Version 1 English Questions - Latest Revision 8/9/2012
Enclosure 3
American Community Survey
Cognitive Test
Interviewer-administered Survey
August 9, 2012
Participant ID #: |___|___|___|___|___|___|___|___|___|___|
DETAILED QUESTIONS—PERSON 1
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NAME ____________________ |
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7a. I will now be asking a series of questions about you. The next few questions deal with your place of birth and citizenship...
Where were you born? ENTER STATE, IF KNOWN. IF STATE NOT KNOWN, ENTER US
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__________ State Go to 10a1 OR Not born in the US
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7b. In what country were you born?
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___________ Country |
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7b-SKIP IF COUNTRY IN 7B IS PUERTO RICO, GUAM, THE U.S. VIRGIN ISLANDS, OR NORTHERN MARIANAS, GO TO QUESTION 9C. OTHERWISE GO TO QUESTION 8.
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8. Are you a citizen of the United States? |
Yes No Go to 9c |
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9a. Were you born abroad of U.S. citizen parent or parents, or did you become a citizen by naturalization? |
Born abroad of U.S. citizen parent or parents go to 9c. Citizen by naturalization |
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9b. In what year did you become a naturalized citizen of the United States? |
_______ Year |
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9c. When did you come to live in the United States?
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_______ Year |
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10a1. The next questions are about schooling and education.
At any time IN THE LAST 3 MONTHS, have you attended school or college? Include only nursery or preschool, kindergarten, elementary school, home school, and schooling that leads to a high school diploma or a college degree. |
Yes No Go to 11 |
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10a2. Was that a public school or college, a private school or college, or home school?
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Public school or college Private school or college or home school |
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10b. What grade or level were you attending?
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Nursery school or preschool Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12 College undergraduate years, that is a college freshman to senior Graduate or professional school beyond a bachelor’s degree, for example a Master’s or PhD program or medical or law school |
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11. What is the highest degree or level of school you have COMPLETED?
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No schooling completed Nursery school Kindergarten Grade 1 Grade 2 Grade 3 Grade 4. Grade 5 Grade 6 Grade 7. Grade 8 Grade 9. Grade 10 Grade 11 Grade 12, no diploma Regular high school diploma GED or alternative credential Some college, no degree Associate’s degree (for example: AA, AS) Bachelor’s degree (for example: BA, BS). Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA) Professional degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD) Doctorate degree (for example: PhD, EdD) Vocational or technical license |
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Instruction F IF RESPONSE TO QUESTION 11 IS BACHELOR’S DEGREE OR HIGHER, ASK QUESTION 12. OTHERWISE GO TO QUESTION 13. |
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12.
This question focuses on your BACHELOR’S DEGREE. What was
the specific major or majors of any BACHELOR’S DEGREES you
have received? For example, chemical engineering, elementary
teacher education IF THIS PERSON HAS MORE THAN ONE MAJOR OR BACHELOR’S DEGREE, ASK FOR ALL MAJOR FIELDS. |
_______________________________ _______________________________ _______________________________ |
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13. What is your ancestry or ethnic origin?
(For example: Italian, Jamaican, African-American, Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian and so on.)
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__________________________________ __________________________________ |
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14a. Do you speak a language other than English at home?
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Yes No Go to 15a
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14b. What is this language? |
__________________________________ |
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14c. How well do you speak English – very well, well, not well, not at all?
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Very well Well Not well Not at all |
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14c-SKIP IF PERSON IS LESS THAN ONE YEAR OLD, GO TO QUESTION 16A. OTHERWISE GO TO QUESTION 15A. |
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15a. Did you live in this <house/apartment/mobile home> 1 year ago? |
Yes Go to 16a No
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15b. Did you live in the United States, Puerto Rico, or another country?
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United States Go to 15d Puerto Rico Go to 15d Another country Go to 15c |
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15c. What was the foreign country?
