44 Health Care Access and Utilization

Attachment 44
Health Care Access and Utilization

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

Health Care Access and Utilization – Adults
Estimated time burden: 10 minutes
[HCA-00]
On the next screens, we will ask you questions about your access to health care.
Consider each question by itself; then choose or type in the answer that best shows
your experience.
1

After you make your choice, click on the NEXT button to go on to the next question.
If you want to change your last answer, click on the GO BACK button to return to the
previous question and then choose or type in a different answer.
Click on the CONTINUE button when you are ready to begin
[HCA-1]
About how long has it been since you last saw or talked to a doctor or other health
care professional about your own health? Include doctors seen while a patient in a
hospital.
Never
6 months or less
More than 6 months, but not more than 1 year ago
More than 1 year, but not more than 2 years ago
More than 2 years, but not more than 5 years ago
More than 5 years ago

Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[HCA-2]

In the last 12 months, have you visited a doctor or medical clinic for any
reason, including check-ups or visits to the emergency room or hospital
outpatient department?
Yes
No

[HCA-3]
Do you have a regular doctor or other health professional, such as a nurse or a
midwife, you usually go to when you are sick or need health care?
Yes
No
Have more than one regular doctor

[HCA-4]
Where do you usually go when you are sick or need health care?
Doctor’s office or private clinic
Community health center or other public clinic
Hospital outpatient department
Hospital emergency room
Some other place
No regular place of care

[HCA-5]
How much choice do you have in where you go for medical care?
A great deal of choice
Some choice
Very little choice

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[HCA-6]
During the last 12 months, was there any time when you had a medical problem but
put off, postponed or did not seek medical care when you needed it?
Yes
No

[HCA-7]
There are many reasons why someone may delay getting medical care. Have you
delayed getting care for any of the following reasons in the past 12 months? (check
all that apply)
You couldn’t get through on the telephone
You couldn’t get an appointment soon enough
Once you got there, you had to wait too long to see the doctor
The office wasn’t open when you could get there
You didn’t have transportation
You could not afford it
Insurance wouldn’t approve it
The clinic wasn’t physically accessible

[HCA-7a]
Are there any other reasons why you delayed getting care in the past 12 months?
Yes
No

[HCA-7b]
If you delayed getting care for any other reasons in the past 12 months, please
specify.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[HCA-8]
During the past 12 months, was there any time when you needed any of the following,
but didn’t get it because you couldn’t afford it?
Prescription medicines
Mental health counseling
Dental care
Eyeglasses

•

None of the above

[HCA-9]
The last time you saw a doctor, did the doctor listen to:
Everything you had to say
Most of what you had to say
Some of what you have to say
Only a little of what you had to say

[HCA-10]
The last time you saw a doctor, did you understand:
Everything the doctor said
Most of what the doctor said
Some of what the doctor said
Only a little of what the doctor said

[HCA-11]
The last time you saw a doctor, did you have questions about your care or treatment
that you wanted to discuss, but did not?
Yes
No

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[HCA-12]
How much confidence and trust did you have in the doctor treating you?
A great deal
A fair amount
Not too much
None at all

[HCA-13]
The last time you saw a doctor, did the doctor treat you with respect and dignity?
A great deal
A fair amount
Not too much
None at all

[HCA-14]

The last time you saw a doctor, did the doctor involve you in decisions about your
care?
As much as you wanted
Almost as much as you wanted
Less than you wanted
A lot less than you wanted
More than you wanted

[HCA-15]
The last time you saw a doctor, did the doctor spend as much time with you as you
wanted?
As much as you wanted
Almost as much as you wanted
Less than you wanted
A lot less than you wanted

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[HCA-16]
Overall, how satisfied or dissatisfied are you with the quality of health care you have
received during the last 2 years?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

[HCA-21]

On the next screens, we will ask you questions about your exercise and sleep habits.
Consider each question by itself; then choose or type in an answer that best shows
your experience.
After you make your choice, click on the NEXT button to go on to the next question. If
you want to change your last answer, click on the GO BACK button to return to the
previous question and then choose or type in a different answer.
Click on the CONTINUE button when you are ready to begin.
[HCA-17-1]
In a typical week, how often do you do vigorous leisure-time activities that cause
heavy sweating or large increases in breath or heart rate for at least 20 minutes?
Never
Less than once a week
1 to 2 times a week
3 times a week
More than 3 times a week

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[HCA-18-2]
In a typical week, how often do you do light or moderate leisure-time physical
activities for at least 10 minutes that cause only light sweating or a slight to moderate
increase in breathing or heart rate?
Never
Less than once a week
1 to 2 times a week
3 times a week
More than 3 times a week

[HCA-19-3]
In a typical week, how many times do you do strengthening physical activities?
Never
Less than once a week
1 to 2 times a week
3 times a week
More than 3 times a week

[HCA-20-4]
On average, how many hours of sleep do you get in a 24-hour period? Enter number
of hours: