Baseline Survey

Benefit Offset National Demonstration (BOND) Project

BOND Stage 2 Baseline Survey

Baseline Survey

OMB: 0960-0785

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0785 can be found here:

2014-02-03 - Revision of a currently approved collection

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BOND Implementation and Evaluation

Appendix B.

Abt Associates Inc.

Contract No. SS00-10-60011

Benefit Offset National Demonstration
Stage 2 Baseline Survey Instrument

Appendix B. BOND Stage 2 Baseline Survey Instrument

B-1

BOND Implementation and Evaluation

Contract No. SS00-10-60011

Table of Contents

SECTION A:

CONFIRMATION OF RESPONDENT / SCREENER / INTRODUCTIONS .. 1

SECTION B:

EDUCATION AND TRAINING ...................................................................... 5

SECTION C:

CURRENT EMPLOYMENT STATUS ........................................................... 7

SECTION D:

WORK HISTORY FROM 12 MONTHS PRIOR TO
RANDOM ASSIGNMENT ........................................................................... 14

SECTION E:

TRANSPORTATION................................................................................... 17

SECTION F:

BARRIERS TO EMPLOYMENT ................................................................. 18

SECTION G:

HEALTH AND FUNCTIONAL STATUS ...................................................... 23

SECTION H:

HEALTH INSURANCE ............................................................................... 29

SECTION I:

PERSONAL CHARACTERISTICS ............................................................. 31

SECTION J:

CONTACT INFORMATION ........................................................................ 34

SECTION K:

RESPONDENT CONTACT INFORMATION .............................................. 36

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. §
3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget control number. The OMB control
number for this information collection is [INSERT NUMBER], expiring [INSERT EXPIRATION DATE]. We
estimate that it will take about 41 minutes to read the instructions, gather the facts, and answer the questions.
You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 212356401. Send only comments relating to our time estimate to this address, not the completed form.

SECTION A: CONFIRMATION OF RESPONDENT / SCREENER /
INTRODUCTIONS

INITIAL CONTACT WITH RESPONDENT
NOTE TO INTERVIEWER: DO NOT READ TEXT IN ALL CAPS.
Hello, my name is _________, and I work for Abt Associates, Inc a research company in Cambridge, MA.
Thank you for taking the time to speak with me today.
We are conducting a study for the Social Security Administration. As part of this study, we will interview
thousands of people who currently receive Social Security Disability Benefits. The study is about a new
program that they are administering called the Benefit Offset National Demonstration or BOND. Thank
you for volunteering to participate in this program.
The purpose of this study is to learn about your past work experience and future work goals you may
have. We will also ask some questions about your health. Your participation in this interview is
completely voluntary. It will in no way affect your current or future receipt of benefits. You can stop the
interview at any time. If any question makes you feel uncomfortable, you can refuse to answer that
question.
Do you have any questions?
IF YES: Interviewer respond to questions as they arise.
IF NO:

Alright then, do you mind if we start the interview now? It should take approximately [41
minutes estimated duration]. At the end of the interview I will give you $40 to thank you
for your time. [IF INTERVIEW DONE IN SITE OFFICE: I will also give you $10 to help
with any transportation or child care costs you incurred.]

REVIEWER NOTE: There is also a screener to verify the identity of the respondent that begins by
checking birth date and continues by checking other data (perhaps name of informant) if
interviewer cannot verify birth date. To simplify review, verification screeners have been removed
from this draft.
Screeners vary depending upon:
 if a proxy is needed; or
 if there is a language barrier.
Let’s begin with some general questions. We may have asked similar questions in the past. If we repeat
questions you have answered before, it is so we can update our information.
* INDICATES QUESTIONS NOT TO BE ASKED OF PROXIES.

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

A5.

Contract No. SS00-10-60011

Compared to {THIS MONTH, LAST YEAR}, how would you rate your health in general now?
Much better now,.................................................................................1
Somewhat better now, ........................................................................2
About the same, ..................................................................................3
Somewhat worse now, or....................................................................4
Much worse now? ...............................................................................5
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

A6.

What is your current marital status? Are you now married, widowed, divorced, separated or have
you never been married?
MARRIED............................................................................................1
WIDOWED ..........................................................................................2
DIVORCED .........................................................................................3
SEPARATED ......................................................................................4
NEVER MARRIED ..............................................................................5
REFUSED ...........................................................................................7 (SKIP TO SECT B)
DON’T KNOW .....................................................................................8 (SKIP TO SECT B)

A7.

Are you currently living with a spouse or with someone who is like a spouse to you?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

A8.

CHECK FOR ABILITY TO CONTINUE WITH SELF-RESPONSE. HOW MANY ITEMS IN
QUESTIONS A1-A7 ARE ANSWERED REFUSED OR DON’T KNOW?
1 OR 2.................................................................................................1
3 OR MORE ........................................................................................2

(SKIP TO SECT B)

[INSTRUCTION: IF RESPONDENT FAILS SCREENER, CAPI WILL PROMPT FOR NAME OF A
PROXY RESPONDENT. IF PROXY IS AVAILABLE SCREENERS WILL REPEAT WITH PROXY. IF NO
PROXY AVAILABLE INTERVIEWER WILL TERMINATE]

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

A9.

Contract No. SS00-10-60011

It seems like some of these questions are difficult for you. Is there anyone who can help do this
interview you or answer questions for you?
YES .....................................................................................................1
NO .......................................................................................................2 (THANK/END)
REFUSED ...........................................................................................7 (THANK/END)
DON’T KNOW .....................................................................................8 (THANK/END)

a.
b.
c.
d.

A10.

What is his/her first name?
What is his/her middle name?
What is his/her last name?
Does his/her name have a suffix?

What is (his/her) street address?
A10a. Is there a complex/building name?
A10b. Is there an apartment number?
A10c.

In what city?

A10d. In what state?
A10e. What is the zip code?

A11.

What's the best phone number to reach (him/her) at starting with the area code?
Telephone # with area code: (_______) ________-________

A12.

