLASHCARD KK
Now I'm going to ask you a few questions about your satisfaction
with certain aspects of your housing.
Are you very satisfied, somewhat satisfied, somewhat dissatisfied,
or very dissatisfied, with the following:
(1)
(2)
(3)
(4)
(5)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Haven't lived here long enough to know
@1
@2
@3
@4
@5
@6
(1)
(2)
(3)
(4)
(5)
(6)
The
The
The
The
The
The
Tuesday, November 24, 2009
general state of repair of your home
amount of room or space in your home
furnishings in your home
warmth of your home in winter
coolness of your home in summer
amount of privacy your home offers
Page 69 of 82
Survey:
Section: ADULT WELL BEING
Items Booklet
Mark One Only
AW12_SATLV1
SHOW FLASHCARD LL
READ ANSWER CATEGORIES IF NECESSARY
Overall, how satisfied are you with your home?
(1)
(2)
(3)
(4)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
@
Mark One Only
AW13_SATLV2
Are conditions in your home undesirable enough that you would
like to move?
(1)
(2)
Yes
No
@
Mark One Only
AW14_CRIME1
The next few questions are about crime and
things you have done to protect yourself from crime.
Is there any area right around your home --- that is, within a
mile --- where you would be afraid to walk alone at night?
(1)
(2)
Yes
No
@
Multiple Entry
AW15_CRIME2
In the past month, have you done any of the following because you
thought you might be unsafe?
(1)
Yes
@1
@2
(1)
(2)
@3
(3)
(2)
No
Have you stayed in your home at certain times?
Have you taken someone with you or traveled with other
people when going out into your neighborhood?
Have you carried anything to protect yourself?
Mark One Only
AW16_CRIME3
Do you consider your neighborhood very safe from crime, somewhat
safe, somewhat unsafe, or very unsafe?
(1)
(2)
(3)
(4)
Very safe
Somewhat safe
Somewhat unsafe
Very unsafe
@
Page 70 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: ADULT WELL BEING
Mark One Only
AW17_CRIME4
How about your home? Do you consider it very safe from crime,
somewhat safe, somewhat unsafe, or very unsafe?
(1)
(2)
(3)
(4)
Very safe
Somewhat safe
Somewhat unsafe
Very unsafe
@
Mark One Only
AW18_CRIME5
We are interested in finding out if people do anything in
particular to keep thieves or intruders out of their homes.
[fill TEMP2] [fill TEMP1] have a dog?
(1)
(2)
Yes
No
@
Mark One Only
AW19_CRIME6
When you got (this dog/these dogs), was it in part to keep your
home safe from thieves or intruders?
(1)
(2)
Yes
No
@
Mark One Only
AW20_CRIME7
[fill TEMP2] [fill TEMP1] have any special safety DEVICES such
as electric timers for lights, or an alarm system?
(1)
(2)
Yes
No
@
Mark One Only
AW21_SATLV3
Overall, is the threat of crime where you live undesirable enough
that you would like to move?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 71 of 82
Survey:
Section: ADULT WELL BEING
Multiple Entry
Items Booklet
AW22_NBRHD1
Now I will ask some questions about general conditions in your
neighborhood.
SHOW FLASHCARD MM
READ ANSWER CATEGORIES IF NECESSARY
Do you think any of the following conditions are problems in
your neighborhood?
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
[fill
[fill
[fill
[fill
[fill
AW22_1:b](1) Street noise or heavy street traffic
AW22_2:b](2) Streets in need of repair
AW22_3:b](3) Trash, litter, or garbage in the streets and lots
AW22_4:b](4) Rundown or abandoned houses or buildings
AW22_5:b](5) Industries, businesses, or other
non-residential activities
[fill AW22_6:b](6) Odors, smoke, or gas fumes
@1
Enter Text
AW22_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Mark One Only
AW23_NBRHD2
SHOW FLASHCARD LL
How satisfied are you with your relationship with your neighbors?
Are you very satisfied, somewhat satisfied, somewhat dissatisfied,
or very dissatisfied?
(1)
(2)
(3)
(4)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
@
Mark One Only
AW24_SATLV4
SHOW FLASHCARD LL
Overall, how satisfied are you with conditions in your neighborhood?
READ IF NECESSARY
(1)
(2)
(3)
(4)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
@
Page 72 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: ADULT WELL BEING
Mark One Only
AW25_SATLV5
Is your neighborhood undesirable enough that you would like to move?
(1)
(2)
Yes
No
@
Mark One Only
AW27_CS1
SHOW FLASHCARD LL
How satisfied are you with the local public schools in your
neighborhood?
READ IF NECESSARY
(1)
(2)
(3)
(4)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
@
Multiple Entry
AW28_CS2
SHOW FLASHCARD NN
READ ANSWER CATEGORIES IF NECESSARY
We are interested in schools from kindergarten through 12th grade.