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Go to 16a |
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15d. What was the street address?
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15e. What was the city or town?
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15f. What was the [county if in United States, municipio if in Puerto Rico]?
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15g. What was the state?
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15h. What was the ZIP code?
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16a. I am now going to ask you some questions about your health insurance and health coverage.
Are you currently covered by health insurance through a current or former employer or union of [yours/yours or another family member]?
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Yes No |
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16b. Are you currently covered by health insurance purchased directly from an insurance company by [you/you or another family member]?
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Yes No |
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16c. Are you currently covered by Medicare, for people age 65 or older or people with certain disabilities?
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Yes No |
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16d. Are you currently covered by Medicaid, Medical Assistance, or any kind of government-assistance plans for those with low incomes or a disability?
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Yes No |
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16e. Are you currently covered by TRICARE or other military health care?
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Yes No |
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16f. Are you currently covered through the Veteran’s Administration or have you ever used or enrolled for VA health care?
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Yes No |
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16g. Are you currently covered through the Indian Health Service?
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Yes No |
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16h. Are you currently covered by any other health insurance or health coverage plan?
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Yes No Go to 17
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16i. What is the name of the health care plan? |
_____________________ |
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Instruction G IF PERSON ANSWERED YES TO ANY PART OF QUESTION 16, CONTINUE WITH 17; OTHERWISE SKIP TO QUESTION 18. |
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17. Is the cost of your health insurance reduced based on your family income? |
Yes No |
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18a. I am now going to ask some questions about difficulty you may have with ordinary daily activities.
Are you deaf or do you have serious difficulty hearing?
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Yes No |
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18b. Are you blind or do you have serious difficulty seeing even when wearing glasses?
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Yes No |
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Instruction H IF PERSON IS 15 OR OLDER CONTINUE WITH 19; OTHERWISE SKIP TO NEXT PERSON (p. 14). IF LAST PERSON, END INTERVIEW.
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19. Because of a physical, mental, or emotional condition do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
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Yes No |
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20. I will now be asking about your marital status.
Are you married, widowed, divorced, separated or never married? |
Now married Widowed Divorced Separated Never married Go to Instruction I |
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21a. In the past 12 months, did you get married?
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Yes No |
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21b. In the past 12 months, did you become a (widow/widower)?
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Yes No |
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21c. In the past 12 months, did you get divorced? |
Yes No
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22. How many times have you been married? Is that once, twice, or three or more times? |
Once Twice Three or more times |
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23. In what year did you (get/last get) married?
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_______ |
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Instruction I IF THIS PERSON IS MALE, GO TO QUESTION 25A. IF THIS PERSON IS FEMALE AND OVER 50 YEARS OLD, GO TO QUESTION 25A. OTHERWISE ASK QUESTION 24. |
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24. Have you given birth to any children in the past 12 months? IF RESPONDENT ASKS WHETHER TO INCLUDE STILLBIRTHS, SAY “DO NOT INCLUDE STILLBIRTHS”
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Yes No
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24-SKIP IS THERE ARE NO CHILDREN UNDER 18 YEARS OLD IN THE HOUSEHOLD OR RESPONDENT IS LESS THAN 30, GO TO QUESTION 26.
OTHERWISE, ASK QUESTION 25A. |
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25a. Do you have any of your grandchildren under the age of 18 living in this <house/apartment/mobile home>?
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Yes No go to 26a
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25b. Are you currently responsible for most of the basic needs of any grandchildren under the age of 18 who live in this <house/apartment/mobile home>?
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No go to 26a
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25c. How long have you been responsible for these grandchildren?
(If financially responsible for more than one grandchild, answer for the grandchild for whom the grandparent has been responsible for the longest time.) |
Less than 6 months 6 to 11 months 1 or 2 years 3 or 4 years 5 or more years |
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26a. Have you ever served on ACTIVE DUTY in the U.S. Armed Forces, Reserves, or National Guard?
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Yes No go to 26d
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26b. Were you on active duty ONLY FOR TRAINING in the Reserves or National Guard? |
Yes go to 28a No
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26c. Are you currently on active duty? |
Yes go to 27 No go to 27 |
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26d. Have you ever been in the Reserves or National Guard? |
Yes go to 28a No go to 29a |
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27. Did you serve on active duty at any time during the following periods: READ ALL ANSWER CATEGORIES.
September 2001 or later August 1990 to August 2001 (including Persian Gulf War) May 1975 to July 1990 Vietnam Era (August 1964 to April 1975) February 1955 to July 1964 Korean War (July 1950 to January 1955) January 1947 to June 1950 World War II (December 1941 to December 1946) November 1941 or earlier
ENTER ALL THAT APPLY, EVEN IF THE PERSON SERVED FOR ONLY PART OF THE PERIOD. |
September 2001 or later August 1990 to August 2001 (including Persian Gulf War) May 1975 to July 1990 Vietnam Era (August 1964 to April 1975) February 1955 to July 1964 Korean War (July 1950 to January 1955) January 1947 to June 1950 World War II (December 1941 to December 1946) November 1941 or earlier |
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28a. Do you have a VA service-connected disability rating?
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Yes (such as 0%, 10%, 20%, …, 100%) No go to 29a
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28b. What is your service-connected disability rating? Is it: READ ALL ANSWER CATEGORIES.
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0 percent 10 or 20 percent 30 or 40 percent 50 or 60 percent 70 percent or higher |
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29a. Now, I am going to ask a series of questions about employment…
LAST WEEK, did you work for pay at a job or business?
(Include any work even if you worked only 1 hour, or helped without pay in a family business or farm for 15 hours or more, or were on active duty in the Armed Forces.)
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Yes go to 34a No |
29b. LAST WEEK, did you do ANY work for pay, even for as little as one hour?
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Yes go to 34a No go to 30a
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Instruction KIF RESPONSE TO QUESTION 29B IS “NO” ASK QUESTION 30A. OTHERWISE, GO TO QUESTION 35A.
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30a. LAST WEEK, were you on layoff from a job?
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Yes go to 30c No
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30b. LAST WEEK, were you TEMPORARILY absent from a job or business because of vacation, temporary illness, maternity leave, other family or personal reasons, bad weather, etc.?
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Yes go to 33 No go to 31 |
30c. Have you been informed that you will be recalled to work within the next 6 months OR been given a date to return to work?
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Yes go to 32a No
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31. During the LAST 4 WEEKS, have you been ACTIVELY looking for work?
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Yes No go to 33
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32a. LAST WEEK, could you have started a job if offered one (or returned to work if recalled)?
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Yes go to 33 No
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32b. Why was that?
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Own temporary illness Going to school or some other reason |
33. When did you last work, even for a few days?
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Within the past 12 months Between 1 and 5 years ago go to 36a Over 5 years ago or never worked go to question 37c1a
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34a. During the PAST 12 MONTHS or 52 weeks, did you work 50 or more weeks? Count paid time off as work.
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Yes go to 35 No
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34b. How many weeks DID you work, even for a few hours, INCLUDING paid vacation, paid sick leave, and military service? Was it: READ ALL ANSWER CATEGORIES
50 to 52 weeks 48 to 49 weeks 40 to 47 weeks 27 to 39 weeks 14 to 26 weeks 13 weeks or less
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50 to 52 weeks 48 to 49 weeks 40 to 47 weeks 27 to 39 weeks 14 to 26 weeks 13 weeks or less |
35. During the weeks worked IN THE PAST 12 MONTHS, how many hours did you usually work each week?
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____ Hours
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36a. The next series of questions are about the type of business you worked for and the type of work that you did. Let’s start with the first question. I am going to read 5 categories. Please pick the one that best describes who you worked for - a private organization or company, government, the US Armed Forces (active duty), self-employed, or working without pay in a family business.
