CHIP and Medicaid Personnel

ATTACHMENT H
RESPONDENT MATERIALS (CONSENT FORM, LETTERS, FAQ)

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ATTACHMENT H1
ADVANCE LETTER (ENGLISH, SPANISH)

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ASPE LETTERHEAD

Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear (NAME):
Does your child have health insurance?
Would you like to tell the government about your experiences with it?
The Assistant Secretary for Planning and Evaluation (ASPE) is interested in hearing from parents of children who
currently have or used to have health insurance from [CHIP or MEDICAID (use relevant state program names].
ASPE is a division of the U.S. Department of Health and Human Services (HHS), and oversees programs like [CHIP]
and [MEDICAID]. ASPE has asked Mathematica Policy Research (Mathematica) and the Urban Institute to do a
survey with parents so ASPE can learn about their experiences with children’s health insurance.
ASPE is writing to ask you to take part in this survey, called the Children’s Health Insurance Survey.
In about one week, a telephone interviewer from Mathematica will call to ask you to complete the survey on the
phone. Please say YES when they call. You can do the survey with the interviewer at that time. Or, you can decide
that you want to schedule an appointment and have the interviewer call you back. We know you are busy and we
want to make this as easy as possible for you to do.
The survey should take about 30 minutes of your time.
If you complete this survey we will send you a $20 gift card to thank you for your help.
We will keep your answers to the survey questions strictly confidential, and use them for study purposes only. We
will combine the answers from everyone who completes the survey into one report and we will send that report to
Congress. We will write the report in such a way that no one will be able to identify you, or your answers. We will
not publish your name, and will not share your information with anyone who is not directly working on this study.
Your benefits will not be affected whether you decide to participate or not. There are no extra benefits for
participating, and there are no known risks to you or your child.
Please answer when Mathematica Policy Research calls! ASPE needs the information to help make children’s
health insurance programs better.

Sincerely,

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0990- . The time required to complete this information collection is estimated to
average 30 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W.,
Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

ASPE LETTERHEAD
DATE
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Estimado (a) (NAME):
¿Tiene Su hijo (a) seguro de salud?
¿Quisiera contarle al gobierno sus experiencias con él?
El Subsecretario para Planear Y Evaluación (Assistant Secretary for Planning and Evaluation (ASPE)) tiene interés en
oír de los padres de niños que actualmente tienen, o anteriormente tenían, seguro de salud de [CHIP o MEDICAID
(use relevant state program names]
ASPE es una división del Departamento de Salud y Servicios Humanos (HHS) de los EE.UU. y supervisa programas
tales como [CHIP y MEDICAID]. ASPE le ha pedido a Mathematica Policy Research (Mathematica) y el Urban
Institute que lleven a cabo una encuesta con padres para que ASPE pueda aprender de sus experiencias con seguro
para niños.
ASPE está escribiéndole para pedirle que tome parte en esta encuesta, la cual se llama la Encuesta de Seguro de
Salud para Niños.
Dentro de una semana (más o menos) una entrevistadora de teléfono de Mathematica le llamará a usted para
completar la encuesta por teléfono. Por favor diga “sí” cuando llame. Puede hacer la encuesta con la
entrevistadora en aquel entonces. O puede decidir que quiere hacer una cita para que la entrevistadora vuelva a
llamarle a usted. Sabemos que usted está ocupado(a) y queremos hacer esto lo más fácil posible para usted.
La encuesta tomará unos 30 minutos de su tiempo.
Si completa esta encuesta le enviaremos una tarjeta de regalo por $20 para agradecerle su ayuda.
Guardaremos sus respuestas en confianza estricta y las usaremos sólo para propósitos del estudio. Vamos a
combinar las respuestas de todas las personas que completan la encuesta en un sólo informe y enviaremos ese
informe al Congreso. Escribiremos el informe de tal manera que nadie pueda identificarle a usted. No
publicaremos su nombre, y no compartiremos su información con nadie que no esté trabajando directamente en
este estudio.
No se van a afectar sus beneficios si usted decide participar o no participar. No hay beneficios adicionales por
participar y no hay riesgos conocidos para usted ni su hijo(a).
Por favor, ¡conteste cuando llame MPR! ASPE necesita la información para ayudar a mejorar los programas de
seguro para niños.
Atentamente

ATTACHMENT H2
CONSENT/PARTICIPANT RIGHTS (ENGLISH, NOT YET TRANSLATED INTO
SPANISH)

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Attachment H Survey Consent Procedure
SQ14

Before we start, I am required to tell you about the survey and your rights as a
participant.