Is she/he a friend or a relative, or what is (his/her) relationship to you?
ACCEPT ONE RESPONSE ONLY.
FRIEND...............................................................................................1
RELATIVE...........................................................................................2
LEGAL GUARDIAN.............................................................................3
CASE MANAGER ...............................................................................4
OTHER (SPECIFY):____________________________ ...................5
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

SECTION B: EDUCATION AND TRAINING
The next set of questions are about your education.
B1.

What is the highest year or grade in school that you have completed?
INTERVIEWER: ENTER HIGHEST GRADE COMPLETED IN SPACE PROVIDED FOR GRADE.
IF BEYOND GRADE 12, SELECT APPROPRIATE CODE.
GRADE (1-12)___________________________________
SOME COLLEGE/SOME POSTSECONDARY VOCATIONAL
COURSES ......................................................................................13
2-YEAR OR 3-YEAR COLLEGE DEGREE (ASSOCIATE’S
DEGREE) OR VOCATIONAL SCHOOL DIPLOMA .....................14
4-YEAR COLLEGE DEGREE (BACHELOR’S DEGREE) ...............15
SOME GRADUATE WORK/NO GRADUATE DEGREE ..................16
GRADUATE OR PROFESSIONAL DEGREE
(e.g., MA, MBA, Ph.D., J.D., M.D.) .................................................17
NEVER ATTENDED SCHOOL .........................................................18
SPECIAL EDUCATION WITH NO CERTIFICATE OF
COMPLETION ................................................................................19
SPECIAL EDUCATION WITH A CERTIFICATE OF
COMPLETION ................................................................................20
REFUSED .........................................................................................97
DON’T KNOW ...................................................................................98

B1a.

B2.

Do you have either a high school diploma or a GED?
YES, HIGH SCHOOL DIPLOMA ........................................................1
YES, GED ...........................................................................................2
NO, NEITHER .....................................................................................3
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

[ASK IF A2=YES; OTHERWISE SKIP TO C1] Are you working toward a degree, a certificate or
license, or are you just taking classes?
WORKING TOWARD DEGREE .........................................................1
WORKING TOWARD CERTIFICATE/ LICENSE ...............................2
ONLY TAKING CLASSES ..................................................................3 (SKIP TO B4)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

B3.

Contract No. SS00-10-60011

Toward what type of {degree/certificate or license} are you working?
GED OR HIGH SCHOOL EQUIVALENCE PROGRAM/COURSES ..1
VOCATIONAL PROGRAM .................................................................2
ASSOCIATE DEGREE PROGRAM (AA DEGREE) ...........................3
UNDERGRADUATE DEGREE PROGRAM (BA, BS DEGREE) ........4
GRADUATE DEGREE PROGRAM (e.g., MA, MS, MD, EdD) ...........5
OTHER................................................................................................6
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

B4.

Are you a full-time or part-time student?
FULL-TIME..........................................................................................1
PART-TIME.........................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Appendix B.

Abt Associates Inc.

Contract No. SS00-10-60011

Benefit Offset National Demonstration
Stage 2 Baseline Survey Instrument

Appendix B. BOND Stage 2 Baseline Survey Instrument

B-1

BOND Implementation and Evaluation

Contract No. SS00-10-60011

Table of Contents

SECTION A:

CONFIRMATION OF RESPONDENT / SCREENER / INTRODUCTIONS .. 1

SECTION B:

EDUCATION AND TRAINING ...................................................................... 5

SECTION C:

CURRENT EMPLOYMENT STATUS ........................................................... 7

SECTION D:

WORK HISTORY FROM 12 MONTHS PRIOR TO
RANDOM ASSIGNMENT ........................................................................... 14

SECTION E:

TRANSPORTATION................................................................................... 17

SECTION F:

BARRIERS TO EMPLOYMENT ................................................................. 18

SECTION G:

HEALTH AND FUNCTIONAL STATUS ...................................................... 23

SECTION H:

HEALTH INSURANCE ............................................................................... 29

SECTION I:

PERSONAL CHARACTERISTICS ............................................................. 31

SECTION J:

CONTACT INFORMATION ........................................................................ 34

SECTION K:

RESPONDENT CONTACT INFORMATION .............................................. 36

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

SECTION A: CONFIRMATION OF RESPONDENT / SCREENER /
INTRODUCTIONS

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

A1.

Contract No. SS00-10-60011

Are you currently working at a job or business for pay or profit? This includes work you may do
for a business that you own.
IF NEEDED READ: By ‘working at a job for pay or profit’ we mean at a job where you get paid
money for the work you do.
[INTERVIEWER: IF R IS SELF-EMPLOYED, CODE RESPONSE AS YES]
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

A2.

Are you currently enrolled in school or taking any classes?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

A3.

Do you currently do any volunteer work for an organization?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

A4.

In general, would you say your health is . . .

(SF-12)

Excellent,.............................................................................................1
Very good,...........................................................................................2
Good, ..................................................................................................3
Fair, or.................................................................................................4
Poor?...................................................................................................5
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

A1.

Contract No. SS00-10-60011

A2.

A3.

A4.

In general, would you say your health is . . .

(SF-12)

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

SECTION C: CURRENT EMPLOYMENT STATUS
These next questions are about your current work-related activities.
C1.

INTERVIEWER: CHECK A1 IS SAMPLE MEMBER CURRENTLY WORKING AT A JOB OR
BUSINESS FOR PAY OR PROFIT?
YES .....................................................................................................1 (SKIP TO C4)
NO .......................................................................................................2

C2.

Now I’d like you to think about the last four weeks. Have you been looking for work during the
last four weeks?
NOTE: By looking for work, I mean looking for a job, either full-time or part-time, for which you
will be paid.
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

C3.

When did you last work for pay?
|__|__|
MO

|__|__|__|__|
YEAR

REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

SKIP TO VOLUNTEER WORK, ITEM C22.

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

[INTERVIEWER: ASK C4-C21 ONLY OF THOSE WHO ARE WORKING (C1=YES)
Now I am going to ask some questions about the job or jobs you currently have. When answering these
questions, please include both part-time and full-time jobs, but only include jobs you work at for pay or
profit. This could be work that you do for a business that you own. (NBS modified)

C4.

How many jobs do you currently have?
NUMBER OF JOBS: ______________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

C5.