(If you had more than 1 job, describe the one at which the most hours were worked. If you did not work last week, give information for the last job or business in the past five years.)
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Private organization or company Government go to 36c US Armed Forces (active duty) go to 37a1a Self-employed go to 36d Working without pay in a family business go to 37a1a |
36b. Was this a non-profit organization or a for profit company? |
Non-profit organization go to 37a1a. For profit company go to 37a1a.. |
36c. Was this for Local, State, or the Federal Government?
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Local go to 37a1a State go to 37a1a Federal go to 37a1a |
36d. Was this self-employment incorporated or not incorporated?
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Incorporated Not incorporated |
The next few questions are about income DURING THE PAST 12 MONTHS, that is from [current month, year – 1] to [month -1, current year]…
37a1a. Did you receive any wages or salary? |
Yes No go to 37a2a
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37a1b. How much did you receive in wages and salary from all jobs before taxes and other deductions?
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$__________.00 |
37a2a. Did you receive any (additional) tips, bonuses or commissions DURING THE PAST 12 MONTHS?
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Yes No go to 37b1
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37a2b. How much did you receive in tips, bonuses, or commissions from all jobs before taxes and other deductions?
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$__________.00 |
37b1. Did you receive any self-employment income DURING THE PAST 12 MONTHS?
REPORT INCOME FROM OWN BUSINESSES (FARM OR NON-FARM) INCLUDING PROPRIETORSHIPS AND PARTNERSHIPS.
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Yes No go to 37c1a
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37b2. What was the amount?
REPORT NET INCOME AFTER OPERATING EXPENSES. INCLUDE EARNINGS AS A TENANT FARMER OR SHARECROPPER.
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$__________.00 |
37c1a. READ LEAD-IN ONLY IF PERSON WAS NOT EMPLOYED LAST YEAR: (The next few questions are about income DURING THE PAST 12 MONTH, that is from [current month, year – 1] to [month -1, current year]...)
Did you receive any interest or dividends [DURING THE PAST 12 MONTHS]? Report even small amounts credited to an account.
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Yes No go to 37c2a
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37c1b. What was the amount?
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$__________.00 |
37c2a. Did you receive any net rental income DURING THE PAST 12 MONTHS?
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Yes No go to 37c3a
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37c2b. What was the net amount?
IF INCOME WAS A LOSS, PRECEDE AMOUNT WITH A '-'. BREAKEVEN = 1. |
$__________.00 |
37c3a. Did you receive any royalty income or income from estates and trusts DURING THE PAST 12 MONTHS?
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Yes No go to 37d1
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37c3b. What was the amount?
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$__________.00 |
37d1. Did you receive any Social Security or Railroad Retirement benefits DURING THE PAST 12 MONTHS?
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Yes No go to 37e1
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37d2. What was the amount?
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$__________.00 |
37e1. Did you receive any Supplemental Security Income (SSI) payments DURING THE PAST 12 MONTHS?
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Yes No go to 37f1
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37e2. What was the amount?
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$__________.00 |
37f1. Did you receive any public assistance or public welfare payments from the state or local welfare office DURING THE PAST 12 MONTHS? |
Yes No go to 37g1
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37f2. What was the amount?
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$__________.00 |
37g1. Did you receive any retirement, survivor, or disability pensions DURING THE PAST 12 MONTHS?
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Yes No go to 37h1
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37g2. What was the amount?
DO NOT INCLUDE SOCIAL SECURITY.
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$__________.00 |
37h1. Did you receive income on a REGULAR basis from any other sources such as Veterans’ Administration (VA) payments, unemployment compensation, child support or alimony DURING THE PAST 12 MONTHS?
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Yes No go to 38
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37h2. What was the amount from all sources?
DO NOT INCLUDE LUMP SUM PAYMENTS SUCH AS MONEY FROM AN INHERITANCE OR SALE OF A HOME.