HHS is conducting this survey to learn if children are getting the health care they
need and if there are any barriers to getting health care. The survey takes about
30 minutes.



When you finish the survey, we will mail you a $20 gift card.



We will keep your identity, [CHILD]’s identity, and all answers to survey
questions private from everyone except the research team unless prescribed by
law.



Taking part is voluntary. You may refuse to answer any question you consider
sensitive or that you don’t wish to answer. You may refuse to take part in the
survey. You are very important to the success of the survey and I hope you’ll
agree to continue.

•

There are no known risks to taking part in the survey. Nothing you tell me will
affect [CHILD]’s insurance benefits. By answering the questions you may be
helping HHS to improve health care for other children.



If you want to speak to someone about the survey, I can give you the contact
information for Alisa Ainbinder.



If you want to speak to someone about your rights as a participant in the study,
I can give you the contact information for someone at P/PV.

New
SQ14 = has been read
SQ15
Do you have any questions about anything I just told you?
ANSWER ALL QUESTIONS BASED ON FAQ.
YES.................................................................................. 1
NO................................................................................... 0

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ATTACHMENT H3
LOCATING LETTER (ENGLISH, SPANISH)

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DATE, 2011

Vea el otro lado para español
Dear NAME:
The U.S. Department of Health and Human Services (HHS) is trying to reach NAME about an
important national survey about children’s health insurance.
We would like NAME to contact us as soon as possible. Please help us by passing along the
message below to him/her.
Thank you.

___________________

Message
Please call this toll-free number (1-xxx xxx-xxxx) to take part in an important
national health survey sponsored by the U.S. Department of Health and Human
Services (HHS).
Someone is available to talk to you Mon-Fri 8:00 a.m. to 8:00 p.m. You may
also leave a message, with your area code and telephone number, and we will
call you within 24 hours.
We need your help! Please call us.

DATE, 2011

See other side for English
Estimado (a) NAME:
El Departamento de Salud y Servicios Humanos de los EE.UU.(HHS) está tratando de contactar a
NAME acerca de un importante estudio nacional sobre seguro de salud para niños.
Quisiéramos que NAME se ponga en contacto con nosotros lo más pronto que le sea posible.
Por favor, ayúdenos por transmitirle el mensaje de abajo.
Gracias.

Mensaje

Haga el favor de llamarnos libre de cargos al (1-xxx- xxx-xxxx) para
participar en una importante encuesta nacional sobre salud, patrocinada
por el Departamento de Salud y Servicios Humanos de los EE.UU.
(HHS).
Hay alguien disponible para hablar con usted de lunes a viernes de las
8:00 de la mañana hasta las 8:00 de la noche. También puede dejarnos
un mensaje dándonos su área y número de teléfono y le llamaremos
dentro de 24 horas.
¡Necesitamos su ayuda! Por favor, llámenos.

ATTACHMENT H4
SORRY I MISSED YOU CARD (ENGLISH, SPANISH)

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(Vea el otro lado para español)

Sorry I missed you

My name is _______________ from Department of Health and
Human Services.
I stopped by to talk to you about an important national survey about
children’s health insurance.
Please call our toll-free number 1-xxx-xxx-xxxx to complete the
survey for this study, or 1-xxx-xxx-xxxx if you have any questions
about the study.
To show our appreciation, we will give you a [STORE NAME] gift card
for $20.00 for completing the interview.
I look forward to hearing from you soon.
Thank you.