Let’s talk about your current/main job. What kind of business or industry is this, that is, what do
they make or do where you work? (RECORD VERBATIM) (CPS/MTO modified)
IF MORE THAN ONE JOB [C4>1] READ: Your main job is the job at which you work the most
hours
_________________________________________
_________________________________________
DON’T KNOW .....................................................................................7
REFUSED ...........................................................................................8

C6.

What kind of work do you do, that is, what is your occupation? For example, plumber, typist,
farmer [RECORD VERBATIM] (CPS/MTO modified)
_________________________________________
_________________________________________
DON’T KNOW .....................................................................................7
REFUSED ...........................................................................................8

C7.

What are your usual duties or activities at this job? For example: typing, keeping account books,
filing, selling cars, operating printing press, laying brick. [RECORD VERBATIM] (CPS/MTO
modified)
_________________________________________
_________________________________________
DON’T KNOW .....................................................................................7
REFUSED ...........................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

C8.

Contract No. SS00-10-60011

Are you self-employed at this job? (NBS)
IF NECESSARY READ: Self-employed means that you work for yourself or own your own
business.
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

C9.

Is this job a temporary or seasonal job? (NEW)
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

C10.

In what month and year did you start working there?
IF SELF-EMPLOYED [C8=01] ASK: In what month and year did you start this business? (NBS:
Modified)
INTERVIEWER: ENTER MONTH HERE AND YEAR ON NEXT SCREEN
IF NECESSARY READ: Your best estimate is fine.
|__|__|
MO

|__|__|__|__|
YEAR

C11.

How many hours per week do you typically work at this job?
NUMBER OF HOURS PER WEEK: ______________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

For the purpose of this survey, it is important to obtain some information on how much you are paid on
this job. Please remember that we will keep all of your responses private.
[Programming in CAPI will control for main job versus current job, depending on the response to
C4.]

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

C12.

Contract No. SS00-10-60011

Before taxes and other deductions how much are you paid on this job? (NBS-modified)
$___________.______
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

C12a. Is that amount paid daily, weekly, bi-weekly, twice a month, monthly, annually, or per
unit?
HOURLY .............................................................................................1
DAILY..................................................................................................2
WEEKLY .............................................................................................3
EVERY TWO WEEKS.........................................................................4
TWICE A MONTH ...............................................................................5
MONTHLY...........................................................................................6
ANNUALLY .........................................................................................7
PER UNIT OR PIECE .........................................................................8
REFUSED .........................................................................................97
DON’T KNOW ...................................................................................98

C13.

(SKIP TO C16)
(SKIP TO C14)
(SKIP TO C17)
(SKIP TO C17)
(SKIP TO C17)
(SKIP TO C14)
(SKIP TO C15)

[IF RATE OF PAY IS NOT DAILY (C12a2) SKIP TO C14] How many days a week do you
usually work? (CPS; MTO Interim Evaluation)
NUMBER OF DAYS PER WEEK: ______________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

C14.

[IF RATE OF PAY NOT ANNUAL (C12a7 SKIP TO C15] How many weeks a year do you get
paid for? (CPS; MTO Interim Evaluation)
NUMBER OF WEEK: ______________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

C15.

[IF RATE OF PAY NOT PER UNIT (C12a8 SKIP TO C16] For how many [UNIT]s are you
usually paid per week (on this job)?
NUMBER OF UNITS: ______________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

C16.

Contract No. SS00-10-60011

[IF RATE OF PAY IS NOT HOURLY (C12a1) SKIP TO C17] How many hours per week are you
paid for at this rate? (CPS; MTO Interim Evaluation)
NUMBER OF HOURS PER WEEK: ______________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

C17.

Do you usually receive tips, or commissions (at your main job)? (CPS–modified)
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO C18)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
C17a. (At your main job,) how much do you usually earn in tips or commissions, before taxes or
other deductions? (CPS-modified)
$___________.______
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

C18.

I’d like you to think about your earnings in a typical week. How much do you think you typically
earn, before taxes or other deductions, in a typical week.
$___________.______
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

C19.

I’d like you to think about the past year. Have you received any promotions at this job during the
past year?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

C19a. I’d like you to think about the past year. Have you received any bonuses or awards at
this job during the past year?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
C20.

(SKIP TO C21 IF SELF-EMPLOYED [C8=1]) Now, I’d like to ask you a few more questions about
your current job. I am going to read to you a list of benefits that some employers offer their
employees. Please tell me whether or not your current employer offers any of these benefits.
Does your employer offer
PROGRAMMER: USE “MAIN” IF C4>01, OTHERWISE USE “CURRENT.”
IF NECESSARY READ: Please answer ‘yes’ if you are eligible for the benefit but haven’t yet
started to receive it.
YES

REF

C20a. Health care insurance? (IF NECESSARY:
medical and/or hospital)

C20b. Dental benefits?

C20c. Sick days with pay?

C20d. Paid vacation?

C20e. Free or low-cost childcare?

C20g. Long-term disability benefits?

C20h. Pension or retirement benefits?

C20i.

Short-term disability benefits?

C20j.

Flexible health or dependent care spending accounts?

C20f.

C21.

Transportation, a transportation allowance, or
transportation discounts?

* Taking all things into account, how satisfied are you with your current job? Would you say you
are:
PROGRAMMER: USE “MAIN” IF C4>01, OTHERWISE USE “CURRENT.”
Very satisfied.......................................................................................1
Somewhat satisfied .............................................................................2
Not very satisfied.................................................................................3
Not at all satisfied................................................................................4
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

C22.

Contract No. SS00-10-60011

Do you use any special equipment related to your disability that helps you work at your job, for
example a brace, cane, wheelchair, modified computer hardware or modified computer software?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO C23)
REFUSED ...........................................................................................7 (SKIP TO C23)
DON’T KNOW .....................................................................................8 (SKIP TO C23)

C22a. What kinds of special equipment do you/ use? Anything else?
ENTER ALL THAT APPLY. READ IF NECESSARY
BRACE................................................................................................1
CANE/CRUTCHES/WALKER.............................................................2
WHEELCHAIR ....................................................................................3
MODIFIED COMPUTER HARDWARE...............................................4
MODIFIED COMPUTER SOFTWARE ...............................................5
OTHER (SPECIFY).............................................................................6
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
C23.