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$__________.00 |
38. What was your TOTAL income during the PAST 12 MONTHS?
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$__________.00 |
Instruction L
IS THIS THE LAST PERSON TO COLLECT DETAILED PERSON DATA FOR?
THIS IS LAST PERSON – END INTERVIEW MORE PERSONS - CONTINUE WITH THE REMAINDER OF THE ACS SURVEY ON THE FOLLOWING PAGES |
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NAME ___________________ |
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7a. I will now be asking a series of questions about <Name> The next few questions deal with <Name>'s place of birth and citizenship...
Where was <Name> born? ENTER STATE, IF KNOWN. IF STATE NOT KNOWN, ENTER US
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__________ State Go to 10a1 OR Not born in the US
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7b. In what country was <Name> born?
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___________ Country |
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7b-SKIP IF COUNTRY IN 7B IS PUERTO RICO, GUAM, THE U.S. VIRGIN ISLANDS, OR NORTHERN MARIANAS, GO TO QUESTION 9C. OTHERWISE GO TO QUESTION 8.
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8. Is <Name>a citizen of the United States?
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Yes No Go to 9c |
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9a. Was <Name> born abroad of U.S. citizen parent or parents, or did [he/she] become a citizen by naturalization? |
Born abroad of U.S. citizen parent or parents go to 9c. Citizen by naturalization |
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9b. In what year did <Name> become a naturalized citizen of the United States? |
_______ Year |
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9c. When did <Name> come to live in the United States? |
_______ Year |
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10a1. The next questions are about schooling and education.
At any time IN THE LAST 3 MONTHS, has <Name> attended school or college? Include only nursery or preschool, kindergarten, elementary school, home school, and schooling that leads to a high school diploma or a college degree. |
Yes No Go to 11 |
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10a2. Was that a public school or college, a private school or college, or home school?
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Public school or college Private school or college or home school |
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10b. What grade or level was <Name>attending?
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Nursery school or preschool Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12 College undergraduate years, that is a college freshman to senior Graduate or professional school beyond a bachelor’s degree, for example a Master’s or PhD program or medical or law school |
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11. What is the highest degree or level of school <Name> has COMPLETED?
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No schooling completed Nursery school Kindergarten Grade 1 Grade 2 Grade 3 Grade 4. Grade 5 Grade 6 Grade 7. Grade 8 Grade 9. Grade 10 Grade 11 Grade 12, no diploma Regular high school diploma GED or alternative credential Some college, no degree Associate’s degree (for example: AA, AS) Bachelor’s degree (for example: BA, BS). Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA) Professional degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD) Doctorate degree (for example: PhD, EdD) Vocational or technical license |
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Instruction F IF RESPONSE TO QUESTION 11 IS BACHELOR’S DEGREE OR HIGHER, ASK QUESTION 12. OTHERWISE GO TO QUESTION 13. |
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12.
This question focuses on <Name>’s BACHELOR’S
DEGREE. What was the specific major or majors of any BACHELOR’S
DEGREES [he/she] has received? For example, chemical engineering,
elementary teacher education IF THIS PERSON HAS MORE THAN ONE MAJOR OR BACHELOR’S DEGREE, ASK FOR ALL MAJOR FIELDS. |
_______________________________ _______________________________ _______________________________ |
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13. What is <NAME>’s ancestry or ethnic origin?
(For example: Italian, Jamaican, African-American, Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian and so on.)
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__________________________________ __________________________________ |
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14a. Does <Name> speak a language other than English at home?
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Yes No Go to 15
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14b. What is this language? |
__________________________________ |
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14c. How well does <Name> speak English – very well, well, not well, not at all?
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Very well Well Not well Not at all |
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14c-SKIP IF PERSON IS LESS THAN ONE YEAR OLD, GO TO QUESTION 16. OTHERWISE GO TO QUESTION 15A. |
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15a. Did <Name> live in this <house/apartment/mobile home> 1 year ago?