Do any of the children in your household attend:
(1)
Yes
@1
@2
(1)
(2)
@3
@4
@5
(3)
(4)
(5)
(2)
No
Private school
Magnet, charter, or other public school apart from the
assigned school
Assigned public school
Home school
Not in school or other arrangement
Mark One Only
AW29_CS3
Would [fill TEMP1] prefer a different school for any
child in this home?
(1)
(2)
Yes
No
@
Tuesday, November 24, 2009
Page 73 of 82
Survey:
Section: ADULT WELL BEING
Multiple Entry
Items Booklet
AW30_CS4
Are you very satisfied, somewhat satisfied, somewhat dissatisfied,
or very dissatisfied with each of the following services in your
neighborhood:
(1)
(2)
(3)
(4)
(5)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Haven't lived here long enough to know
@1 (1)
@2 (2)
@3 (3)
Hospitals, health clinics, and doctors
Police services
Fire department services
Mark One Only
AW31_CS5
Are the public transportation services available in your
neighborhood adequate for you?
(1)
(2)
(3)
Yes
No
Not sure because you do not use public transportation
@
Mark One Only
AW32_SATLV6
SHOW FLASHCARD LL
Overall, how satisfied are you with the public services
in your neighborhood?
READ IF NECESSARY
(1)
(2)
(3)
(4)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
@
Mark One Only
AW33_SATLV7
Are the public services undesirable enough that you would
like to move?
(1)
(2)
Yes
No
@
Page 74 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: ADULT WELL BEING
AW34_MEET
Mark One Only
Next are questions about difficulties people sometimes have in
meeting their essential household expenses for such things as
mortgage or rent payments, utility bills, or important medical
care.
During the past 12 months, has there been a time when
[fill TEMP1] did not meet all of your essential expenses?
(1)
(2)
Yes
No
@
AW35_NEED1
Mark One Only
The following are some of the specific difficulties people
experience with household expenses.
Was there any time in the past 12 months when [fill TEMP1]
did not pay the full amount of the rent or mortgage?
(1)
(2)
Yes
No
@
AW36_GETH1
Mark One Only
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
AW37_WHOH1
Multiple Entry
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
@1
AW37_1:b](1)
AW37_2:b](2)
AW37_3:b](3)
AW37_4:b](4)
AW37_5:b](5)
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
Enter Text
AW37_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Tuesday, November 24, 2009
Page 75 of 82
Survey:
Section: ADULT WELL BEING
Items Booklet
AW38_NEED2
Mark One Only
In the past 12 months [fill TEMP1] [fill TEMP2]
evicted from your home or apartment for not paying the rent or
mortgage?
(1)
(2)
Yes
No
@
AW39_GETH2
Mark One Only
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
AW40_WHOH2
Multiple Entry
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
@1
AW40_1:b](1)
AW40_2:b](2)
AW40_3:b](3)
AW40_4:b](4)
AW40_5:b](5)
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
Enter Text
AW40_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Mark One Only
AW41_NEED3
How about not paying the full amount of the gas, oil, or
electricity bills?
Was there a time in the past 12 months when that happened to
[fill TEMP1]?
(1)
(2)
Yes
No
@
Mark One Only
AW42_GETH3
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
Page 76 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: ADULT WELL BEING
Multiple Entry
AW43_WHOH3
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
AW43_1:b](1)
AW43_2:b](2)
AW43_3:b](3)
AW43_4:b](4)
AW43_5:b](5)
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
@1
AW43_ERR
Enter Text
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Mark One Only
AW44_NEED4
In the past 12 months did the gas or electric company turn off
service, or the oil company not deliver oil?
(1)
(2)
Yes
No
@
Mark One Only
AW45_GETH4
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
Multiple Entry
AW46_WHOH4
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
AW46_1:b](1)
AW46_2:b](2)
AW46_3:b](3)
AW46_4:b](4)
AW46_5:b](5)
@1
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
Enter Text
AW46_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Tuesday, November 24, 2009
Page 77 of 82
Survey:
Section: ADULT WELL BEING
Items Booklet
Mark One Only
AW47_NEED5
How about the telephone company disconnecting service because
payments were not made?
Was there a time in the past 12 months when that happened to
[fill TEMP1]?
(1)
(2)
Yes
No
@
Mark One Only
AW48_GETH5
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
Multiple Entry
AW49_WHOH5
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
AW49_1:b](1)
AW49_2:b](2)
AW49_3:b](3)
AW49_4:b](4)
AW49_5:b](5)
@1
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
Enter Text
AW49_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Mark One Only
AW50_NEED6
In the past 12 months was there a time [fill TEMP2] needed
to see a doctor or go to the hospital but did not go?
(1)
(2)
Yes
No
@
Mark One Only
AW51_GETH6
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
Page 78 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: ADULT WELL BEING
Multiple Entry
AW52_WHOH6
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
AW52_1:b](1)
AW52_2:b](2)
AW52_3:b](3)
AW52_4:b](4)
AW52_5:b](5)
@1
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
AW52_ERR
Enter Text
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Mark One Only
AW53_NEED7
In the past 12 months was there a time [fill TEMP2] needed
to see a dentist but did not go?