Do you use any personal assistance services related to your/his/her disability that helps you
work, for example, a job coach, a sign language interpreter, a reader or interpreter for the blind,
or a personal care attendant?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO D1)
REFUSED ...........................................................................................7 (SKIP TO D1)
DON’T KNOW .....................................................................................8 (SKIP TO D1)

C23a. What kind of personal assistance services do you use? Anything else?
ENTER ALL THAT APPLY. READ IF NECESSARY
JOB COACH.......................................... ................... .........................1
SIGN LANGUAGE INTERPRETER....................................................2
READER/INTERPRETER FOR THE BLIND ..................................... 3
PERSONAL CARE ATTENDANT/PERSONAL ASSISTANT .............4
OTHER (SPECIFY).............................................................................5
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

SECTION D: WORK HISTORY FROM 12 MONTHS PRIOR TO RANDOM
ASSIGNMENT
IF C3=MORE THAN 12 MONTHS AGO SKIP TO E1
D1.

Now, I will ask you about any other jobs you have had since [MONTH/YEAR 12 MONTHS PRIOR
TO RADATE]. When answering these questions, please include both part-time and full-time jobs,
but only include work you did for pay or profit at a job that lasted for one month or longer.
You should include self-employment
IF CURRENTLY EMPLOYED (C1=1) ASK: Excluding the job we just talked about, between
[MONTH/YEAR 12 MONTHS PRIOR TO RADATE] and today, did you work for pay at any other
jobs for longer than one month?
IF NOT CURRENTLY EMPLOYED (C1<>1) ASK: Between [MONTH/YEAR 12 MONTHS PRIOR
TO RADATE] and today, did you work for pay at any jobs for longer than one month?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO E1)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

IF RESPONDENT IS CURRENTLY WORKING, CAPI WILL INCORPORATE BRACKETED TEXT IN
D2.
D2.

[Excluding your current job,] How many (other) jobs did you hold for at least one month during the
past three years?
NUMBER OF JOBS: ______________ (1-15)
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

D3.

Let us start with the job before your [current one/ last job]. What was the name of the place that
you worked before you [current/last job]? [IF SELF-EMPLOYED, RECORD PLACE AS ‘SELFEMPLOYED’]
NAME1:______________________________________________________________
D3a. What was the name of the place that you worked before that?
NAME2:______________________________________________________________
NAME3:______________________________________________________________
NAME4:______________________________________________________________
NAME5:______________________________________________________________

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

D3 LOOPS UNTIL ALL EMPLOYERS IN FOLLOW_UP ARE ACCOUNTED FOR.
D4 TRHOUGH D8 WILL LOOP ACCORDING TO D3RESPONSE, FOR UP TO 5 RESPONSES.
D4.

In what month and year did you start working at [D3 JOB]?
IF NECESSARY READ: Your best estimate is fine.
INTERVIEWER: ENTER MONTH HERE AND YEAR ON NEXT SCREEN
|__|__|
MO

|__|__|__|__|
YEAR

D5.

In what month and year did you stop working at [D3 JOB]?
IF NECESSARY READ: Your best estimate is fine.
INTERVIEWER: ENTER MONTH HERE AND YEAR ON NEXT SCEEN
|__|__|
MO

|__|__|__|__|
YEAR

That means that you worked at this place [NAME OF EMPLOYER] for about [INSERT
NUMBER] months [OR YEARS]. Does that sound right?
YES .....................................................................................................1 (SKIP TO D6)
NO .......................................................................................................2
REFUSED ...........................................................................................7 (SKIP TO D6)
DON’T KNOW .....................................................................................8 (SKIP TO D6)

D5b.

About how many months [OR YEARS] did you work at that job?
_____ MONTHS
______YEARS
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

D6.

Contract No. SS00-10-60011

Were you self-employed at [D3 JOB]?
PROBE: Self-employed means that you work for yourself or own your own business.
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

[IF D6=1 THEN CAPI WILL SUBSTITUTE ‘at this business’ FOR ‘at this job’ in D7 and D8.]
D7.

How many hours per week did you usually work [at [D3 JOB]/at this business]?
IF NECESSARY READ: Include overtime if you usually worked overtime.
HOURS PER WEEK: ______________ (SKIP TO D6)
IT VARIED......................................................................................... -3
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
D7a.

D8.

Did you usually work more than 35 hours per week?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

How much did you earn per week on average when you worked at [D3 JOB]?
IF R IS NOT SURE WHAT WEEKLY EARNINGS WERE, ASK THEM FOR THEIR BEST
ESTIMATE
$___________.______
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

SECTION E: TRANSPORTATION
Now I’m going to ask you about different types of transportation and which ones you may use.
E1.

[IF C21 =1 SKIP to E2] Are you able to drive a car at this time? (NEW)
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO E2)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
E1a.

Do you have a valid driver’s license?
[IF NEEDED READ: By valid driver’s license we mean a license that allows you to
operate a motor vehicle and is current, not suspended or revoked.]
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO E2)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

E1b.

Do you currently have access to a car, truck or van that runs?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

E2.

When you have to go places, how do you usually get there? Do you usually :
YES

REF

E2a.

Use you own car, truck or van?

E2b.

Take the bus?

E2c.

Take a train or use the subway?

E2d.

Rely on Friends or Relatives?

E2e.

Walk?

E2f.

Use a taxi, van or paratransit service?

E2g.

Do you usually wheel?

E2h.

Do you usually wheel a motorized scooter?

E2i.

Use another form of transportation
(SPECIFY__________________________________)?

INTERVIEWER IF NEEDED READ: Paratransit is a transportation service for individuals with
disabilities who are unable to use public bus or train transportation systems.

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

SECTION F: BARRIERS TO EMPLOYMENT
Personal Views
Now I am going to read you a few statements. I’m going to ask you whether or not you agree with each
one.

F1.