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Yes Go to 16a No
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15b. Did <Name> live in the United States, Puerto Rico, or another country? |
United States Go to 15d Puerto Rico Go to 15d Another country Go to 15c |
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15c. What was the foreign country?
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Go to 16a |
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15d. What was the street address?
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15e. What was the city or town?
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15f. What was the [county if in United States, municipio if in Puerto Rico]?
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15g. What was the state?
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15h. What was the ZIP code?
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16a. I am now going to ask you some questions about <Name>’s health insurance and health coverage.
Is <Name> currently covered by health insurance through a current or former employer or union of <him/her> or another family member?
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Yes No |
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16b. Is <Name> currently covered by health insurance purchased directly from an insurance company by <him/her> or another family member?
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Yes No |
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16c. Is <Name> currently covered by Medicare, for people age 65 or older or people with certain disabilities?
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Yes No |
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16d. Is <Name> currently covered by Medicaid, Medical Assistance, or any kind of government-assistance plans for those with low incomes or a disability?
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Yes No |
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16e. Is <Name> currently covered by TRICARE or other military health care?
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Yes No |
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16f. Is <Name> currently covered through the Veteran’s Administration or has <he/she> ever used or enrolled for VA health care?
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Yes No |
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16g. Is <Name> currently covered through the Indian Health Service?
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Yes No |
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16h. Is <Name> currently covered by any other health insurance or health coverage plan?
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Yes No Go to 17a
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16i. What is the name of the health care plan?
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_____________________ |
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Instruction G IF PERSON ANSWERED YES TO ANY PART OF QUESTION 16, CONTINUE WITH 17; OTHERWISE SKIP TO INSTRUCTION H. |
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17. Is the cost of <Name>’s health insurance reduced based on [his/her] family income? |
Yes No |
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Instruction H
IS THIS THE LAST PERSON TO COLLECT DETAILED PERSON DATA FOR?
THIS IS LAST PERSON – END INTERVIEW MORE PERSONS - CONTINUE WITH THE REMAINDER OF THE ACS SURVEY ON THE FOLLOWING PAGES |
DETAILED QUESTIONS – PERSON 3
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NAME ___________________ |
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7a. I will now be asking a series of questions about <Name> The next few questions deal with <Name>'s place of birth and citizenship...
Where was <Name> born? ENTER STATE, IF KNOWN. IF STATE NOT KNOWN, ENTER US
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__________ State Go to 10a1 OR Not born in the US
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7b. In what country was <Name> born?
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___________ Country |
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7b-SKIP IF COUNTRY IN 7B IS PUERTO RICO, GUAM, THE U.S. VIRGIN ISLANDS, OR NORTHERN MARIANAS, GO TO QUESTION 9C. OTHERWISE GO TO QUESTION 8.
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8. Is <Name>a citizen of the United States?
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Yes No Go to 9c |
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9a. Was <Name> born abroad of U.S. citizen parent or parents, or did [he/she] become a citizen by naturalization? |
Born abroad of U.S. citizen parent or parents go to 9c. Citizen by naturalization |
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9b. In what year did <Name> become a naturalized citizen of the United States? |
_______ Year |
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9c. When did <Name> come to live in the United States? |
_______ Year |
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10a1. The next questions are about schooling and education.
At any time IN THE LAST 3 MONTHS, has <Name> attended school or college? Include only nursery or preschool, kindergarten, elementary school, home school, and schooling that leads to a high school diploma or a college degree. |
Yes No Go to 11 |
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10a2. Was that a public school or college, a private school or college, or home school?
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Public school or college Private school or college or home school |
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10b. What grade or level was <Name>attending?
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Nursery school or preschool Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12 College undergraduate years, that is a college freshman to senior Graduate or professional school beyond a bachelor’s degree, for example a Master’s or PhD program or medical or law school |
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11. What is the highest degree or level of school <Name> has COMPLETED?