(1)
(2)
Yes
No
@
Mark One Only
AW54_GETH7
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
Multiple Entry
AW55_WHOH7
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
AW55_1:b](1)
AW55_2:b](2)
AW55_3:b](3)
AW55_4:b](4)
AW55_5:b](5)
@1
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
Enter Text
AW55_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Tuesday, November 24, 2009
Page 79 of 82
Survey:
Section: ADULT WELL BEING
Mark One Only
Items Booklet
AW56_HELP1
SHOW FLASHCARD OO
READ ANSWER CATEGORIES IF NECESSARY
If [fill TEMP1] had a problem with which you needed help
(for example, sickness or moving), how much help would you expect
to get from family living nearby?
(1)
(2)
(3)
(4)
All of the help needed
Most of the help needed
Very little of the help needed
No help
@
Mark One Only
AW57_HELP2
SHOW FLASHCARD OO
READ ANSWER CATEGORIES IF NECESSARY
If [fill TEMP1] had a problem with which you needed help
How much help would you expect to get from friends?
(1)
(2)
(3)
(4)
All of the help needed
Most of the help needed
Very little of the help needed
No help
@
Mark One Only
AW58_HELP3
SHOW FLASHCARD OO
READ ANSWER CATEGORIES IF NECESSARY
If [fill TEMP1] had a problem with which you needed help
How much help would you expect to get from other people in the
community besides family and friends, such as a social agency
or a church?
(1)
(2)
(3)
(4)
All of the help needed
Most of the help needed
Very little of the help needed
No help
@
Mark One Only
AW59_FOOD1
SHOW FLASHCARD PP
Getting enough food can also be a problem for some people. Which
of these statements best describes the food eaten in your household
in the last four months:
READ ANSWER CATEGORIES IF NECESSARY
(1)
(2)
(3)
(4)
Enough of the kinds of food we want
Enough but not always the kinds of food we want to eat
Sometimes not enough to eat
Often not enough to eat
@
Page 80 of 82
Tuesday, November 24, 2009
Items Booklet
Survey:
Section: ADULT WELL BEING
Multiple Entry
AW60_FOOD2
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
In which of the last four months did [fill TEMP2]
NOT have enough to eat?
[fill
[fill
[fill
[fill
[fill
AW60_1:b]
AW60_2:b]
AW60_3:b]
AW60_4:b]
AW60_5:b]
(1)
(2)
(3)
(4)
(5)
@1
4 mos. ago [fill month1]
3 mos. ago [fill month2]
2 mos. ago [fill month3]
last month [fill month4]
current month [fill month5]
Enter Text
AW60_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Mark One Only
AW61_FOOD3
I'm going to read you some statements that people have made
about their food situation. For these statements, please
tell me whether it was OFTEN TRUE, SOMETIMES TRUE, or NEVER
TRUE for [fill TEMP2] in the last four months.
"The food that [fill TEMP3] bought just didn't last and
[fill TEMP3] didn't have money to get more."
Was that often, sometimes or never true for [fill TEMP4]
in the last four months?
(1)
(2)
(3)
Often true
Sometimes true
Never true
@
Mark One Only
AW62_FOOD4
The next statement is: "[fill TEMP3] couldn't afford to eat
balanced meals."
Was that often, sometimes or never true for [fill TEMP4]
in the last four months?
(1)
(2)
(3)
Often true
Sometimes true
Never true
@
Mark One Only
AW63_FOOD5
The next statement is: "[fill TEMP1] not eating enough
because [fill TEMP3] couldn't afford enough food."
Was that often, sometimes or never true for [fill TEMP2] in
the last four months?
(1)
(2)
(3)
Often true
Sometimes true
Never true
@
Tuesday, November 24, 2009
Page 81 of 82
Survey:
Section: ADULT WELL BEING
Mark One Only
Items Booklet
AW64_FOOD6
The next questions refer to adults in the household.
In the past four months did [fill TEMP1]
ever cut the size of your meals or skip meals because there
wasn't enough money for food?
(1)
(2)
Yes
No
@
Mark One Only
AW65_FOOD7
In the past four months, did [fill TEMP1] ever eat less than
you felt you should because there wasn't enough money to
buy food?
(1)
(2)
Yes
No
@
Mark One Only
AW66_FOOD8
In the past four months, did [fill TEMP1] ever not eat for a
whole day because there wasn't enough money for food?
(1)
(2)
Yes
No
@
Page 82 of 82
Tuesday, November 24, 2009
| File Type | application/pdf |
| File Title | N:\SIPP96\Items Booklets\2008 Panel\Wave 6\rptItemsBooklet.snp |
| Author | okon0001 |
| File Modified | 2009-11-24 |
| File Created | 2009-11-24 |