(See other side for English)

Siento no haberme encontrado con usted
Me llamo _______________ de Departamento de Salud y
Servicios Humanos.
Pasé por aquí para hablar con usted acerca de una importante
encuesta nacional sobre seguro de salud para niños.
Haga el favor de llamar nuestra oficina libre de cargos al
1-xxx-xxx-xxx para completar la encuesta, ó al 1-xxx-xxx-xxxx
si tiene cualquier pregunta acerca del estudio.
Como muestra de nuestra gratitud, le daremos una tarjeta de
regalo de [STORE NAME] por $20.00 por completar la
entrevista.
Espero tener noticias de usted dentro do poco.
Gracias.

ATTACHMENT H5
THANK YOU LETTER (ENGLISH, SPANISH)

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Dear NAME:
Thank you once again for participating in the children’s health insurance
survey. The survey will help us learn more about the families that participate in
state health insurance programs, and how these programs can better serve
families like yours.
As promised during the interview, enclosed is the $20 [STORE NAME] gift card
to show our appreciation. To use the gift card, simply present it to the cashier at
the time of payment as you would with cash. Using the card will not affect your
benefits in any way, and your name will not be associated with the gift card.
If you have any questions, please feel free to call us toll-free at 1-8xx-xxx-xxxx.

Sincerely,
Elizabeth Pham
Department of Health and
Human Services

Estimado (a) NAME
Le agradecemos otra vez su participación en la encuesta sobre seguro para niños.
La encuesta nos ayudará a aprender más acerca de las familias que participan en
programas estatales de seguro, y de cómo estos programas pueden servir mejor a
familias tales como la suya.
Como prometimos durante la entrevista, adjuntamos la tarjeta de $20 de STORE
NAME como muestra de nuestra gratitud. Para usar la tarjeta, sólo hay que
entregarla al cajero cuando pague, tal como lo haría con (dinero) efectivo. Usar la
tarjeta no afectará de ninguna manera sus subsidios/beneficios, y no van a asociar
su nombre con la tarjeta.
Si tiene algunas preguntas, no dude en llamarnos gratis al 1-8xx-xxx-xxxx.

Atentamente,
Elizabeth Pham
Departamento de Salud y
Servicios Humanos

ATTACHMENT H6
BROCHURE (ENGLISH, NOT YET TRANSLATED IN SPANISH)

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ATTACHMENT H7
POSTMASTER LETTER

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UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES
Washington, DC 20201
TO: POSTMASTER

DATE:
ADDRESS INFORMATION REQUEST

Please furnish Mathematica Policy Research, or an authorized representative of Mathematica, with the new address
for the following individual, or verify whether or not the address given below is one at which mail for this individual
is currently being delivered. If the following address is a post office box, please furnish the street address as
recorded on the box holder’s application form.
Old name and address:

I certify that CONTRACTOR NAME is under contract to the Assistant Secretary for Planning and Evaluation in the
US Department of Health and Human Services to conduct a survey that will help the government evaluate and manage the
Children’s Health Insurance Programs. The individual listed above was chosen at random for the survey. The address
information for this individual is required for the performance of Mathematica’s official duties. Information about this study is
available at: http://www.xxxxxxxxxxxxxxx
Department of Health and Human Services 200 Independence Ave, SW, Washington, DC 20201 http://www.hhs.gov/
NAME @hhs.gov

Please return this form to Mathematica at:

Contractor’s address
Attn: NAME

FOR POST OFFICE USE ONLY
( ) MAIL IS DELIVERED TO ADDRESS GIVEN

NEW ADDRESS:

( ) NOT KNOWN AT ADDRESS GIVEN
( ) MOVED, LEFT NO FORWARDING ADDRESS
BOX HOLDER’S STREET ADDRESS:
( ) NO SUCH ADDRESS
( ) DECEASED: DATE:
( ) OTHER (SPECIFY):

POST OFFICE REPRESENTATIVE:

The name & address of the individual for which information is sought
has been provided by Mathematica. This information & any information
provided by the USPO will be held in strict confidence by Mathematica
and the Department of Health and Human Services.