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No schooling completed Nursery school Kindergarten Grade 1 Grade 2 Grade 3 Grade 4. Grade 5 Grade 6 Grade 7. Grade 8 Grade 9. Grade 10 Grade 11 Grade 12, no diploma Regular high school diploma GED or alternative credential Some college, no degree Associate’s degree (for example: AA, AS) Bachelor’s degree (for example: BA, BS). Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA) Professional degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD) Doctorate degree (for example: PhD, EdD) Vocational or technical license |
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Instruction F IF RESPONSE TO QUESTION 11 IS BACHELOR’S DEGREE OR HIGHER, ASK QUESTION 12. OTHERWISE GO TO QUESTION 13. |
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12.
This question focuses on <Name>’s BACHELOR’S
DEGREE. What was the specific major or majors of any BACHELOR’S
DEGREES [he/she] has received? For example, chemical engineering,
elementary teacher education IF THIS PERSON HAS MORE THAN ONE MAJOR OR BACHELOR’S DEGREE, ASK FOR ALL MAJOR FIELDS. |
_______________________________ _______________________________ _______________________________ |
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13. What is <NAME>’s ancestry or ethnic origin?
(For example: Italian, Jamaican, African-American, Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian and so on.)
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__________________________________ __________________________________ |
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14a. Does <Name> speak a language other than English at home?
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Yes No Go to 15
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14b. What is this language? |
__________________________________ |
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14c. How well does <Name> speak English – very well, well, not well, not at all?
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Very well Well Not well Not at all |
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14c-SKIP IF PERSON IS LESS THAN ONE YEAR OLD, GO TO QUESTION 16. OTHERWISE GO TO QUESTION 15A. |
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15a. Did <Name> live in this <house/apartment/mobile home> 1 year ago?
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Yes Go to 16a No
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15b. Did <Name> live in the United States, Puerto Rico, or another country? |
United States Go to 15d Puerto Rico Go to 15d Another country Go to 15c |
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15c. What was the foreign country?
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Go to 16a |
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15d. What was the street address?
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15e. What was the city or town?
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15f. What was the [county if in United States, municipio if in Puerto Rico]?
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15g. What was the state?
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15h. What was the ZIP code?
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16a. I am now going to ask you some questions about <Name>’s health insurance and health coverage.
Is <Name> currently covered by health insurance through a current or former employer or union of <him/her> or another family member?
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Yes No |
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16b. Is <Name> currently covered by health insurance purchased directly from an insurance company by <him/her> or another family member?
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Yes No |
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16c. Is <Name> currently covered by Medicare, for people age 65 or older or people with certain disabilities?
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Yes No |
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16d. Is <Name> currently covered by Medicaid, Medical Assistance, or any kind of government-assistance plans for those with low incomes or a disability?
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Yes No |
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16e. Is <Name> currently covered by TRICARE or other military health care?
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Yes No |
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16f. Is <Name> currently covered through the Veteran’s Administration or has <he/she> ever used or enrolled for VA health care?
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Yes No |
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16g. Is <Name> currently covered through the Indian Health Service?
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Yes No |
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16h. Is <Name> currently covered by any other health insurance or health coverage plan?
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Yes No Go to 17a
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16i. What is the name of the health care plan?
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Instruction G IF PERSON ANSWERED YES TO ANY PART OF QUESTION 16, CONTINUE WITH 17; OTHERWISE END INTERVIEW. |
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17. Is the cost of <Name>’s health insurance reduced based on [his/her] family income? |
Yes No |
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Instruction H:
END INTERVIEW
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| File Type | application/msword |
| File Title | HOUSING QUESTIONS |
| Author | emcfarlane |
| Last Modified By | demai001 |
| File Modified | 2012-08-21 |
| File Created | 2012-08-21 |