*For the following statements, please tell me whether you strongly agree, agree, disagree, or
strongly disagree. (NBS modified)

Agree

Neither
Agree Nor
Disagree

Disagree

Strongly
Disagree

REF

F1b. I am limited in my ability to
work because I do not have
reliable transportation to and
from work.

F1c. I am limited in my ability to
work because I am caring
for children or others

F1d. It is difficult for me to work
because I am afraid I will
lose my disability benefits

F1e. I am limited in my ability to
work because I am finishing
a school or training program

F1g. I don’t have the skills or
training I need to return to
work.

F1h. It will be difficult to re-qualify
for Social Security disability
benefits in the future if I
work.

Strongly
Agree
F1a. I am limited in my ability to
work because of a physical
or mental condition. Do you
strongly agree, agree,
neither agree or disagree,
disagree, or strongly
disagree?

F1f.

F2.

Many workplaces are not
accessible to people with my
disability

Does a physical or mental condition limit your ability to work?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

F3.

Contract No. SS00-10-60011

How old were you when you first became limited in the kind or amount of work or other daily
activities you could do?
AGE AT ONSET____________________________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

F4.

Were you working at a job for pay or profit when you first became limited?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

F5.

What kind of work were you doing when you first became limited? That is, what was your
occupation? For example were you a plumber, typist, farmer [RECORD VERBATIM] etc.?
(CPS/MTO modified)
_________________________________________
_________________________________________
DON’T KNOW .....................................................................................7
REFUSED ...........................................................................................8

F5a.

Are you able to do the same type of work now?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

F6.

*Do your personal goals include [IF A1=2: getting a job], moving up in a job or learning new job
skills?
YES .....................................................................................................1
NO .......................................................................................................2
I CAN’T WORK DUE TO DISABILITY ................................................3 (GO TO G1)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

Now I’d like to talk about different aspects of the social security disability insurance program.

F7.

*Have you ever heard of a Trial Work Period? This is a Social Security incentive that lets you
earn above $1,000 per month for nine months without losing your benefits?
PROBE: If you’re not sure or never heard of a Trial Work Period, please let me know.
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO F9)
REFUSED ...........................................................................................7 (SKIP TO F9)
DON’T KNOW .....................................................................................8 (SKIP TO F9)

F8.

Have you used any of your Trial Work Period?
PROBE: If you’re not sure or never heard of a Trial Work Period, please let me know.
INTERVIEWER: IF ‘NOT SURE’ OR ‘NEVER HEARD OF’ CODE AS NO
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

F9.

Have you ever spoken with or received services from a benefit specialist or Work Incentive
Planning Assistance (WIPA) program provider?
PROBE1: These are programs funded by Social Security to provide information to beneficiaries
about how their benefits are affected by work.
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

F10.

* Have you ever heard of an Extended Period of Eligibility for Medicare? This is a Social Security
support that lets you keep Medicare coverage when you go to work, even if your benefits have
stopped.
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

F11.

Contract No. SS00-10-60011

Have you ever used an Extended Period of Eligibility for Medicare?
PROBE: If you’re not sure or never heard of an Extended Period of Eligibility for Medicare, please
let me know.
INTERVIEWER: IF ‘NOT SURE’ OR ‘NEVER HEARD OF’ CODE AS NO
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

INTERVIEWER READS THIS INTRODUCTION: Under the current rules of the Social Security Disability
Insurance program, disability beneficiaries are allowed to earn up to $1000 per month without a change to
your benefits. This limit is called the level of Substantial Gainful Activity or SGA and the Social Security
increases this limit each year to adjust for inflation. When disability beneficiaries go to work while
receiving disability benefits, SSA ignores the cap of $1000 for up to 9 months, no matter how much a
beneficiary earns from work.

F12.

*We’d like to know which of the following things you think would happen to your monthly
disability cash benefits if you were to work and earn more than the SGA limit of $1000 month
after those initial months have passed. Thinking about the amount of your disability cash
benefits, if you earned more than $1,000 after those initial months…
*F12a. Do you think you would lose your monthly benefits completely? That is, would the
amount of your benefits fall to $0?
YES .....................................................................................................1 (SKIP TO F14e)
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
*F12b. Do you think your benefits would be reduced but that you would be able to keep receiving
some of your monthly disability benefits?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO F14d)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

*F12c. [IF F5b=YES] How do you think those benefits would be reduced? Do you think that they
would be reduced…
By the full amount of your benefit? ....................................................1
By half of the amount of your benefits, that is a $1 reduction in benefits
for every $2 you earn from work? .......................................................2
By some other amount? .....................................................................3
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

*F12d. Do you think your disability benefits would stay the same? That is, nothing would happen
to your monthly disability benefits if you earned more than $1,000 per month after the
initial 9 months that SSA allows?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Now, we’d like to know which of the following things you think would happen to your eligibility for
disability benefits if you were to work and earn more than the SGA limit of $1000 month after
those initial months have passed. Thinking about your eligibility for disability benefits…
*F12e. Do you think you would remain eligible for disability benefits in the future, no matter how
much you earn from work? That is, you would never have to re-apply for benefits?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

*F12f. Do you think you would remain eligible for disability benefits for awhile, but eventually you
would no longer be eligible to receive benefits? That is, do you think eventually you would
have to re-apply for benefits?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

SECTION G: HEALTH AND FUNCTIONAL STATUS
The next few questions ask about your health and how well you are able to do your usual activities. As I
read each item, please tell me if your health now limits you a lot, limits you a little, or does not limit you at
all in these activities.

G1.

Does your health now limit you in moderate activities such as moving a table, pushing a vacuum
cleaner, bowling, or playing golf? Does it limit you…

(SF-12)
A lot, ....................................................................................................1
A little, or .............................................................................................2
Not at all? ............................................................................................3

G2.
Does your health now limit you in climbing several flights of stairs? Does it limit you…
(SF-12)
A lot, ...................................................................................................1
A little, or .............................................................................................2
Not at all? ............................................................................................3

The next two questions ask about your physical health and your daily activities.

G3.

* During the past 4 weeks, how much of the time have you accomplished less than you would
have liked to as a result of your physical health? Would you say…

(SF-12)
All of the time, .....................................................................................1
Most of the time,..................................................................................2
Some of the time, ................................................................................3
A little of the time, or ...........................................................................4
None of the time?................................................................................5

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

G4.

Contract No. SS00-10-60011

During the past 4 weeks, how much of the time were you limited in the kind of work or other
regular daily activities you do as a result of your physical health? Would you say…

Now I will ask about any emotional problems and your daily activities.

G5.

* During the past 4 weeks, how much of the time have you accomplished less than you would
have liked to as a result of any emotional problems, such as feeling depressed or anxious?
Would you say…

G6.

* During the past 4 weeks, how much of the time did you not do work or other activities as
carefully as usual as a result of any emotional problems, such as feeling depressed or anxious?
Would you say…

G7.

* During the past 4 weeks, how much did pain interfere with your normal work, including both
work outside the home and housework? Did it interfere.

(SF-12)
Not at all, .............................................................................................1
A little bit,.............................................................................................2
Moderately, .........................................................................................3
Quite a bit, or.......................................................................................4
Extremely? ..........................................................................................5

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

These next questions are about how you feel and how things have been with you during the past 4
weeks. For each question, please give me the one answer that comes closest to the way you have been
feeling.

G8.

* During the past 4 weeks, how much of the time have you felt calm and peaceful? Would you
say…

G9.
* During the past 4 weeks, how much of the time did you have a lot of energy? Would you say…
(SF-12)
All of the time, .....................................................................................1
Most of the time,..................................................................................2
Some of the time, ................................................................................3
A little of the time, or ...........................................................................4
None of the time?................................................................................5

G10.

* During the past 4 weeks, how much of the time have you felt downhearted and depressed?
Would you say…

G11.

* During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities, like visiting with friends or relatives? Would you say…

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

Health Care Service Utilization
G12.

During the past 12 months, have you stayed overnight in a hospital? (HCC)
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO H14)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

G13.

During the past 12 months, how many nights in total did you stay in the hospital? (HCC)
|__|__| TIMES
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

Now I’d like to ask some general health related questions.

G14.

How tall are you without shoes? (NHIS 97)
IF NECESSARY READ: Please respond in feet and inches?
|__| FEET
(3-8)

|__|__| INCHES
(1-11)

G15.

How much do you weigh without shoes? (NHIS97)
|__|__|__| POUNDS (50-300)
(50-600)
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

Now I’d like to ask you some questions about everyday activities and how much difficulty you have doing
these activities. Please give me your best answer even if the questions don’t seem to apply to you.

G16.

Do you need help with personal care such as bathing, dressing, or getting around the house
because of an impairment or a physical or mental health problem?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

G17.

During the past 12 months, about how many days did illness or an injury keep you in bed more
than half of the day? (Please include days that you were an overnight patient in a hospital.)
NUMBER OF DAYS ____________________
NONE..................................................................................................0
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

G18.

Do you need the help of another person in order to get around inside your home?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

G19.

Do you need the help of another person in order to get around outside your home?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

G20.

* Do you have a lot of trouble concentrating long enough to finish everyday tasks?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

G21.

Contract No. SS00-10-60011

* Do you have a lot of trouble coping with day-to-day stresses?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

SECTION H: HEALTH INSURANCE
Now, I’m going to ask you about different types of health insurance coverage you might have.

H1.
Do you have health insurance coverage now?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “For instance, are you covered by a plan that
someone else in your family has, or through a health plan your employer provides, or Medicare,
Medicaid, or a plan you bought on your own?”]
YES .....................................................................................................1 (H3)
NO .......................................................................................................2

H2.
So, you are uninsured, is that correct?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “This means no Medicaid coverage or any other
government sponsored health insurance coverage.”]
YES ....................................................................................................1 (SKIPTO H5)
NO ......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

H3.

What kinds of health coverage do you have?
PROBE: Any other kind?
INTERVIEWER: CODE ALL THAT APPLY.
MEDICAID/{STATMED}......................................................................1
MEDICARE .........................................................................................2
CHAMPUS/CHAMP-VA, TRICARE, VA, OTHER MILITARY .............3
INDIAN HEALTH SERVICE................................................................4
MEDI-GAP ..........................................................................................5
STATE PROGRAM .............................................................................6
PRIVATE INSURANCE THROUGH OWN EMPLOYER ....................7
PRIVATE INSURANCE THROUGH SPOUSE/PARTNER/PARENT .8
PRIVATE INSURANCE PAID BY SELF/FAMILY ...............................9
PRIVATE DISABILITY INSURANCE PAID BY SELF/FAMILY ........10
OTHER PLAN (SPECIFY)_____________________ ......................95
REFUSED .........................................................................................97
DON’T KNOW ...................................................................................98

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

The next set of questions is about the use of health care. Please do not include dental care.

H4.

During the past 12 months, have you delayed seeking medical care for you or a member of your
family because of worry about the cost?
YES ....................................................................................................1
NO ......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

H5.

During the past 12 months, was there any time when you needed medical care, but did not get it
because you couldn't afford it?
YES ....................................................................................................1
NO ......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

SECTION I:

Contract No. SS00-10-60011

PERSONAL CHARACTERISTICS

Demographics
I have a few more questions about you.
I1.

What is your ethnic background? Are you:
Hispanic or Latino, or ..........................................................................1
Not Hispanic or Latino?.......................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

I2.

What is your race? Do you think of yourself as:
INTERVIEWER: CODE ALL THAT APPLY.

I3.

YES

REF

I2a.

IF VOLUNTEERED: MULTIRACIAL,

I2b.

Alaska Native or American Indian

I2c.

Asian

I2d.

Black or African American

I2e.

Native Hawaiian or Other Pacific Islander

I2f.

White

I2g.

OTHER (SPECIFY_______________)

What is the primary language spoken in your home?
ENGLISH ............................................................................................1
SPANISH ............................................................................................2
AMERICAN SIGN LANGUAGE ..........................................................3
OTHER(SPECIFY__________________________) .........................4
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

I4.

INTERVIEWER: RECORD RESPONDENT’S GENDER:
MALE / FEMALE ........................... [query or interviewer observation]

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

Current Living Situation
The next questions are about your current living situation.

I5.

Thinking about the place you live, would you say that this place is a…
[INTERVIEWER: CODE ONE ANSWER.]
[IF RESPONDENT LIVES IN ONE UNIT WITHIN A TWO- OR THREE-FAMILY HOME, CODE
AS REGULAR APARTMENT (03).]
Single family home .............................................................................1
Mobile home. ......................................................................................2
Regular apartment .............................................................................3
Supervised apartment ........................................................................4
Group home .......................................................................................5
Halfway house.....................................................................................6
Personal care or board and care home .............................................7
Assisted living facility ..........................................................................8
Nursing or convalescent home ...........................................................9
Shelter ..............................................................................................10
Some other type of supervised group residence or facility ...............11
Something else________________________________.................12
REFUSED .........................................................................................97
DON’T KNOW ...................................................................................98

I6.

Is this place primarily for people with hearing or vision impairments, mental illness psychiatric
disabilities, mental retardation, or developmental disabilities?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

I7.

Not including yourself, how many other people live in your household with you now?
NUMBER OF PEOPLE____________________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

I8.

Contract No. SS00-10-60011

The next set of questions asks about the other people who currently live with you.

(Household Roster)
I8a1. What is the (FIRST/
SECOND/THIRD) other
member's first name?
I8a2. Does his/her name have
a suffix, such as Jr or
Sr.?

OTHER MEMBER #1

OTHER MEMBER #2

OTHER MEMBER #3

FIRST:
SUFFIX:

REFUSED .............................. 97
DON’T KNOW ........................ 98

REFUSED............................... 97
DON’T KNOW......................... 98

I8b.

How old was (OTHER
MEMBER'S) on her/his
last birthday?

AGE____
REFUSED ............................... -2
DON’T KNOW ......................... -1

AGE____
REFUSED................................ -2
DON’T KNOW.......................... -1

AGE____
REFUSED................................-2
DON’T KNOW..........................-1

I8c.

What is (OTHER
MEMBER'S) relationship
to you?

BIRTH CHILD ......................... 01
ADOPTED CHILD .................. 02
GRANDCHILD........................ 03
FOSTER CHILD ..................... 04
SPOUSE/PARTNER .............. 05
MOTHER………………………09
FATHER ................................. 10
PERSONAL CARE ASST. ..... 11
OTHER RELATIVE ................ 06
NON-RELATIVE ..................... 07
OTHER CHILD ....................... 08
REFUSED .............................. 97
DON'T KNOW ........................ 98

BIRTH CHILD ......................... 01
ADOPTED CHILD................... 02
GRANDCHILD ........................ 03
FOSTER CHILD ..................... 04
SPOUSE/PARTNER............... 05
MOTHER………………………09
FATHER ................................. 10
PERSONAL CARE ASST....... 11
OTHER RELATIVE................. 06
NON-RELATIVE ..................... 07
OTHER CHILD ....................... 08
REFUSED............................... 97
DON'T KNOW......................... 98

BIRTH CHILD ......................... 01
ADOPTED CHILD................... 02
GRANDCHILD ........................ 03
FOSTER CHILD...................... 04
SPOUSE/PARTNER............... 05
MOTHER………………………09
FATHER.................................. 10
PERSONAL CARE ASST. ...... 11
OTHER RELATIVE ................. 06
NON-RELATIVE ..................... 07
OTHER CHILD........................ 08
REFUSED............................... 97
DON'T KNOW ......................... 98

I8d.

JOBAGE FLAG IF
I8b>15 CODE YES

YES .......................................... 1
NO ............................................ 2
DON’T KNOW .......................... 8

YES........................................... 1
NO ............................................ 2
DON’T KNOW........................... 8

YES........................................... 1
NO............................................. 2
DON’T KNOW........................... 8

I8e.

Last week, did [OTHER
MEMBER] do any work
for pay?

YES .......................................... 1
NO ............................................ 2
REFUSED ................................ 7
DON’T KNOW .......................... 8

YES........................................... 1
NO ............................................ 2
REFUSED................................. 7
DON’T KNOW........................... 8

YES........................................... 1
NO............................................. 2
REFUSED................................. 7
DON’T KNOW........................... 8

I8f.

Are
there any other members
in your household?

YES (REPEAT I8a-I8f) ............. 1
NO (SKIP TO J1)...................... 2

YES (REPEAT I8a-I8f).............. 1
NO (SKIP TO J1) ...................... 2

COMPLETE SUPPLEMENTAL FORMS AS NEEDED

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

SECTION J: CONTACT INFORMATION
Thank you very much for your time today. To help us be able to get back in touch with you in the future,
we would like to collect the names, telephone numbers and addresses of two people who will always
know how to reach you. Please tell me about people who live at a different address than you. This
information will be kept strictly confidential and will only be used if we are unable to contact you.
J1.

Could you tell us the name of a primary person who does not live with you and will always know
how to contact you?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO K1)
REFUSED ...........................................................................................7 (SKIP TO K1)
DON’T KNOW .....................................................................................8 (SKIP TO K1)

CONTACT #1:
J2.

J3.

J4.

What is his/her first name?
J2a.

What is his/her middle name?

J2b.

What is his/her last name?

J2c.

Does his/her name have a suffix?

What is (his/her) street address?
J3a.

Is there a complex/building name?

J3b.

Is there an apartment number?

J3c.

In what city?

J3d.

In what state?

J3e.

What is the zip code?

What's the best phone number to reach (him/her) at starting with the area code?
Telephone # with area code: (_______) ________-________
J4a.

Is she/he a friend or a relative, or what is (his/her) relationship to you?
ACCEPT ONE RESPONSE ONLY.
FRIEND...............................................................................................1
RELATIVE...........................................................................................2
OTHER (SPECIFY): _______________________________ ............3
REFUSED ..........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

CONTACT #2:
J5.

Could you tell us the name of a second person who does not live with you and will always know
how to contact you?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO K1)
REFUSED ...........................................................................................7 (SKIP TO K1)
DON’T KNOW .....................................................................................8 (SKIP TO K1)

J6.

J7.

J8.

What is the name of someone else who keeps in contact with you?
J6a.

What is his/her first name?

J6b.

What is his/her middle name?

J6c.

What is his/her last name?

J6d.

Does his/her name have a suffix?

What is (his/her) street address?
J7a.

Is there a complex/building name?

J7b.

Is there an apartment number?

J7c.

In what city?

J7d.

In what state?

J7e.

What is the zip code?

What's the best phone number to reach (him/her) at starting with the area code?
Telephone # with area code: (_______) ________-________

J8a.

Is she/he a friend or a relative, or what is (his/her) relationship to you?
ACCEPT ONE RESPONSE ONLY.
FRIEND...............................................................................................1
RELATIVE...........................................................................................2
OTHER (SPECIFY): _______________________________ ............3
REFUSED ..........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

Contract No. SS00-10-60011

SECTION K: RESPONDENT CONTACT INFORMATION
Thank you very much for your time today. At this time we’d like to just confirm some information about
you. The information we confirm now will allow us to help us be able to get back in touch with you in the
future. [It will also allow us to ensure that your incentive payment is sent to the correct address.]
K1.

I have your name listed as [READ AND CONFIRM SPELLING OF NAME, FIRST MIDDLE LAST
SUFFIX]. Is that correct?
YES, ALL CORRECT..........................................................................1
NO, CORRECT FIRST NAME ............................................................2
NO, CORRECT MIDDLE NAME.........................................................3
NO, CORRECT LAST NAME .............................................................4
NO, CORRECT SUFFIX .....................................................................5
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

K2.

(SKIP TO K3)
(GO TO K2A)
(GO TO K2B)
(GO TO K2C)
(GO TO K2D)
(SKIP TO K3)
(SKIP TO K3)

Could you please tell me how to spell your name?
K2a.

FIRST:

What is your first name?

K2b.

MIDDLE:

What is your middle name?

K2c.

LAST:

What is your last name?

K2d.

SUFFIX:

Is there anything after your last name, like Jr. or Sr.?

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

K3.

Contract No. SS00-10-60011

Our records show that your current address is (READ FROM SAMPLE SHEET). Is this correct?
YES, ALL OF THAT IS CORRECT)....................................................1
NO–UPDATE STREET .......................................................................2
NO–UPDATE APARTMENT/UNIT .....................................................3
NO–UPDATE CITY ............................................................................4
NO–UPDATE STATE..........................................................................5
NO–UPDATE ZIP................................................................................6
REFUSED .........................................................................................97
DON’T KNOW ...................................................................................98

K4.

K3a.

STREET:

What is your current street address?

K3b.

APT:

Is there an apartment number?

K3c.

CITY:

In what city do you live?

K3d.

STATE:

In what state do you live?

K3e.

ZIP:

What is your zip code?

(SKIP TO K4)
(GO TO K3a)
(GO TO K3b)
(GO TO K3c)
(GO TO K3d)
(GO TO K3e)
(SKIP TO K4)
(SKIP TO K4)

IF CAPI: Our records show your phone number as [AREA CODE/PHONE NUMBER]
IF CATI: I called you at [AREA CODE/PHONE NUMBER].
Is this the best number to reach you at?
YES .....................................................................................................1 (SKIP TO K7)
NO .......................................................................................................2
REFUSED ...........................................................................................7 (SKIP TO K7)
DON’T KNOW .....................................................................................8 (SKIP TO K7)

K5.

What is your home phone number, starting with area code?
(____) _____-________
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

K6.

Do you have a cell phone number?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO K7)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

K6a.

Contract No. SS00-10-60011

What is your cell phone number, starting with area code?
(____) _____-________
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

K7.

Do you have an email address?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO K8)
REFUSED ...........................................................................................7 (SKIP TO K8)
DON’T KNOW .....................................................................................8 (SKIP TO K8)

K7a.

What is your email address?
_____________________________@____________ . _________
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

K8.

What is the best way for me to reach you in the future? Would you prefer that I call you on the
phone, send you a letter in the mail, send you an email, or should I call someone else?
PHONE ...............................................................................................1
LETTER ..............................................................................................2 (SKIP TO K9)
EMAIL .................................................................................................7 (SKIP TO K10)
SOMEONE ELSE................................................................................7 (SKIP TO K11)

K8a.

What is the best phone number to call you at, your home phone or your cell phone
number?
HOME PHONE....................................................................................1
CELL PHONE .....................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

K9.

(SKIP TO END)
(SKIP TO END)
(SKIP TO END)
(SKIP TO END)

Is [CORRECTED CURRENT ADDRESS IN G4] the best address to mail something to you?
YES .....................................................................................................1 (SKIP TO END)
NO .......................................................................................................2
REFUSED ...........................................................................................7 (SKIP TO END)
DON’T KNOW .....................................................................................8 (SKIP TO END)

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

K9a.

Contract No. SS00-10-60011

What address should we use if we mail something to you?
STREET ADDRESS:
APT NUMBER:
CITY:
STATE:

K10.

___________________ ZIP:

Is [G7EMAIL] the best email address to contact you at?
YES .....................................................................................................1 (SKIP TO END)
NO .......................................................................................................2
REFUSED ...........................................................................................7 (SKIP TO END)
DON’T KNOW .....................................................................................8 (SKIP TO END)
K10a. What is a better email address to use to contact you?
_____________________________@____________ . _________
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8

K11.

What is the name of the person I should contact first when I need to reach you in the future?

a.
b.
c.
d.

K12.

What is his/her first name?
What is his/her middle name?
What is his/her last name?
Does his/her name have a suffix?

What is (his/her) street address?
K12a. Is there a complex/building name?
K12b. Is there an apartment number?
K12c.

In what city?

K12d. In what state?
K12e. What is the zip code?

K13.

What is the best phone number to reach (him/her) at, starting with the area code?
Telephone # with area code: (_______) ________-________

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

BOND Implementation and Evaluation

K14.

Contract No. SS00-10-60011

Thank you very much for your time today.

Abt Associates Inc.

Appendix B. BOND Stage 2 Baseline Survey Instrument

File Type	application/pdf
File Title	Abt Single-Sided Body Template
Author	NicholsonJ
File Modified	2010-08-18
File Created	2010-08-18